Complicated Grief Treatment: Instruction Manual [1 ed.]

Citation preview

Complicated Grief Treatment Instruction Manual Used in NIMH Grants1,2

M. Katherine Shear, M.D. Copyright ©2015, Columbia Center for Complicated Grief, The Trustees of Columbia University in the City of New York. All rights reserved. 1

This manual was used in the following NIMH-funded R01 studies: MH60783,

MH70741, MH085297, MH085308 and MH085288 2

This version is lightly edited for use by practicing clinicians. The editing

includes a preface with useful information for users.

Not to be cited or used without the written permission of the authors

“By following the instructions in this manual and using other training supports as needed, you can learn to administer a simple, highly effective treatment that can change the lives of people caught in a seemingly endless cycle of grief.” - M. Katherine Shear, M.D.

CONNECT WITH US: http://complicatedgrief.columbia.edu @CompGrief

DISCLAIMER The information provided in this Manual is for educational and informational purposes only. The Manual is intended for use by experienced mental health professionals, and in conjunction with training and supervision by experts. Columbia University and the Columbia University School of Social Work make no warranties, express or implied, as to the value, usefulness or completeness of any information that is made available in this Manual.

CONNECT WITH US: http://complicatedgrief.columbia.edu @CompGrief

Table of Contents Preface

Session Instructions

•

Using this Manual

•

Session 4: First Imaginal Revisiting

•

Summary of Efficacy Study Results

•

Session 5: Adding Situational Revisiting

•

Identifying People With CG

•

Session 6: Adding Memories Forms

•

Co-Occurring Conditions and

•

Session 7: Full core revisiting (1)

Suicidality

•

Session 8: Full core revisiting (2)

•

Measurement-Based Care

•

Session 9: Full core revisiting (3)

•

Common Challenges in Learning

•

•

CGT

Phase III Midcourse Review

Overview of the Thinking Behind the

(Sessions 10)

Treatment

•

Topics for Consideration during midcourse review

Some selected references •

Session 10 instructions

Phase I: Getting Started (Sessions 1-3)

Phase IV Closing Sequence

Overview, Phase I Tools and Their Use,

(Sessions 11-16)

Session Instructions

Overview, Session Instructions

•

Session 1: History Taking

•

Session 2: Information about CG

•

•

Sessions 11 – 15: Closing Sequence Personalized Sessions

and CGT

•

Session 16: Ending CGT

Session 3: Including a Close Friend

•

References

or Family Member

•

Appendix

Phase II: Core Revisiting Sequence (Sessions 4-9) Overview, Phase II Tools and Their Use,

Preface Pages 5-15

Preface Using this Manual This manual provides instructions for a 16-session intervention for complicated grief (CG). CG is a painful and impairing condition that affects tens of millions of people worldwide. People with CG have lost someone close and are caught up in relentless pain that dominates their lives and holds hostage their future. Complicated Grief Treatment (CGT) is a well-specified evidencebased approach that can help these people. This treatment has been evaluated in 3 separate clinical trials with a total of 641 participants. These studies, funded by the National Institute of Mental Health, were uniformly positive with an average response rate of 70%. CGT is the best documented treatment for CG in the world. By following the instructions in this manual and using other training supports as needed, you can learn to administer a simple, highly effective treatment that can change the lives of people caught in a seemingly endless cycle of grief. Working with bereaved people can seem sad and hopeless so clinicians sometimes shy away from it and fear burnout. It may seem paradoxical, but therapists have often told us that learning CGT has been the most rewarding experience of their career. Knowing how to administer a short-term treatment that has a 70% response rate is very gratifying and a powerful antidote to burnout. A component of learning CGT entails being mindful of your own reactions to death and loss and developing ways to use your responses most effectively. Most therapists find this one of the rewarding aspects of working with bereaved people. People sometimes imagine bereavement as the beginning of a journey but grief is not a voyage from which people return. We do not experience a period of grief, come back, and return to life as usual. Instead, grief is a new homeland. It is a permanent place in which bereaved people must reside and redefine their lives. Life is permanently changed by an important loss. Still, it is possible to restore the sense that life can be rich and satisfying even though grief is not over. To restore enthusiasm for life is a natural goal of bereaved people. Yet the ways we transform our lives after death of a loved one are as individual and personal as the love that was lost. Bereaved

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Preface people differ in the kinds of problems they face, and in the adjustments they must make after a loss. People also differ in the availability of supportive companionship and the effectiveness of personal coping mechanisms. People with CG have usually exhausted their supply of both and feel they have nowhere to turn. As a result their grief does not mature and it remains intense and disruptive. Grief complications prevent people with CG from finding a place of integration where loss and renewal coexist. A CGT therapist can help. This treatment guides people through a process by which they can restore their capacity for joy and satisfaction in life while accepting the finality and consequences of their loss and maintaining a sense of connection to the person who died.

Summary of Efficacy Study Results CGT has been tested in three NIMH-funded randomized controlled trials entailing six separate grants. The first was a randomized controlled trial conducted at the University of Pittsburgh comparing CGT to interpersonal psychotherapy (IPT), a well-tested and very effective treatment for depression. Results published in 2005 showed CGT was significantly better at alleviating CG symptoms and reducing their impact. The second study also compared CGT to IPT, this time in older adults. This study was conducted at Columbia University in New York City. Results published in 2014 mirrored those in our 2005 study with a lower drop out rate and a higher response rate to CGT but not IPT. The third study was a four-site trial conducted in Boston, New York, Pittsburgh, and San Diego. We compared antidepressant medication to a pill placebo. All patients received either citalopram or placebo. Half of the participants were also randomly assigned to receive CGT. Results again strongly supported the efficacy of CGT. The paper reporting these results has been submitted for publication. Study therapists were experienced mental health clinicians, including psychiatrists, psychologists, social workers, marriage and family counselors or grief counselors. They were trained to deliver CGT using the instructions provided in this manual along with ongoing supervision. Therapists

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Preface attended a didactic workshop and then treated at least two training cases. Often a third case was required to reach competence. Each session was audiotaped reviewed separately by the therapist and supervisor and then discussed. Weekly group supervision meetings were held to review cases throughout the study and treatment sessions were audiotaped for adherence assessments. CGT is not difficult to learn. The treatment is simple and well-specified. However, many therapists have questions when they are learning a new approach and it is often useful to have an opportunity to discuss difficult cases. We offer a range of different ways to supplement the information in this manual. If you want consultation or supervision or if you have any questions you can contact us at the Center for Complicated Grief www.complicatedgrief.columbia.edu.

Identifying People With CG Identification of CG is not difficult or complicated. However, the lack of official consensus criteria can be confusing. We provide a simple way to screen and diagnose CG that is very similar to the one we used in our treatment studies. You can also contact the staff at the Center for Complicated Grief if you have questions about assessment of CG. The way we identified people with Complicated Grief in our studies was as follows: 1. A score of 30 or greater on the 19-item Inventory of Complicated Grief (ICG Prigerson et al 1995) 2. A clinical interview in which there was evidence for: a) Clinically significant symptoms of prolonged acute grief and impairment in daily functioning. Typical symptoms include frequent yearning, longing and sorrow, frequent insistent preoccupying thoughts of the deceased, difficulty acknowledging the painful reality of the loss such as a sense of disbelief, difficulty accepting the loss, persistent intense emotional or physiological activation when confronted with reminders of the loss.

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Preface b) Grief complications e.g. maladaptive rumination about troubling aspects of the circumstances or consequences of the death—frequently counterfactual in nature — excessive avoidance of reminders of the loss, inability to regulate emotions or severe social or environmental problems. c) A determination that grief was the person’s most important problem.

1) Screening for the possibility of CG The first step in screening is to determine that a person has lost someone close. Then you should evaluate grief symptoms, including the frequency and intensity of yearning, sorrow, preoccupying thoughts of the person who died, feelings of estrangement from other people and from activities that are usually meaningful, and frequency of behaviors that foster escape from the painful reality or avoidance of reminders of the loss. You can use the Brief Grief Questionnaire, available through the Center for Complicated Grief as a screening tool if you wish. You also want to consider the time since the loss. There is as yet no set time after which grief is considered complicated. We know that normative time to restore a sense of vitality varies depending upon the circumstances of the loss. For example, normative time to regain a footing in life is generally longer after loss of a child or young adult or when a death occurs violently, by suicide, homicide or accident. At present the question of time rests on clinical judgment that is based upon the severity of current symptoms and impairment, the trajectory of adaptation to the loss, and by the attitude of the bereaved person as well as their friends and family. As a rule of thumb, we do CGT only after at least six months have passed since the death. We also consider whether the bereaved person seems to be on a course that is progressing or not. Sometimes people are confused by the intensity and duration of their grief and when they are reminded that suffering after

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Preface an important loss is universal and permanent, they stop questioning themselves and no further treatment is needed. More commonly, a person who is still grieving intensely after many months or even years have passed has gotten caught up in grief complications and needs some help to move forward. 2) Using a structured clinical interview to identify people with CG We developed a structured clinical interview for CG that can also be used as a self-report questionnaire. The interview consists of 12 questions and takes about 10 minutes to administer. You can obtain this instrument from the Center for Complicated Grief at www.complicatedgrief.columbia.edu.

Co-Occurring Conditions and Suicidality Patients suffering from CG often have co-occurring mental and physical disorders. As always, it is important to complete a full assessment of anyone you are planning to treat. You should be aware of the likelihood of suicidal thinking and behavior associated with CG and you should monitor suicidal thinking throughout the treatment. As with anyone, any suicidality is of concern and active plans or actions require intervention. When CG occurs in a setting of long-standing problems or comorbid chronic disorders, you need to decide what to address first. Rather than interweaving CGT into treatment for depression, anxiety or other disorders, it is generally better to focus on one at a time. If you decide that another problem is more pressing, treat that problem first. If a new problem emerges during the treatment, stop doing CGT while you deal with that problem. For people with multiple problems, CGT is intended to be one component of a sequenced model whereby at the end of the sixteen-session model you re-evaluate the patient to decide if you need to address a different problem. Of course a life crisis or emergency psychiatric problem must be addressed immediately. Sometimes such events can be managed in a short period of time and you can return to the work with CG. Sometimes you need to shift to work on the new problem and postpone further work with CGT.

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Preface Measurement-Based Care “Measurement-based care” is a term coined by depression researchers (Trevedi et al 2006) to describe an intervention approach that includes regular structured assessment with simple validated instruments. Using this approach for bereaved people enables you to systematize the selection of individuals, who are similar to those who participated in the research studies that validated the treatment. Validated questionnaires can help benchmark your progress with a patient, com- pare this progress to others you work with and to patients treated by others who use the same scales. Questionnaires provide a common language you can use to describe symptoms. The questionnaires we developed are available from the Center for Complicated Grief. This manual includes information about how we used this approach in our research studies.

Common Challenges in Learning CGT Our experience in training hundreds of people in this model is that once you master it, the approach is simple and one of the more effective brief therapies available for mental health problems. We alert you to four common issues that may arise as you are learning the treatment: 1. Activation of personal feelings about loss and/or death; 2. Unfamiliarity with using principles and procedures from positive psychology; 3. Discomfort with the structure of the treatment, or 4. Discomfort with one or more of the core procedures. If you find yourself confronting one or more of these issues, it can be helpful to know that this is common and that these issues can be resolved and should not stand in your way. 3) Activation of personal feelings about loss and/or death Almost everyone reacts emotionally to thoughts of loss and death. We know that death is inevitable and unknowable and it is natural to feel anxiety when contemplating our own death or that of people we love. Most therapists I have worked with have been surprised and somewhat unsettled by their reactions to hearing the stories of people with CG. Not infrequently, new CGT therapists find themselves wanting to tell their loved ones how

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Preface much they care about them. When learning CGT you may have intrusive thoughts or dreams about death, dying, or loss. If you have experienced a difficult loss yourself, you may find your thoughts and feelings about that loss are activated. This kind of response to thoughts of death or loss and it is natural and not a problem for the therapy unless you are uncomfortable. Most CGT therapists find it is important to think through their own feelings about losing a loved one and about dying themselves. You can do this in a variety of ways such as turning to your own religion, journaling, meditating, talking with a close friend or a therapist, reading stories or philosophical texts, using artistic expression, etc. However you chose to do it, the important thing is to focus on self-awareness, monitor your own thoughts and feelings and find ways to manage your reaction so that it can be useful in the treatment. 4) Unfamiliarity with principles and procedures from positive psychology Most mental health professionals are taught to diagnose and treat psychological problems. Most consider it their mandate to understand and treat underlying vulnerabilities, correct maladaptive thinking and behavior and to relieve current emotional distress. They may not be in the habit of thinking of suffering as a common human experience. Additionally, when things are going well in a patient’s life, many therapists are pleased but generally do not consider optimizing the positives to be as important to their work as minimizing the negatives. By contrast, positive psychology concerns itself with personal and community strengths that support the ability to thrive. The foundation for this approach is the idea that people are naturally oriented toward meaningful and fulfilling lives, that humans have a basic need to express themselves and to experience love, satisfying work, and enjoyable play. A corollary is that suffering also has its place in our lives. CGT makes these assumptions. The overarching model follows positive psychological thinking in that there is an assumption that suffering and adaptation to suffering is a natural experience and people will adapt to the most painful loss unless there is something blocking adaptation. CGT seeks to help people flourish and one of the core procedures is to facilitate CGT Manual 2015

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Preface aspirational goals work. However, many therapists find it awkward or uncomfortable to focus on positive elements of a patient’s life. To be effective, a CGT therapist needs to spend time helping patients capitalize on positives and conveying acceptance and comfort in confronting the painful reality. We do not seek to resolve grief or end the pain of loss but rather to ensure that people have the support and tools to find a pathway to restoration. If you are not in the habit of working in this way, you need to pay close attention to learning the aspirational goals component of the treatment and to checking your tendency to come up with solutions to pain. 5) Discomfort with the structure CGT uses a structured approach to conceptualizing CG, assessing symptoms, and planning and implementing treatment. This does not mean that the treatment is implemented robotically. As always in psychotherapy, it is important to listen closely and tailor your work to each patient. To both implement structure and personalize the treatment may be difficult if you are not used to a structured treatment. It can feel uncomfortable to stop a patient and redirect them, especially if they are talking about emotionally meaningful material. CGT uses motivational interviewing skills that convey empathy and respect as well as guidance in redirecting the conversation. If you don’t know motivational interviewing, there are many opportunities to learn this very useful and interesting approach. 6) Discomfort with one or more core procedure(s) CGT includes 7 core procedures: 1. Psychoeducation about CG and CGT; 2. Self-assessment and self-regulation; 3. Aspirational goals work; 4. Rebuilding connections; 5. Revisiting the story of the death; 6. Revisiting the world changed by the loss; and 7. Memories and continuing bonds. Very often one or more of these procedures is difficult for the bereaved person. Sometimes therapists are uncomfortable encouraging someone to try

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Preface something difficult. It is important to remember that the choice is always the patient’s but at the same time you need to feel comfortable and confident in recommending that she or he engage in the recommended activities. You need to convey a sense of safety in your presence and confidence in your skills so that your patient will feel comfortable taking some risks. The imaginal revisiting exercise is usually the most difficult for both patients and therapists because it can be intensely emotionally activating. Getting comfortable doing this procedure can take some time. You may want to seek consultation if you are uncertain about the wisdom of this component of the treatment. You need to be clear about how and why it is done. Although we have not specifically identified the mechanism of action of CGT, there are theoretical reasons why this is an especially important part of the treatment, and patients often tell us that it was doing this painful exercise that seems to have made the most difference for them.

Overview of the Thinking Behind the Treatment This manual does not describe how CGT was developed and you do not need that information in order to do this treatment. However, you may be interested to know something about the logic and the empirical science behind the treatment. When asked to help identify an effective way to help people struggling with intense and persistent grief symptoms our team realized that in order to understand the experience of losing a loved one, we would need to understand what was lost. This led to an in-depth reading of theory and research related to close relationships. There is an extensive body of knowledge pertaining to relationship science which we are not going to review here. However, it became increasingly clear that people we love become part of our lives in a myriad of ways, many of which you could list if you tried. In fact, our loved ones also impact our lives in many ways that are out of awareness. Knowing how pervasively they influence us helps explain why acute grief is such a surprisingly intense and lasting experience. But grief is not one thing. It’s a small word for a big, complex, time-varying experience. Grief is usually transformed from an acute dominant and disruptive form to a more subdued form

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Preface that provides the background for a “new normal” life moving forward. The transformation of grief occurs as we adapt to the large changes (both internal and external) that occur as a consequence of the loss, reconfigure our relationship to the deceased person, and redefine our own life goals and plans. Complicated Grief is the syndrome of persistent intense acute grief that occurs when adaptation is interrupted or stalled. The goals of CGT are to resolve complications and facilitate the natural adaptive process. To do so we draw upon self-compassion and self-determination theory as well as the science of learning and emotion regulation. You can learn more about the underpinnings of CGT by contacting the Center for Complicated Grief or visiting our website http://complicatedgrief.columbia.edu

Some selected references Learning and using CGT is an ongoing process. You may want to do some reading to support this learning experience. You can find on our website a list of papers from our group and others that you might find helpful. Opportunities for learning collaboratives focused on studying the science of grief are available through the Center for Complicated Grief.

