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Summer Study Guide Week 3

For everyone who wanted specific How-Tos, the Rando book is chock full! This week’s chapter
assignments, particularly, offer what to ask and how to ask it, and then based on the answer,
what to ask next. And your Traumatic Bereavement text is equally thorough in assessing the
client for appropriateness and readiness for their proposed intervention strategy. So, here we go:
Assessment, assessment, assessment.
Rando Chapter 6 Clinical Assessment of Grief and Mourning
Part I: Introduction (Why this is important and why it may be tricky):
Assessment Issues
 Three unique assessment issues are
o Importance of continual assessment
 P 244 “Without an appreciation of all the factors involved few judgements
can be made about the health or pathology of a response, and little
confidence can be placed in the efficacy of interventions.
 Grief and mourning do not necessarily decline in a linear fashion over
time. ..there are many twists and turns
 Assumptions based on initial assessment without continual monitoring can
be quite incorrect for the mourner down the line.

o Influence of the Mourners State of Mind on Assessment

 Conducting an assessment of a mourner can be different from evaluating
an individual under other circumstances. These are examples of reasons
why this is true:
 P 245”…the mourner experiences additional agony because she
has no choice regarding the death---it has already taken place
o This lack of choice regarding the death can make the
mourner feel hopeless as well as bitter and these emotions
can interfere with necessary data gathering.”
 Another important difference…is that the state of loss initiating or
perpetuating the difficulty is permanent. …(last sentence in this
par:)…there may be a strong “whats the use” attitude.
 The loss may so violate the mourners assumptive world that there
is little ongoing structure, order, stability, or meaning to sustain
her. This may cause the mourner to experience even more threat or
danger. P 245
 (bottom of p 245) The breadth and intensity of acute grief and the
long term impact of mourning under these circumstances may
deplete the mourner of the necessary energy and strength to cope,
as well as exacerbate stress, fear of loss of control, and anxiety
about the meanings and consequences of often unexpected
reactions. All of this can cause the mourner presenting for
treatment to be more distressed and less willing to cooperate than
the client presenting with a different problem.
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 Finally, the death of the loved one may resurrect unfinished

business and feelings about old losses. P 246

o Caregiver Orientation
 The caregiver must identify and understand all of the specific losses
associated with the death, each of which generates its own grief and
mourning processes.
 It is a mistake to assume that one has the luxury to discover information
about the mourner in the course of whatever treatment has been initiated.
 Rather, one must tailor the treatment based on what is revealed in the
assessment and, as noted earlier, carefully observe fluctuations and
changes over time.
 The caregiver also may think that when a mourner says that she wants to
eliminate pain she means it, not recognizing that she wants to maintain her
pain as a connection to the deceased and wants to eliminate only what she
perceives as the less functional parts. P 246
 Absent or incomplete assessment may actually hurt the mourner if the
wrong treatment is applied (bottom p 246 thru half of 27) Three examples
given:
 Parkes and Weiss (1983) note the most effective treatments for
conflicted mourning syndrome (see study guide for chapter 4)
involve:
o Promotion and facilitation of uncomplicated mourning
o Expression of feeling and review of memories are urged.
 By contrast, for Chronic mourning [syndrome]:
o Attempts to promote expression of feelings and memories
are counter indicated because they would only encourage
the mourner to remain mired in her grief
o Instead, insistence on forward movement and increased
increased autonomy as well as support for the mourners
taking a more active roles in developing goals and making
decisions is appropriate.
 In response to the Unanticipated mourning syndrome:
o The mourner requires repreated oppurtunities to _talk
through the implications of the loss and to react
emotionally in order to make sense out of the death, bring
order, and reduce feelings of being overwhelmed by stress
and insecurity.
 Therefore comprehensive assessment is necessary to assure that the
correct diagnosis has been made and that proper treatment can be initiated
Part II: Assessment Situations
Four assessment Situations [remember Assessment is Ongoing, you learned this in Practice I]
 Whatever the purpose of the assessment, once it has been determined that there is a need
to work on grief, there are a number of options for treatment
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o Pg 248First Mourning issues may be separated from other treatment issues and
addressed in isolation
o Second, Mourning issues may be integrated with other issues faced by the
mourner and addressed as appropriate within the context of ongoing treatment
o Third, issues may be merely taken into consideration in designing treatment for
the current loss
o Finally, Mourner may be referred elsewhere.

 Assessment during Crisis

o P 248 (2 par for section) Crisis aspects must be the first priority
o P 248 Very briefly appropriate steps must be taken to do what?
 Mourner’s safety and safety of others
 Considering the potential for suicide, homicide, unintentional or
sub intentioned life-endangering acts or omissions
 Meet immediate needs for medical evaluation and treatment
 Providing medication, physical examination, medical testing and
consultation, hospitalization
o P 249By definition, crisis prohibits the comfortable, leisurely, and orderly
collection of information
o Additionally, caregiver (social worker) must obtain the following information
 The nature of the loss and the circumstances around it.
 Whether the loss was expected or unexpected and the degree of its
suddenness
 The meaning of the loss and the degree to which it will influence the
mourner’s life
 The mourners prior losses and how the mourner has coped with them
 The mourner’s current life circumstance and what resources and forms of
support are available.
o Key issue for the caregiver (social worker) will be how to sensitively balance the
need for assessment with the mourner’s obvious needs
o P 249 Key issues may be:
 Asking direct questions that do not seem relevant to the immediate distress
(previous losses, personality traits)
 Mourner may not have the control to put aside immediate upset in
order to provide seemingly irrelevant background
 Rather than ask questions in an interview style, worker must frame
questions within a response to the mourner and gather information in bits
and pieces throughout the interview P 149
 For example, instead of asking: What is the nature and extent of
your support system?” choose different wording: Clearly, this is an
overwhelming experience to deal with. Is anyone helping you cope
with all of this?’
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 This indirect approach serves to: collect the desired information at

