for our patients' reactions to their loss. IPT. SPECIFICITY. FOR. GRIEF. In the second edition of the classic text. Grief. Counseling and. Grief Therapy,. Worden23.
Applying Interpersonal Psychotherapy to BereavementRelated Depression Following Loss of a Spouse in Late Life D.
MARK CLEON
M.D.,
MILLER,
M.D.,
CORNES,
BARBARA
M.S.,
MALLOY,
LEE
WOLFSON,
F.
depression
eral controlled adapted life.
pression their
been
trials.
IPT
depression
Grief into
has
in late in
IPT to geriatric patients whose deis temporally linked to the loss of
spouses.
Detailed
are illustrated
with
treatment
techniques
case vignettes.
Prelimi-
nary treatment outcomes are presented for 6 subjects who showed a mean change on the 17-item
Hamilton
Rating
Scale forDepres-
T anxiety
Engel
of bereavement
rates
of depressive
increased
or
an annual
after
of
exacerbadiminished premature
rates of cardiovascular
more
to 20% rate by Clayton
and
consumption
from increased cirrhosis, and
suicide, dis-
widowhood,
a
of major depression was and Darvish,” translating
incidence
of 80,000
Practice
Received
June
accepted
November
22,
Institute
and
University
Medicine,
18,
OF PSYCHOTHERAPY
1993;
Clinic,
Pittsburgh,
quests
to Dr.
Clinic, Room
University 742 Bellefield
PRACTICE
Western of
to 160,000
November
From
American
RESEARCH
18,
Western
School
Address Psychiatric
Psychiatric
1993;
Psychiatric
of Pittsburgh
Pittsburgh School Towers, Pittsburgh,
© 1994
AND
revised 1993.
Pennsylvania.
Miller,
Copyright
JOURNAL
can develop
in el-
derly subjects. (The Journal of Psychotherapy Research 1994; 3:149-162)
disorders;
mortality accidents,
into
and
consequences increased
ease.’’#{176} A year
treat-
depression
it
alcohol, tobacco, and tranquilizers; tion of existing medical illness; immune competence; and
appears
ment for bereavement-related
he known include
10% noted
short-term
but
-George
sion from 18.5 ± 2.3 SD to 7.2 ± 4.6 after an average of 17 weekly 1Ff sessions. 1Ff to be an effective
is not a disease, one.
been
on their experience
report
L.S.W.
in sev-
documented
Recently,
specifi cally for
The authors
applying
has
D.
M.D.
The efficacy of interpersonal psychotherapy (1Ff) as a treat ment for outpatients with major
.
PH.D.
ZALTMAN,
III,
ii
L.S.W.
SILBERMAN,
JEAN
REYNOLDS
P
IMBER,
EHRENPREIS,
REBECCA
M.ED.,
CHARLES
D.
LIN
L.S.W.,
Pn.D.
FRANK,
STANLEY
ANDERSON,
JULIE
ELLEN
of
reprint
re-
Institute
and
of Medicine, PA 15213. Press,
Inc.
150
BEREAVEMENT
cases
of bereavement-related
cently,
Zisook
major
depression
as 24%
and
at 13 months
23%
after
4% rate of depression jects whose spouses
rates
and
loss,
and
compared
reported
with
a large
decline
reavement-related
depression
showed
only
by data
decline
psychological
applying chotherapy spousally
in grief
symptoms may
antidepressant makes little distress
intensity
will
of the
argues to the major
our
efforts
in
the
principles of interpersonal psy(IPT) to elderly, depressed, bereaved patients in a research set-
ting. These efforts draw aptation of 1FF for the depression
in late
life:
case examples will specific techniques tion. Response data pendent raters Interpersonal
will
on our treatment IPT/LL.’6
terpersonally focused, proach to the treatment It has been established
female
efficacy
in
preventing
and
that
older
pa-
addressed
trial
the
financial
tirement, elements
and that
reactions
to their
by
recently using
it
of therapies
by in a in
loss
late
often
that most palife will be
occurs
in the
strain,
adjustment
to re-
loneliness are a few of the set the stage for our patients’
IPT
loss. SPECIFICITY
FOR
previous adof major
In the
GRIEF
second
edition
of the
classic
text
the deceased relocate the Kierman
is missing; and 4) emotionally deceased and move on with life.
et al.’7
define
strategies for using grief as follows:
consistent
1FF
goals
to treat
unresolved
Illustrative The two
for depresare 1) to facilitate the mourning process, and 2) to help the patient reestablish interests and relationships that can substitute for what has been sions
in 5 cases. is an in-
lost.
VOLUMES
NUMBER
The
of the
center
therapist’s
on
treatment
grief
major
tasks
are
to help
assess the significance of the loss realistically and emancipate themselves from a crippling attachment to the dead person, thus becoming free to cultivate new interests and form satisfying new relationships. The therapist adopts and utilizes strategies and techniques that help the patient bring into focus memories of the lost person and emotions related to the patient’s experiences with the lost person. (pp. 97-98)
of
#{149}
goals
that
patients
strategy with Itwas developed would today be
recurrence
Grief
Counseling and Grief Therapy, Worden23 outlines four tasks of mourning: 1) accept the reality of the loss; 2) work through the pain of grief; 3) adjust to an environment in which
considered a continuation therapy. Subsequently, two large trials’8.’9 have demonstrated its efficacy as an acute treatment, and Frank et al.2#{176} have now shown IFF’s prophylactic
depressed
depression.