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Phase I: Getting Started (Sessions 1-3) Pages 16-25

Sessions 1-3 Getting Started

Introductory Phase Overview: Getting Started Martha sat in the waiting room filling out forms. Tears slid silently down her face. When she entered the therapist’s office, the therapist welcomed her and Martha remained silent. She finally said she was sorry to be so emotional. This was not at all like her. A hint of resentment in her voice, she told the therapist she was a mess since her beloved husband Paul died 5 years ago and, no offense intended, she didn’t really see how anyone could help. The therapist told her that it was understandable that she was very emotional, adding that this is a natural reaction to losing someone very close. A person who is generally able to manage strong emotions and even prides herself on her ability to do so, can feel disconcerted by the intensity and uncontrollability of this very natural acute grief reaction. The therapist said, “These feelings are part and parcel of your deep love for Paul. Please know that I don’t see this as something you need to apologize for. “Martha seemed to relax a little and said “Thank you for saying that. Everyone else in my life seems to think I am self centered and pathetic— like I am wallowing in my grief, or not wanting to move on. That’s not true. I just feel so lost, I don’t know what to do. I’ve never dealt with anything like this.” The therapist then said, “Yes. It’s very true that you have never dealt with anything like this, and there is also truth to the fact that you are stuck in your grief, but I am confident that if we work together, we can figure out what that’s about and get past it. Even though I think your reaction to Paul’s death is entirely natural, I also believe that you are having trouble coming to terms with it. I believe it is possible for you to make peace with this loss, even if you can’t see that right now. I am very glad you came to see me.” Martha said, “Well I knew I had to do something.” This kind of interaction is not an uncommon opening in CGT. In the first few minutes of the meeting, the patient demonstrates ambivalence and the therapist accepts this and begins work to build the kind of alliance that will help Martha feel respected, comforted, and hopeful. Alliance building is one of the main goals of the Introductory Phase, usually comprised of three sessions, beginning after the pre-treatment assessment described in an appendix to this chapter. Therapists seek to

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Sessions 1-3 Getting Started

accomplish the following goals during these first three sessions: 1.Establish a companionship alliance 2. Learn enough about the patient’s history to develop a meaningful preliminary formulation 3. Explain and begin using interval plans and grief monitoring 4. Educate the patient about CG and CGT and use the preliminary formulation to help the patient see how the model fits her or his personal situation 5. Begin work on long term aspirations and plans 6. Begin work to rebuild connection to supportive companions Instructions for CGT are provided for each session and contain information about 1) session goals, 2) guidelines for how to address goals, 3) suggested strategies illustrated with clinical examples, and 4) some pitfalls and how to avoid them. In addition, there is a template for how to put the different activities together in a way that you can cover the session material. The template includes a suggested time for each component. In spite of this detail, keep in mind that all treatments must be individualized to meet the needs of the specific person you are treating. The sessions are arranged in four phases: 1) Introductory (Getting Started), 2) Intermediate (Core Revisiting Sequence), 3) Midcourse Review, and 4) Concluding Treatment (Closing Sequence). Readers may want to read the introduction to the phase and read through all the sessions in a given phase and then review instruc- tions for a particular session in preparation for doing that session. It is helpful to prepare notes about what you plan to cover ahead of time, and use them, along with a checklist like the one provided here, in the session. A word about structure: CGT is a semi-structured treatment. We use structure to provide a framework for the treatment, to allocate time in the session, to assist in both gathering and providing information, and to plan for the interval between sessions. Structural elements provide useful scaffolding for the treatment, though this does not mean you should use them rigidly. There is a lot to cover in each session and it is easier to get it all done if you set an agenda and follow

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Sessions 1-3 Getting Started

it. Therapists who are not used to structuring sessions may be surprised to find that patients appreciate the structure. People with CG feel lost and out-of-control and find predictability reassuring. At the same time, patients vary in their willingness and ability to accept and use an agenda, complete questionnaires, read handouts or follow interval plans. One of the challenges in learning a new treatment approach is that prior beliefs about how best to work may not be the best guide to decision making. It may be difficult to effectively encourage patients to work with an agenda if you have not done structured treatments before and you might find it awkward at first. We have found that it is best to follow the treatment as closely as possible, at least until you are comfortable working this way. Knowing when and how to deviate from the session structure, to modify or omit use of one or more of the tools, or to agree there will be little or no between-session work, is an advanced CGT skill that is not addressed comprehensively in these instructions. Each session begins by setting an agenda that divides the session in three parts, 1) a brief introduction to discuss the plan for the session and review the past week, 2) a longer period of time in which you implement the main session content content containing some time focused on dealing with the loss and some on restoration of wellbeing and enthusiasm for life, and 3) a brief ending of the session in which you summarize and get feedback from the client, and plan for the upcoming week. CGT sessions can be very intense and emotional. You need to track patients empathically and it’s easy to lose track of time. You may want to set a timer to remind you when to shift the focus. This treatment is supported by a group of questionnaires, monitoring forms, handouts and worksheets. Some therapists find it difficult to build these into their work, and again, we urge you to work on doing this, right from the beginning. In the next section we describe tools used in the introductory phase and explain their use.

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Sessions 1-3 Getting Started

Introductory Phase Tools and Their Use Handouts and forms are used to elicit or provide information and to help structure work between sessions. If you are like some therapists, it may be a struggle to learn to use these forms effectively. We encourage you to take the time to learn what each of these tools contains, how and when it is used, and to develop a system to organize your use of forms and handouts. Four kinds of tools are used in the introductory phase: 1) assessment instruments that the patient completes outside of the session, 2) handouts that contain information for the patient, 3) between session planning, note-taking, and monitoring forms for the patient, and 4) checklists, diagrams, and worksheets for the therapist.

Assessment Questionnaires A set of simple CG symptom-focused questionnaires are designed to be administered before the first session, readministered sometime between sessions 7-10. and again before session 16. You can use these in session 1 to help identify complicating thoughts and behaviors and to aid in discussing social support and other losses. You can use them in session 10 to monitor progress. These instruments are not included in the manual but are available for purchase at complicatedgrief.columbia.edu. Here is a brief description of each: 1. Grief-related Avoidance Questionnaire (GRAQ): a 15-item questionnaire that asks the patient to rate the degree of avoidance of specific situations related to bereavement. It is important to ask very specific questions about avoidance because otherwise it is easy for the patient to forget what they are avoiding. 2. Typical Beliefs Questionnaire (TBQ): a 25-item questionnaire that asks the patient to rate the extent to which they believe various statements related to the loss. This is an

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Sessions 1-3 Getting Started

efficient way to elicit some of the specific thoughts that often get people sidetracked from their grief. Most patients feel these questions are very relevant to how they are feeling. 3. Grief Support Inventory (GSI): a 2-item questionnaire that asks patients to list people in their life who have been supportive since the loss and people who have been actively unsupportive. Giving this to a patient helps her consider if there are supportive people, even if she is not feeling very close to them. It also allows the patient to see that we know people can be unsupportive. This can feel very validating. 4. Loss summary (LOSS SUM) and Inventory of Complicated Grief (ICG): The Loss Summary is a list of close friends and relatives the patient has lost and a rating of how difficult this loss was. The ICG is a 19-item rating of grief symptoms the patient completes for the loss that has brought them to treatment. Very often people with CG have experienced other losses. The loss summary tells the patient you know that. Asking the patient how difficult these other losses have been also tells the patient that you know this can vary. Sometimes patients want to emphasize how they coped well with loss in the past, and this gives them the opportunity to tell you that. Sometimes they feel that the current loss is hard because it is “piled up” on so many other losses, and again, this gives you the opportunity to discuss that. Sometimes there are several losses that have been very difficult and the patient wants to talk about all of them. You use the loss summary to discuss ways to do that. 5. Difficult Times Questionnaire (DTQ): On this form the patient is asked to rate how difficult they find certain calendar dates (e.g. anniversary of the death, birthdays, wedding anniversary, holiday times, and any other op Most people need about 15-30 minutes to complete these forms. You can ask them to come early and complete the forms in the waiting room, administer them in the pre-treatment assessment phase, or mail them to the patient and ask them to complete the forms at home. You use the GRAQ and TBQ in session 1 during your discussion of grief symptoms. You use the GSI in discussing support from others, and the LS and ICG in reviewing other important losses. You need to review

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Sessions 1-3 Getting Started

the GRAQ, TBQ and GSI in order to develop a preliminary formulation in preparing for session 2. You need to review the DTQ before the session to identify any calendar dates that are listed on this form that will occur during the 16-week treatment. We provide instructions for managing difficult times later in the chapter.

Handouts These are short pamphlets with information for patients and their families. Most patients find them very helpful. They usually recognize themselves in the descriptions and this can be reassuring. A single sheet with information for the client is provided in this manual. You may also purchase the longer form of each handout at www.complicatedgrief.columbia.edu. You should read the information sheets or pamphlets before giving them to the patient and be sure you understand them and that you can talk about the information in them and reinforce it. We have occasionally worked with people who can’t read because of illiteracy, blindness, or difficulty concentrating. We have made audio recordings of the pamphlets for use with these patients and that has worked well. These are also available for purchase. The two handouts are as follows:

1.“Complicated Grief and Its Treatment”: You give the patient this handout or information sheet at the end of the first session and give them a second copy at the end of the second session for the person who will attend the next session. You ask them to read it between sessions 1-2. You then begin with a discussion of the information in this handout in providing psychoeducation in session 2. 2. “Managing Difficult Times”: We use the difficult times handout only occasionally in the Introductory Phase. More commonly, it is used in the intermediate phase or later. If someone comes to treatment at a time when an anniversary or other difficult time is about to occur, you can interrupt the usual plan for session 2 or 3 in order to introduce the idea of anticipating and planning for difficult times. You should be familiar with the

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Sessions 1-3 Getting Started

information in this handout or information sheet and review it with the patient in the session. Then you give the patient the handout or information sheet to review at home. Note that if you need to work with difficult times in the introductory sessions, you will need to come back to the standard session in order to achieve the introductory phase goals. This means you will need an extra session in this phase.

Between Session Planning, Note-taking and Monitoring Forms These are a set of forms that are given to the patient at the end of each session to assist in the interval work. The interval planning form and grief monitoring diary are used in each session, as is the interval notes form. These are provided in the appendix of this manual. 1.Interval plans form (IPF): A one-page form provided in the appendix to this manual on which you list and describe activities you are asking the patient to do over the week or other interval before the next session. This is a good way for both you and the patient to be sure you both agree and understand what the patient is going to do during the upcoming week and also a good cue sheet for setting the agenda the following session. 2.Interval Notes form (INF): This is a one-page form provided in the appendix and used to encourage the patient to think about the session and/or various issues that you want her to begin to consider; she is encouraged to use the INF to record reflections during the week and any questions that might come up. Again, this is a good way for you and the patient to structure a discussion of topics the patient is concerned about and/or things you want her to think about. 3.Grief monitoring diary (GMD): A one-page form provided in the appendix on which you

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Sessions 1-3 Getting Started

ask the patient to rate and record at the end of each day her grief intensity on a scale from 0-10. You ask her or him to record the highest, lowest, and average intensity and the situations in which the highest and lowest levels occurred. This is a simple instrument that is a useful tool throughout the treatment. One of the important principles in CGT is that self-observation and reflection are needed in coming to terms with a difficult loss. The GMD provides a very simple first step in building these skills. We are asking people to observe their grief experiences each day and to reflect on what situation they were in when grief was high or low. Some people find this surprisingly difficult, but we urge you to encourage them to try to do it anyway. Usually after a few sessions they start to catch on. The GMD is also useful in helping people see that their grief does fluctuate during the day. Not infrequently, they feel like grief is all there is in their lives. The GMD can help them start to see that this may not be true. Finally, we use the GMD to track changes in grief intensity throughout the treatment. People find it helpful to go back and look at how their grief intensity has changed.

Checklists, Diagrams and Worksheets for the Therapist A set of simple forms to help the therapist organize and monitor the sessions and prepare for and present information to the patient. These are provided in the appendix of this manual.

1.Session Form Checklists: There is a Session by Session Schedule of CGT forms which provides an outline of the materials a therapist will use in each session and the forms a patient will take home. 2. Diagrams of the natural instinctive response to bereavement and of complicated grief: These are used in session 2 to help explain the CGT model and to discuss the preliminary individual formulation.

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Sessions 1-3 Getting Started

3. Therapist worksheet: This is a summary of the information used in the preliminary formulation. Therapists complete this at the end of session 1 to ensure they have all the information they need. If there is anything missing, they can add this to the session 2 checklist and agenda. The worksheet guides the therapist in developing the provisional formulation.

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Instructions for Session 1: History Taking Pages 26-37

Session 1

SESSION GOALS Begin building a companionship alliance Obtain information about the patient’s life, including important relationships, life events, education and work history, religious orientation, personal strengths, and accomplishments Learn about the patient’s relationship with the deceased, the story of the death, and her experience of grief Introduce interval plans and grief monitoring

SESSION CONTENT Beginning: Introductions Middle: a) Discuss early relationships, school, work, and current family and friends; b) Discuss talents, achievements, values, and other strengths c) Discuss relationship with the deceased, the story of the death, and expe- rience with grief Ending: a) Summarize the session and ask the patient for feedback b) Introduce interval plans (interval notes about what is most troubling about the death, think about who to invite to session 3, begin grief monitoring) c) Explain grief monitoring diary

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Session 1 MATERIALS NEEDED Pre-session Questionnaires (or their equivalent): Grief Support Inventory (GSI) Grief-related Avoidance Questionnaire (GRAQ) Typical Beliefs Questionnaire (TBQ) Loss summary with Inventory of Complicated Grief (ICG with LOSS SUM) Therapist review (before session): Pre-session questionnaires a) Highlight the items with the highest scores on each questionnaire b) Check TBQ for any endorsement of items 5 (Grief is your main tie to your loved one because it feels like all you have left of them); 11(Grieving less would mean you were uncaring, heartless or cold, or that you were betraying your loved one); or 20 (You need to guard against for- getting the person who died) Note: You will use these scores in your discussion of the GMD Session instructions. Therapist gives to patient: Interval Plans Form Interval Notes Form CG Handout Grief Monitoring Diary (GMD) Sample GMD

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Session 1 SESSION PROCEDURES The instructions that follow include basic information to be covered in session 1 and a suggested time frame for doing so. This session moves quickly and is meant to be introductory, to set the stage, rather than to fully cover the material. To work effectively, the therapist needs to be comfortable being directive, and skilled in making smooth transitions. Suggestions for transitions are provided in boxes throughout the instructions. To assist in covering all the material, there is a rough estimate of time for each area; however, in some cases more time will be spent in one area and less in another. You want to convey respect, interest in the patient’s agreement with suggested plans, empathy, optimism, support, and confidence.

Beginning (About 5 Minutes) • Introduce yourself and set agenda Welcome the patient and tell her you are glad to see her. You want to spend this session getting to know each other a little. Tell her you want to start by setting an agenda for the session, as you will do throughout the treatment. Sessions are planned to last about 45 minutes and generally follow a structure that starts with a review of the week and plans for the session, a middle part focused on the topics for the day, and an ending to summarize and plan for the next week. The agenda for today is to start getting to know one another. You want to tell her a little about yourself and to learn some basic information about her. You want the patient to begin to get to know you, including who you are as a person, how you work, how you think about grief. You want to get to know her including how she is feeling and thinking, something about her relationship with the person who died and other important people in her life, including people who are still here, and her experience of bereavement and grief. Introduce yourself to the patient and tell her something you might not ordinarily say.

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Session 1 For example, you might tell her how long you have been in practice, what kind of work you do, what you like about your work, etc., or you might tell her something a little more personal—like where you grew up, where you went to school, whether you have had any losses. Ask if there is anything else she would like to know about you. If so, answer any questions as openly as possible, according to your comfort level. If not, let the patient know that if she has questions later she should feel free to ask. Tell her that you want her to feel as comfortable as possible working with you. The treatment will include some challenging procedures and you understand that she needs to trust you and feel comfortable with you in order to do this work together. The agenda for today is to talk about her life, including her early relationships, other important people and important losses, and about her school and work history and her current family. You are interested in her talents, aspirations, and achievements as well as her struggles. You also want to hear about her relationship to the person who died, the story of the death, and how things have been since then. You want to review her grief symptoms, and will be reviewing some of the forms she filled out. This is a lot to cover in 45 minutes. You are going to talk about a lot of important things and you will not be able to talk about everything she could say about these topics so you might need to stop her and move to another topic. You want her to know that this is not meant to signal that what she is talking about is not important. Ask if this is okay with the patient and if she has any questions.

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Session 1 Middle (about 35 minutes) Begin with a discussion of early relationships with parents and siblings. Ask what it was like for the patient when she was growing up. Get a sense of how supportive and how critical the patient’s parents were, as well as how available they were. You are looking for the big picture. Some examples can be helpful, but you do not want to have an extensive discussion of her childhood. Then you discuss other important relationships, including people who are currently in the patient’s life, and people who have died. Move to a discussion of the deceased, and then to the story of the death and a review of grief symptoms. You want to include the relevant forms in each section. • Discuss, in broad strokes, family and early relationships, school and work history, religious orientation, interests, hobbies and accomplishments (about 5-10 minutes) Tell the patient you want to get a big picture sense of who she is. You will fill in details as needed, later in the treatment. Ask the patient where she grew up and who was in her family. Ask if she was close to her parents, to siblings? To anyone else? Ask who she would turn to for help when she had a serious problem or was feeling upset? Who was in her life that she could always count on? If there was no one, validate her efforts to rely on herself. Ask about her family’s religion. How important was it? How important is religion in her life now? Ask about where she went to school and how far she got. Ask about her interests and her abilities. Has she worked? What kinds of meaningful things has she done in her life? Work? Supporting herself? Other interests or hobbies?

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Session 1 • Discuss the deceased person and their relationship (about 5-10 minutes) Ask the patient to tell you about the person they have lost. Again, you want a broad strokes picture. What were they like? Facilitate this discussion as needed, to get a picture of how the patient sees the deceased. Ask the patent to tell you about her relationship with the person who died. Again, facilitate this discussion as needed. Ask about what happened that led to the person’s death. If needed, make an explicit transition, by saying something like “Lets stop there for now. Thank you for telling me about John. I know there is a lot more to say, and you and I are going to be talking about him and your relationship throughout this treatment. Now, though, if its okay with you, I want to hear about how he died.” • Discuss the story of the death (5-10 minute) Ask about when and how the death occurred. Where was the patient at the time of the death? How did the patient learn about it? Then make an explicit transition, using a comment that summarizes what you have heard or that indicates empathy and then suggests a transition to talk about grief symptoms. For example you might say something like “So it was really a shock,” or “Even though you knew s/he was dying, it was very intense when it happened. Let’s talk a little about what you felt then, and what things have been like for you since they died.” • Overview of grief symptoms Ask the patient to tell you about her grief. Listen to what she says and reflect on it . Then tell her that a distressing emotional experience like grief can be broken down into its different components. What you mean by components are the thoughts, feelings, behaviors and physical sensations she has been experiencing. Tell her we asked her about these when she filled out the questionnaires before the session, and you have highlighted some of her answers.

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Session 1

• Review the Grief-related Avoidance and Typical Beliefs Questionnaires Review the items on the GRAQ that are highlighted. Ask for examples of one or two of these. Tell the patient that avoidance is very common in CG and it is one of the things that can keep people stuck in acute grief. Avoidance can also restrict a person’s ability to engage fully in their ongoing life. You are going to be working with avoidance and you would like her to try to think more about it, and try to notice the things she is avoiding. You want to work with her to identify as many things as possible that she is avoiding. Ask if this is okay with her. Then review the TBQ. Note the highlighted items. Tell her that these thoughts are very typical but they are problematic when they occur frequently. You will be working with her to reflect on the beliefs she has and to rethink some of them. Ask if she agrees. Ask if she has any questions. Tell her you want to shift now and talk about who has been there for her since the death. • Review the Grief Support Inventory Ask about people on the GSI. First review the people who are supportive and ask who they are and how they have been most helpful to her. Tell the patient that it is very difficult to mourn alone and CG often makes people feel estranged from friends and family. “We need other people during a period of grief, so one of the things I am going to try to help you do is to feel more connected to your friends.” Ask if that’s okay. Then review the people who have been actively unsupportive. What are they doing that is difficult? How much does this bother her? Thank her for telling you about these people, and tell her you want to move to a summary of the session and plans for the interval until the next session.