the same time it validates the mourner and sends the message that
the mounrer has been heard
 Another example: When the mandatory questions of suicidal or
homicidal ideation might not fit within the context of the
conversation, they can be brought up directly with and associative
link: You obviously are in a great deal of pain right now. Has that
pain raised any thoughts about harming yourself or others?”
 Assessment at the Beginning of Treatment
o This may be easiest because: it occurs simultaneously with the general assessment
process that usually commences treatment
o P 251 Yet clients coming to treatment for issues other than those relating to loss
often wonder about the relevance of assessment topics unrelated to their perceived
focus of treatment:
 “I came here to talk about my anxiety about speaking in public. Why are
you asking me about my relationship with my parents?” [For those of you
who had me for SOWK 620, (Group and Family therapy) remember the
Monica McGoldrick DVD, where the father wanted the worker to focus on
the teenager’s truancy, not issues about the mother’s death? And it turned
out it was ALL related to the unresolved and complicated grief?]
 “I am coming here for assistance in coping with my sister’s murder. Why
do you expect me to discuss my father’s death 10 years ago?”
 With this rationale in mind (what rationale?) the caregiver must point out
that the assessment will seek to clarify the influence of the past on the
present and the interrelationships among all aspects of the persons life,
both of which need to be understood to provide the best possible treatment
 Assessment during Ongoing Treatment.
o P 251 “Ideally, a full loss history should be taken during all comprehensive intake
evaluations and prior to the commencement of all types of intervnetions
o Shifting roles to gather more information can be a bit awkward. Can explicitly
make the shift: “I need to go back and ask you some specific questions about the
losses
 Assessment for specific purposes
o Determining treatment disposition
o Obtaining psychiatric diagnosis
o Supporting legal action
o Determining treatment disposition
o Ascertaining the mourning status of caregivers who wish to work with the
bereaved
o Etc.
Part III: Areas of Assessment
Specific Areas of Assessment: Using the Grief and Mourning Status Interview and Inventory
 The GAMSII is a tool, not a measurement.
 Organized into three parts.
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 Allows evaluation with regard to the 6 “R” processes and within the context of the factors
circumscribing the particular loss and mourner.
 Part 1 Demographics
 Part 2 Comprehensive evaluation of history, mental status, and selected premorbid
personality characteristics.
o Caution: if assessment is restricted to loss-related areas, it will be impossible to
determine how much of what is presented stems from a grief or mourning reaction
and how much represents the individual’s premorbid personality and functioning.
Without the baseline data necessary to differentiate, to a reasonable level of
certainty, grief and mourning from premorbid character, the caregiver’s
conclusions will be questionable. P 253
o Psycho-social/medical history
 Presenting problem
 History of Presenting problem
 Past personal and current psychological functioning
 Family history and current status
 Concurrent stresses or crises
o Mental status exam
 Appearance
 Behavior and psychomotor activity
 Speech and language
 Mood and affect
 Thought process and content
 Perceptual disturbances
 Sensorium functions
 Insight and judgement
 Symptoms of depression
 Symptoms of anxiety and PTSD
 Suicide and homicide risk
o Selected premorbid personality characteristics
 Ego functioning and strength
 Coping and defense mechanisms, styles, and abilities
 Frustration tolerance
 Personality dynamics and conflicts
 Characterological scripts
 Sense of self, self-concept, and self-esteem
 Internal versus external locus of control and processing
 Cognitive style and biases
 Problem-solving skills
 Maturity
 Assumptive world components
 Sense of personal meaning and fulfillment in life
 Philosophy of life and values
 Spirituality
 Communication style
 Relationships patters
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 Characteristic wats of managing psychosocial transitions

 Specific strengths, skills, and assets
 Specific vulnerabilities and liabilities
 Part 3 Structured Interview Schedule
o Answers here help worker to locate progress in 6 “R”s
Part IV: Topic Areas and Example Questions
o Topic area A Circumstances of the death, events that led up to and followed it
 Example questions: “Tell me about the death and what led up to it”;
“What happened immediately after the death and in the few days
thereafter?”
 Other areas to explore (11):
 Death surround and specific effects on the mourner: location of
death, type of death, circumstances, reason for the death, mourners
degree of preparation for the death, mourners presence or absence
at the death, mourners degree of involvement at or participation in
the death and/or responsibility for it, immediate effect of the death
on the mourner
 Mourners specific reactions to the death surround and its effects
 Circumstances prior to the death and/or context within which it
occurred
 Mourners perception of the death as anticipated or unexpected, as
well as the degree of suddenness
 Mourners perception of the preventability of the death
 Mourners perception of the timeliness of the death
 Manner and impact of death notification
 Degree of confirmation of the death
 Mourners opportunity to see the body, spend time with it, and say
goodbye
 Extent of the mourners comfort with and participation in postdeath
rituals; initial impact and subsequent effects of and reactions to
them
 Mourners degree of acceptance of the reality of the death and
commencement of grief and mourning during postdeath activities
and rituals
o Topic area B: Nature and meaning of what has been lost:
 Example questions: “What kind of relationship did the two of you have?”;
“you’ve told me a great deal about what was positive in the realtisonhip,
could you tell me a little about the aspects that were not so positive?
 Other areas to explore (12)
o Topic area C: Mourner’s reactions to the death and coping attempts
 Example questions: “Tell me what have you done to cope with __ death”
 Other areas to explore (5)
 Degree to which the mourner has completed the R process of
mourning
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 Defenses against experiencing and expressing recognition of the

implications of the death, paint affect, or negative emotions
 Coping strategies and techniques
 Ways of discriminating an undifferentiated mass of painful stimuli
into specific components with different causes and demands
 Specific response known to have profound consequences in
bereavement

o Topic Area D: Reactions of others in the mourner’s world and perceived degree
of support
 Example questions: “how have others reacted to ___ death?”; have your
relationships with others changed since __ death?”
 Other areas to explore (5)
 The acceptance and assistance of the mourners support system
 Disenfranchised grief and mourning
 The bereaved individuals ability to ask for what he needs from
others
 Dynamics of the family as a system and as a constellation of
individual mourners
 Number, type, and quality of secondary losses related to social
support
o Topic Area E: Changes in the mourner and the mourner’s life since the death
 Example questions: “please describe what has happened to you in the time
since ___ died”
 Other areas to explore (8)
 Type and extent of grief and mourning reactions
 Degree to which the mourner has relinquished the old attachments
to the deceased and the old assumptive world
 Degree to which the mourner has readjusted to move adaptively
into the new world without forgetting the old
 Changes occasioned by the death
 Number, type, quality, and effect of secondary losses experienced
 Search for meaning
 Degree to which the mourner has reinvested since the loss
 Positive outcomes or gains from the bereavement
o Topic Area F: Mourner’s relationship to the deceased
 Example questions: “how would you describe __ role in your life at this
time?”
 Other areas to explore (11, including linking objects (see Volkan) and
STUG)
 Degree to which the mourner has relinquished old attachments to
the deceased
 Degree to which the mourner has developed a new relationship
with the deceased
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 Degree to which the mourner has met the two criteria for a healthy
new relationship with the deceased
 Degree and appropriateness of the mourner’s reinvestment since
the loss
 use of personal bereavement rituals
 identification with the deceased
 health ways of keeping the deceased alive
 content of memories
 linking objects
 STUG reactions
 Intrusive repetitions of thought
o Topic Area G: History, status, and influence of prior loss experiences, including
the mourner’s methods of coping
 Example questions: “What other difficult physical or psychosocial losses
have you experienced in your life?”
 Other areas to explore (4)
 The mourners general coping behaviors, personality, and mental
health
 Unfinished business
 Past experiences with loss and death, the mourners success in
coping, and the information and expectations derived from these
experiences
 Resurrection of past losses by the current loss

o Topic Area H: Mourner’s self-assessment of healthy accommodation of the loss

now and in the future
 Example questions: “how do you think you are coping/have coped with
this specific loss?”
 Other areas to explore (3)
 Degree to which the mourner has readjusted to move adaptively
into the new life without forgetting the old
 Degree to which the mourner has reinvested since the loss
 Criteria for successful accommodation of the loss

o Topic Area I: Mourner’s degree of realistic comprehension of and expectations

for grief and mourning
 Example questions: “In your estimation, what is normal to experience
after this kind of death?”
 Other areas to explore (5)
 Degree to which the mourner has readjusted to move adaptively
into the new life without forgetting the old
 Criteria for successful accommodation of the loss
 The harmful nature of myths and stereotypes about grief and
mourning
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 The mourners past experiences with loss and death and the
information and expectations derived from them