disability,
present-oriented apof affective disorder. as an effective acute,
continuation, and maintenance unipolar depressed patients. by Kierman et al.’7 as what
with
specifically
It should be acknowledged who lose a spouse in
tients
be provided, as well as relevant to this populaobtained through indebe presented psychotherapy’7
maintenance
specifically
This finding component
outline
of IPT been
maintenance
medication, change in the
of bereavement-related report
a 3-year
context of other stressors associated with this life stage. Medical, sensory, or ambulatory
of bereavebenefit from
associated
with the loss of a spouse. for a psychotherapeutic management depression. This
nortrippatients
the Texas Inventory suggest that although
somatic or vegetative ment-related depression treatment with such treatment
be-
in
Sholomskas et al.2’ and more Frank et aL,’6 who are currently late-life
who
antidepressant these same
a small
as measured Grief.’5 These
a
use has
long-term
for Depression subjects with
major
tients
sub-
in Hamilton Rating Scale (Ham-D) ratings in elderly were treated with the tyline.’3”4 However,
depression
LIFE
trial. The
16%
in 126 age-matched were still living.
recently
major
of
widowers
at 7 months,
their
Re-
reported
in 350 widows
at 2 months,
We have
depression.
Schucter’2
IN LATE
2
SPRING
#{149}
1994
and
MILLER
151
ETI4L.
GRIEF
AS
PROBLEM
Focus
A
AREA
date Was
IPT
IN
the spouse’s illness the death a welcomed
prior to death? end to suf-
fering? Once
the
1FF
about
the
nature
next lem
step area
focus,
is the
has
completion
and
interpersonal
inventory,
following
series
with
spousally
sure
a complete
of
the
such
home
be
as paying
be sold?
have hobbies in place that
spouse? income
Must
5.
If the much tient cial
with port
mat-
or did
the
illness than
8.
was dying? Suicide extensive exploration.
couple
shoulder?
Was from
there
medical
that
a great care?
other riage
What ships? how clear
the re-
diffi-
ended?
discussions
other
legal
matters
handled
areas of disagreematters discussed,
plans in place the remaining
to adequately suppartner? Were fu-
discussed? Were as agreed?
frequently
has
about
the
patient
beginning Had
of waiting
they
this
with patient
the patient’s feel that a pe-
is “proper?”
Are
the
patient’s
quality there
roman-
possibility
Were
relationships during the that are producing guilty
is the
had
a new
there marrumina-
children
of those
living?
relation-
grandchildren,
and
often is contact made? The nufamily has become widely dis-
persed, with children moving away find jobs. Thus, although children
to may
mean well, their practical availability may be an issue. Have there been discussions about moving closer to chil-
finan-
dren?
Do
OF PSYCHOTHERAPY
finally
Were there Were money
tions now? 9. Where are
many large bills remain to be paid? What changes in the patient’s customary lifestyle were required to accommo-
JOURNAL
and
How
riod
do
obviously
there
patient experithat, through
contingency
ever been discussed spouse? Does the
A
and Were
relationship
tic relationship?
spouse had a chronic illness, how caregiving burden did the paburden
decisions shared?
thoughts
a
allows more time for adan acute illness or accidifficulty or accepting
were
neral plans implemented
or independent activities will provide a ready-made
dent. Was there acknowledging spouse quires
wills jointly? ment?
of activity was indejoint? Did the patient
system,
a
with the spouse in the event that one or another partner died first? Were
drop?
virtually everything together? 4. What was the manner of death? chronic justment
the there
a patient down:
is required to current lifestyle
marriage?
recognizing
in the marriage? Were there of separation during the Was the marriage, in fact, a
death,
to en-
deceased Practical
How
7. Were
of potential
the
of their
severe burden? Does the ence relief on some level
bills?
Will
3. What proportion pendent versus
helpful
patients
or of points where stuck or bogged
his or her
support
found
to
older
How much adjustment manage the patient’s without
have
history therapist
cult times any periods marriage?
fa-
we
1.How much support did provide in social matters? ters
may
the
understanding
areas of conflict may have become
2.
that
the 1FF
responsibilities
of earlier of cur-
of the mourning In addition to
questions
bereaved
ences.
inven-
supports
was the
tendency to idealize a lost mate, specific questions will allow for useful infer-
interpersonal
interpersonal
the last phase (reintegration).
With
the
of the probexpects to
to assess the quality as well as the availability
relationships
cilitate process
illness,
of the
6. What
educated
regardless the therapist
A thorough
tory is essential relationships
been
of depressive
in treatment, on which
inventory.
rent
patient
10.
What
are available? What other tained,
PRACTICE
and
AND
other
sources
of support
losses
has
patient
what
were
RESEARCH
the
his or her
susreac-
152
BEREAVEMENT
tions
to those
tion life,
is focused with early
losses?
Particular
atten-
losses loss
in early clearly asso-
on any parental
ciated with increased sion in adulthood.24 11.
Has the surviving dispose of personal ceased,
for
spouse items
depres-
been able to of the de-
clothing?
In our
or, if the
process
is pro-
tracted, of fixation. Leaving the room “just as it was” is common parents
of a lost
seen with therapist’s
child
but
loss of a spouse. direct inquiry
can provide about the
valuable patient’s
“hold on at all costs” ting go” in a measured for emotional
ing
that
be
these to to “letallows
attachment”
the may
where their
should
be
for
that
older These
older
persons
positively
persons, authors
than
suggesting further
an noted
not
who
the
were
attachment
quality
bereaved.
of early-life
attach-
mote that
a positive self-image and other satisfying affectional In
contrast,
the
impaired
realization bonding
and the degree of satisfaction the marital relationship have to the quality of affectional
and
outlines
autonomy,
doubt (engendering of grief therapy Davidsen-Nielsen2 who had to have
lev-
ing
els of feeling.