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Session 1 Ending (about 7 minutes) Briefly summarize what you learned about the patient and thank her for sharing this information. Then ask her how the session was for her. Tell her you want to spend the last 5 minutes or so talking about other plans for the next week. • Introduce the Grief Monitoring diary and explain how to use it (review sample GMD) Give the patient the Grief Monitoring Diary and tell her you want to start tracking the intensity of her grief on a daily basis. You want her to start paying attention to her grief, notice when it is at the highest and lowest level during each day, and make some notes about what she is doing or thinking at that time. Show her the sample GMD and review it with her. Ask if she gets the idea. Ask her to think about what happened yesterday. When was her highest grief? When was her lowest level? What was happening at those times? What was her average grief level yesterday? If necessary, do this for another day. Remind her that it’s important to record whatever grief level she experiences. Tell her you have no expectations about how high or low it will be. She should try not to judge herself about high or low grief levels. IF SHE HAS ENDORSED ITEMS 5,11 OR 20 ON THE TBQ: Remind her of her ratings, and tell her that a lot of people have thoughts like this. One of the things we are going to do in this treatment is to reflect on these thoughts, but for now, these beliefs may make her feel badly when her grief is lower. You want her to try to notice when this happens.

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Session 1 People can do very well with this treatment when their grief monitoring levels are very low or very high. The most important thing is for her to pay close attention to her grief levels and do this as accurately as she can. You are going to be using this diary throughout the treatment and she will get a lot better at it as time goes on. Ask if she has any questions. Ask if this makes sense and if she thinks she can do this. If there is time, or if the patient asks, make the following additional points about Grief Monitoring: • Sometimes people are trying so hard to move on, or they are so tired of the grief, that they try not to notice it. But it turns out its better to pay attention to it. • Once she gets used to it, she may find that she likes this monitoring. A lot of people do. In any case, you want her to know that it is important to do this in order to get the most out of your relatively short time together. It will help her summarize her week for you and also cue her to issues she struggled with through the week. • You are interested in hearing about her grief and how she is feeling all week long, not just in the session. • You expect grief to be higher at some points and lower at others. The better you are doing with the mourning process, the more this happens—you feel the pain and then you set it aside. • Starting to see when your levels of grief are highest can help in the process of defining and working with the problems. • Noticing times when grief is lowest will help you see some ways to work on setting the emotional pain aside.

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Session 1 NOTE: For many reasons, it is very important for the patient to monitor grief levels. You want her to get in the habit of observing and reflecting upon her grief. The diary is a useful tool for this. You will use the diary at the beginning of each session to increase your efficiency in reviewing the week. You will use the diary to monitor progress in the treatment and to identify residual problems, as things start to improve. For all of these reasons, you will want to spend some time working with patients who are reluctant to complete the diary. For example: If Martha had not agreed to try doing what you asked, you might urge her to try something else. She might record only the lowest grief levels during the week, or the highest—whichever she is most comfortable doing. Or she might use words instead of numbers, like high, medium high, medium, medium low, and low, or even just high, medium or low. Or, if she can’t do it every day, do it just a few days in the week. The important thing is to engage her in a process that is as close as possible to the GMD. Introduce and complete interval plans • Explain that CGT is designed to continue between sessions in order to increase the power of the treatment. You want to work together for more than 45 minutes a week. The Grief Monitoring diary is one of the ways you will do this. You will usually do other things too. You don’t want to overwhelm her, so these activities are usually fairly simple and brief. If it is ever too much, she can let you know. Take out the Interval Plans Form and write on it as you talk about the activities below. For this week, you have three more things you want her to do: 1. Think about what is bothering her most about _______’s death and make some notes. Give her the Interval Notes Form, Session 1 and ask if she has any questions about this. 2. Tell her we have a handout that describes complicated grief and the treatment. Give her the CG Handout and ask her to read it before the next session. Tell her you are going to talk about this in the next session. Most people find it interesting and you’ll want to

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Session 1 hear her thoughts and reactions and you will also answer any questions. 3. Think about someone she might invite to the third session. Tell the patient that the in session 3 of CGT you would like to invite the patient to bring a friend or relative to the session. This is not required but you encourage people to do this, because it can be very helpful for someone else in her life to know about the way you see CG and what the treatment is going to involve. Therapists have also found that sometimes another person can add a perspective on what the patient is experiencing that is very useful to the patient herself and to the therapist. So, you hope that she will bring someone to session 3. You can discuss this more at the next session. Give the patient the Interval Plans Form. Thank her again for coming and tell her you look forward to working with her. End the session.

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Instructions for Session 2: Information about CG and CGT Pages 38-55

Session 2 SESSION GOALS Continue building a companionship alliance. Provide psychoeducation about attachment loss, grief, and mourning. Explain complicated grief. Provide rationale and plan for the treatment. Begin work on long-term aspirations and goals.

SESSION CONTENT Beginning: Set agenda and review interval plans Middle: a) Discuss attachment theory, including care giving and exploration b) Describe the attachment theory model of loss, grief, and mourning c) Explain CGT using the preliminary formulation to personalize this d) Discuss the rationale for CGT and procedures used e) Begin work on long-term aspirations and goals Ending: a) Summarize the session and ask the patient for feedback b) Give the patient the interval notes and interval plans forms c) Decide who to invite to session

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Session 2 MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Pre-session 1 questionnaires (OPTIONAL; It’s a good idea to have the GRAQ and TBQ in the session so you can refer to them if you wish) Therapist Worksheet—Provisional formulation Session instructions Therapist gives to patient: Interval Plans Form CG Handout to give a friend or relative Grief Monitoring Diary (GMD)

SESSION PROCEDURES The instructions that follow are designed to help you frame your presentation

of material about

attachment theory, grief, mourning, and complicated grief, to outline the goals and procedures used in CGT, and instructions for beginning a discussion of long term aspirations and goals. There are a few things to keep in mind during this session. First, the patient will have read the handout and you want to review that with her, and build on it on your discussion. Another thing to remember is that you don’t want to lecture. Be sure you use a give-and-take dis- cussion style—something like a Socratic method of dialogue, as long as you don’t put the patient on the spot. When you’re finished with each part, ask if the model makes sense, and if there’s anything the patient is unclear about. This session, like the first, moves quickly and the therapist needs to be comfortable being directive, and skilled in making smooth transitions. As in session 1, it is most important that the therapist tailor the work appropriately to the individual patient at their level of understanding and

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Session 2

receptivity. It is important to convey respect, interest in the patient’s agreement with suggested plans, empathy, optimism, support, and confidence. You always want to keep in mind your wish to build a strong companionship alliance that incorporates who you are as a person as well as your professional knowledge and skills.

Beginning (about 5 minutes) Welcome the patient back and set the agenda Welcome the patient and ask her how she is doing. Listen to be sure there is no urgent matter that needs to be addressed. If you are unsure, ask if there is. Then tell her you want to hear more about her week, but you have a lot to cover again today and you would like to set the agenda, if that’s ok with her. When she agrees, tell her you first want to start by reviewing her grief diary and other weekly plans. Then you are going to spend some time talking about the information in the handout, and expanding on it some. After that, you want to spend a little time discussing her long-term aspirations and goals, and then make your plans for next week. Ask if this sounds okay. Review weekly plans Tell the patient you want to start by reviewing her Grief Monitoring diary. Look over the monitoring form and comment on the overall pattern. For example, you might say that you can see that her average levels were generally pretty high this week, almost as high on average as the highest level. On Thursday it was a little lower though. Any idea why that was? You might also notice that the highest level for the week was last Tuesday during your session. How does she feel about that? The patient might say, well, you were asking me to talk about some things I don’t usually think about. If so, you can respond by saying—exactly. It makes sense, right? When she thinks about the deceased and how they died, it’s pretty hard. Part of what has her stuck is that it is so hard to think about this. So, you want to underscore how understandable it is that her grief level was the

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Session 2 highest when she was here and also how great it is that she came here and did this. It’s actually very hopeful. As you move forward through the treatment, she may well find that some of her highest levels are either during the session or while doing one of the exercises from the treatment at home. That’s what we expect. Then you can look at the lowest level and briefly discuss that. If the patient did not complete the GMD, you make the assumption that there is a good reason for this. Sometimes people tell you what that reason is and you can discuss it. You want to make it clear that participation in the treatment procedures and exercises is always a choice. At the same time, she should understand that these procedures have helped a lot of people, even though most people find them difficult or awkward, especially in the beginning. Tell her that whatever she decides, you do not want her to be self-critical. The diary is a simple exercise, but many people find it hard. Ask if it is ok if you revisit this discussion at the end of the session when you are making plans for next week. After reviewing the diary, ask her whether she thought about what troubles her most about the deceased’s death. Make an empathic statement about this. Then ask if she is ready to discuss the handout.

Middle (about 35 minutes) Explain that today you will talk about complicated grief and its treatment, expanding some on the information in the handout. Ask if the patient read the handout. If so, take a few minutes to walk through it with the patient, answer any questions and make note of things that they have highlighted. Use this as you talk about the topics below, weaving the patient’s self-observations into the discussion. Point out that the discussion you are going to have today will follow the organization of the information in the handout.

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Session 2 Discuss attachment, caregiving, loss, and grief The handout describes grief as the painful psychological response that follows the loss of a close friend or family member. It points out that close relationships help regulate our physical and psychological well-being. Ask if that makes sense to the patient? Then tell her you want to explain a little more about that. Explain that there is a lot of evidence that we are biologically programmed to seek, form, and maintain close relationships with a small number of people in our lives—generally between 1-5. In the mental health field we call these especially close people “attachment figures.” These are people who we want to be with, all things being equal—people we prefer not to be separated from. Our attachment figures are the people we turn to when we feel stressed or need to solve an important problem. They are also the people we know are cheering for us when we are trying something new or risky or difficult and they feel proud of us when we do something well. It turns out that lots of mammals and also birds form these kinds of relationships and they are very important in a person’s (or animal’s) life. Attachment figures are especially important to our well-being and positive emotions. They regulate some of our physical as well as psychological functions. People who live together often literally get both emotionally and chemically synchronized. They are often part of our patterns of sleeping and eating. Even when we don’t live together, people we love affect us psychologically in many small as well as large ways. They help us regulate our emotions and our thinking and our social behaviors. Having close attachments helps us feel good about ourselves and gives us a sense of well-being. Another important thing about attachment figures is that these are the people we are most interested in taking care of. Care giving is the opposite side of the coin from attachment. For most adults, it is even more important to feel we take good care of people we love than that they take good care of us. If we feel like we let someone down that we love, we feel very badly. If we lose someone who takes care of us, we also feel badly. Because

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Session 2 they are so important in some many different ways—both large and small—it is natural to react very strongly to the loss of a loved one. This reaction is what we call grief. In our work, we call it acute grief to differentiate it from another kind of grief that is permanent. In essence, we never stop missing someone we love, but the way we miss them and the intensity of the feelings usually changes over time. Ask if this makes sense and if it is similar or different from the way she has been thinking about grief. Ask if she thinks that her relationship with the deceased would fit this description. Explain the exploratory system Another system that is linked to attachment is the inborn motivation to explore the world—to learn and grow and master new things—and to use our skills and talents to do things that we are proud of. Active functioning of the exploratory system also contributes to our sense of well-being and positive emotions; it’s fun to learn and grow and do things effectively

by ourselves. Interestingly, though, the exploratory system is linked to the

attachment system and when our attachment relationships are distressed, this can shut down the exploratory system. The result is loss of motivation to do new things and a loss of a sense of competence. This is one of the important things that happens when you lose someone close. In the beginning, you lose your interest in ongoing life and you don’t even feel competent to do the simplest things. We instinctively know this about each other, and so we step in and help bereaved people in ways that would be unusual in other situations—in fact in some cases it could be considered rude or intrusive. Ask the patient if this makes sense and if she has any questions. Acute and integrated grief and successful mourning (use the figure 1) The handout talks at some length about the symptoms of acute grief and how they can motivate and guide us to come to terms with the loss, honoring our love and attachment

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Session 2 and also releasing us to continue our life without the person who died. Ask if the patient has any questions about that. Tell her you want to say a little more about what happens when mourning is successful. In essence this is the process by which acute grief is transformed to integrated grief. She can think of it as the difference between what she usually expects if she visits a friend who has been bereaved only a few days or a week compared to visiting a friend for whom it has been 5 years since the loss. She expects to see a person who is very preoccupied and upset, with many of the symptoms on the figure. She may be able to talk with her friend, but she can see her friend easily loses her concentration. She may start to weep. She may not seem like her usual self. Now fast forward to a number of years later. She is visiting this same person, but she no longer expects to see her tearful and preoccupied. She expects her to be interested in things and able to concentrate on the conversation. But if she tells her friend she has been thinking about her friend’s deceased loved one, would her friend say that person has not crossed her mind in months? Not likely. Years later, her friend probably still thinks about the person she lost quite frequently—maybe even more than once a day. And she may still feel sad, or certainly a bittersweet feeling, and maybe some longing, when she does. So her grief is not really gone or completed, but grief plays a very different role in her life than it did shortly after the death. This is what we call integrated grief (see figure 1). Integrated grief is permanent, though that doesn’t mean it is always the same. One thing to remember is that integrated grief, as well as acute grief, is not one thing. It changes from day to day, week to week and month to month. It can have peaks and troughs. But integrated grief does not interfere with our lives. Sometimes it can even enrich our lives because we may become more sensitive, more empathic, more tuned in to the value of our lives. Ask if the person is with you? Ask for any questions.

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Session 2 The progress of grief Now lets think about how we get from acute to integrated grief. In the beginning, before we fully comprehend that a loved one is gone and come to terms with this, the pain is very intense and we need respite from this pain. In the beginning our only recourse is to distract ourselves, to put it out of our mind; almost like forgetting it. At the same time, before we set it aside, we need to take in information, bit by bit, about the finality and consequences of this loss and make some kind of peace with the painful reality. Sometimes this happens fairly automatically but usually it requires reflection. It usually requires thinking about different ways to understand what happened. We have to solve the problem of accepting something that is the last thing we want. Sometimes this means forgiving others or ourselves or accepting human limitations. Sometimes it means having faith in others or ourselves— faith that we can go on without our loved one, and that others genuinely want to help and can help. Part of solving the problem of coming to terms with the death is rethinking the future without the person who died. This can be just as difficult as finding a way to make peace with the death and it is also as important. Thankfully, positive emotions arise naturally during acute grief and that helps us in this difficult process. Explain that what this process requires is the ability to keep remembering that a loved one is gone, and to gradually consider all that this means, in order to fully comprehend its finality. Memories of the death and thoughts about the future without our loved one are naturally very painful so we can’t think about those all the time. We need some respite. Our brains naturally provide this and the process of coming to terms with the loss entails a natural oscillation, or swinging, between paying attention to the painful reality and then setting it aside. This oscillation occurs whenever we deal with something intensely painful. We don’t take it all in at once. In the case of loss, whether thinking about the past or about the future, we oscillate between confronting the deep sadness and yearning and

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Session 2 longing for the person who died, and thinking about other things, either mundane or even positive to have some respite from this pain. However, over time, as we set it aside, we do so increasingly less completely. It’s almost like the reality that the person we love has died is gradually infused into our everyday lives and thoughts about the future. As this infusion happens, acute grief symptoms begin to abate. Check with the patient for understanding and ask if she has any questions. Complicated Grief (Use figure 2) Sometimes, because of certain kinds of thoughts or behaviors, or because painful emotions are just too strong or too difficult to set aside, a person has trouble taking in information about the finality and consequences of the loss, and its reality is kept entirely separate from ongoing life. When this happens, acute grief does not progress. Instead of reflecting on ways to come to terms with the painful reality and imagining ways to move forward in her own life, a person with complicated grief is sidetracked. She may find herself repeatedly thinking about something troubling related to the death. For example, she might think it should never have happened, or that she can’t possibly manage without the person who died, or she might spend a lot of time trying to find way to avoid reminders of this reality. In other words she might daydream about being with her loved one, or do things like holding or smelling their clothes, or spend hours looking at pictures, to try to stay connected to the person, or she might go to great lengths to avoid reminders that the person is gone. She might train herself to distract her thoughts whenever she is reminded of her loved one. The result of these types of thoughts and behaviors is paradoxical—acute grief is prolonged with no end in site. This is the condition we call complicated grief. It happens most often when someone loses a person with whom they had a relationship that was especially close and rewarding. The handout suggests using a medical model to think about CG and many people find that helpful. Unless the patient has questions, though, there is no need to walk through this. Instead, remind her that last

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Session 2 session you talked about her life, her relationship with the person she has lost, and her experience of grief. Ask if she is ready to put these into the equation. Discuss preliminary formulation (use figure 3) Show the patient figure 3 and ask if it seems to fit her situation. If she tells you yes, work with her on this. If not, walk through the barriers to reflection and problem solving and/or supportive companionship in the patient’s case. You can add some underlying vulnerabilities. Add her strengths and possibilities for companionship. Tell her that what you want to do is to help clear the field so that her natural mourning process can proceed. You want to help her use her very real strengths and open herself to her friends and even maybe to some new relationships so that she can move forward in her own life. You want to spend a few minutes telling her a little more about what you will be doing together. Introduce CGT goals and procedures We are guided by our understanding that successful mourning entails self-observation and reflection, problem solving and supportive companionship and proceeds by oscillating between confronting the painful reality of the loss and all of its ramifications, and setting that aside. The overall goal is to find a way to make peace with this most unwanted event and to re-envision her own life without them in a way that offers the potential for joy and satisfaction. In general, you will include some work on the loss and some work on restoration of the capacity for satisfaction in her own life. You will use imagery exercises as well as discussions and self-monitoring activities. You are going to tell her about the revisiting exercise today. Last week you talked more about loss. Today you are going to introduce the first exercise, which is focused on restoration. You will do some of these together in the sessions and some you will ask her to do on her own or with other people between the sessions. Several of the activities are difficult and painful when you do them at first, and you hope she will feel comfortable enough to do these with you. You will do

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Session 2 this as gently as possible, and you want her to know that you are not going to leave her alone without support. You will be there with her and you will help her identify other people who can help too. You are going to explain some of these activities today, and she can read about them in the handout. However, you will also explain this to her again when you are ready to do it. For everything you do in this treatment, it will be up to her to decide if she wants to do it. Introduce “revisiting” Tell the patient you want to explain the most difficult and most important exercises you will do with her. This is an activity that you do first in the office and then at home. Revisiting means to go back to something in memory or in actual life, and observe this place from the vantage point of the present. When we revisit memories, we consider whether it makes sense to think of them in new ways. When we revisit places we focus on experiencing them in a new way. So we are going to do both Imaginal and Situational revisiting. Ask if the patient has any questions. Ask her if she would like to hear a little more about this now. You usually start the Imaginal Revisiting in session 4 and situational revisiting in session 5. If she wants to hear more, then describe these exercises in broad strokes. Explain Imaginal Revisiting of the death and Situational Revisiting of reminders of the loss Imaginal Revisiting is a procedure in which you will ask the patient to close her eyes and visualize herself back at the time that she first learned of the death, and then tell you what happened for the immediate period after that. She will do this exercise for about 10-15 minutes. After she finishes you will ask her to observe and reflect on this story. You might also add some observations. Additionally you will tape record her telling this story and ask her to listen to the tape at home. This procedure is repeated at each session for about 4-5 weeks. During that time, the patient will likely experience a noticeable reduction in the intensity of emotions, and this will help her feel more free to think about the death.