o Topic Area J: Open topic

 Example questions: “are there any topics we have discussed that you feel
we should consider further?”
Okay, I told you this was a thorough presentation of what to ask, and how, and where to go from
there. Now on to the next portion of our discussion on assessment, where there will be other
examples of questions and how to best proceed and why.
Part V: Client Assessment
Traumatic Bereavement Text:
Please identify several of the reasons presented by this author for conducting a thorough,
comprehensive assessment of the client who may be experiencing traumatic bereavement (p
133): the more care that goes into the assessment and planning phase, the more the client will
feel hopeful, safe, and understood, and the greater likelihood of a successful treatment will be
WARNING: P 134 “ Without adequate information about who this client is, how he manages
memories and feelings and what resources he possesses for dealing with distress, there is a
genuine risk of endangering the client. Without such a foundation, treatment may retraumatize
the client, solidfy the client’s avoidance, shame or humiliate him, use his valuable therapy time,
money, and motivation to no avail.
Appropriateness of this treatment approach for a particular client
 This approach (the one offered by these authors) is for clients who have experienced the
sudden, traumatic death of a loved one.
o Occurred suddenly
o Characterized by risk factors such as untimely, or viewed as preventable
o The death must overwhelm the persons capacity to manage their thoughts,
feelings, and behavioral responses to the death and related losses
o This approach can help clients who have one or more of the following:
 Needs to process both trauma and grief
 Trauma as evidenced by: symptoms of PTSD or other trauma
responses
 Grief as evidenced by: symptoms such as shock, sadness, yearning
for the deceased, difficulty accepting the loss, avoidance of
reminders of the loss, anger, feeling. Number, suicidal thoughts
 Person feels stuck or is having difficulty fulfilling role obligations or
moving forward
 Person is experiencing relentless, debilitating automatic thoughts or
disrupted cognitive schemas
 Readiness for this treatment approach
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o This treatment requires clients to

 Participate actively in the process of mourning
 To engage with trauma material
 Identify and challenge problematic cognitions that interfere with mourning
 Connect with internal experiences that can include a host of very
challenging feelings
o Decisions regarding appropriateness are both clinical and ethical in nature.
o Keep in mind severity of the symptoms and available resources, as well as client’s
ability to tolerate exposure work
 P 137 Clients who currently live in a dangerous situation need to work on
these concerns BEFORE pursuing exposure activities.
 P 137Clients who are mildly dissociative or emotionally numb may
benefit from a stronger emphasis on the strategies for coping with emotion
and other resource building strategies
o How might the client’s current circumstances seem to be in conflict with the
treatment? (P 137) overusing alcohol, work related crisos

 Pg. 140 Table 8.2 Considerations for deciding whether to use this treatment approach
with a particular client.
Progression through the 6 “R” processes
[see p 137. And I quote, “Because the treatment will foster movement through Rando’s (1993)
six “R” processes, you will also need to understand where each client is in that journey at the
outset of treatment. …here it comes: We refer you to Rando’s (1993) volume Treatment of
Complicated Mourning—particularly the appendix containing the GAMSII and Chapter 6 of
that book…” Well, how about that? Kismet! Synchronicity!! So please for this segment, review
the blue part above!
Resources
 Both traumatic bereavement and this treatment approach (particularly the exposure
component) are likely to elicit strong affect
o For this reason the following supportive resources constitute the foundation for
this treatment:
 Self-capacities or feeling skills
 Social support
 Coping skills
 The ability to manage bereavement specific issues
 Values and goals
 Meaning and spirituality
o Certain coping strategies may be problematic for anyone examples are:
 Immersion in potentially addictive behaviors – drinking, shopping,
gambling
 Destructive activities – aggression against onself or others
o Other activities may not be destructive but may still avoid feelings these include:
work or exercise to distract themselves
 Table 8.1 Guide to Assessing a Client’s Resources
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o Self-Capacities
 Signs of difficulties sin self capacities
 Depression anxiety etc.
 Questions to explore
 How does the client respond to his own strong affect etc.
 The inner experience questionnaire and the inventory of altered self
capacities
o Social Support
 Signs of social support difficulties
 discomfort in the presence of others etc.
 questions to explore
 What type of support does the client need? Etc
o Coping Skills
 signs of coping difficulties
 use of destructive coping strategies etc.
 Questions to explore
 what questions is the client currently using? Etc
o Bereavement specific…
 which bereavement specific issues does the client identify as problematic
 how has the client managed these issues to date
o Meaning and Spirituality
 is the client struggling to make sense of or find meaning in what happened
 does the client feel that life has no meaning without the deceased
o Values and goals
 if you ask the client what matters most to him at this point is he able to
articulate any values that guide her behavior
 if you ask the client whether he has any goals at the present time is he able
to articulate future goals
Trauma and loss history and processing
 Why is it important to assess a client’s entire trauma history? P 139
o Processing one loss may trigger thoughts and emotions related to another
 It is important to determine whether any traumatic event from the past stands out as more
problematic now than the sudden death. Why is this important? P 139
o If another loss is more significant than the target loss, the client will have
difficulty focusing and working effectively on the target loss
 The follow up question, “what helped you cope at that time” can be helpful and
informative in your assessment of clients who have experienced prior traumatic events.
What 4 questions might be asked at the bottom of page 139?
o Are there any other experiences the client would like to let you know about?
o What has been going on in the clients life since the death?
o Does some other traumatic event stand out as more powerful than the current
death?
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o Has she received treatment related to these experiences? Has she told anyone
about the violence, victimization, abuse, or traumatic loss or had the opportunity
to think, write, or express or process feelings about it?
First, please note that this week’s readings contain an important section on the
use of Ritual. See your Rando text, pp 331-331. This may be useful for your term
paper. Also, see your Traumatic Bereavement text for a look at the importance
of meaning (see index).
Okay, we are focusing on the necessity of comprehensive assessments, with detailed examples of
what to ask, what those answers tell us, and what to ask next. We are ready for the next topic
this week: Interventions. For this topic of study, the color coding of readings will be particularly
helpful. As you will see, I have combined the readings, to thicken the engagement with the
material. Recently, there is a commercial about a client in a dental office. The professional
identifies the problem to the client, and then starts to leave the office. The client protests. The
professional responds, “Oh, I am just the dental MONITOR. I just identify where the dental
problem is, I don’t do anything about it.” Our education equips us to precisely assess where
there are problems in the clients’ lives. But we sometimes feel ill-equipped to intervene with the
same level of precision. Our interventions can become “general” or we expect clients to
essentially do their own work. That may sound great on the surface, but crisis theory reminds us
that clients in crisis are unable to do this on their own: their resources are drained and they
require a more directive stance from their social worker. Therefore, in this unit of study, we will
review treatment research as well as the historical development of various intervention
strategies. This will help us not only know what to do, but why we are doing it. So, let’s dig in.
Part VI: Treatment for Grief and Mourning
Classic Grief Theories: Overview and Description
 Freud’s Grief Work Perspective
o “The primary task of mourning is the gradual surrender of ones psychological
attachment to the deceased. Freud believed the relinquishing [decathexis] of a
loved object involves a painful internal struggle. P 108)
o P 108-109) “For years it was common for therapists to: organize their entire
treatment approach around the notion of loosening or breaking down bonds
between the mourner and the deceased
o Have studies found support for this? See p 109 top: No
o Role of Negative Emotions
o “With notable exceptions, theories focusing on the grieving process have
failed to consider the role that positive emotions may play. P 109
o Volkan’s Re-Grief therapy p 270
o Why is this one of the best-known treatments for complicated mourning?
Many caregivers are familiar with his concept of the linking object
o What is a linking object? An object the mourner invents with the magical
power to maintain an external relationship with the deceased
o What is the re-grief treatment process?
 Patient selection
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 Demarcation
 Review
 Clarification of ambivalence
 Abreaction: Beginning to re-grieve
 Revisiting and revising
 Working with the linking object
o Issues related to re-grief?
 P 275 Volkan also notes that, despite the use of the special device of
the linking object, the transference relationship is still the vehicle
whereby insight into ambivalence and the conflict between longing
and dread may be gained and resolution accomplished.
o Stage Models of Grief
 Bowlby (and Parkes)
o People form affectional bonds, called attachments
o Bowlby suggests that there is a relationship between: a personas attachment
history and how he will react ot the loss of a loved onep 109
o How is Bowlby unlike Freud? Bowlby believe that the biological function of
these behaviors is not withdrawal from the loved one but rather reunion
o However, in the case of a permanent loss, the biological function of: ensuring
proximity with attachment figures becomes dysfunctional
o What are the 4 stages Bowlby offers:
 1 initial numbness, disbelief or shock
 2 yearning or searching for the deceased, accompanied by anger and
protest
 3 despair and disorganization as the bereaved gives up the search,
accompanied by feelings of depression and hopelessness
 4 reorganization or recovery as he accepts the loss, with a gradual
return to former interest