S
the
critical
as versus
difficulty with more protracted
NUMBER
#{149}
2
SPRING
#{149}
et al.26 recently
that examines perceptions
they
received
1994
shame
and
will). In their 15 years experience, Leick and have noted that those pa-
ature patients’
network. Parker
may
to deepen
ambivcan
lead to lifelong difficulty in forming satisfying interpersonal relationships. Therefore, according to attachment theory, an individual’s
tients tended
Al-
memorabilia
is
attachments
importance of early relationships in the initial two stages of his development model: basic trust, as versus mistrust (engendering
getting in have they conletter to the
VOLUME
postulates
parental
photographs
stimulus
their
their mardepressed
theory
tions. It was harder for them and to welcome new contacts make use of the healing power
further
of
idealizing bias. that bereaved
older
though “homework” is not a focus of 1FF in general, we have found that its use is justified because it helps patients reach deeper levels of feeling and promotes progress. Similarly, reviewing provide
rated
viewed than did
patients
the
quality
nonbereaved
depressed older patients riages more positively
hope),
or other
history, the
shown to affect the Futterman et al.27
bonding in early life. Erikson28 similarly
them to and draw
Davidsen-Nielsen2 letter writing.
marital
realize
bereaved more
choice of mate obtainable in roots traceable
to pa-
throughout
If patients have difficulty touch with their feelings, sidered writing a farewell Leick and extensive
not
“old-old” (80 be at a stage in
it is best memories
on the
in early life (resulting from neglectful, alent, indifferent, or abusive parenting)
to the
all patients on.” Many
on them for sustenance their remaining years.
deceased? encourage
that
marriages
possible.
therapists
must
ments sets the stage for all future affectional bonding. Secure attachments in early life pro-
(as described by Bowlby and et al.) may be best for them.
their lives consolidate
found
that
may benefit, however, therapist’s acknowledg-
particularly or older),
further
therapist
Bowlby’s25
indirect struggle
trapped into expecting “get over it” and “move
12.
also
The along
as opposed way that
“a timeless
Bereavement
tients, years
bedfor
growth.
Some patients from their 1FF deceased Parker
can
MARITAL
the marriage has been process of bereavement.
ex-
LIFE
QUALITY
To expand
in our pilot study, this act is a metaphor; it is indicative of
movement
lines clues
EXPLORING
1FF
particularly
perience powerful true
risk
LATE
IN
attachments grief reacto say goodbye as well as to of a supportive
reviewed
the links of the quality and
their
social
the
liter-
between of parentbonds
in
MILLER
153
ETJ4L.
toward the deceased, God, tions may be intolerable
adulthood (the concept of “continuity”). Parker et al. point out that exceptions exist that
run
ity
theory;
counter
hood impaired
is
satisfying negative
to expectations
for
example,
relationships. bias” can
at a later
that need have
to conclude
It
Negative
parent-child
bonding
to judge negatively,
by shaping
mental
may
relational
mate
partners
Horowitz
an uncaring is established
with
with
significant have
less
of a profound negative
latent,
counterbalanced
greater
the
reactivatself-images
marriage
or for
the loss of the negative-bias-cormore acutely than those parenting. NEGATIVE
AMBIVALENT
A common of the anger,
who
OR
reason
for
inhibited
completion
process is ambivalence, (often at being left behind)
JOURNAL
the
an
apfrom
patient’s
are
in
toward
a
underpinnings
and depression. Havto focus on grief, the
will often need the patient
tionships
to work
of the
to make some about common
effort pat-
to loss. The therapist that all significant
may rela-
characterized
by some
feelings and that the agreed-upon learn as much as possible about
process
feelings-negative Careful empathic
in a safe
died,
ages lems
mixed
task is to both sides of as well review
as posof the
environment.
OF PSYCHOTHERAPY
the
with
make have 1FF
their
references to how become since their therapist
therapist
might
attempts
difficulty
them to talk about that arose in response
the
and
to
encour-
personal probto their loss. The
say, “Having just heard about you’ve had adjusting to if it sometimes seems
all the difficulties your loss, I wonder unfair to you responsibilities?”
that
you The
now have therapist
all these extra might further
say, “In my experience, it’s not uncommon for people to feel some annoyance or anger toward the deceased as the negative part of those mixed feelings we talked about Similarly, Leick and Davidsen-Nielsen2 invitation,
after
“...and
patiently
attributes ceased.
EMOTIONS
mourning or rage
and
agrees
of the continued grief ing obtained permission
the MANAGING
patient
understanding
empathize
about loss
awareness. reached feelings
inventory
will ask if the
spouses
inti-
or compen-
of a dysfunctional
experiencing recting spouse had adequate
interpersonal
When patients difficult their lives
others.
written
patient’s
events surrounding the death and the subsequent necessary adjustments will provide an invitation to renew the unfinished mourning
sated for by the living spouse. Patients with histories of deficient early parenting should be seen as being at greater risk for the establishment
the
1FF therapist has of these common
those mixed itive aspects.
in likely
in early parental be modified by
experiences
et al.
been
in or
partner at all).
associated
and
related concept ing previously
dis-
bonding directly
models.
vulnerability
later
had
social either
who had extreme deficits parental care appear more
Initial
beyond
terns of adjustment remind the patient
pose people adulthood Those early
the
therapist to educate
that
extreme difficulties care apparently can
that
in life.
forms a link with grief to recognize that the played the role of cor-
to associate with (if a relationship 3.
point
be
When the preciation
emothus
own understanding of his or her difficulty dealing with the spouse’s death, the therapist
that “pervasive negative bias.” Parker et al.26 report that ample evidence
exists
2.
child-
That is, a “pervasive corrected if a secure
be
is made
is this last point work: therapists lost spouse may
1.
in
not always associated with an ability in adulthood to form stable,
attachment
recting
may
of continu-
adversity
or fate; these to admit and
the With
listening
what to
don’t you all
survivor ascribes gentle persistence,
the
earlier.” use miss?” positive
to the dethe 1FF ther-
apist will clarify, interpret, and sometimes confront the patient with the evidence already assembled from the patient’s verbaliza-
PRACTICE
AND RESEARCH
154
BEREAVEMENT
tions these
to suggest that further lines is indicated, at
inquiry the same
along time
educating him or her about common feelings many people harbor in the grief process. This approach mizes
provides the
ate
state
under
reassurance
of mixed
the
feelings
current
and
circumstances.