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Session 2 You can tell her that we do this exercise for several reasons. It helps people identify and work on the things that are really bothering them about the death. It can help her learn to feel more comfortable and confident in confronting the painful memories and setting them aside—a process that facilitates the progress of grief. You can tell her that you know the exercise is difficult, and you will be with her when she does it and also provide as much support as you can when she is listening at home. Ask if she thinks she can do this and if she has any questions. Explain that the other kind of revisiting you are going to ask the patient to do is called Situational Revisiting. This is a procedure that helps reduce avoidance of painful reminders. This kind of revisiting can be done in a gradual way so it is not as painful as the Imaginal exercise. However, it is important for the patient to plan these activities and to stick with them as best she can. You will help her do this. Revisiting actual situations also helps emotions fade and helps people to feel less restricted in their lives. Ask if she understands and if she has any questions. Discuss the role of supportive people Tell the patient you want to emphasize one more aspect of mourning—that it is not something we do very well alone. People often feel very alone, even when others are around, but it is much worse if we actually are alone. More than almost any other time in our lives, we need other people when we are grieving. They can serve a lot of functions, but maybe one of the most important is to bear witness and to share in the fundamental human tragedy we are experiencing. You will be a companion to her in this process moving forward, and you also want to encourage the patient to open herself to important people in her life. As she knows, you want her to invite someone to the next session. In addition, you will encourage her to think about pleasurable things she might do with others—ways she might have fun. You are about to shift to talk about her long term aspirations and you want her to think about who can help her in this area too. Ask if she has any questions.

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Begin work on Long Term Aspirations Ask the patient to come with you on another kind of imaginary journey. Tell her you would like her to imagine that her grief is not so strong and disruptive. Say to her, “If I could wave a magic wand and you had found a way to make peace with the death, what would you want for yourself?” Give the patient some time to think about this. Many times the patient will tell you something quite surprising and it is clear that she has already been thinking about it. If this happens, use the aspirations worksheet to discuss it or add the interval notes-aspirations to the weekly plans. Often the patient has difficulty coming up with something right away. If this happens, tell her a lot of people have trouble with this, but its important and you would like to keep working on it. Ask if that’s okay. Tell her to think about things that she has found satisfying in the past, things that she has wanted to do, but couldn’t or didn’t do, things that are wishes or dreams. Tell her you want her to think about things that she considers rewarding and fun. Consider giving her some examples. As you develop experience with the treatment you will collect them. You can also use vignettes from the manual. Encourage her to try to have some fun with this even if it means being unrealistic. You want her to try her best to let herself dream—think big and think long term. You want her to do this even if she really doesn’t feel like it and even if she feels a little guilty. Ask her if she understands and if she is willing to try. Ask if she has any questions.

Ending (about 5 minutes) Briefly summarize what you discussed today and ask the patient how the session was for her. Tell her you want to spend the last few minutes planning what she is going to do over the next week. Give the patient the Grief Monitoring diary

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Session 2 Tell her you would like her to do the diary again this week. Discuss this if necessary. Give the patient the Interval Notes form Tell the patient you want her to work on long-term aspirations and goals. Remind her of your earlier conversation and discuss how she is going to use the form this week. Go through the form with the patient and decide how she will use it. Confirm the plans for session 3 and give the patient a second copy of the CG Handout for the visitor Finalize the plans to bring someone in for session 3. Explain that you will be interested in hearing a little about their relationship with this person and the person’s perspective on the death and its aftermath. You also want to talk about a lot of the ideas you talked with the patient about today and help the person understand how we see grief and some of what the treatment entails. Ask if this is okay. Confirm the schedule and end the session.

 

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Instructions for Session 3: Including a Close Friend or Family Member Pages 56-69

Session 3 SESSION GOALS Session With Patient And Visitor: Get another perspective on the patient’s situation Be sure that the visitor understands how we see CG and what the treatment entails and has a chance to ask questions Begin the process of increasing sense of connectedness to people who are still alive Session With Patient Alone: Get a sense of patient’s experience of the session Review past week interval plans and plan those for the next week

SESSION CONTENT Beginning: Welcome the visitor and set the agenda Middle: a) Discuss visitor’s relationship with the patient b) Discuss visitor’s observations about the patient before, during and after the death c) Provide information about CG and CGT d) Consider ways the visitor might be helpful

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End: a) Summarize and thank the visitor b) Meeting with the patient alone debrief review GMD and other interval plans make plans for the week

MATERIALS NEEDED Pre-session Questionnaires: None Therapist reviews (before session): Session instructions Therapist gives to patient: Session 3 Weekly Plans Form CG Handout to give to a Significant Other (if desired) Grief Monitoring Diary

SESSION PROCEDURES This session is held with a significant other as a visitor to the session. It is important that this session experience is supportive and positive for the patient. Every effort should be made to ensure this. As in prior sessions, the therapist is empathic, supportive, non-neutral, directive, and optimistic. You want to get another perspective on the patient’s current situation. You want to be sure that someone in the patient’s social network, preferably someone close, knows the model of grief and complicated grief that informs this treatment. You also want this person to know the basics of the treatment. Sometimes revisiting the death is the last thing that a significant other will want the patient to do. You want to elicit this attitude and discuss it, if necessary. You are striving to get agreement to support the patient as she moves through the treatment. Sometimes other people in the family are also suffering from CG related to the same death. It is good to know this as you move forward with the patient.

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Occasionally there is significant hostility from the person who comes into the session. If this occurs, you should become more active and work to elicit feelings of love and support. If this shift is not possible, find a way to gracefully bring the session with the visitor to an end. You do not need to achieve the session goals. Spend the time discussing the visitor’s hostility with the patient and help her decide how to best manage this relationship. Although this situation is not what we are looking for, in some cases, the fact that you can see and acknowledge the hostility can be validating and supportive for the patient.

SESSION INSTRUCTIONS: JOINT COMPONENT Beginning (about 5 minutes) Welcome the visitor and set the agenda Welcome the visitor and thank her for coming. Ask what her understanding is about why you wanted her to come in. Clarify that you have several goals. You are interested in her perspective on the patient’s problems. In particular, what has she observed? How has the patient changed since the death? How would she like the patient to be different? Additionally, you want to be sure she knows how you are thinking about the patient’s problems and what your treatment entails. You want to make sure she can ask any questions she has about this and confirm her interest in supporting the patient as she moves through the treatment. Tell her that you will talk for about 40 minutes and then you will want to meet with the patient alone for about 15-20 minutes. Ask if this is okay and if either of them have any questions.

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Session 3 Middle (about 35 minutes) Discuss the visitor’s perspective of the patient Ask the visitor to talk a little about her relationship with the patient: how long they have known each other, how close they are, what kinds of things they do together, how they have supported each other in the past. Then ask about her experience with the patient before and after the death. You are interested in ways the patient seems to have changed, in what the visitor misses about her and what she would like to see changed. As the visitor talks about this, elicit her thoughts about things she thinks the patient might be avoiding, about the ways she seems to be thinking about her grief and her life without her loved one and about her emotions and daily activities and rhythms. In other words, you want to review the components of grief, similarly to the way you did in the first session with the patient. After you get a pretty good picture of this, summarize, thank the visitor, and ask if there is anything else she wants to add. If not, tell her you want to shift and talk about how we see bereavement and grief and what happens in complicated grief. Define bereavement and grief The discussion in this session is very similar to that in session 2, though more abbreviated. You might ask if the visitor read the handout and, if so, ask if she has any thoughts or questions. After this, you can start by talking about attachment. Discuss attachment, caregiving, loss and grief The handout describes grief as the painful psychological response that follows the loss of a close friend or family member. It points out that close relationships help regulate our physical and psychological well-being. Ask if that makes sense and say that you want to explain a little more about that. There is a lot of evidence that we are biologically programmed to seek, form and maintain close relationships with a small number

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of people in our lives. In the mental health field we call these especially close people attachment figures. These are people who we want to be with, all things being equal— people we prefer not to be separated from. Our attachment figures are the people we turn to when we feel stressed or need to solve an important problem. They are also the people we know are cheering for us when we’re out there trying something new or risky or difficult and they feel proud of us when we do something well. These people help regulate some of our physical as well as psychological functions. Even when we don’t live together, people we love affect us psychologically in many small as well as large ways. They help us regulate our emotions and our thinking and our social behaviors. Having close attachments helps us feel good about ourselves and gives us a sense of well-being. Another important thing about attachment figures is that these are the people we are most interested in taking care of. Care giving is the opposite side of the coin from attachment, and is also instinctive. In addition, for most adults, it is even more important to feel we take good care of people we love than that they take good care of us. If we feel like we let someone down that we love, we feel very badly about that. If we lose someone who takes care of us, we also feel badly. That’s going to play a role in grief too. And then there is a third system that is linked to attachment that’s called the exploratory system. This is another instinctive desire. We naturally wish to explore the world, to learn and grow and master new things, and to use our skills and talents to do things that we are proud of. Active functioning of the exploratory system also contributes to our sense of well-being and positive emotions. It is fun to learn and grow and do things effectively by ourselves. Interestingly, though, the exploratory system is linked to the attachment system because when our attachment relationships are not secure, this can shut down the exploratory system and suddenly we don’t care about anything else—not about learning new things or doing things we know how to do, and we also lose our sense of competence. Do you follow this? Do you have any questions? So now lets apply this to

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bereavement. When someone close dies, we lose a relationship that is so important in so many different ways, both large and small, it is natural to react very strongly. We not only feel adrift and cut loose from our anchor, but also like somehow it is our fault (that’s the caregiving system) and like we are incompetent and uninterested in learning (that’s the exploratory system). The overall response is the reaction of grief. In our work we use the term “acute grief” to differentiate this initial intense reaction from another kind of grief that is permanent. In essence, we never stop missing someone we love, but the way we miss them and the intensity of the feelings usually changes over time. Ask if this makes sense and if it is similar or different from the way the visitor has been thinking about grief. Ask if the person thinks that the patient’s relationship with the person they have lost would fit this description. Acute and integrated grief and successful mourning (use the figure 1) The handout talks at some length about the symptoms of acute grief and how they can motivate and guide us to come to terms with the loss, honoring our love and attachment and also releasing us to continue our life without the person who died. Ask if the patient has any questions about that. So, what happens when mourning is successful? It is not that we complete grief or detach from the deceased person, but rather years later, we may still think about the person we lost quite frequently—maybe even more than once a day. We may still feel sad, or certainly a bittersweet feeling, and maybe some longing. That’s very natural. It’s what we call integrated grief. It’s not gone, but grief plays a very different role in our lives than it does shortly after the death (see figure 1) One thing to remember is that integrated grief, as well as acute grief, is not one thing. It changes from day to day, week to week and month to month. It can have peaks and troughs. But integrated grief does not interfere with our lives. Sometimes it can even enrich our lives because we may become more sensitive, more empathic, more tuned in to the value of our lives. Ask if the person is with you? Ask for any questions.

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Now, lets think about how we get from acute to integrated grief. Right after someone dies, we can’t possibly fully comprehend that they are gone. Especially if the death is unexpected, the pain is very intense and uncontrollable. Somehow we need to confront the pain, so we can take in the information and come to terms with the finality and consequences of the death. This means we need to keep remembering that a loved one is gone, and gradually to consider all that this means. Memories of the death and thoughts about the future without our loved one are naturally very painful so we can’t think about it all the time. We need some respite. Our brains naturally provide this by oscillating, or swinging, between paying attention to the painful reality and then setting it aside. This oscillation occurs whenever we deal with something intensely painful. We don’t take it in all at once. In the case of loss—whether thinking about the past or about the future, we oscillate between confronting the deep sadness, yearning and longing for the person who died, and thinking about other things, either mundane or even positive, to have some respite from this pain. However, over time, as we set the loss aside, we do so increasingly less completely. It is almost like the reality that the person we love has died, is gradually infused into our everyday lives and our thoughts about the future. As this infusion happens, acute grief symptoms begin to abate. Check with the patient for understanding and ask if she has any questions. Complicated grief (Use figure 2) Most people manage to come to terms with even the most difficult loss, but sometimes they can’t seem to do this. Complicated grief occurs mostly when someone has had an especially rewarding relationship with the deceased. Certain kinds of thoughts or behaviors, or excessively painful emotions interfere with the ability to make peace with the loss, and its reality is kept entirely separate from ongoing life. When this happens, acute grief does not progress. People with CG are caught up in troubling concerns about the circumstances or consequences of the death or preoccupied with trying to manage

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intense uncontrollable emotions. This leaves them stuck in an endless cycle of acute grief. There is a treatment that is designed to help with this and you want to tell the visitor a little about it, especially one of the components that some people find counter-intuitive. Show the visitor Figure 2 (with figure 1 still out): the cartoon of complicated grief. Tell her that the purpose of the treatment is to shift figure 2 to figure 1. Another way to think about CG is that it occurs because acute grief gets off track. If grief is a journey, you can think of it as a railroad journey that has to go through some difficult terrain. Sometimes there are branches on the track and the train gets derailed. The treatment is aimed at getting the train back on track. The method we use to do this has several important components. One of them is to revisit the patient’s) experience with losing their loved one. Revisiting, as done in this treatment refers to going back to something in memory or in actual life, and observing it from the vantage point of the pres- ent. In general, when we have a knotty problem to solve in our lives, we often work on it for a while, set it aside, and then revisit the problem later. That’s the basic idea here. You can think of it as the patient having a problem with the natural progression of grief. We are going to revisit the time that this problem began (i.e. the death) and revisit it as part of the way we might solve this problem, and we are going to revisit places and activities that the patient is having a problem being at or doing, in order to solve that problem. When we revisit memories, we consider whether it makes sense to think of them in new ways. When we revisit places we focus on experiencing them in a new way. So we are going to do both Imaginal and Situational Revisiting. Ask if the visitor is with you and if she has any questions. Then suggest that you first explain the Imaginal revisiting procedure. Imaginal revisiting is an exercise in which we ask the patient to tell the story of the death. We do this in a very specific way, and we do it repetitively. Each time we do it, we discuss it afterwards and then we put it away. Also, each time we do it, we tape record the story she tells and ask her to listen to it at home. When she comes back to the next session, we talk

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about her experience listening, do this exercise again, make a new tape, and again ask her to listen to the new one. Each time the patient makes a tape or listens to the story at home, the therapist will ask her to plan something to reward herself; something a little special that she likes, but would not ordinarily do. Using this technique, what we find is that over just a few weeks, the emotions lessen noticeably and the patient is more comfortable thinking about the death. She is also more comfortable setting those thoughts aside. It’s important that you know it is not just dwelling on something very painful. This procedure also helps us work with the patient to find the barriers that knocked her grief off track and clear those away. The treatment helps remove the impediments in figure 2 (point to them) and enhance the facilitators (point to them) in figure 1. There are other parts to the treatment, but the one that most friends and relatives are most puzzled by, and sometimes worry about, is Imaginal Revisiting. Ask for any questions. Tell the visitor that sometimes it helps to have someone listen to the tape, or to know someone is around when the patient is listening. Sometimes friends or relatives can help by participating in planning or in dong the reward afterwards. Ask the patient if she would like help from the visitor in either of these ways, or in any other way. If she does, get the visitor’s agreement, ask if the visitor thinks they could do this. Move to a discussion of situational revisiting. Tell the visitor that another kind of revisiting we work on in this treatment is revisiting certain places or doing activities that the patient is avoiding because they are too painful right now. Starting next week, we are going to list some of these things and decide how to approach them. You will be asking the patient to go places or do things that are currently out of her comfort zone. She may want to have help with this. Sometimes it is helpful to have someone do the revisiting with her, for example to go to a favorite restaurant or maybe to the park; someplace the patient and the deceased enjoyed together and now is painful because it reminds the patient of his departure. (NOTE: instead of using the example of the restaurant or the park, if possible use a specific example from the GRAQ or from the

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earlier discussion with the visitor.) Sometimes it just helps for someone to know that the patient is doing this. Ask if the visitor understands? Ask if they have any questions. Tell the visitor that these are two important things we will do in this treatment. There are other parts of the treatment, including looking at pictures, asking about memories, and working on an important personal goal. They will do some of these together in the sessions and you will ask the patient to do some on her own or with other people between the sessions. Several of the activities are difficult and painful when you do them at first, so you are going to take the patient out of her comfort zone. You will do this as gently as possible, and you want her to know that you are not going to leave her alone without support. You will be there with her and you will help her identify other people who can help too. This is one reason you asked the visitor to come today. Does this make sense? Move to a discussion of personal goals and the role of other people. Discuss the role of other people in the treatment Other people are usually very important in the process of adjusting to a difficult loss. As her therapist, you plan to encourage the patient to interact with important people in her life in a new way. In addition to asking the patient to allow you to help with the difficult revisiting exercises, she will be encouraged to think about ways that she might interact with other people in ways that could be pleasurable. The next thing she is going to think about is personal goals. You are going to ask her to think about who can help her in this area too. In the beginning of this work, the discussion will be more general. When she is ready, the patient may want to share this with you as well. Most experts believe that grief progresses best when bereaved people attend to both the loss—the emotions, the thoughts, and the memories of the person who died—and to the restoration of their own lives. For someone who has complicated grief, both are often very difficult. You can say something like, “We have been talking about the ways we problem solve the difficulty

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with the loss. Now I want you to know that we also work on the restoration side.” You will work with the patient to think about something satisfying that she might want to be doing when her grief is back on track—a long-term goal. Once this is identified, you can guide the patient to think about taking steps to make it happen. That’s where the visitor might come in. The patient might want to talk with the visitor about her goal or she might want to brainstorm how to approach some aspect of it, or she might want some other kind of help. Ask the patient what she thinks. Does she think the visitor might be able to help with her goal? (NOTE: If the patient has identified a goal at this point, you can ask her if she would like to share her thinking about this so far. You can ask how she thinks the visitor might be able to help. Otherwise, keep this discussion generic.) Ask if the visitor has any questions. Then close the session with the visitor.