 Kubler-Ross
o “This model was designed to explain how dying persons react to their own
impending deaths.
o P 111, middle page, “Shortly before her death in 2004, she (Kubler-Ross)
stated that despite her best intentions, the stages she proposed have
contributed to misunderstandings about the mourning process.”
 Behavioral, Cognitive and Social Approaches P 276
o Learning Theory
 Early exposure to loss appears to have the effect of sensitization. (So
early grief -> more intense grief responses in subsequent
deaths...again, the importance of a thorough grief history.
o The Behavioral Approach
 Application
 “In the treatment of pathological grief reactions (complicated
mourning) the application of a behavioral model yields 3 essential
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parts: thorough assessment the establishment of goals for therapeutic

operations and the selection of effective treatment procedures” p 277
 Treatment Goals
 May be focused on 5 areas: list:
 Physiological complaints
 Subjective (private) events
 Overt behavior
 Interpersonal relationships
 Environment support
 Treatment Procedures
 Systematic desensitization, covert conditioning, cognitive rehearsal,
thought stopping, role-playing, contingency contracting and skills
training.
 Pure Behavioral Therapy (Ramsay)
o Ramsay summarizes the mourner’s situation: ( p280)
o Grief as phobia
 P 280 “How is grief similar to phobia? In both, there is a need to
extinguish emotional reactions
 How are they different?
 How are treatments different? Treatment of phobias can be
accomplished gently – there does not appear to be a gentle
manner of treatment for unresolved grief
o Goals (p 282 “ The goal of all this is to evoke avoided emotions by means of
appropriate stimuli and then allow time for these feelings to extinguish
subsequent to the mourners choice of expressing them
 Cognitive-Behavioral Therapy (Gauthier and Marshall)
o Pathological (complicated) grief is influenced by two factors: describe both: p
283 1. Family and friends wither fail to withdraw attention for grieving or do
not provide consistent encouragement – 2. Family and friends or the mourner
themselves may decide to avoid the grief reaction completely
o Grieving behavior can be avoided; grieving thoughts are not so easily stopped.
Discuss P 283
o This approach offers the theoretical grounding for EMDR, which is brief, and
offers no secondary traumatization. It also requires certification but recent
research indicates it is as effective as CBT. And the authors of your Trauma
Readings suggest it as an alternative to their own model.
o Guided mourning (Mawson, Marks, Ramm and Stern)
 “Unresolved grief is likened to phobic avoidance and treated by
exposure to the avoided situation” p 286
 Bottom page 286-287: Two implications may be drawn:
 First: mood disturbance and avoidance of bereavement are less
related than commonly thought
 And, second,: treatment effective for some forms of
pathological grief is not necessarily effective for others
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 Guided mourning appears most helpful in: instances where

mourning has been avoided, repressed, or delayed

o Grief-Resolution Therapy: Reliving, Revising, and Revisiting (Melges and

DeMaso)
 In general Grief-resolution therapy involves using: guided imagery in
order to remove obstacles and binds that previously inhibited grieving
at the time of loss
 It is designed for whom? Individuals with unresolved grief
 Individuals who suffer from the wish to redo and reunite with the past
 Cognitive (re)structuring
 The mourner is directed to discuss: (p 290) positive exchanges
that occurred with the deceased shortly before the death and
then asked to close eyes and attempt to reexperience the feeling
stimulated by the exchanges
 Guided Imagery
 Three steps compose the guided imagery part:
 Reliving: mourners closing eyes and viewing sequences fo the
loss in her minds eye as if the scene were happening now
 Revising: asking the mourner to remove barriers or binds that
formerly inhibited full grieving
 Revisiting: revised scene taking place in the present tense as if
it was happening now
 Social Systems Approach (Goalder) p 294
o Complimentary to which approach? Psychodynamic
o Goalder discusses 3 types of relationship subsystems (see Minuchin)
 Mourner/spouse: inability to perform the necessary life roles
previously assued by the spouse
 Person/relationship
 Relationship/relationship
 Existential Theory: Gestalt p 298
o There is much more that the “empty chair”
o Gestalt theory considers grief as one of the four primary emotions
o Loss and grief are: P 298 viewed as inherent process of life
o Avoiding grief is considered: contributing to an abortion of the normal cycle
o The role of grief and mourning as essential elements of life can be described
as: P 298
o E. Smith specifically addresses complicated mourning and its treatment
specifically.
 2 types of situations:
 There is loss but griever unable to mourn ( absent, delayed,
inhibited)
o Describe fully
o Absent, delayed, inhibited mourning
 Those who grieve, but it is for too long (chronic)
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o Describe fully
o Chronic mourning
The Mourning Process: More Recent Theoretical Developments:
 “Both Worden and Rando have rejected the idea that grief should be regarded as a fixed
series of stages_.” P 112
 Moving beyond stages: Worden’s Tasks and Rando’s “Rs”

o Worden
 The idea of “tasks” the client has something to do, is empowering to
clients. Discuss: task approach is flexible because tasks can be done in
different orders depending on needs
 Grief therapy (not grief counseling)p 310
 Grief counselling does what? Also pg 117 in Trauma Readings
 counseling intended to facilitate the normal process of mourning
 Grief therapy does what? Also pg 117 in Trauma Readings
 Therapy is to resolve conflicts of separation and assist mourning in
completing tasks
 Time limited contract of how many visit? 8-10
 There are 4 tasks of mourning
 Task 1: focus on reality of death
 Task 2 stresses that it is safe to experience both positive and
negative feelings for deceased
 Task 3 problem solving
 Task 4 become emancipated from crippling attachment to then
form new relationships
o NOTE: After receiving many cards and letters, Bill Worden
rephrased this fourth task. The new wording is: “To
relocate the deceased emotionally, and to reinvest in life
and living.” People felt badly about the “withdrawing” as
a task, so he reworded it.
 Discuss how each task can get complicated and interventions to
help client move through these tasks. (Bottom pg 311-313.
This is of significant importance so learn these tasks
and how to work with them)
o Rando
 Prefers to focus on the Processes, rather than the tasks. Discuss this view:
keeping the focus on processes rather than tasks helps a therapist to focus
on what a mourner is doing at present thus providing immediate feedback
where the mourner is in the process and how to intervene
 Beverly Raphael’s Focal Psychotherapy p 267
o This involves: an assessment of the specific syndrome of complicated mourning
with specific treatment being dictated by the syndrome
o The goal of therapy is: convert syndrome into a more normal pattern
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o Strategies may be implemented when:

 In the crisis when: inherent lowered defensiveness permites more rapid
working through after pathological patterns have solidified
 Later in treatment when:
o Strategies for Absent, Delayed, or Inhibited Grief:
 Worker conveys certain recognized facts. How are these conveyed?
 1. Mourners inner pain is difficult to bear and express
 2. Inner pain and fears are common among mourners and the
caregiver understand this
 3. Mourners defenses serve a psychological purpose and will not
be torn down harshly without consideration of function
 4. Mourner is resultant to relinquish deceased – explore reasonings
for reluctance
 5. Mourner dreads and wishes to avoid the pain of the loss and
other intense emotions that naturally occur at this time

o Strategies for Distorted grief:

 What is the dynamic in Extreme anger helping mourner work through the
anger
 What is the dynamic in extreme guilt denied ambivalence and guilt
o Strategies for Chronic Grief
 When is Chronic grief diagnosed? When acute responses fail to subside
 What are secondary gains? Controlling and punishing others and eliciting
care
 What does the worker need to focus on? The lost relationship with the
deceased, nature of death, perception of social support
 What is the place of behavioral strategies in this diagnosis? Setting a series
of concrete tasks
 Stress and Coping Approach
o Addresses why some people show intense and prolonged distress following the
death of a loved one while others do not. P 112
o Clarifies how risk factors can help account for the variability in individual
responses (p 112)
 Breaking down attachments (maybe they do not need to be severed p 112 )
o P 114”An increasing number of researchers and practitioners now believe: that it
is normal to maintain a continuing connection to the deceased
o And that such connection may actually: promote good adjustment following the
loss
o However such bonds may not always be helpful to the client: p 114 bottom-115
 Role of positive emotions Dual-process model
o Loss oriented responses – such as experiencing intrusive images of the loved ones
death
o Restorative activities p 112, - such as engaging in new pursuits or meeting new
people
 Importance of meaning
18

o Process of mourning is often a search for meaning. P 112 helps therapists engage
with clients who ways of finding meaning in life have been disrupted, destroyed
by the loves on death and tis related losses
o Rando’s 313 Schema for Creating therapeutic Rituals (You have a term
paper on use of rituals with a particular group…just saying.)
 Rituals are used universally.
 Rituals are defined as: (bottom pg 313-314) a specific behavior or activity
which gives symbolic expression to certain feelings nad thoughts of the
actors individually or as a group
 For The individual mourner, rituals provide: a structured way to affirm the
death, recall the loved one, or clarigy, express, integrate, and make
statements about the mourners feelings and thoughts
 For the social group, therapeutic bereavement rituals can: solidify family
relationships and assist the realignment of the family roles and the healthy
promotion of mourning
 Rituals involve specific healing properties that are beneficial in promoting
healthy mourning.
 Derivation of benefits form acting out: enabling the individual to
do something besides fall victim to the emptiness and
powerlessness
 Legitimizations of emotional and phsyical ventilation: validates the
mourners expression of feeling
 Provision of symbols and outlets to focus thoughts, feelings and
behaviors:
 Rendering of control : militate against the feeling of hopelessness
 Delimitation of grief: help channel feelings of mourning into
behavior having a distinct beginning and end and helping the
individual experience mourning in a less global manner
 Enhancing appropriate connection to the deceased: interacting with
memory of deceased
 Enablement of the 6 “R” process (no surprise here!) confronting
and working through mourning
 Enhancement of learning gained thru experience: helps mourner
learn that the deceased is truly gone, validates loss, helps prepare
for and readjust to environment
 Provision of structure, form and containment for ambivalent,
nebulous, and poorly defined affect and cognition confronting
confusing disorganization and loss of control
 Prescription of actions for dealing with emotional or social chaos
reduce stress overload, conserve energy, provide structure and
meaning
 Provision of experience that allow the participation of other group
memners and affirm kinship and social solidarity:
 Structuring celebrations, anniversaries, and holidays
 Steps in Creating Therapeutic Bereavement Rituals:
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 1. assess
 2. Determine the focus and purpose with regard to mourning
 3. Specify what message is to be conveyed
 4.Choose type of Ritual
o Rituals of transition
o Rituals of continuity
 5. Choose the elements of the ritual
o Who is involved
o Symbols used
o Symbolic acts undertaken
o Characteristics employed
 6. Create the context
 7. Prepare the mourner for the ritual
 8. Implement the ritual
 9. Process the ritual experience
 10. Reevaluate and redecide
Part 7: Grief Treatment Effects
 There is considerable variation in the impact of different treatments. What contributes to
this and what do we know about these variations P 118: respondents’ levels of distress
strongly influence the benefits derived from the treatment
o Not too soon….not too late
Complicated Grief
 What have been the AKA terms for complicated mourning: bottom p 118 atypical,
neurotic, pathological, unresolved, chronic, and prolonged grief
 There is increasing interest in creating a classification for complicated grief for the DSM.
Please discuss the issue fully: there has been no standard guidelines to determine how
therapists or diagnose and treat complications following bereavement
 P 119, toward the bottom: “Virtually all of the empirical work on complicated grief has
focused on these two sets of criteria. However it must be noted that there are other ways
of conceptualizing complicated grief. For instance, Complicated grief can be manifested
o in a variety of symptoms or syndromes
o Diagnosable mental or physical disorder (PTSD)
o Recently, a panel of experts identified several types of grief-related syndromes
that, in their judgement, reflect complicated grief and warrant further research and
consideration. These include (but are not limited to):
 delayed grief, inhibited grief, and other forms of chronic grief
Treatment for PTSD includes the following:
 Time-Limited Dynamic Psychotherapy for Phase-Oriented treatment of the stress
response syndrome (Mardi Horowitz) p 301
20

o P 302 “Very briefly, Horowitz asserts that following any stressful life event,
certain processes must occur in order for assimilation, accommodation, and
healthy resumption of living to occur.
o Five responses can be predicted:
 1 outcry
 2 denial and numbing
 3 intrusion
 4 working through
 5 completion
o In undergoing these responses, the individual must work through the meanings of
the stressful event, as well as its implications for relationships, self image, and
behavior
o This process entails reappraisal of…(one’s assumptive world).
o Overview of Treatment Procedures
 Treatment of stress response syndrome consists of 12 session, once a week
time limited dynamic psychotherapy
 Time-limited dynamic psychotherapy.
 Main goal of intervention is to :
o Reduce the indiviudals need for controls tht ward off stress
related ideas and the intolerable emotional states
threatening to emerge if these ideas aren’t kept in check
 Put simply, this is accomplished by: helping the mourner complete
the cycle of ideation and emotional repsonses to the stressful event
 Completion demands: the integration of the events meaning and
the development of appropriate adaptational responses
 Interventions are dictated by the demands of the specific phase of the
stress response. (outcry, denial and numbing, intrusion, working through,
completion)
 Phase of denial and numbing, what is done? Abreactive-cathartic
methods to reduce control
 Phase of intrusion, what is done? Goal is to supplent relatively
weak controls
 What is the purpose of the therapeutic alliance in this approach (last par pg
303) altering the statis of the controls the inidivual uses to interrupt
processing of the stress response
o Individual factors in treatment
 Who can develop a stress response? P 309 any person to extreme stress
 Pre-existing characteristics include:
 1 belief in magical causation, leading to the view that past bad
thoughts brough present harm
 2 active conflict with a theme similar to meanings contained in the
traumatic event
 3 habitual tendency to use pathological defense mechanisms in
order to externalize personal emotional propensities, leading to
memory distortions about the traumatic event
21