The
experience of relief or unburdening session along these lines often instills the
patient
that
therapist’s the
grief
he
or
she
expertise
to
the
accompanying
and
legiti-
as appropri-
help
after hope
can “get
use
a in the
through”
depression.
Case!:
Coming to Terms With Ambivalent or Affect. Mrs. H. was referred because of uncontrollable crying spells and inability to concentrate at work. Her husband had died suddenly of a heart attack 6 months earlier. She had been previously divorced and had enjoyed her second marriage for 12 years. She spent the first sessions talking about her embarrassment at being unable to control her emotions and how much she had enjoyed her lost love, especially compared with her first husband. The first task of therapy was to give her permission to grieve, to allow herself to feel whatever was there at the moment. Some time was also spent in early sessions on practical matters such as encouraging her to respectfully decline invitations she was not up to and realistically appraising alternative ways to better handle her emotional outbursts at work. After several sessions of idealizing the patient’s dead husband, the question “Where is the ambivalence?” arose in the mind of the therapist. Why is this patient unable to move forward? Gradually, a theme began to emerge concerning her husband’s unwillingness to get adequate medical examinations. She felt that if she had been successful maybe his death could have been prevented. She admitted feeling enraged at the thought that he might have concealed knowledge of medical illness with which he did not want to burden her. Finally, she also came to acknowledge angry feelings that he might still be here (for her) if he had heeded her advice to get medical evaluation. These thoughts were quickly followed by guilty ruminaNegative
tions
for
thinking
A parallel
her
husband’s
so
selfishly.
development
sexual
potency
was
a decline
in
in the months
VOLUME
be-
S
NUMBER
#{149}
IN LATE
LIFE
fore
his death. She described a mutually satisfysex life and said that both were dismayed about recent difficulties. She was very careful to downplay the loss of erectile function (and of missing her own sexual pleasure) to avoid making him feel insecure. They had discussed the possibility of “getting it checked” medically but had never done so. The patient described coning
siderable
unburdening
relief
at the
opportunity
to discuss these issues in detail, particularly her guilty ruminations about having selfishly encouraged medical evaluation for a sexual problem when, in retrospect, he really needed medical help to save his life. Out of “respect” for her dead husband she had been unable to discuss all these ramifications with well-meaning friends and family. Mrs. H. progressed, with continual clarification and confrontation of these themes, to the point of accepting plans to travel with family, and she got through the death anniversary with less stress than expected. She was no longer crying at work nor thinking constantly about her late husband, and she agreed that it was time to terminate treatment. Comment: example reaved sessions. from find
This
of the depressed
case
It is this
job
common rence,
or
authors’ sal, and overzealous
the
protects
first,
to
them
affects The
they IPT
understand
this
anticipate its occurevidence to support its patient’s
own
verbaliza-
to reflect it back to the patient in manner, at the same time edupatient that his or her experience
is well within Although alent
is,
from
tions, then a therapeutic cating the
that
or ambivalent acknowledge.
phenomenon, and look for
presence
is a good
posture that bebring to the initial
posture
the negative painful to
therapist’s
vignette
idealizing patients
the range of the “normal.” conflict over expressing
negative
affect
experience, 1FF therapists interpretations
Case
is common
in
it is by no means are cautioned along
ambiv-
these
the
univeragainst lines.
2: Struggling to Do the Right Thing. Mr. a construction worker, presented with a 30pound weight loss, anergia, anhedonia, and passive suicidal ideation. He reported severe grief reactions after his mother, father, and father-in-
2
SPRING
#{149}
1994
law died. “my
He described
best
friend,
lingering
to
death
after
care.
pounds,
he
ticipate
her
spending her
sions ate
was
sexual
years
of
illness,
the
her
not
deal
how
about
of
system”
he
felt
43
years.
lence
He
that
he
missed
doubted didn’t up
to
with
them,
to
down”
and
find
Mr.
necessary
to
had
dated
his
He
dated
trust
and
said
he
could
of
overactivity
session,
He
in
said
exhaustion
he wife’s
redecorating decor.
he
was
that
had
reported
that
his
house
his
first
in date
and
looks
upon
rightly shame
dating
a square
dance
group,
and
as a challenge.
Comment: Leick and Davidsen-Nielsen2 point out that feelings of guilt and that follow steps of progress in form-
JOURNAL
OF PSYCHOTHERAPY
he
reached
death
initial
bypass
undergone
he
preoccupation
the
10-year
re-
14.months dating
poor
a
feeling
He
friends had
did
because
he
that
he
on
his
guarantee
(two surgery
sleep, with
example,
surgery
6 months).
mandatory
began
were
and
bypass
his
junior.
of death-for
cardiac
the
complaints
outlived
P. lost
depressed
when
his
motivation,
now
Mr.
He became
wife’s
who
died
not
want
felt
he
in
help had
also the
had previ-
from to
“do
any this
himself.” Mr.
a
of his struggle with the realization that experience was bound to be new and different. He continued his ambivalent struggle with sexual activity. Mr. G. reported on his progress in therapy, saying: “I’ve come through some bad months; I never thought I’d make it.” He described reducing his cemetery visits to once a joined
only to be The follow-
with breast cancer. Almost death, he was called to acGulf, where he served
her
17 years
themes
reminders
talked
has
his
medication
his
week,
after woman
ous
at night.
of his
to relocate and begin
a plateau, events.