Session 3 Joint Component Ending (about 5 minutes) Bring the session to an end Thank the visitor for coming. Tell her that this has been very helpful. Ask the patient if there is anything else she wants to say to the visitor at this time. Ask the visitor if there is anything else she wants to say or to ask. Tell the visitor that if questions come up in the future she is very welcome to ask. Tell her that like any other treatment, what the patient tells you is confidential, but you will always be happy to answer general questions and you will be open to having her come to another session, if this is something that the visitor as well as both you and the patient decide will be helpful. Tell the visitor that you want to spend a few minutes alone with the patient. Ask her if this is okay. Tell her it has been good to meet her and thank her again for coming.

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Session 3 SESSION INSTRUCTIONS: INDIVIDUAL COMPONENT Session 3 Individual Component Ending (about 5 minutes) This component is very brief. The purpose is simply to touch base with the patient regarding the session—to be sure they experienced the session as supportive and positive, to answer any questions they have about the Grief Monitoring, and to let them know that you will review two weeks of grief monitoring and two weeks of goals work at the next session. You also want to remind the patient that you will begin Imaginal Revisiting at the next session and that you will begin to generate a list of things for the Situational Revisiting. Ask the patient how they think the meeting went Tell the patient that you will discuss this again next session, if she wishes, but you would like to get a general idea about how she thinks this went. “So how do you think that went, Lisa?” the therapist asked. “I think that it went pretty well. I know that Alex is there for me, but it is hard for me to tell when I want to do certain things alone or if I’m just thinking that I have to do them alone because I don’t want to take any help from anyone or bother them with my needs. I’m not going to want him with me when I do any of those tapes or exercises. I just don’t feel comfortable sharing those feelings with anyone; it feels very private to me. But I am pretty sure I’ll be able to do the rewards part with him, when I’m sup- posed to do something pleasurable or comforting. It’ll still be new for me, to call him and ask him, but I know that he wants to do it and I think it’ll be a good thing for me to try.” “Good,” says the therapist, “he is a very nice guy, I’m glad I got to meet him and that you have such excellent support to help you move along here.”

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Give the patient a new Grief Monitoring Diary. Ask the patient if there is anything she wants to say about the Grief Monitoring diary. Reinforce the helpfulness and importance of doing the monitoring. Tell her you will review the diary for two weeks at the next session. However, if she has any questions or wants to comment on anything, give her that opportunity. Ask about goals Ask if the patient has been working on her goals and how that is going. Ask if she has any questions or anything that is important to talk about now. Otherwise, the plan is to review two weeks of work next time.

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Phase II: Core Revisiting Sequence (Sessions 4-9) Pages 70-78

Session 4-9 Overview The intermediate phase of CGT begins with the first revisiting exercise, usually in the 4th session of the treatment. This phase includes focused work on loss and restoration that is designed to revitalize the natural healing process. The sessions are structured such that Imaginal Revisiting begins with session 4 and continues for about 4-5 sessions. At the same time, work on long-term aspirations is ongoing throughout the treatment. The main goal of revisiting exercises is to bolster the patient’s capacity to reflect on the death. We seek to help her come to terms with the death in a way that integrates this focal event into the life history of both her- self and the deceased. As C.S. Lewis came to recognize, death is not an aberration but rather a natural part of life. In his words: For all pairs of lovers without exception, bereavement is a universal and integral part of our experience of love. It follows marriage as normally as marriage follows courtship or as autumn follows summer. It is not a truncation of the process but one of its phases; not the interruption of the dance, but the next figure. We are ‘taken out of ourselves’ by the loved one while she is here. Then comes the tragic figure of the dance in which we must learn to be still taken out of ourselves though the bodily presence is withdrawn, to love the very Her, and not fall back to loving our past, or our memory, or our sorrow, or our relief from sorrow, or our own love.

A Grief Observed, P. 63. Death is fundamentally unfathomable. Yet it is part of the human condition that we must know about death and find a way to live with this knowledge. C.S. Lewis was a deeply religious and profoundly intellectual man. He wrote about the death of his wife. His thoughts about the problem of living with awareness of death are colored by his particular situation and may or may not be directly applicable to others. Patients need to find their own way of understanding mortality. Moreover, because our minds have limited ability to comprehend eternity, no explanation is likely to be entirely adequate. People with complicated grief, like the rest of us, need to come to terms with the fact that all life ends with death, and in this sense, death is an integral part of life. As

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such, unwanted as it is, death is as much to be honored, as are the many human faults we come to treasure, or at least accept, in those we love. Imaginal Revisiting is a method for helping people honor the death of a loved one and grapple with the painful reality. When revisiting is successful, a patient begins to find a way to think about the death of her loved one that is compatible with continuing to live her own life fully. We also do semistructured memories work, using a series of forms. These procedures further promote the sense of connection to the deceased and encourage continued reflection. Therapists should keep in mind that reflection is never completed after a loved one’s death. We all grapple with the meaning of death throughout our lives. As we do so, we naturally revisit and revise our understanding of the death of our loved ones. The goal of CGT is to release this natural process from the stranglehold of complicating thoughts, feelings, and behaviors. This phase contains the heart of the treatment. The treatment is fast-paced and emotionally activating. We seek to restore an effective oscillation between confrontation with painful information related to the loss and respite from that pain. The goal of the loss focus is for the patient to fully acknowledge the finality and consequences of the death and to integrate this knowledge into cognitive and emotional memory systems that contain models of self, others, and the world at large. The long-term objective is that she will have a strong sense of connection to her deceased loved one that integrates the information that the person is no longer living. Frederich Buechner explains this in an interesting way:

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How well they [the deceased] manage to take even death in their stride because although death can put an end to them right enough, it can never put an end to our relationship with them. Wherever or however else they may have come to life since, it is beyond a doubt that they still live in us. Memory is more than a looking back to a time that is no longer; it is looking out into another kind of time altogether where everything that ever was continues not just to be, but to grow and to change with the life that is in it still. The people we loved. The people who loved us. The people who, for good or ill, taught us things. Dead and gone though they may be, as we come to understand them in new ways, it is as though they come to understand us—and through them we come to understand ourselves—in new ways too.

The Sacred Journey, p.21 The goal of the restoration focus is for the patient to restore her capacity to envision a value-laden future for herself, and to participate in life in a way that allows her to find joy and satisfaction even without the person who died. Several strategies are used to achieve loss-focused goals. They include helping the patient to confront and reflect upon painful information about the death, and finding respite from this pain through shifting attention. We seek to help people establish a rhythm of confrontation and respite that optimally supports the process of integration. We encourage patients to reflect upon and rethink problematic beliefs related to the death. We use phased exercises, beginning with confronting the painful, stark reality of the death itself and moving to work on memories and an Imaginal Conversation (beginning at session 11) to facilitate integration of her relationship with the deceased into her ongoing life. We continue the process of self-observation and reflection and encourage the patient to open herself to comfort and support from others. Loss-focused procedures include use of the grief monitoring diary, Imaginal Revisiting of the story of the death, Situational Revisiting of reminders of the loss, memories work, and an Imaginal Conversation with

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the deceased. Procedures for gaining respite and generating positive emotions are interwoven with these, as is self-observation and reflection. We discuss concepts of acceptance and faith, encouraging patients to bring these into their thinking about the loss of their loved ones. Strategies for work on restoration include helping the patient to identify long-term aspirations, to learn to care for herself in both large and small ways and to open herself to the caring of others. We encourage the pursuit of both long-term goals and plans and short-term pleasurable activities. Procedures used include: identification of long term aspirations, and consideration of ways to move forward with these; identification of small pleasurable activities that are practical and ways to build these into everyday life; and situational revisiting exercises that will reduce barriers to people, places, and activities, and increase the sense of freedom and self confidence. In each of these endeavors we seek to help the patient identify roles for other people. You want to accomplish the following goals in this phase: 1. Decrease the emotional impact of the story of the death and help the patient comprehend the painful reality 2. Introduce and discuss the concepts of acceptance and faith 3. Reflect on the troubling aspects of the death and come to terms with the finality of the loss 4. Reduce behavioral and experiential avoidance of reminders of the loss 5. Facilitate the process of integration of memories with the reality of the death 6. Help identify and begin to incorporate long-term aspirations and plans 7. Encourage re-engagement in ongoing daily life and relationships 8. Facilitate the experience of genuine positive emotions This chapter, like the last one, provides instructions for how you can work to accomplish these goals during the first nine sessions of the intermediate phase. Session 10, covered in the next

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Session 4-9 chapter, is a review in which you check with the patient about what you have accomplished and what is still left to do. It is also a reminder that there are now just six more sessions. Once again, we suggest that you read through the whole chapter and then review instructions for a specific session in preparation for doing that session. It is helpful to prepare notes about what you plan to cover ahead of time, and use them, along with our checklist, in the session. Intermediate sessions, like those in the introductory phase, begin by setting an agenda that divides the session in three parts, roughly 5-10 minutes for agenda setting and review of the past week, about 30 minutes for implementing the main session content, and about 5-10 minutes to summarize the session and plan for the upcoming week. In addition, some therapists like to think about breaking up the middle section into two parts of roughly 15-20 minutes devoted to Imaginal Revisiting and reflection and 10-15 minutes spent on restoration-related activities. It is important to do the revisiting exercises early in the session and to end with restoration-related material.

Intermediate Phase Tools and Their Use We continue to use handouts and forms to elicit or provide information in the intermediate phase, and to help structure work between sessions. Some therapists have found the number of tools a little daunting and they sometimes struggle to learn how to use them. As for the introductory phase, we encourage you to take the time to learn what each of these tools looks like, how and when

it is used, and to develop a system to stay organized in your use of these forms and

handouts. In this section, we describe two main kinds of tools used in the intermediate phase. These include specific note taking and monitoring forms for the patient, and checklists, monitoring forms, and worksheets for the therapist. In addition, you do use assessment questionnaires, but they are

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administered only after session 8 or 9 and they are the same ones that are used in the introductory phase. The forms described below will continue to use the between session plans form described in the last chapter. The tools you will use in the intermediate phase are as follows:

Assessment Instruments No new assessment instruments are used in this phase. You will administer the set of simple CG symptom-focused questionnaires before sessions 8 or 9 (to use in session 10), and again before session 16 to monitor progress. Here is a list of these instruments: 1. Grief-related Avoidance Questionnaire (GRAQ) 2. Typical Beliefs Questionnaire (TBQ) 3. Grief Support Inventory (GSI) 4. Loss summary (LS) and Inventory of Complicated Grief (ICG)

Handouts These are short pamphlets with information for the patient and her family. They have been described in the Introductory Phase Instructions. They are listed here because you may find it helpful to use them in this phase. The handouts are available in the appendix of this manual. 1. “Complicated Grief and Its Treatment” 2. “Managing Difficult Times”: You want to keep track of when a patient is anticipating a difficult time and introduce the idea of planning for these times. You should be familiar with the information in this handout and review it with the patient in the session. Then

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you give the patient the hand- out to review at home. Note that if you need to work with difficult times, you should not do any highly activating exercises in the session nor assign such plans for the week when the difficult times occur.

Between Session Planning, Note taking and Monitoring Forms These are a set of forms that are given to the patient at the end of each session to assist in the interval work. The interval planning form and grief monitoring diary are used in each session, as is some version of the interval notes form. 1. Interval plans form (IPF): This is the one-page form on which you list and describe activities you are asking the patient to do over the week or other interval before the next session. This is a good way for both you and the patient to be sure you both agree and understand what the patient is going to do during the upcoming week and also a good cue sheet for setting the agenda the following session. 2. Interval Notes form (INF): This is a one-page form used to encourage the patient to think about the session and/or various issues that you want her to begin to consider; she is encouraged to use the INF to record reflections during the week and any questions that might come up. Again, this is a good way for you and the patient to structure a discussion of topics the patient is concerned about and/or things you want her to think about. 3. Grief monitoring diary (GMD) is given to the patient each week. The form is described earlier. 4. Between-session Imaginal Revisiting Form: this form is given to the patient after session 4 and each subsequent Imaginal Revisiting session. 5. Situational Revisiting List: is used in session 5 and given to the patient to complete at home. 6. Between-session Situational Revisiting Form: given to the patient after sessions 6-12.

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7. Memories Forms: These are a series of 5 forms that are given to the patient in order, after the first two Imaginal Revisiting exercises (usually at session 6) and weekly thereafter for an additional 4 weeks. 8. Difficult Times Plan: given to the patient when a difficult time is coming.

Checklists, and Worksheets for the Therapist A set of simple forms to help the therapist organize and monitor the sessions and prepare for and present information to the patient. 1. Session Form Checklist: There is a Session by Session Schedule of CGT forms which provides an outline of the materials a therapist will use in each session and the forms a patient will take home. 2. Therapist Imaginal Revisiting Form

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Instructions for Session 4: First Imaginal Revisiting Pages 79-95

Session 4 SESSION GOALS Reflect on Session 3 Discuss grief monitoring diary, review past week interval plans, and orient patient to the session Introduce revisiting a) Brief reminder of rationale b) Detailed description of the revisiting exercise and Subjective Units of Distress (SUDS) c) Conduct revisiting exercise d) Reflect on revisiting e) Put away story f) Discuss goals work g) Continue grief monitoring and interval plans

SESSION CONTENT Beginning: a) Discuss grief monitoring diary b) Review past week interval plans c) Orient patient to session Middle: a) First revisiting session, reflect, put away, plan a rewarding activity b) Review goals progress

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Ending: a) Session summary and feedback, b) Grief monitoring c) Interval plans

MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Session instructions Materials used in session: Imaginal Revisiting Form—therapist version. Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Interval Notes Form—standard form Between Session Imaginal Revisiting Form and Tape

SESSION PROCEDURES Session 4 introduces Imaginal Revisiting. The first revisiting exercise is brief, between 5-10 minutes. Generally people with CG do fine with revisiting. Occasionally, how- ever, a patient is reluctant to do it. The therapist should encourage the patient, telling her that the exercise will be very brief today—about 5 minutes or so—and that you will help her reflect on it and put it away afterward. Tailor the work to the individual patient at their level of readiness. Occasionally, you might

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decide to let the patient do the exercise with their eyes open or allow them to speak in a more conversational, open-ended way about the death. In these cases, your goal should be to prepare the patient to do the revisiting exercise in the next two sessions. You’ll want to convey confidence in the procedure and create the kind of supportive atmosphere that will make the patient feel safe doing the exercise. Many patients, wary of this exercise, agree to it only reluctantly. Their hesitation is understandable. When the patient does agree to Imaginal Revisiting, tell her you know that she is uneasy about it. Thank her for her willingness, and express admiration for her courage to work with you on this issue. Explain that you are going to start slowly—doing the exercise for just 5-10 minutes—and that afterward you will discuss what it was like for her. Later you will do the exercise for slightly longer. Therapists need to balance encouragement with sensitivity to the patient’s concerns. If necessary, the exercise can be modified. The modifications are described below. Sessions that include an imaginal exercise may be slightly longer than other sessions but ideally should remain within the 45-50 minute session length.

Beginning (about 7 minutes) Continue debriefing Session 3 (if visitor attended) Welcome the patient and tell her you are glad to see her. Tell the patient you enjoyed meeting their visitor. Remind her that last week she told you she thought the session went well (or “okay” or however she described it). If the patient voiced concerns at the previous debriefing, note these as well. Ask if she has had any further thoughts about the previous session. Ask if anything that was said surprised her. Share your thoughts about the session. Discuss the possibility of the significant other being involved in her interval plans work. How might that work? Encourage the patient to share what she is doing with the significant other, what she is feeling about them. Ask if it’s okay for you to continue to monitor their relationship. Discuss briefly and move on.

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Review Grief Monitoring Diary Ask the patient for the diary and comment on the overall pattern. For example, “It looks like this week was pretty hard. So far things haven’t changed much, right?” Or, “The beginning of the week showed pretty high grief intensity, especially on the day you were here. We expect that, of course, but then it looks like there was less grief intensity toward the end of the week. That’s great.” Ask the patient for her feedback about the pattern and discuss briefly. Then ask about the highest levels. What triggered them? What was the situation? Ask about the lowest levels. When did they occur? What were they doing or thinking? Ask the patient if she is beginning to see that her grief is not at just one level. Ask if this observation interests her. Discuss briefly and move on. Review Other Interval Activities Review the Interval Notes Form and answer any questions. Notice whether she mentions goals work, or if there was a specific activity planned for goals work. If there was, note whether the patient did the work and her appraisal of it. If she did not think about goals or do an activity that you agreed upon, ask if she found the goals work or the activity too difficult. Tell her you want to rethink this issue, and decide whether to try a different approach or if she is willing to try again next week. Tell her you would like to return to this topic at the end of the session. Ask if that’s okay. If she did think about goals or move forward with an activity, express enthusiasm and tell her you want to hear about it, but later in the session. Ask if this is okay. (You always want to do revisiting early in the session so that there is sufficient time for all five parts of it. Also, as a part of the strategy of restoring the natural oscillation, you want to shift from loss work—the revisiting—to goals work. In general, it’s best to end the session with a restoration activity or focus.

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Set Agenda and Orient Patient to Revisiting Explain that today you will begin the Imaginal Revisiting exercises. Remind the patient that this is usually a difficult part of the treatment but that you will be with her and you will support her while she does it. Explain that afterward, you are going to ask her to reflect on the experience and then you are going to practice setting the story aside or taking a rest from it. Also, tell her that you are going to record the exercise and give her the recording to take home. You’ll ask her to listen to the tape every day at home. You’ll also want her to reward herself for doing this assignment. You will discuss the rewards idea after you begin the exercise. Ask if this is okay.

Middle (about 35 minutes) Introduce Imaginal Revisiting Tell the patient you want to talk about Imaginal Revisiting. Ask if she understands the Imaginal Revisiting exercise and why you do it. If she doesn’t understand, ask if it’s okay to again explain the exercise and its rationale. If she does understand both, show her your enthusiasm for her awareness and correct any misconceptions she might have. If she does not, explain to her that although her rational mind grasps the reality of the loss, her emotional mind hasn’t fully accepted it. The result is that she is left in a prolonged state of acute grief. Imaginal Revisiting will address this problem. It will help her process the loss at an emotional level. As a result, she won’t need to be so preoccupied with the deceased, and yet she will feel more consistently connected to them. Deliberately and repeatedly revisiting the story of the death lessens the intensity of the emotions associated with it. In a way, she’s getting used to the story. The constant re-telling also tends to unearth details that help the story make sense and remain accurate. Finally, explain that the retelling helps both you and her see what is bothering her.