 4 using fantasy based reparation of injuries and loss, hinders

realistic appraisal of the personal implication of the traumatic
event
 5 latent self-concepts of incompetency or relationships conflicts
that are readily activated as a consequence fo the traumatic event
 6 fatigue of biological substrates from acute and chronic stress,
leading to a repetition of depressions
 7 activation of emergency response system, exacerbating previous
somatic reactions and thus hindering psychological adaptation and
providing additional stress
PTSD Treatment Effects
 Most include some type of CBT:
o Prolonged exposure: imaginal exposure to the traumatic memory and behavior
exposure to reminders of the traumatic event
o Cognitive processing therapy: involves challenging distorted beliefs and includes
a form of PE
o EMDR (see footnote pg 122): eye movement desensitization and reprocessing
o These are not just for survivors of traumatic death
 Further comments on PE and CPT
 Strengthening Self Capacities (first developed for treating survivors of childhood sexual
abuse)
We are exploring therapeutic approaches from an historical perspective, how intervention
strategies have developed over time with research offering evidence of effectiveness. We are
continuing in that vein but narrowing our focus. Your Rando text began with a review of the
research literature and this was updated in your Traumatic Bereavement text. Moreover, in this
section, Rando addresses the evidence on certain interventions (Horowitz’s Time-limited
Dynamic Psychotherapy, and Cognitive Behavioral approaches). So mark down here how these
approaches rated, and other evidence identifying the populations best suited for these
approaches. Finally, in our last segment of this week, we will camp out firmly on general issues
of “how” to intervene. These ideas are echoed in your Traumatic Bereavement text for this week
as well. There are lots of examples of what to say to clients, how to phrase things. While many of
you have years of experience, (and I am tip-toeing here) none of you have any experience as an
MSW or as an LCSW (YET). So please try not to bristle, and please also try to be open to these
suggestions. I believe you will find this segment particularly helpful as you begin your own
practice (when you get that LCSW [start nodding your heads]). It will be equally helpful when
you are called upon to begin or develop/implement a new outreach or new program. So, grab
that cup of coffee/tea/hot chocolate/whatever and let’s dig in.
Part VIII: Generic Issues in the Treatment of Complicated Mourning
Relevance
 Primary Prevention
o refers to: efforts to reduce or eradicate the incidence of a disorder, ultimately
prevening its occurrence
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o Relates to grief how? Practice by those who facilitate the anticipatory grief
experience for families of the terminally ill
 Secondary Prevention
o refers to: attempts to identify and treat a disorder as early as possible in order to
reduce its length and severity
Relates to grief how? Provided by those who practice crisis intervention with
populations at high risk
 Tertiary Prevention refers to:
o Refers to: deals with disorder that already has occurred and attempts to minimize
long-term impairment
 By the time mourning has become complicated, mere grief “facilitation” is insufficient.
Please discuss: the individual requires much more
 Intervention in complicated mourning requires knowledge of:
o A) what is necessary to convert complicated to uncomplicated mourning
o B) ways to facilitate uncomplicated grief an mourning in order to promote healthy
accommodation of loss, appropriate readjustment, meaningful investment
General Psychotherapy Issues
 Therapeutic Relationship
o P 146 “Pearlman and Saakvitne (1995) have described the ideal therapeutic
relationship with a trauma survivor client as one in which you as the therapist:
 Provide information about the common effects of traumatic events, help
the client develop self capacities are genuine and present emotionally,
focus on development of the therapeutic relationship, and openly invite the
client to process transference
o These principles apply equally to the relationship with the traumatically bereaved
client since: such clients constitute A subset of the trauma survivor population
o A collaborative relationship empowers the client to do 2 things:
 empowers the client to face his fears
 and do the difficult work of processing the loss
o Such a relationship is based on respect information connection and hope
 Provide respect by: acknowledging the clients experience as valid
attending closely to his needs and concerns about both the content in
process of the treatment, offering a collaborative approach, participating in
the treatment with honesty and integrity, and maintaining the treatment
frame
 Provide information about sudden, traumatic death and traumatic
bereavement, as well as about paths to adaptation to the new reality
 Connection: the sense of partnership between you and the client and the
connection that client will make with his own feelings, his past
relationships with the disease, and his future without her and the
connection with the supportive community
 Hope: encouraging the client to fully engage in the treatment process by
giving feedback on progress and successes and guiding the client to create
23

a meaningful future and maintaining your own belief that the client can
continue to move forward through the morning process
 Therapy Frame
o Sudden traumatic death creates chaos; often people feel disoriented and lost
o Creating the frame of therapy and Boundaries helps by: create the sense of safety
and support necessary for clients to engage in this treatment
 Therapy frame is established how? by discussing the nature of goals and
process of therapy
 Boundaries in this situation includes:
 Clients need to understand that they will not overwhelm you with
their stories or their distress. (p 147
 The struggle with counter-transference
 Your struggle to make up for the loss or overprotect the client
 Documentation and Informed Consent
o P. 148 Documentation is a legal requirement and often traumatically bereaved
clients have legal involvements, worker’s notes may be required in legal
proceedings.
 What should you keep in mind in terms of your documentation?
 P 148 “It is important to note in the client’s records that self-blaming
thoughts are distorted thoughts” Why is this important: poorly worded or
misrepresented descriptions of a client self playing could be used against
her in a court case
 Why is verbatim note-taking beneficial in these early stages? we'll make it
possible to go back to at a later point in therapy
 What do you discuss with clients about your note-taking: P 148 explain to
the client how you take notes and to show the client the former format you
use so that they do not worry about you right what you are writing about
them or feel intimidated
 Independent Activities (AKA homework)
o What are the and when are they to be done? designed to be completed between
sessions giving the opportunity for the clients to practice the desired behaviors on
a regular basis
o Identify some of the numerous benefits to using independent activities:
 First: provides the client with additional opportunities to practice specific
skills
 Second: provide an opportunity for clients to test the validity of their
underlying assumptions and beliefs
 Third: enable clients to collect information regarding their thoughts moods
and behaviors in different situations
 Fourth help clients generalize what they have learned
 Fifth help clients gain confidence in their ability to deal with their
problems without the assistance of a therapist
 Sixth: permanent record of the issues that have been addressed and can be
utilized as a resources as needed
 Seventh: opportunity for clients to work on issues that cannot be addressed
fully in sessions
24