Mourning.
Persian until
age.
poor
“nail
the
6 months
His
described he
in
tirement
by break-
which
a level to sleep
him
illustrates.
after
duty
had
some
begun
tive for
saying
alternatively
a parallel
can reach by subsequent
immediately in
ambiva-
and
he
Grief work reactivated
Case 3: Incomplete wife in a 2-year battle
along,
not
her.
relationship
eighth
away
“manly”
came
about
activities,
reach him his
put
sex
on.
sport
allow After
more
a new
he
it, enabling wife emotionally
and
left him exhim to deal conflict and
MOURNING
ing vignette
relationships,
anyone
in his flirtatiousness
INCOMPLFTE
emptiness.
had
replace
but
count
and
had
hurt
the
by conflict over formsince his wife’s death,
He was
openness
could
G. described
hobbies
would
wife’s
he
want
a wish
and
his
that
a
against
and
he
new
paralyzing,
betraying
compan-
woman
at length
be
and
to get his wife “out
because
talked
be truly
dating.
confrontation,
loneliness
forming
his defenses
his
conflicted
this
another
would
to work through deceased
ses-
hiding
female
be able
until
be
considerably.
his
awkward
about
been and
tearful
prohibitions
down
can
progress
his immersion in activities that hausted. His 1FF therapist helped with both sides of this underlying
members.
must
greatly
After
relationships Mr. G., torn relationships
showed
an-
inappropri-
staff
if any
the interpretation
missed
felt
religious
aware
his
had
early
and
G. became
he he
He said he wouldn’t but
of his
advances
toned
painfully
he praying,
with
Mr.
of marriage.
his flirting
death,
female
much
Catholic
outside
to
Mass,
aspect
new
as
in weight
himself
preoccupation
ing
deceased. ing new
daily.
of pain,
however,
decline
allowed her
with
ionship;
a
to be bedridden her
finally confronted
discussed
he
many
striking
that his overzealous
ing
died
Since
flirtatiousness
great
of
as
had
attending
grave
most
When
years
She
had
time
The
wife
Despite
death. his
visiting
of 43
wife.”
required
24-hour
76
his and
lover,
last 4 of which with
155
ETAL.
MILLER
ing
fun”
P. described with
his
feeling new
lady
guilty friend,
about feeling
“havthat
it
wasn’t fair that it couldn’t knowledged that he had nity
to grieve
for
his
now unfair to burden grief. He was obsessed might wife’s
mistakenly
with
refer
to
the his
thought new
that
friend
he
by his
name.
Mr. P. felt that and
be his wife. He acnever had the opportulate wife and felt that it was his new friend with his
that he had
he had
“been
there”
a good
marriage
for his wife
throughout her decline and death. He expressed gratitude for the opportunity to discuss his feelings and reported feeling and sleeping better after several sessions. A tragic coincidence occurred during the
PRACTICE
AND RESEARCH
156
BEREAVEMENT
his mother was diagnosed with breast cancer and was near death on the 2-year anniversary of his wife’s death. Upon exploration, Mr. P. did not feel that he had a good relationship with his mother, summing his feelings for her as “respect” for “raising her kids alone.” As his mother’s condition deteriorated he was able to make time for her without resentment or guilt feelings. therapy:
After
his mother’s
death,
Mr.
P. dealt
Comment:
The
restart the his military his
new
solved tionally
first
a safe mourning service.
task
of 1FF with
forum
in which
Mr. P.
process interrupted by The inhibition he felt in
relationship
was
not
going
to be
re-
of emohe could
accept. His 1FF therapist was able to allow him to explore all the feelings he was experiencing without the “unfair” burdening of his new friend. His mother’s illness caused him to review as well
realistically as revisit
his relationship his role
with
as caregiver
for
her both
his mother and his wife. Ultimately, Mr. P. was able to acknowledge that he had been there for them both and could now let them rest and move on to new relationships. Leick and Davidsen-Nielsen2 describe the readiness to love again as being prepared to live through the
grief
of a new
OTHER
Although four problem experience
loss.
PROBLEM
grief
is the
AREAS
most
areas that we focused with bereaved older
may
through
grieving these
4: Role
Transitions.
4 months
earlier treatment
treatment
with
liver
by
her
brought
following
areas.
cancer. adult
had
She
was
children
with
medication.
considerable
pendency
to
to be supby her de-
needs. When
the
psychotherapy
outpatient basis, Mrs. P. expressed tendance at her
The
relief
the children, who were very willing portive but had been overwhelmed
home
and
resumed
the greatest was for the
feeling
children
at Sunday
by grown her
loss
past
of status
on
an
of loss that obligatory
as the
at-
dinners “hub”
of family activity. It was as if she were willing to overlook or tolerate her husband’s abusiveness as long as she could counterbalance it with satisfaction from the maternal role, in which everyone came home to her. One daughter, in particular, revealed her own struggles in her psychotherapy and Children of Alcoholics support groups to break from what she termed an “enmeshed, dysfunctional family.” Therapy with this patient was clearly fo-
on in our persons,
#{149} NUMBER
The
may goes
Mrs. P.’s husband of
antidepressant
hospitalization
on
S
family
deficits a patient
whom she had been living sequentially, exhausting and frustrating each one in turn. They described her as weepy, clinging, and unwilling to be left alone even for short periods. In private, her children described their late father as an abusive alcoholic, and they collectively expressed their amazement that their mother had stayed with him. At the initial evaluation, the patient was severely depressed and required 3 weeks of hospitalization that included
exploring
VOLUME
remaining
process.