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After the patient does the exercise, you and she will spend time reflecting on it. Explain that you will talk about what she might have noticed when doing the revisiting and start to reflect upon it., Visualizing the scene together, telling the story, and reflecting upon it will help her come to terms with the reality of the death at a deep emotional level. Ask if this makes sense and if she has questions. Acknowledge again that telling this story is very painful but that you expect the pain to lessen with repeated listening and retelling. Explain that you are going to do this exercise repeatedly during the next four to six weeks and possibly longer. While she does it, you will record her telling the story. You will then give her the tape of her retelling the story so that she can listen to it between sessions. Tell her that you understand that it will never be easy to tell this story, but gradually she will find a way to come to terms with it, which will make it less painful. If the patient is extremely anxious about the revisit- ing, you may additionally explain that revisiting is different from the kind of intrusive and painful remembering she may have done in the past because it is deliberate and the therapist is there, listening with her. Because feelings about the death are so strong, some people are afraid they can’t tolerate them or that the feelings will never leave once aroused. In fact, the opposite happens: the more emotion people experience during the revisiting exercise, the faster the painful feelings subside. Ask the patient if she is ready for you to explain the revisiting exercise in more detail. If she agrees, tell her you want to explain the procedure first and then ask her to do it. In a few minutes, you will ask her to close her eyes and visualize where she was when she learned of the death. You want her to visualize where she was beginning with the moment just before she learned that her loved one had died, or just before she learned of the death, and tell the story aloud as she sees it unfolding. Be specific. For example: “I want you to close your eyes and try to visualize yourself with John, at his bedside, just before he died.” Or “I want you to close your eyes and visualize yourself at home watching

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TV when the phone rings.” As much as possible, you want her to see in her mind the place where she was, and to tell the story in the pres- ent tense, as if it were happening now. If you wish, you may offer an example. For example, you might say, “Let me illustrate what I mean by talking about a trip I took last year.” Close your eyes and say, “I am driving to the airport. It is snowing hard and the roads are slippery. I can hardly see. I am feeling nervous and wondering if the plane is going to take off. I have to concentrate on my driving. I am pretty tense. I arrive at the airport and there are people everywhere. Most of them look bored or annoyed. I realize that I am going to have a long wait.” Open your eyes and ask if she gets the idea. Explain that as she is visualizing and telling the story, you will interrupt periodically to ask for a rating of her distress level. We refer to this rating system by the acronym SUDS, which stands for Subjective Units of Distress. Ask if that term is okay with her. Explain that the SUDS level is usually a number between one and one hundred, and it reflects how emotional or distressed she feels at that moment. The highest SUDS level, 100, represents the most intense distress she has ever experienced. The lowest, zero, represents no stress at all. Ask what her SUDS level is right now. Discuss if there are any questions. Remind the patient that when you ask for her SUDS level, she should just say the first number she thinks of—even if she is not sure how accurate it is—and go on with her story. You do not want to interrupt either her visualizing or telling the story. Ask if she understands and if she has any questions. If the patient prefers, you may use a scale of zero to ten. If she does not like the term SUDS, you can simply ask for her “level.” Other similar modifications might be okay as long as you get a sense of her distress level periodically during the exercise—and you cannot ascertain that level without some kind of rating.

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Explain that you are going to record the exercise on a tape that you will give her to take home. At some point, after about 10-15 minutes, you will ask her to stop and open her eyes. Then you will ask her to reflect on the experience of visualizing and telling the story. You will discuss her thoughts about it for about 5-10 minutes and then you will introduce another visualization exercise to help her set the story aside. You will check her SUDS levels before and after the reflection period and after the second visualization exercise. Ask if she has any questions. Ask if she is ready to begin. Ask for her SUDS level. Begin Imaginal Revisiting (10-15 minutes) Turn on the tape recorder. Record the time that you begin the revisiting exercise and the patient’s SUDS level as you start. Tell the patient that when she is ready she can close her eyes and visualize herself at the time of the death. Provide details, for example, “visualize yourself at John’s bedside just as he takes his last breath.” Ask her to describe out loud what is happening. Take notes on what the patient is saying. Underline or otherwise note the periods that seem especially difficult. Ask for a SUDS level at those points, as well as at at least every two minutes so the tape has a minimum of three SUDS levels. This will help the patient more strongly feel your presence. When you ask for the SUDS level, say “you are doing fine” or “you are doing a great job. Just keep going.” At about seven minutes, start listening for a stopping point and gently tell the patient, “Okay, I would like you to stop and open your eyes.” Ask the patient her SUDS level. Turn off the recorder. Tell her she has done an excellent job. Sometimes the patient does not understand the instruction or for some other reason does not follow it. In that case, stop the revisiting exercise and review with the patient the model and the rationale for it. For example, a patient refuses to close her eyes. Instead

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of imagining herself back at the time of her mother’s death, she talks about how she was mistreated by her relatives at the time of the death, and begins skipping from the time of the death to the months before and afterward. She ruminates about her mistreatment rather than doing an imagery exercise where she merely observes herself and her feelings—and she may have felt them again—at the time of the death. The therapist should stop her, repeat the instructions and ask her to try again. If she still can not stick to the visualization, end the exercise. If the patient is not doing the revisiting exercise, do not send her home with a tape of the rumination, which will further activate the ruminating and the negative emotions associated with it. This is not what you desire. It is acceptable for a patient to do the revisiting exercise with her eyes open if she is very activated by the story. We are seeking to generate intense emotion. However, it is best for her to try to do the exercise with her eyes closed. The therapist should explain that the images generated with her eyes closed provide a more powerful access to the emotional part of her brain, which is very helpful. Try asking her to close her eyes and imagine a neutral or pleasant image or scene. If she is successful, do a very brief revisiting of the death for five minutes or less. Let her work with this brief image for the first week and then you can usually increase the time. If the patient is reluctant to do even this brief revisiting, you can do the revisiting with eyes open. However, it is important that she not engage in “time travel.” You are still looking for a blow-by-blow description of what she experienced without any explanatory comments. If she cannot do this, it’s best to end the exercise and move to situational revisiting or goals work.

Reflect on Imaginal Revisiting (about 10 minutes) Ideally, reflecting on the revisiting accomplishes many desired ends. It encourages the patient to begin to consider the story of the death and how it unfolded, to observe her own emotions, and to start to identify troubling thoughts and images. The important

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point is that she engage fully in the reflection process rather than turn to you to do it. In later sessions you will begin to direct her attention and ask focused questions. In this session, you simply want to invite the patient to observe and reflect on the story however she can. To help her reflect upon the experience, you can ask, “What was this like for you?” Most people respond by saying things like. “It was pretty hard.” Or “It was worse than I thought it would be,” or “It wasn’t as bad as I thought it would be.” Acknowledge her response, and ask what she observed as she was telling the story. Discuss as appropriate. Your goal is to help her notice her own reactions and reflect upon them. If the patient is disturbed by the intensity of her emotion, remind her that she did this exercise exactly as you were hoping she would and that through continuing to do so, and reflecting on that process, you believe you can best address her CG problem. Continue to ask the patient what she observed in telling the story. Ask what she noticed. Briefly discuss her observations and ask if she noticed anything else. Remind the patient of the problems that the two of you think might be derailing her mourning process. If she does not spontaneously mention it, ask if she noticed anything in the story that is related to the problems. For example, “A few weeks ago we discussed the fact that the guilt that you are feeling plays a big role in keeping your grief from progressing. Did you notice any detail or aspect of the story that is related to your guilt?” Let her do the talking, and if she begins to talk about her guilt, tell her that you want to start to think about this part of the story with her. Ask if that’s okay. She might also want to think about this aspect when listening to the tape at home. Here are some examples of starting to work on the grief complications. The patient says, “Thinking about this is so hard. My life ended that day.” You respond by saying, “This is the hardest thing you have ever experienced. It’s so hard it seems as if it ended your life.

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I can see why you feel that way, but of course it is not literally true. As we work together on this, we are going to try to see what makes you feel like your life ended. We are going to see if there is any other way to think about John’s death.” Or, the patient says, “I wasn’t there for him. I should have been there so I could have called 911.” You might say “It’s so hard to think about the fact that John is gone, and it’s even harder because you can’t stop thinking that you could have helped more, or maybe even prevented his death. As we move forward in our work together, we are going to work with this idea. Maybe it’s true. Maybe you really could have helped him more. On the other hand, it might not be so true. It might be that his illness was following an inexorable course and couldn’t really be stopped. Whether or not that is true, we are going to think about what happened, and see how you might be able to come to terms with it. Is that okay with you?” Keep in mind that the main purpose of the reflection period after the first revisiting is for the patient to begin to think about the experience. To help her, you ask about the experience as above and then further inquire, “Did you observe anything while you were telling the story? Or as you are thinking about it now?” Discuss. Ask if she observed anything else. You are introducing the process of reflecting on the revisiting experience. Reflecting upon the revisiting experience provides an opportunity for the patient to verbalize her emotions. It also provides some emotional distance, which helps her reappraise the meaning of the narrative. Reflection on the story highlights the parts that are most difficult, and these parts usually contain the complicating problems. Increasingly, these problems will become a focus of the reflection period. The process of reflection usually lowers SUDS levels, but not always. End the reflection period after about ten minutes by telling the patient again that she did a great job with the revisiting and reflection, and that you would like to move on to the next part of the session, which is putting the story away. Ask if this is okay.

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Ask for her SUDS level. Put Away Story (about 3 minutes) Tell the patient you would like to do another, slightly different, visualization exercise. Ask if this is okay. Ask her to imagine that the story she just told is a video recording. Tell her that in a minute you are going to ask her again to close her eyes and visualize herself as she goes through the process of putting away the recording. First, however, you want to explain what you want her to do and then you will ask her to do it. You want her to visualize herself in the room with the playback machine as she puts the recording into the machine and pushes the rewind button. You want her to continue to see herself in that setting and also to hear the tape rewind and then click when it finishes. She should continue to visualize the setting as she pushes the eject button, removes the recording from the machine and puts it into a sleeve. Then, she should visualize some safe place where she might put the recording. Tell her you want her to talk about this procedure of rewinding and putting the recording away as she visualizes doing it. For example, she might say, “I am standing in my kitchen with the video cassette in my hand. I am putting the tape into the recorder next to the kitchen table. I am listening to it rewind.” Tell her to be sure to visualizes as many details as possible and that she allows the recording to rewind for several minutes. During that time, she should focus on visualizing and noticing the details of the room she is in and on hearing the quiet sound of the rewinding tape. Ask if she understands and if she has any questions. Ask her where the playback machine is located. Ask for her SUDS level. Tell the patient that whenever she is ready, she can close her eyes, imagine she is in her living room (or kitchen or wherever she envisions herself putting away the tape) and begin. When she gets to the end, be sure she tells you where she is putting the tape. If she does not mention it spontaneously, ask her “Where are you going to put the tape?”

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After the tape is put away, ask her to open her eyes and tell you her SUDS level. It should be lower. Tell her she has done an excellent job with this first revisiting exercise. Ask if she is willing to listen to the tape at home during the week. Tell her you would like her to listen every day between now and next week. Get her agreement if possible, but if not, tell her she should just do the best she can. Tell her that the more consistently people listen to the tape, the more effective the treatment tends to be, but also that it is important for people to “dose themselves” with the painful emotions listening may arouse—and that she is the best judge of how to do it. Tell her you would like to talk now about her rewarding herself for her hard work. Ask if this is okay. If her SUDS level remains very high after the imaginal exercise of putting away the story, tell her that it’s understandable that she still feels very emotional, and that the exercise will be easier to do each time she does it. Naturally, she will never stop feeling emotional when she tells the story, but her feelings will become more manageable. Tell her you would like to do one more exercise and this time, you are going to do it with her. You want her to close her eyes and imagine a pleasant scene. Ask her what it will be and discuss if necessary. Tell her you want her to do some slow breathing while she imagines this scene. With you doing the counting, ask her to breathe in for four counts and then out for four counts. You can demonstrate. Ask her to count. As she counts, you breathe in for four counts and out for four. Ask if she has any questions. If not, tell her that when she is ready, she should close her eyes and imagine the pleasant scene. Begin counting, “In, two, three, four,” brief pause, “out, two, three, four.” Do this for about two minutes. Ask for her SUDS level. By this time it is almost certainly down. If not, simply reassure her, and move to the discussion of rewards. Be sure she does not feel critical of herself for staying in a very emotional state, and that she does not become afraid to tell the story.

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Discuss Rewarding Activities Tell the patient that you would like her to reward herself for her hard work. Explain that grief progresses best if difficult painful emotions are balanced with some periods of positive emotions. Discuss. The idea is that she finds an activity or gift that is simple, feasible and pleasurable. Ideally, this is an activity or gift she does not usually give herself permission to do or enjoy. The activity can vary: walking in the park, reading a book, going to a movie, having coffee with a friend, purchasing a favorite cookie or pastry, being with someone fun, taking a bath, getting a massage. Encourage her to think about different kinds of activities that are fun and pleasurable and to plan to do one of them. Tell her that you would like her to do a rewarding activity today and also each time she listens to the tape. Ask if she is willing to do that. Ask if she has any questions. Then tell her that now you would like to shift gears and talk a little about her goals and also about what she will do during the next week. Aspirational Goals Work Tell the patient you want to talk about goals. Return to the discussion about them from the beginning of the session. If there was a specific activity planned, and the patient did it, ask about it. How did it go? What was it like? What might she do next? If she did not do the activity, ask what might have stood in her way. Accept what she says, and ask if she is willing to try to build this goals work into her time next week. Ask if it seems feasible to do so. If not, problem-solve and come up with goals work that she can do. If she has not come up with a goal, ask her if she has had any more thoughts about one. Discuss. If she says she can’t think of any goals, reassure her that it’s okay; you will try to help her. Tell her you want her to think about what she might want to do even if it isn’t realistic. Ask her if she ever daydreamed about what she would do or be—either recently or even as a child. Ask her what kinds of dreams she’s had for herself. Tell her you are interested even if the dreams seem silly or unrealistic. Get her talking about wishes and dreams. Alternatively, ask about experiences that satisfied her in the past. What was her

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most satisfying experience? What are her talents? To what is she drawn? Plan for her to continue thinking about her answers during the upcoming interval.

Ending (about 5 minutes) Summarize Session and Elicit Feedback Recount to the patient that today you did the first revisiting session. Tell her she did a great job. You are hopeful that this painful exercise will prove very helpful to her. Ask how she thought the session went. Briefly discuss. Give Patient Grief Monitoring Diary Remind the patient that you would like her to continue to monitor her grief. Ask if there are any questions about the monitoring. Discuss Listening to Imaginal Revisiting Tape Rewind and give the patient the revisiting tape. Discuss when she can listen to it. Tell her you would like her to do it every day, ideally in the morning so that she can then set it aside and turn her attention to the rest of her day. Ask if there is a good time to listen in the morning. If not, discuss other times when she can listen. Listening in the evening can interfere with sleep. In general, she should not listen to the tape while driving. Most people like to find a quiet, private place in which to listen; however, if she would like someone else to listen with her, that is fine. If the patient says she wants a listening companion, discuss who it would be and how she thinks the companion might help her. Discuss ways to optimize the chances that the other person will agree and that they will provide the help the patient seeks.

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Session 4 Explain that you want her to pay attention to her SUDS level before, during and after listening each day. Give her a form (the Between Session Imaginal Revisiting Form) on which to record the SUDS levels. Ask if she has any questions. Tell her you would like her to plan a reward for herself, preferably right afterward, but if not, sometime during the day. Does she agree? Tell her you would like to talk to her after she listens to the tape tomorrow. Ask if that’s okay. Tell her you want to hear about her experience listening. Set up a time in which to talk. Complete Interval Plans Form and Give to Patient Write down the details of the plans for the next week on the Interval Plans Form and give to the patient. Give Patient Interval Notes Form (standard version) Also give her an Interval Notes Form and ask her to include her goals work on it. Ask if there are any other questions before you stop.

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Instructions for Session 5: Adding Situational Revisiting Pages 96-107

Session 5 SESSION GOALS Discuss Grief Monitoring Diary; review past week interval plans, and orient patient to session Continue Imaginal Revisiting Introduce situational revisiting list Discuss goals work Continue grief monitoring and interval plans

SESSION CONTENT Beginning: a) Discuss Grief Monitoring Diary b) Review past week interval plans c) Orient patient to session Middle: a) Second revisiting session b) Introduce situational revisiting and do list c) Continue goals work End: a) Session summary b) Grief monitoring and other interval plans

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Session 5 MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Session instructions Grief-related Avoidance Questionnaire (GRAQ) Materials used in session: Imaginal Revisiting Therapist Form Situational Revisiting List Optional Values Cards exercise (http://www.motivationalinterviewing.org/ content/ personal-values-card-sort) Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Plans Form Interval Notes Form Between Session Imaginal Revisiting Form and Tape Situational Revisiting List

SESSION PROCEDURES This is the second Imaginal Revisiting session and the first session to introduce situational revisiting. Goals work continues. If the patient has trouble naming goals, a values exercise can be done instead. The session begins with an interval review. It includes: discussion of grief monitoring, the patient’s experience listening to the Imaginal Revisiting tape, and goals work progress. After the review, the therapist orients the patient to the session.

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In your discussion of intervals work, you may discover that while the patient listened to the tape her SUDS levels actually rose through the course of the week rather than dropped as expected. One explanation is that she did the exercise incorrectly. Rather than envision the moment in which she learned of the death, she digressed into ancillary disturbing thoughts—“why did the person die? Why wasn’t I there longer to help him? If only.” You want her to acclimate herself to the story of the death, not aggravate herself by yielding to a cycle of remorse and frustration. Sadness as a result of the death is expected and useful, unlike anger, rage and frustration over its having happened. Be sure the patient has done the revisiting exercise correctly. For patients who have not been able to begin goals work in session two, a values exercise can be substituted for both goals and situational revisiting work. In other words, if the patient could think of no goals and perhaps even said she has never set any goals for herself, then omit the situational revisiting discussion for session five and substitute a values exercise for the goals work. If you proceed in this manner, give the patient the Interval Notes Form—at the end of the session. As usual, the therapist needs to show confidence in the revisiting procedure and maintain a respectful and comforting posture so that the patient feels safe and supported. As revisiting continues, you will begin to see progress. The second revisiting session is important in illustrating how the story changes slightly—different aspects are emphasized, fleshed out or clarified, while others recede in importance. Patients notice the change and usually are reassured by how much they remember. Still, this phase is difficult, and you should keep that in mind. When appropriate (and only if you feel this way), tell the patient that you appreciate her willingness and admire her courage and determination to do these exercises. Again, sessions that contain Imaginal Revisiting are likely to last longer than other sessions.