 Eighth: allow clients to take responsibility for their treatment gains

o How are independent activities crucial as an aspect of treatment? P 150 end of
section provide a structure and rhythm across sessions that are beneficial to many
clients
 Termination
o Why might traumatically bereaved clients terminate prematurely? in order to feel
a sense of control over endings or may avoid intimate connections in order to
protect themselves from the pains of endings
o Why is it helpful for the worker to address termination issues early on and to
revisit them frequently? provides an opportunity for the client to acclimate to the
fact that this treatment will end
o The ending of treatment may signal to the client the ending of the internalized
relationship with the deceased loved one. Why is this not the case and how can
you assist the client with this?
o What is a premature termination as defined by this reading? P 151 if the client
leaves the treatment without starting or resuming movement along the six R
processes of mourning
Part IX: Efficacy of Intervention in Mourning
 A perspective on Intervention studies
o For what population is the support of family and friends, possibly augmented by
the support of a self-help group, generally sufficient? Most individuals who
experience uncomplicated mourning and are not at a particularly high risk for
adverse consequences of bereavement
 Early Intervention Studies
o Crisis intervention provided to families within hours following a sudden,
unexpected death resulted in: the treatment groups utilizing less denial in dealing
with their feelings
o Studies indicate that sudden death is a major life crisis, that has a major impact on
surviving family members, which is influenced by knowledge of certain facts and
circumstances at the time of death.
o Further studies indicate that crisis intervention strategies are not effective….what
issues are raised by these studies? The issue of timing of intervention p 337
 Interventions with High Risk Mourners
o Raphael’s studies receive acclaim as the most: well-controlled and
methodologically sound investigations of bereavement intervention
o These were the first to demonstrate the importance of: identifying high-risk
mourners and to illustrate the efficacy of treatment when offered to this select
population
o Raphael found that perceived supportiveness of the social network is a key
predictor of a successful outcome.
 Time-Limited Dynamic Psychotherapy (Mardi Horowitz)
o Horowitz’ work consistently demonstrates the efficacy of time-limited dynamic
psychotherapy.
25

o Horowitz, Weiss et. al. (1984) p 338 found what: a relationship between
psychotherapeutic outcome and dispositional and process variables
 Cognitive-Behavioral and Behavioral Interventions (what worked, what did not)
o S. Lieberman: treatment resulted in major relief of referral symptoms in most
patients
o Williams and Polak:
o Mawson et al. : most of the treatment was evident on measures of approach to
bereavement cues and less so on mood disturbance
o Hodgkinson: cathartic approach to therapy – most highly improved
o Ramsay: behavioral approach on emotional flooding an prolonged exposure -
most highly improved
 Bereavement Support
o Bereavement support is associated with: decreased distress and symptomatology
 Hypnotherapy, Trauma Desensitization, And Psychodynamic Therapy
o All of the treatment groups evidenced more improvement than did the control
group. P 340
 Confiding (in others) and Confronting (a traumatic event)
o Confiding in others does what? Play a central role in the coping and health
process
o Not confiding is associated with what: increased physiological activity and
rumination
o P 341 A subsequent…found that confronting and disclosing…was associated with
what: improved measures of cellular immune system function and physical health
o Confronting trauma is beneficial form 2 perspectives
 It reduces: the necessity for inhibition
 It permits: assimilation, reframing, or finding meaning in the event
 Self-Help and Other Groups
o Some evidence suggests what: intervention not only reduced risk but accelerated
recovery
 Treatment for Bereaved Parents (This is sobering)
o … p 343the absence of demonstrable effect in mental health or social functioning
for breaved parents stems from the limits of any intervention to alter the
devastating sequelae of losing a child…this will be covered further in chapter 13.
 Conclusions
o Well-controlled studies have demonstrated that intervention is most successful
when: it is directed toward bereaved individuals who have been identified as
being high risk either because of current high distress or as having high potential
for distress due to specific risk factors
o Some research suggests that (p 343) timing of the intervention is crucial
 Intervention provided too soon: may have no positive effect or even delay
or interfere with uncomplicated bereavement
 Optimal time for prevention intervention for those identified as being at
high risk appears to be: the first 2 to 8 weeks up until 3 months postdeath
[The Worker’s Own] Philosophical Perspectives on Treatment
26

 One’s philosophical perspective shapes and guides one’s actiona

 To facilitate UNCOMPLICATED Mourning (table 8.1 p 346)
o Remember that you cannot take away the pain from the bereaved
o Do not let your own sense of hopelessness retrain you from reaching out to the
bereaved
o Expect to have to tolerate volatile reactions from the bereaved
o Recognize the critical therapeutic value of your presence
o Make sure to view the loss from the bereaveds unique perspective
o Let genuine concern and caring show
o Do not let personal needs determin the experience for the breaved
o Do not attempt to explain the loss in religious or philosophical terms too early
o Do not suggest tha thte bereaved feel better because there are other loved ones
still alive
o Do not attempt to minimize the situation
o Do not forget to plant the seeds of hope
o Do not encourage actiosn or responses antithetical to health mourning
o Maintain an appropriate therapeautic distance from the bereaved
o Do not fail to hold out the expectation that the breaved ultimately will
successfully accommodate the loss and that the pain will subside at some point
 To facilitate COMPLICATED Mourning: (p 347- on) list or identify how to intervene in
the following situations:

o The mourner who is experiencing complications is actually only attempting to

mitigate the loss of the loved one. Deny, repress, avoid aspects of the loss, its
pain, and the full realization of its implication and to hold on to and avoide
relinquishing the loss loved one
o If mourning has become complicated, it can become uncomplicated. Working
through resistances, defences, or blocks
o The processes of mourning build upon themselves, and insufficient working
through of earlier processes complicates subsequent ones.
o Mourning involves cognitive processes to a much greater extent than generally
acknowledged.
 One set of cognitive processes is: associate more with acute grief than
with mourning
 A second set of cognitive processes is associated more with: mourning
than with acute grief
o Treatment always must seek to address the underlying 2 attempts of complicated
mourning Handouts in red book website helpful.
o Each mourner is unique and brings idiosyncrasies to the perception of and
response to the loss, as well as an individual ability to contend with treatment.
Mourners experience is an individual one
o Male and female responses to loss are different and should be respected
o Crying is not necessarily equivalent to mourning
27

o Often, even when external appearances are to the contrary, the mourner has not
accepted the reality of the loved one’s death (Worden’s task 1) may be harboring
a feeling that it can be reversed
o Unlike most other therapeutic situations, the person coming for treatment may not
want the treatment to work. Does not want to lose connection with the deceased
o Pain is a multidimensional concept when it comes to the treatment of complicated
mourning can be interpreted as a link to the loved one
o Complete treatment of complicated mourning typically takes time.
o The worker should be flexible in style and technique
o Understanding timing can make or break treatment involves issues of readiness,
appropriateness, dense and coping, ability, resources, perception, judgement, and
fit
o The establishment of specific treatment goals is critical keep the caregiver
focused and provide criteria for change
o Physical release is a legitimate goal of intervention
o The worker’s criteria for success must be both specific and general
o Transference and termination are critical issues in the treatment of complicated
mourning. Important opportunities to understand the loss and help them work
through and adjust appropriately
 Generic guidelines for treatment (there are 21, start p 365), table 8.2 lists, they are then
described in more detail.) Please identify or list how to intervene in these situations.
[How to do it] Designing the treatment plan [NOTE: This book has an extensive set of
appendices with handouts. These handouts are referenced throughout this chapter. The
introduction of the book gives permission for the worker who purchases the book to use
the handouts, freely, with their clients. So this is a required text that keeps on giving!