died
transitions
circumstances interpersonal
problem
Case
LIFE
required;
role
interpersonal the way
the
spent
of grief reactions. Exploraimmediate reactions and
that
exacerbate
illustrate
to
is clearly
case
by changing of a spouse;
relationships; and strongly influence
cused
of
each of the other three 1FF problem areas (role transition, interpersonal conflict, and interpersonal deficits) has come to bear on the management tion of the patient’s
conflicts
death the
are often dictated after the death
the
common
the
it is also
brought
he could
until he finished the process relocating his wife to a place
about
however,
cases
with
her estate and felt satisfaction in his ability to “be there” for her even though his mother had not been there for him during his wife’s battle with cancer. He was able to find satisfaction in the knowledge that he attended without reservation to his mother as well as his wife on their deathbeds.
was to provide
feelings
IN LATE
role
transition. the
Many differences
sessions between
were her
wishes and more realistic expectations concerning her grown children’s aspirations and their allegiance to her. She was gently challenged to take more responsibility for her own needs and to learn better ways to cope with their independent activities. She somewhat idealized her late husband but referred far less often to him than
2
SPRING
#{149}
1994
to
157
ETAL.
MILLER
the
loss
of her
After moved
to
an
spread
her
area
by “looking
building
and
where she Her family
lifestyle.
of steady
apartment
fully
portive
previous
3 months
building
served food continued
over
widows”
a local
P.
felt
a wider
in her
senior
center,
to less able members. to be involved and sup-
with
which
they
were
of
more
comfortable.
Comment:
As
patients with were heavily
the
above
strong invested
case
dependent in the
illustrates, who their
traits
support
spouses provided will have a much more difficult time adjusting to the loss and establishing new roles for themselves. Traits of excessive
dependency
can
conflict
among
terpersonal Case
5: No More
Mrs.
T.’s husband
week 12
illness.
suddenly
the
50th
wedding
Mrs. T. described somehow band
was
able
to
should
have
even
though
She
“was
Upon
describe
and
always bulk
moods
changing she
as crabby of
the style
as he
even
her.
She
giving
sider.
On
versations
her
with
preference feelings
toward
he
who
though now her
out as if her had
to T.
about
“go
and
for
“just
disastrously
Mrs.
first”
became
husband
husband
him
diffi-
described
guilty,
opportunity
recon-
recalled
con-
his
angry
admitted
successfully
“willing
it to
happen.” After
Mrs.
to express
her
much
missed
grapple
she
with
T.
had
negative his
the role
had
ample
feelings
changes
her
as how
attempts
to
in her life came
JOURNAL
firsts.”
had
kept
up
with
gret
that
the
party
her
friends
than
Mrs.
each
T.
to
similar a more
has
was
The end
their
it
as a couple.
acutely
aware
and
lives
in
stance.
short-lived,
to terminate
considerable
day
a change
protective
was
of re-
next
with approaching noted
isolated,
pangs
the
individual
therapist
posture
shown
to
difficulties
Her
to
other.
had
return
Mrs. T. was able
This
however,
and
successfully
independent
and capability.
Comment: Mrs. T. clearly felt husband’s death was untimely. He died
her after
a short
he’d
illness,
OF PSYCHOTHERAPY
he
and
he of
ward volved
him. Their socially,
changes
on
her
died
first
died changing life and part
in
(as he the her
said
midst of approach
together was this required after
his
her to-
quite
ingreat
death.
Mrs.
T.
felt the loss of proximity to her husband even more profoundly. In 1FF she was able to explore all these issues and was able to use the resource of her social network to help fill the void she felt. Predictably, value the relationship
with
she quickly came her 1FF therapist,
to
and the prospect of termination was, at first, a difficult one. The feelings of need that arose in the context of termination were taken up and
opportunity as well
company,
“alone
prefer), experiment
it seemed felt
ended
theme, her
that
spending her
accommodating one
that any
another
She
toward
an experiment
without
to
was,”
for
heard
negative,
it increasingly
the
was
husavail-
years.
therapist
years.
from
in behavior
been
found
how strange
rather
her
later
her
later
usually
character
change
in the
these
defensive
her
alone
of missing the hundreds of daily physical touches from her mate, not the least of which was sleeping together. Not all of her changed roles were unpleasant, however. She realized, for example, that she no longer had to be one of the first to leave parties as her husband had always demanded. She could now make decisions with only one set of preferences to consider. Mrs. T. ‘s social network was extensive, and she was able to draw on it for considerable support. For example, she organized a slumber party with a cohort of grade school friends who
style
were
as “crabby,
but
in
her
soother
that
She described
things
termination.
would
because
clues
doing
portended
therapy
guilty
that
great”
a one-
anniversary.
Mrs. T. described marriage tolerating
of their
so
that
no
husband
angry.”
to do
for
month
known
exploration, her
husband’s cult
herself
acknowledged
not
further
her
the
she
her.
marriage
following
feeling
sick,
in-
members.
Experimentation.
during
her
precipitate
family
presented
later,
marked
for
died
She
months
have
Time
also
the forefront.
For example, now she had to park the car herself, initiate social contacts, and go alone to the country club socials they had attended so often together. She referred to a list she was keeping
success-
needs
in on other joining
Mrs.
and
dependency
at a level
to
progress,
worked
and Mrs. successfully Leick
PRACTICE
through
over
T. was able to make as well. and Davidsen-Nielsen2
AND RESEARCH
several this
sessions, transition emphasize
158
BEREAVEMENT
that
learning
ponent of Mrs.
new
skills
is a prominent
of grief work, as illustrated T. Talking about intense
also with
be a new skill, the experience
new
Using skill
the for
especially when of unburdening
social the
network bereaved.
can
Davidsen-Nielsen2 suggest ask your friend/confidant try
to
while
comfort you
your
you
talk
com-
in the emotion
also Leick
just
how
to
you
1.
with
you
Feeling
like
a “self”
decide
for
rather
than
2.