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Session 5 Beginning (about 5 minutes) Welcome the patient back and set the agenda Welcome the patient and ask her how she is doing to be sure there is no urgent matter that needs to be addressed. Remind her you want to hear more about her week, but as always you have a lot to cover and you would like to set the agenda, if that’s ok with her. When she agrees, tell her you first want to start by reviewing her grief diary and checking completion of other weekly plans. Then you are going to do another revisiting exercise. After that, you will introduce situational revisiting, touch base again about aspirations and goals, and then make your plans for next week. Ask if this sounds okay. Review Grief Monitoring Diary Review the overall pattern of grief and comment. Get the patient’s feedback about the pattern and discuss briefly. Identify the highest points and briefly discuss triggers. Do the same with lowest levels. Ask About Goals Work Briefly review what the patient has done or not done and tell her you want to return to this later in the session. Review Imaginal Revisiting Listening Form Ask the patient for her Imaginal Revisiting Listening Form. Ask her about the listening exercise. How was it? Discuss briefly. Review the form and comment. You expect some decrease in SUDS levels through the course of the week. If the patient hasn’t listened enough for the levels to have dropped, tell her that she might have seen the SUDS level lower had she listened more consistently. Ask what made it difficult for her to listen. If the SUDS level does not decrease with regular listening, explore how the patient did

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the exercise. Sometimes, a patient becomes so immersed in the story that she feels as though she is reliving the death. You want the patient to be emotionally engaged, but at the same time to remember that she is in the present. You want her to be able to feel the intensity of her emotions from within, but be able to observe them from without, and with a more consoling message to herself about them. For example, rather than “why did this happen” to “it happened” and eventually, “I am left with wonderful memories of this wonderful person.” The role is one of both a participant and an observer. The patient is “processing” the experience—viewing it in such a way that she can live with the knowledge and the memory of it. We will discuss this processing in more detail later in this chapter. Most people do it naturally, but occasionally they are too distant from their emotions or too trapped within them to observe and, eventually, accept them. Sometimes, the SUDS levels actually rise during the course of the week. In such cases, typically, the tape is triggering rumination. Often, it’s very compelling, and the patient’s thoughts naturally move toward it. Another possibility is that the revisiting exercise wasn’t done properly in the first place. For example, if the therapist failed to recognize the problem described in session four (above), and completed the exercise, then the patient has been listening repeatedly to a tape of herself ruminating about her mistreatment, which is only likely to further aggravate her negative feelings about her situation. In the case of a faulty Imaginal Revisiting, you should simply do another revisiting exercise more cautiously during this session. As the therapist, you may also choose to spend the session discussing the model of complicated grief and having the patient reflect further upon the death, or engage in problem solving the circumstances related to the mistreatment.

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Session 5 Middle (about 35 minutes) Begin Imaginal Revisiting (about 15 minutes) Tell the patient that you would like to do another revisiting exercise. Ask if she has any questions about it, and if she does, answer them. If not, remind her that in a few minutes you are going to ask her to close her eyes and tell you the story of the death from the moment she first learned of it, just as she did last session. Remind her to visualize the setting as vividly as possible and to speak in the present tense. Remind her that you are again going to tape record the exercise and ask her to listen to the tape during the week. Ask if she has any questions. If so, answer them. Tell the patient that when she is ready, she can close her eyes, visualize being back at the time of the death, and tell the story aloud. Turn on tape recorder. Ask for her SUDS level. Record the time at which you begin the revisiting exercise. Make a note of periods that seem especially difficult, asking for SUDS level at those points, and again every two or three minutes. You want the tape to have at least three SUDS levels so that the patient feels your presence both when she is doing the exercise in session, and when she listens at home. When you ask for her SUDS level, you may say, “you are doing fine” or “you are doing a great job. Just keep going.” After about 10-12 minutes, listen for an appropriate stop- ping point and gently tell the patient “Okay, I would like you to stop and open your eyes.” Ask for her SUDS level. Tell her she has done an excellent job. Reflect on the story (about 10 minutes) Ask the patient to reflect on the exercise as you did in session 4. Ask, “what was it like for you?” Discuss her answer. Again, you want to underscore the importance of identifying and reflecting upon any especially troubling ideas that may arise. You are still not going to discuss them in depth, but rather help the patient identify these as the issues that are keeping her stuck. Ask her to think about the fact that simply telling herself how bad a

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certain situation or event was, or how bad it still is or will be, is keeping her stuck. She needs to consider other ways of dealing with the difficult reality. When she is ready, you will do your best to help her. Painful experiences need to be processed, which means we need to find a way to accept what happened as an unwanted reality and learn to live with it. The patient also needs to put the death in the context of both her own and the deceased person’s life. The death is a part of both the bereaved person’s life and the deceased person’s life, but not all of it. (You will discuss death in the context of the patient’s life and life in general in later sessions). If particular problems block acceptance, you and she need to work toward solving them, which is challenging. One way in which people often solve challenging problems is by revisiting the problem and reflecting on possible solutions. Ask if the patient has ever had a problem that was very difficult to solve. Has she had the experience of reconsidering how she was thinking about the problem? Has she ever helped anyone else view a problem from a different perspective? You may need to help the patient remember that she probably has reconsidered a situation or problem in her past. To help her recognize that she has may require drawing upon what you know of her history, relationships and experience of optimal functioning. For example: Steve was a successful businessman. As such, it is inevitable that he had to solve problems and make hard decisions. He probably occasionally made a decision that he realized in retrospect may have been the wrong decision. The therapist asks, “Did you ever second-guess yourself in that situation?” He said that early on in his career, he did, but he learned that he was better off focusing on the future and not berating himself for what he couldn’t change. The therapist asked him to consider whether this kind of thinking might be applicable to his mother’s death. He said he really hadn’t thought of it that way. He said he wanted to mull this over.

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Continue reflecting in this manner for about ten minutes. Ask for a SUDS level. Put Away Story (about 3 minutes) Ask the patient if she would like to put away the story. Sometimes the SUDS level comes down sufficiently during reflecting and the putting-away exercise isn’t necessary. Or the patient may not find it helpful. Give her a choice. If she wishes to do the exercise, then proceed. Tell her you would like to do the visualization exercise that entails imagining the story is on a videotape, then putting it in the machine, rewinding it, and putting it away. Ask if she has any questions about this exercise and, if not, tell her she can begin whenever she is ready. When she is finished, she will either open her eyes, or you can ask her to open them. Ask for a SUDS level. Discuss a Rewarding Activity (about 2 minutes) Talk with the patient about how she is going to do a rewarding activity. Reinforce the rationale and importance of this as needed. Explain that you would now like to shift to a discussion of avoidance, and then to talk about her goals work. Ask if this is okay. Introduce Situational Avoidance (about 10 minutes) Tell the patient that you want to talk a bit about avoidance. Get out the Grief Related Avoidance Questionnaire. Identify items with the highest scores. Ask for specific examples and how much distress they would trigger if confronted. Ask her to use the SUDS level (0100) to rate her distress. Repeat for one or two situations. Explain that it is understandable that she is trying to avoid these situations since they trigger painful reminders that the deceased is gone. However, avoidance is a problem because it undermines her ability

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to come to terms with the death and its consequences, and also because it is restricting. Explain that she can’t feel free to restore her interest in other people and situations if she has to be careful about where she goes, what she does, whom she is with and what she or anyone else may say. Ask her if your explanation makes sense to her. Tell her that you would like to begin working on situations or people she avoids. Explain that you will start by listing specifically those people, places or situations that she is avoiding. Using a rating of 0-100, she will indicate the level of distress she thinks she would experience in encountering or experiencing them (100 connotes the hardest place or person to visit). Ask her if she understands the process. Going back through the list, she will then rate which activities she most wants to do (or which people she wants most to be able to see). In this case, 100 connotes the person or place or activity she most wants to be able to see or do. Ask again if the process makes sense. Is she willing to work on these ratings at home? Answer any questions. Aspirational Goals Work (about 5 minutes) Return to goals work. Tell the patient that you want to shift and talk about goals. Return to the discussion you had at the beginning of the session. Discuss her progress on goals. Ideally the patient is starting to take some action related to her goals. It can be something very small. You are mostly interested in having her spend time thinking about goals and changing her behavior in some way, however small, to start to really address her goals. Your job is to encourage her to start this work. If the patient is still struggling with goals, consider doing a values exercise derived from motivational interviewing (MI). This exercise uses a values card sort procedure (http:// www.motivationalinterviewing.org/content/

personal-values-card-sort).

Information

about this is available on the MI website. The exercise takes about 10 minutes and results in the patient declaring up to five strongly held values that are rank-ordered. After doing

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the procedure, the therapist can write the values on the Interval Notes Form, and give it to the patient to work on during the interval until the next session.

Ending (about 5 minutes) Summarize Session and Elicit Feedback Summarize what you covered in the session. Ask for feedback from the patient. How did the session go? Briefly discuss her response. Review Interval Plans Form Plans for the upcoming interval include: 1) Grief Monitoring, 2) Goals work or Values work, 3) listening to Imaginal Revisiting tape, and 4) developing Situational Revisiting hierarchy (based on ratings). Tell the patient you want to review each of these components briefly. Plan Listening to Imaginal Revisiting Recording Rewind and give the patient the revisiting tape. Give her a form on which she can monitor her SUDS levels while listening. Ask if she has any questions. Remind her and solicit her agreement to reward herself after listening. Also, ask when she is planning to listen to the tape. Would she like to talk with you afterward? If so, set up a time. Plan Goals or Values Work Review the plans for goals work and write it on the Interval Plans Form. If you are working on values give the patient the Interval Notes Form—and ask her to complete it during the upcoming week.

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Situational Revisiting Hierarchy Remind the patient to complete the revisiting ratings. Ask if she has any questions. Grief Monitoring Diary Remind the patient to continue to keep her diary. Ask if she has any questions. Ask if there are any other questions before you stop:

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Instructions for Session 6: Adding Memories Forms Pages 108-118

Session 6 SESSION GOALS Discuss the Grief Monitoring diary; review past week interval plans, orient patient to session Continue Imaginal Revisiting Do Situational Revisiting hierarchy—begin by completing the situational revisiting list. Discuss goals or values work Continue grief monitoring and interval plans

SESSION CONTENT Beginning: a) Orient patient to session b) Discuss Grief Monitoring diary c) Review past week interval plans Middle: a) Third revisiting session, reflect on the revisiting, put away, plan rewarding activity b) Situational revisiting c) Introduce memories forms d) Continue aspirational goals work Ending: a) Session summary and feedback b) Grief Monitoring and other interval plans

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Session 6 MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Session instructions; Grief-related Avoidance Questionnaire (GRAQ) Materials used in session: Imaginal Revisiting Therapist Form Situational Revisiting List Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Interval Notes Form Between Session Imaginal Revisiting Form and Tape Between Session Situational Revisiting Form Memories Form-1

SESSION PROCEDURES Session Six begins with an interval review that includes grief monitoring, goals or values work, work on the situational avoidance list, discussion of listening to the Imaginal Revisiting tape, and an orientation to the session. The middle of the session includes a third Imaginal Revisiting exercise as well as situational revisiting work and goals or values work. The first of a series of memories forms is introduced in this session.

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Memories work, a semi-structured procedure for reviewing memories, partly through pictures, is introduced in Session 6 and is a focus of interval work for the next five weeks. The purpose of the forms used is to foster a sense of connectedness to the person who died. The patient’s earliest positive memories are explored, followed by more positive memories and then the patient’s favorite memories of the deceased. The fourth memories form asks for memories that aren’t so positive and the final form asks for both positive and less positive memories. We emphasize positive memories of the deceased because data show that it is natural to see more of them over time. We include less positive—even negative—memories because we want people to feel comfortable when these emerge naturally and also, because having a realistic, fully fleshed out picture of the deceased helps the patient feel connected to the real person rather than the idealized one. You will also ask the patient to bring in her favorite pictures of the deceased or any other pictures she wants to bring. If Imaginal Revisiting homework is showing no decrease in SUDS levels, or if the patient says she needs a break, you can alter the protocol. The patient may be like some who do better when the revisiting alternates with at least one session devoted to reflection and cognitive reappraisal or problem-solving. If that is the case or if the patient feels she needs a break, use the session to both review the model and to work on the main cognitive or social/environmental problem. You can also use this approach if a problem in the patient’s life is so distracting that it interferes with her ability to reflect upon the loss or see the future as hopeful. You may also decide that the patient can benefit more from focusing on one of these issues than on avoidance. Think of rumination, social-environmental problems, and avoidance as interlocking gears that you want to see move forward more or less in tandem. If one lags, use the session to address it. Instructions for reflection or problem solving are provided in the appendix. These exercises can be used either separately, or together as alternatives to revisiting. The instructions in this section pertain to revisiting.

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Session 6 Beginning (about 5 minutes) Review Grief Monitoring Diary Ask the patient for the diary and look it over. Discuss the pattern and the triggers. Discuss whether the grief intensity levels are changing. Discuss whether there is movement toward a natural balance between confrontation and respite. At the beginning of treatment, patients are often either overly confrontational—all they can do is ruminate about the loss—or overly avoidant—they refuse to talk about it. Sometimes they are both. The goal is to have the patient confront the loss in a way that allows her to process and accept it, and then to take a conscious break from thinking about it by working on other aspects of her life, such as the goals work. You’re looking to see that she adapts to the movement between confronting the loss and putting it aside. Ask About Other Interval Activities Ask about the situational revisiting exercise. Review briefly and postpone further discussion until later in the session. Ask about goals. Comment briefly and postpone more discussion until later in the session. Ask about listening to the tape. Review the Imaginal Revisiting form. Note how the listening has been going. If SUDS are not going down during the week, discuss before doing revisiting (see below). If SUDS are going up during listening, do not do a revisiting session. Instead work on problems, as discussed below. Provide support and encouragement as indicated. Orient Patient to Session If the SUDS have been coming down, tell the patient you want to do a third revisiting exercise. Ask if this is okay. You will do this in the same way you have done it so far. After you put the story away and discuss rewards, you will talk about the situational revisiting exercise and goals. You are also going to introduce a memories form at the end of this session. Ask the patient if this sounds okay and if she has any questions. If the SUDS levels

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are not coming down during the listening, tell the patient you want to take a break from revisiting and replace this part of the session with reflection and/or problem solving. The purpose of the revisiting exercise is to start to process the loss. When this happens the SUDS come down. If it is not happening, you need to understand the problem preventing it from coming down, and address it.

Middle Do Imaginal Revisiting Exercise (about 15 min) Tell the patient you would like to do another revisiting exercise. Think about where you typically start the exercise. If you have started at a place where she can talk about details before getting to the situation that activates her emotionally the most, start this one closer to the difficult period. Here is an example: A patient was staying in another room in her home when her sister died. The therapist initially had her do revisiting from the time that her brother came to tell her that her sister was gone. In doing the revisiting she spent several minutes talking about how she was lying in bed and had to decide to get up and then she had to open the closet to find her robe and go into the bathroom and brush her teeth. Only then did she venture into the living room where her mother was sitting crying and after hugging her and trying to comfort her, she went into her sister’s room. Her SUDS was high from the beginning but it spiked on the prior two revisiting exercises as soon as she entered her sister’s room. For this reason, the therapist will start the third revisiting exercise differently. The therapist will ask the patient to visualize walking into her sister’s room. Turn on audio-recorder. Ask for SUDS level.

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Record the time that you begin and end the revisiting exercise. Make a note of the periods that seem especially difficult, asking the SUDS level at those points, and at least every 3-5 minutes. At about twelve minutes listen for a good stopping point and gently tell the patient “Okay, I would like you to stop and open your eyes.” Ask the patient her SUDS level. Tell her she has again done an excellent job. Reflect on Imaginal Revisiting (about 10 min) Ask the patient to reflect on the revisiting you have just done. Ask what she observed about it and briefly discuss. Ask if she can reflect upon the part that was most disturbing. Talk about it with her. If she does not talk about the issues you have identified in the case formulation, ask about them. Work with her on how to solve the problem. You want to help the patient begin to see how certain instinctive responses to bereavement have become amplified, among them: thoughts that you can’t manage without the deceased loved one, that you should have done more to help or protect them; that someone else should have done more; that it’s unfair that the loved one died. What is difficult about grief is that we have these thoughts instinctively, and yet they are neither rational nor helpful in the long run. Circumstances that appear to underscore or affirm them only complicate the mourning process. You want to encourage the patient to recognize other ways to view her loss. If necessary, remind the patient that these difficult experiences need to be processed so that we can come to terms with them. Some people automatically “process” difficult experiences in some situations but not in others. In other words, when some unwanted event occurs, most people find a way to cope with it by accepting that it happened and dealing with the consequences. However, sometimes people can get stuck in a futile process of ruminating upon the reasons why it should never have happened. Again, part of processing involves revisiting a problem, thinking about it differently, re-examining certain ideas about it that a person may have simply assumed were givens.

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As stated, you want to encourage the patient to recognize other ways to view her loss. For example: What does it really mean to her life now and in the future? What are the consequences of the loss for her real life? The deceased was more than their death; how can the bereaved person best think about the death as one event in a lifetime of events? Given that we will all die sometime, how bad was it that this person died when they did? Given that everyone dies, where does this death fit into the larger picture of a person who not only died, but also lived. You want to focus the discussion on similar issues. End the reflection discussion after about ten minutes. You can suggest to the patient that she continue to consider these issues as she listens to the tape at home. Ask for a SUDS level Put Away Story (about 3 minutes) Ask the patient if she would like to put away the story. Tell her that when she is ready, she can close her eyes and tell you what she is doing as she puts the tape away. Ask for a SUDS level. Plan a Rewarding Activity (about 2 minutes) Ask how she is going to reward herself. Discuss if necessary. Tell her you would now like to shift to a discussion of avoidance, and then to talk about her goals work. Ask if this is okay.