 Orient the mourner to treatment

o How? Provide overall perspective with information on what to expect and what
the rules are and how the process tends to go
 Plan is jointly created by worker and client (p 152)
o Based on:
 Clients unique manifestation of traumatic bereavement
 His resources
 And your clinical knowledge and judgement
o Together, you will develop the content of specific sessions
 Examples: a client with history of self-injurious behaviors may need more
session devoted to: building seld capacities and coping reosurces in the
beginning of therapy
 Example a client with little social support may need a greater emphasis on:
building and accessing a social network
 This preparation is time-consuming at first but lessens as you get used to
it. Appropriate planning facilitates: smooth development of indiivudal
sessions and the whole treamtent
28

 This approach is highly structured (25 sessions, at 45 min. each) what are
the benefits of this structured approach: provide a level of confidence for
both of you p 153)
o How can you help clients to think creatively about financing therapy? (bottom of
page 153) offering solutions such as 9-12 weekly sessions followed by bimonthly
sessions
o P 155 “If client can only (afford to) attend a small number of sessions and
chooses to schedule individual sessions at 2-3-week intervals, it may be feasible
to: assign more independent activites
 However, this less frequent session scheduling is not recommended if
client’s symptoms are acute or if you are doing exposure work. Another
option would be: to meet for a block of sessions (5 or 10) and take a break
for an interval and then meet for another block of sessions” p 155
PLEASE AVAIL YOURSELVES OF THE BOOK’S WEBSITE SUPPLEMENT FOR YOUR
FUTURE PRACTICE. Framework for a 25 session sample treatment plan…I think this is very
helpful for figuring out the nuts and bolts of this stuff.
 Structured session format (typical session format)
o Introduction
 Session frame
 Occurs at the beginning of each session
 P 157 give an example of how you would begin the session with
the client, what would you say? “Today we will focus on how
traumatic bereavement has two components: trauma and loss. This
may give you a way of understand your experience that will help.”
 Treatment frame issues
 Most salient when? Outset and ending of treatment p 157
 When doing exposure work: how often might you meet with the
client? Twice a week
 What time frame should you have when doing in-session exposure
work? (p 158, top) and plan for longer session when in-session
exposure work is scheduled
 Independent activities
 How do you respond when the client has not completed the
independent activities? (p 158 middle) learn why and then address
relevant issues
 How to intervene when client is avoiding the independent activities
look together at the cleints schedule and decide when and how the
acitivty can be done
 Psychoeducation:
o Using handouts in appendix and also on the book website
are important. Discuss why? P 159 top) addressing the days
topic and core components and create opportunities to
client to ask questions and clarify
o Core treatment Components
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 Building resources
 Processing the traumatic death
 What work is done here? Exposure work and related emotional
and cognitive processing
 Why might workers and clients want to avoid this essential piece
of the work? Because of the feelings it raises
 Mourning
 (Although the how-tos are covered more in chapter 12), what is
done in the “mourning” section of each session? Address the R
process; Independent activities
o Wrap-up
 Integration
 What topics are integrated? Worldview, assumptive world, values,
broad beliefs
 Independent activities
 Introduce independent activities to be done for the next session.
 These include:
o Resource building activities such as: building and using
social support, coping skills, and self care
o Trauma-processing activities such as: cognitive
restructuring, exposure, writing assignments
o Mourning related activities, such as: recollected the
deceased or reflecting upon positive and negative qualities
o Other general activities such as: reading info handouts
about sudden traumatic death
 Again, why are these independent activities essential to the success
of the treatment? P 160 allow the work to further and balance
support and challenge
 How does the worker determine which activities to use? P 160
consider the time and effort involved
 Identify ways the literature suggests for increasing the likelihood
that the client will complete the activities:
o Emphasizing that these activities are important and are
integral for success
o Tompkins (2004) suggests: introducing a particular
independent activity should clarify the relevance of the
activity to what a client has worked on in that session and
the clients goals
o Najavits (2005) recommends: creating a higher meaning for
the activities
 Activities must be appropriate for the client’s sociocultural
context. Give example provided by Tompkins (2004) unemployed,
single mother of four, suffering from depression, who was
assigned the task of going to a movie with a friend
 Provide the mourner with explicit permission—indeed a prescription—to mourn (p 374)
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 Support the mourner in coping with the mourning processes providing information and
support and is critically important in a number of ways
 Promote social support of the mourner
 Maintain a family systems perspective in dealing with the mourner family will influence
the mourner and vice versa
 Ensure that the mourner has appropriate medical evaluation, medication, and treatment
when symptoms warrant.
 Do not necessarily accept what is on the surface; probe for underlying issues and
impaired “R” processes. Look for hidden issues, laten needs, obscured reactions, and
underlying dynamics
 Work with the mourner to recognize, actualize, and accept the reality of the death. Come
to grips with reality
 Normalize and legitimize appropriate affects, cognitions, wishes, fears, behaviors,
experiences, and symptoms. Offers the mourner support, reassurance, and control
 Assis the mourner in identifying, labeling, differentiating, and tracing affective
experiences and their component parts. Doing so allows the mourner better able to cope
and experience sense of control
 Appreciate and enable the working through process.
 Acknowledge that repetition is an inherent part of treatment, but ensure that repetition
takes place within the service of working through repetition in order to master the loss –
comprehend it, new perspectives, closure, work it through, identity and express feelings
and thoughts
 Once affective experiences are identified, labeled, differentiated, and traced, enable the
mourner to feel, accept, examine, give some form of expression to, and work through all
of the feelings aroused by the loss. Feel, accept, examine, and give some form of
expression to and work through the feelings – processing emotions
 Design and tailor treatment to address general and specific issues identified for the
individual mourner.
 Determine the symbolic meanings of persons, objects, experiences, and events to the
mourner. Individual journey – what is required in one mourners treatment may not be for
another
 Identify, interpret, explore, and work through resistances to the mourning process.
 Identify any unfinished business with the deceased and discover or create appropriate
ways to facilitate closure. Unfinished business cause anxiety and getting closure allows
for fewer complications
 Help the mourner identify, label, differentiate, actualize, mourn, and accommodate
secondary losses resulting from the death. They tend to fail to be legitimized even though
they are significant
 Recognize and respond to the importance of security afforded by the caregiver’s
availability to the mourner. Attempts ot be as supportive as possible and recognize the
treatment as stressful
 Recognize the dynamics of complicated mourning and adhere to the five “Ps” in work
with the mourner
o Mourners experiencing difficulties are typically insecure, anxious, and phobic
about acknowledging the loss, its implications and or the painful affects it brings.
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o Workers (caregivers) must ensure that interventions are characterized by five

“Ps”:
 Presence (won’t be frightened away as others may have been
 Permission
 Patience
 Predictability
 Perserverance
 When a normal, expectable emotion is absent, determine why and address the omission.
o What danger exists here? That the caregiver will insist upon the mourners
unconsciously having had emotions he never did have
o How can the worker assist the mourner to own affect? (last par p 391) presenting
the same situation as if it had happened to someone else and inquiring about the
mourners reactions to it
Integrating this approach into an ongoing treatment
 When a loss occurs while you are treating a client for another issue, how might you
integrate grief-focused therapeutic work with the client? P 162 conduct as assessment and
determine what the client needs at this time