“half
required skill demonstrated she realized she could
herself
when
to leave
a
func-
experience, techniques
use
ISSUES
IPT
GRIEF
Focus
IN
of Depression,
Klerman et al.’7 suggest the following in the final three or four sessions to facilitate the termination process: 1) explicit discussion of the end of treatment; 2) acknowledgment of the end grieving;
of treatment and 3)
as a time movement
patient’s recognition of his dent competence. For patients who come help
with
spousal
loss,
the
of potential toward the
or
her to
1FF
indepen-
therapy
for
therapist
must
pay careful attention to the possibility that the patient will experience the termination of the psychotherapy as an additional loss. Much has been written about termination in shortterm therapies in longer term elapsed velop.
being easier to negotiate than therapy because less time has
during Furthermore,
terpretations to keep
of an educational on
(which
figures also
dependency can in 1FF, transference
serves
in
their
everyday
to discourage
on the therapist). Nevertheless, pists should anticipate greater termination pressed
for in the
patients
context
who of a loss
of a temnear is, make
approach
as
one.
exploring (such
alternative as specific
coping plans
dein-
4.
and possible subsequent Encourage
revision of those sessions. new relationships.
Except
patients
for
who
to com-
plans
remain
symptomatic, Klerman et telling patients who report discomfort with the prospect
in
severely
al.’7 recommend a high level of termination
of
that a minimum 4- to 8-week waiting period is required before beginning further treatment of a different type. This conveys a clear message that this therapy will be completed, that
the
ability
therapist
is confidant
to function
before
outside
further
tient
should
first
therapy by other
have been authors.3032
of the
patient’s
of therapy, is started
treatment
his or her own. Termination
are specifically avoided in order patients’ conflicts focused on
the
significant
which
16-20 weeks, with freof the approaching
bat loneliness). Begin well ahead of termination to allow some experimentation on the patient’s part, with review
WORK
Psychotherapy
Interpersonal
clearly state the length of ther-
as a therapeutic
strategies
TERMINATION
fol-
of termination.
well 3.
transition
we suggest the for termination:
the beginning, of the anticipated
full now
social
on role
Frankly discuss the possibility porary resurgence of symptoms the time of termination; that
tions.
In
From our specific
date
to tolerate
focus
LIFE
conflict.
apy, generally quent reminders
tears?”
dyad” is another by Mrs. T. when
a primary
From range
you to
not
be
feel,
lowing
be a and
“Can
with
or interpersonal
coupled relief.
asking, (network)
but
about
tients
case can
LATE
IN
and that the pa-
make
a reasonable
trial
issues
in short-term
psycho-
discussed
in further
on
detail
PRELIMINARY
lives
RESPONSE
DATA
dependence 1FF difficulty
therawith
became than
for
VOLUME
S
We
conducted
de-
efficacy reaved
pa-
and
NUMBER
#{149}
2
3 female
SPRING
#{149}
a preliminary
in the treatment spouses in late life.
1994
patients,
study of depressed In the study,
mean
age
68
of
1FF
be3 male (range
159
ETAL.
MIILER
64-73)
were
Research minor
Diagnostic depression.
ment
an
after
the
69.2
engaged
average loss
scores
spouses.
subjects
± 4.6;
ment Scale33 scores of 62.5 and Texas Revised Inventory ± 14.9
weekly 1FF sessions. These preliminary is an
effective
Interpersonal
data
age
been
married
was
and
Assess-
and have
± 4.3/78.3±9; of Grief scores a mean
of 17
with
suggest
that
1FF
bereavement-
in the elderly. the efficacy combination
We are curof IPT, therapy in
randomized conditions.
and and
6) achieving Behavioral brief been
depressed
deficits
may
reavement may patients degrees greater
also
require
setting.
become
and
foci
secondary
to
bers and comparisons
Surviving
for
inhibited
in the the
or prolonged
taught sionals workers, tical
in conjunction The principles
to a variety
be-
loss,
(psychiatrists, psychiatric treatment
for
pression. When comparing pies for bereavement,
health
psychologists, nurses), making bereavement-related
grief. it it be
professocial it a pracde-
1FF with other thera1FF does appear to
JOURNAL
that
out
personal ments
of the goal
are
are
nication
skills,
and
on goals
OF PSYCHOTHERAPY
relanumthe and
as well
model, focused
on
homework in 1FF,
encouraged
the
it is inter-
assignalthough
to improve
to consider
commu-
pursuit
of ef-
to discuss the at subsequent
sessions. al.
undertook and process
motivation
psychodyfrom this
in the context that even pa-
considered to be relatively for brief therapy because of or low developmental level engaged in treatment by an therapist. Patients with low
had
better
termination issues active therapists. patients
a detailed variables in
treated with A few points
study merit mention Horowitz et al. found
tients ordinarily poor candidates low motivation could still be active, supportive
vated
the
to effective psychoAlthough 1FF devel-
Specific employed
Horowitz et study of dispositional
complex of 1FF.
for the small
psychodynamic
themes. not
patients
of
showed cognitive
rates make Gallagher
a focus
oriented
52 bereaved patients namic psychotherapy.
and
with psychotropic of 1FF can
of mental
argue
dropout clear.
therapy
foci
1FF focuses on interpersonal themes, incorporates an educational approach, and can be used medication.
than
The
with interpersonal deficits (greater of character pathology) may be at risk
Results
groups than group, although
of
necessarily
and Thompson35 outcome for the
differential less
loss,
therapy,
(not
fective coping strategies, and implications of such changes
relationships by
for
persons
bereavement).
by Gallagher slightly better
and behavioral tional/insight
the
psychotherapy the treatment
of grief germane
interpersonal
attention
unbalanced
areas: conflict,
patient.
conflict
for
major
deficit. The are particularly
bereaved
specifically
interpersonal
interpersonal
ther-
4) explorsupport,
(recovery). cognitive
relational/insight compared in older
a
2) exploring
goals therapy,
depression
oped
was four
to all grief
lost relationship, issues, 5) providing
as skill training is essential therapies for depression.
psychotherapy on
transition,
interpersonal role transition
to the of
focusing
role
bereaved, the
Thompson
double-
0 N
I S C U S S I
psychotherapy
depression,
the
3) reviewing ing background
IndeHam-D
Global
for
as a short-term
grief,
common
ship
11-56)
Mean
strongly designed
elements
study
this population under blind placebo-controlled D
key
(range
after
treatment
related depression rently comparing nortriptyline, and
offer
apies. These are defined by Raphael in her excellent review as 1) establishing a relation-
(range 25-49). pre/post
± 2.3/7.2
± 9.6/39.2
meeting
for major or entered treat-
had
of 42 years raters obtained
of 18.5
of 49.3
after
of 26 weeks
of their
± 6.0 SD, and
an average pendent
in 1FF Criteria Subjects
outcomes
when matched Conversely,
had
better
regarding with highly
outcomes
highly motiwhen
their therapists took a less active stance in the termination phase. In general, however, Horowitz et al. found that more exploratory
PRACTICE
AND
RESEARCH
160
BEREAVEMENT
actions
by
the
therapist
highly motivated less well for less
patients. Supportive for the latter group. 1FF is consistent supportive commodate
to agree
of the
both
early
on.
is supportive,
active
capable exploration
transference
decreases
the
termination
studied
for
early a focus difference
intensity issues
effectively Group
of
of
and
1FF
group
or
the intervention tional deterioration control
an
group that
after
waned.
Even
though
caught months,
up to the intervention the intervention group
comparing
the
self-help
that improvement for simply by the of
these
group group was
group
participants
of widows, were truly could passage studies
VOLUME
more
rate
compared
in
with consen-
with
more
particularly or help-seeking with less severe severe
depres-
interpersonal
diffi-
depth among
and breadth of individwidows and widowers,
it is not surprising that a variety of approaches are potentially beneficial. 1FF is one proach that can provide a workable forum address systematically bereavement-related depression
and
of mental
health
that
thank
The authors
Simi-
can
be taught
apto
to a variety
practitioners.
Donna
M. Ulrich for her tech-
a
in a
NUMBER
#{149}
(NARSAD)
Young
InvestigatorAward
(M.D.M.). This
that and
by
Work wassupportedfryNationallnstiMeofMental Health Grants MH43832, MJ-100295, M1-13 7869 (C.FR Ill), MH30915 (Dr. D.j Kupfer), and a NationalAllianceforResearch on Schizophrenia and Depression
,
and
S
dropout
provide
more outgoing styles or those
Given the differences
ual
had
recruited
Al-
reduction and anxiety,
nical assistance.
not be accounted of time. Subjects were
late
or a reluctance to join a group may require a more tailored individual psychotherapeutic approach.4#{176}
at 12 clearly
concluded therapeutic
the
culties,
support
control
with
widowers,
Those
that
resocialization process. and Videka-Sherman
normative sample the interventions
both
postbereavement
and
complicated
resisted the emowas noted in the
group
in the Lieberman
found
widows
sion,
group
and
groups
depression.
to be used
intervention
program)
therapy
therapy. self-help
psysessions psycho-
mourning).
a larger
of group
1FF
authors.372Vachon et al.,37 assigned widows randomly to a
(widow-to-widow
dynamic
groups experienced of depression
1FF
by less experienced therapists. therapy for the bereaved has been
example,
brief
impede
those with interpersonal
by several
control
ahead larly,
many
life experion interperperhaps
this method subgroup. mutual self-
on conflicts
might
LIFE
sual validation, a forum to express difficult affects, peer support, and facilitation of problem solving. These groups are beneficial to
patient-therapist
allows
with
et al. found
individual Mutual
or
and
weekly individual psychodynamic
focused that
participants
of the
interpretations
extensive exploration ences while encouraging sonal themes. This
therapy
therapists, spouse
Marmar
it, less the
and
roots;
group
though both in symptoms
of or motivated are encour-
however,
historical
discourages
and
and
have
however,
chotherapy (12 with experienced
attitude
stance
solicitation,
have selected a help-seeking Marmar et al.4#{176} compared
help
to undertake patients with benefit from
still
can
The
supportive, educational, active 1FF therapist. Psychodynamic psychotherapy common
may
and can aclevels of pa-
educating,
the 1FF therapist in our experience, desire
mailed
organization. 1FF seeks working alliance quickly
active. Those patients for more in-depth aged by however, exploratory
for
indicated
approaches high and low
to a focus
therapist
were
with
therapist both
best
patients and less organized
actions
tient motivation and to establish a positive and
worked
or organized motivated or
IN LATE
paper
was presented
in part at the Confer
ence of the International Psychogeriatric Association, Berlin, Germany, September 1993, and at the NAPSAD Annual Symposium, New York City, October
2
1993.
SPRING
#{149}
1994
-
R
E
161
ETAL.
MILLER
F
E
R
1. Zisook
E
N
S (ed):
C
E
S
Biopsychosocial
Aspects
ment (Progress in Psychiatry ton, DC, American Psychiatric 2. Leick ment,
Series, Press,
N, Davidsen-Nielsen loss, and grief therapy.
Tavistock/Routledge, 3. Valanis
B,
M: Healing London
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