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Discuss Situational Revisiting Review the situational revisiting hierarchy list. Discuss. If possible, select an activity or situation that is feasible to do repeatedly and that is high on desirability. You want her to have repeated confrontation with the chosen situation or activity. Ideally you want an activity in the range of 40-60 on the SUDS scale and 80 or higher on the desirability scale. This is not always possible. Work with the patient to find an activity that is challenging but do-able, and that she wants to be able to do. Discuss as needed. Decide upon the activity. Note that the exercise needs to be feasible, and the patient needs to be motivated to do the activity. Also note that you want her to select something that she will do every day or almost every day, regardless of how she feels on that particular day. You do not want her to do one of these activities only if she feels like doing it. Instead, you want her to choose something that she can do even when she isn’t in the mood. For example, a patient wanted to order her favorite meal at a restaurant in which she and her deceased husband frequently dined. Although the waiters and cook would be happy to see her, she feared the experience would be difficult. She proposed trying it if and when she felt strong enough. The therapist did not accept this proposal. Instead, you— the therapist—want her to think about a less challenging activity, one she could do even when she is not feeling strong. For example, maybe she could walk past the restaurant every day. She could stop and read the menu. Or she could visit a different restaurant and order a meal. You want her agreement that what she chooses is something she can do every day. Aspirational Goals Work Tell the patient that you want to shift and talk about goals. Return to the discussion at the beginning of the session. Discuss her progress working on goals. Ideally the patient is starting to take an action related to her goals. It can be a modest one. Mostly, you want

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her to begin to think about her goals and to take steps, however modest, to set them in motion. Your job is to encourage her as she proceeds. If you are working on values, review the Interval Notes Form. If she has completed the form, discuss her responses. If she has not completed the form, spend some time talking about the items on it. Decide whether you will ask her to continue to work on it or if you think she is ready to return to goals work

Ending (about 5 minutes) Summarize Session and Elicit Feedback Summarize what you covered in the session. Ask the patient how she thinks the session went. Briefly discuss. Review Interval Plans Form Plans for the upcoming interval include 1) Grief Monitoring 2) goals work 3) listening to Imaginal Revisiting tape 4) doing a situational avoidance exercise and 5) completing Memories Form-1. Tell the patient you want to review each briefly. Listening to Imaginal Revisiting Tape Give the patient the revisiting tape and form on which to record SUDS levels. Remind her to reward herself after she listens. Ask when she is planning to listen to the tape. Plan Goals or Values Work Review plans for goals work and write this on the Interval Plans Form. Situational Revisiting Plans Review the plan for situational revisiting and write it on the Interval Plans Form

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Memories Form-1 Tell the patient that you are going to begin reviewing memories with her. Tell her there are a series of forms to help with this. Review and give her Memories Form-1. Also, ask her to bring in a favorite photograph of the deceased, or other favorite pictures. Grief Monitoring Diary Remind the patient that you want her to complete her GMD. Ask if she has any questions. Ask if there are further questions before you stop.

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Instructions for Session 7: Full Core Revisiting (1) Pages 119-128

Session 7 SESSION GOALS Discuss Grief Monitoring diary; review past week interval plans and orient patient to session Continue Imaginal Revisiting Continue Situational Revisiting Review Memories Form-1 Discuss goals or values work Continue grief monitoring and interval plans

SESSION CONTENT Beginning: a) Discuss Grief Monitoring diary b) Review past week Interval Plans c) Orient patient to session Middle: a) Do Imaginal Revisiting exercise; b) Review Situational Revisiting; c) Review memories, d) Continue Aspirational Goals work

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End: a) Session summary and feedback, b) Grief monitoring and other interval plans

MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Session instructions Materials used in session: Imaginal Revisiting Form-therapist version. Situational Revisiting List Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Interval Notes Form Between Session Imaginal Revisiting Form and Tape Between Session Situational Revisiting Form Memories Form-2

SESSION PROCEDURES The interval review starts with discussion of grief monitoring and then moves on to goals or values work, situational avoidance work and memories work, using the form that was handed out at

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the previous session. Interval review will be followed with discussion of the patient’s experience listening to the Imaginal Revisiting tape, and an orientation toward the session. The middle of the session will include an Imaginal Revisiting exercise, situational revisiting work, memories form work and goals or values work. The second of a series of memories forms is introduced in this session.

Beginning (about 5 minutes) Review Grief Monitoring Diary Ask the patient for the diary and examine. Discuss pattern and the triggers. Ask if the patient has noticed any changes. Ask About Other Interval Activities Ask about situational revisiting exercise, memories form, and goals. Review these briefly and postpone further discussion until later in the session. Ask about listening to the tape. Review Imaginal Revisiting Form. Discuss her progress with the listening. Discuss the SUDS pattern and talk about her experience listening to the tape. Ask what thoughts she is having about the death. Confirm that if the patient is listening to the tape, the SUDS levels are shifting. You should see a reduction from the beginning of the week to the end in at least one of the measures. If not, you need to focus on what is happening when the patient listens to the revisiting exercise. Is she engaged in listening? Is she distracted? Is she veering off into ruminations? If so, you want to spend time during this session to work on the patient’s thoughts about the death.

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Orient Patient to Session If the SUDS are lowering during the listening period, tell the patient you want to do another revisiting exercise. Ask if this is okay. You will do it in the same way you have done it in the past. After you put the story away and discuss rewards, you will talk about the situational revisiting exercise and values or goals. You are also going to discuss the memories form toward the end of the session. Ask if the plan sounds okay, and if she has any questions. If the SUDS are not responding, tell the patient you are not going to do a revisiting exercise today because you want to talk to her about reflecting on the story of the death. Tell the patient that you want to talk about coming to terms with the loss and what it will take to do that. Remind the patient of the problems identified in the treatment formulation.

Middle (about 35 minutes) Begin Imaginal Revisiting (about 15 minutes) Ask the patient if she is ready to do another revisiting exercise. Ask if she has any questions about it and if so, answer them. If not, tell her that when she is ready, she can close her eyes and tell you the story of the death, just as she did during the last session. Remind her to imagine she is back at that time and to speak in the present. Turn on audio-recorder. Ask for SUDS level. Record the time that you begin and end the revisiting exercise. Make a note of the periods that seem especially difficult, asking the SUDS level at those points, and at least every 3-5 minutes. At about 12 minutes listen for a good stopping point and gently tell the patient “Okay, I would like you to stop and open your eyes.” Ask the SUDS level. Tell her she has

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again done an excellent job. Reflect on Imaginal Revisiting Reflect on the experience as in prior sessions. In this session you should be engaged in a focused reflection and reappraisal of problematic cognitions. You still ask “what was this like for you?” and briefly discuss the answer. If the patient does not talk about her problematic thinking, the therapist should bring it up directly. Use the formulation to ask focused questions or provide comments. Link the dysfunctional thoughts to early history and to instinctive responses. Work with the patient to challenge these thoughts. Here is an example. A patient, Susan, has been suffering from complicated grief since the death of her husband five years ago. She and her husband had a close, mutually supportive relationship that she described as “magical.” Though they did not agree about everything, they had a deep understanding of each other, treated each other with kindness and respect, and never fought. Each had grown up in a family where their parents were in constant conflict; both felt determined to live their lives differently. Their relationship was the envy of their friends. Susan is plagued by the thought that she should have been able to be more helpful to her husband during the terminal stages of his illness. Sometimes she thinks she should have diagnosed his illness herself, even though she has no medical training. She feels guilty that she did not protect him. She imagines that if she had been more attentive, he would not have died in the way that he did. During the revisiting exercises it becomes clear that her husband was on significant pain medication and was relatively comfortable as he lay dying in the hospice where he was being treated. He was not able to communicate much in the last weeks, except that the night before he died he seemed more alert than he had for many days. He felt a surge of hope that he might recover. When he died, Susan was overwhelmed with disappointment, anxiety, and self-blame. Since the day he died, she has not been able to think about his

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last hours without feeling waves of remorse and anxiety. The strength of these emotions frightened her. As a result, she has tried desperately to avoid reminders of his death. During the revisiting exercises she began to talk about her husband’s peaceful state as he lay dying. In reflecting upon the exercise she focused on her anxiety about managing without him and her guilt about not having helped him more than she did. The therapist wonders if perhaps as a result of her difficult upbringing, she developed a strong sense of self reliance as well as a determination and ability to be a caring and responsive spouse, noting that she seemed to succeed in that role until her husband died. At that point, it was as though the pain and uncertainty she experienced during her childhood resurfaced and she “forgot” how well she had adjusted for most of her life. The therapist suggests that the way out may not be so difficult asking Susan to think about how she actually has managed since her husband died. Recognition of small successes began to emerge. Similarly, when the therapist asks her to talk about how much she really did care for her husband, Susan was able to see that she had in fact been a devoted wife both before and during her husband’s illness. As she began to see her guilt and anxiety as reminiscent of her childhood experiences and not so relevant to her current life, the intensity of these feelings subsided. After a similar period of discussion relevant to your case, tell the patient you would like her to continue to think about these issues as she listens to the tape during the upcoming week. Ask for a SUDS level. Put Away Story (about 3 min) Ask the patient if she would like to put the story away. Tell her that when she is ready, she can close her eyes and describe what she is doing as she puts the tape away. Ask for a SUDS level.

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Plan a Rewarding activity (about 2 min) Ask what rewarding activity she is going to do for herself. Discuss if necessary. Tell her you would now like to shift to a discussion of avoidance, and then to talk about her goals work. Ask if this is okay. Discuss Situational Revisiting Return to the Situational Revisiting Form. Review the form and discuss the patient’s experience with it. You are looking for repeated confrontation with the target situation or activity, and if she has complied, whether the SUDS levels fell as expected. Discuss as needed. Decide whether to continue to work on this revisiting exercise or add a second one. Use these principles to decide: first, it’s a good idea to work on one situation until there is definite progress; second, that the exercise needs to be feasible and the patient needs to be motivated to do it. Discuss Memories and Pictures Return to the memories form. Read and discuss the most enjoyable times the patient had with the person who died, the deceased’s most likeable characteristics, what the patient loved about them and what the deceased added to the patient’s life. Ask about pictures. Ask to see the pictures and discuss them. Tell the patient you want to shift gears, and talk about her goals or values work. Ask if that’s okay. Goals or Values Work Return to a discussion of goals or values. Discuss progress on goals. Ideally the patient is starting to take actions related to her goals. They can be small ones. As always, you are mostly interested in having her think about goals and address them, in whatever small way she can. Your job is to encourage her. If you are doing values work, ask if the patient has had any more thoughts about her values, her abilities, or other satisfying experiences

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in her life. Begin to use her responses to help her formulate or consider goals. Brainstorm with her about goals, drawing upon her values, abilities and past satisfactions

Ending (about 5 minutes)

Summarize Session and Elicit Feedback Summarize what you covered in the session. Ask patient for feedback. Ask how she felt about the session. Briefly discuss. Review Interval Plans Form Plans for the upcoming interval include: 1) grief monitoring, 2) goals work, 3) Imaginal Revisiting tape listening, 4) situational avoidance exercise, and 5) completion of Memories Form-2. Tell the patient you want to review each of these briefly. Listening to Tape of Imaginal Revisiting Give the patient the revisiting tape and form on which to record her SUDS levels. Remind her to reward herself after she listens. Ask when she is planning to listen to the tape. Plan Goals Work Review the plans for goals work and write them on the Interval Plans Form. Situational Revisiting Plans Tell the patient that you want to continue reviewing memories. Tell her that the next form is about not-so-positive memories and aspects she didn’t really love about this person. It asks about her least favorite memories, their most annoying traits, what the patient might want to be different about them, what she doesn’t really miss and what might be

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easier now that they are gone. Ask if she is okay working on these less positive memories. Explain that it is important that these negative memories are accessible and not blocked, even though the positive ones are more prominent and important and the ones she wants to recall. Review Memories Form-3 with her and give it to her. Grief Monitoring Diary Remind the patient, as usual, that you want her to complete the GMD. Ask if she has any questions.

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Instructions for Session 8: Full Core Revisiting (2) Pages 129-138

Session 8 SESSION GOALS Discuss Grief Monitoring Diary, review past week interval plans and orient patient to session. Continue Imaginal Revisiting, consider doing “hot spots” (described below) Continue situational revisiting Discuss goals work Discuss Memories Form-2 Continue grief monitoring and interval plans.

SESSION CONTENT Beginning: a) Discuss GMD b) Review past week interval plans c) Orient patient to session Middle: a) Revisiting exercise (possibly with hot spots) b) Situational revisiting c) Memories review d) Goals work End: a) Session summary

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b) Grief monitoring and Interval Plans

MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Session instructions Materials used in session: Imaginal Revisiting Form-Therapist version Situational Revisiting List or optional values exercise Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Interval Notes Form Between Session Imaginal Revisiting Form and Tape Between Session Situational Revisiting Form Memories Form-3

SESSION PROCEDURES This session again begins with an interval review. In it are: grief monitoring; Memories Form-2, goals work, situational avoidance list, discussion of listening to the Imaginal Revisiting tape, and an orientation to the session. The middle of the session includes an Imaginal Revisiting exercise— with hot spots if needed. Hot spots refer to the part of the story at which the patient’s SUDS level spikes and are discussed further below. If the patient’s SUDS levels overall are still not dropping, you may need to revisit merely the hot spots. The procedure, in which the patient does an Imaginal Revisiting that only encompasses the hot spot and then repeats the exercise three or four times

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in rapid succession, is outlined in detail below. It is done only if there is a particular place in the story that remains highly activating (i.e., SUDS spikes) after three or four revisiting sessions. Hot spot revisiting used in this way brings the SUDS down pretty dramatically. (The term “hot spot” is borrowed from PTSD therapy.) In addition, the middle segment will include situational revisiting, memories and goals work. As in earlier sessions, the therapist may choose to work on reflection or problem solving instead of revisiting. Memories Form-2 is reviewed in this session and the patient is given Memories Form-3.

Beginning Review Grief Monitoring Diary Ask the patient for the diary and review. Discuss pattern and the triggers. Note any changes. Comment on her GMD work. Ask About Other Interval Activities Ask about situational revisiting exercise. Review briefly and postpone further discussion until later in the session. Ask about memories work and postpone discussion of it, too. Same with goals work: comment briefly and postpone further discussion until later in the session. Ask about listening to the tape. Review the Imaginal Revisiting Form. Discuss her listening experience. Discuss the SUDS pattern and what it was like for her to listen to the tape. Ask what thoughts she is having about the death. Praise the patient for listening and note how much the SUDS levels are decreasing. Orient Patient to Session Tell the patient you want to do another revisiting exercise. Ask if this is okay. Do the exercise in the same way you have done it so far, including a hot spot revisiting if the SUDS level is still spiking. After you put the story away and discuss rewards, you will discuss

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the situational revisiting exercise, memories and goals work. Ask if this plan sounds okay and if she has any questions. Alternatively, if the patient is having some difficulty processing the loss, you can spend the session working on reflection and reconsideration of complicating emotional problems.

Middle Begin Imaginal Revisiting Tell the patient that when she is ready, she can close her eyes and tell you the story of the death just as she has been doing. Turn on audio recorder. Ask for SUDS level. Record the time that you begin and end the revisiting exercise. Make a note of the periods that seem especially difficult, asking SUDS level at those points, and at least every 3-5 minutes. At about 12 minutes listen for an appropriate stopping point and gently say, “Okay, I would like you to stop and open your eyes.” Ask the SUDS level. Tell her she is doing great. If there are one or more places where the SUDS level clearly spikes, consider doing a “hot spot” revisiting. Hot spot refers to the place at which the patient’s SUDS level spikes. Identify the segment in which the SUDS level is very high and decide on a cue to note the beginning and end of the segment. Tell the patient you would like to focus on this part of the story instead of reflecting on the entire exercise. Explain that you will ask her to close her eyes again but this time, to focus on this difficult part. She will tell just this part of the story repeatedly. The hot spot segment should be no more than one to two minutes in length. As soon as she completes the difficult segment, you will ask her to begin again. She will repeat the exercise three to four times in rapid succession. As with standard revisiting, first explain the approach. When she is ready, ask her to close her eyes and begin at the place where the hot spot begins and end where the hot spot ends. Turn on audio recorder. Ask for SUDS level.

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Here is an example: Diane describes in a revisiting exercise how she has been calling her son, who lives alone, for several days, and he uncharacteristically fails to answer the phone or call her back. Eventually, she decides to go to his house. She lets herself in and begins calling him. When he doesn’t answer, she goes first to his bedroom, then to the kitchen. Then she walks into the living room and sees him sitting in a strange position on his couch, motionless. She thinks that he is very ill and feels frightened. She isn’t sure what she does next, but she thinks she calls 911. Next she is walking to her car to follow the ambulance to the hospital, feeling as if in a daze. She arrives at the emergency room and is escorted into a special private waiting room. The doctor enters and tells her that he is so sorry but that her son is gone. He asks if she is okay. As she recounts the story, she has a sense of unreality. The first time she tells the story of her son’s death, her SUDS level is 100 during the entire revisiting exercise. However, she listens to the story regularly at home, and she repeats it two more times in treatment sessions. Each time, she recalls more details about what happened that day. As she recalls these additional details, she seems to be making sense of the story. Her SUDS level gradually decreases to a range from 60-80. However the level continues to spike to 100 when she gets to the part where she enters the living room. At session eight the therapist suggests they do a hot spot revisiting. She asks the patient to begin when she walks into the living room and to end when she leaves the house. Diane begins. She describes walking into the living room but this time, she recalls that her anxiety and dread have increased as she has walked through the house. She has an odd premonition that something terrible has happened. She sees her son and at first, a wave of relief washes over her. She calls out, “There you are. Why didn’t you answer me?” As she approaches him, however, the feeling of dread returns, only more strongly. She thinks he is not okay and that she better get help. She runs to the phone and calls 911. She then goes back to her son’s side and shakes his arm. She sees that he is so still. Why

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isn’t he answering me? She begins to pace and to try to think what she can do. She isn’t sure how long it is but she next recalls paramedics arriving and asking her how long he has been like this. She says she doesn’t know. She is crying and afraid. She asks if she can go with them and they say she should follow them in her car. The therapist asks her to stop and begin again at the point when she is walking into the living room. During the second retelling, Diane says her dread and fear are growing as she walks through the house, calling her son. She now reports feeling momentary relief as she stands at the door of the living room; then, a wave of fear as she sees the empty pill bottles strewn on the coffee table and notices how still her son seems. She thinks he must have had pain in his old leg injury and only a few pain pills left so he had to get several bottles. She thinks to herself that she needs to get help and runs to the kitchen to call an ambulance. Shortly afterward the paramedics arrive and she leaves with them to go to the hospital. Again, the therapist asks her to stop, and to keep her eyes closed and start the story over; from the time she enters the living room. The third time Diane tells this story she says that she has been wandering around the house becoming increasingly concerned. She sees her son in the living room and experiences a brief flash of hope that he fell asleep watching television, but as she nears him and sees how still he is, she knows that her worst fears have been realized and he is gone. She starts to cry and she says that she loved him so much and that she could never help him. She knew he was taking too many pain pills and that he was possibly addicted to them, and she knew she should talk to him about this, but she could never find the right time or the right way to do it. He was very sensitive about this topic. Diane’s experience is one of the ways hotspot revisiting can be helpful. In this case, Diane began to rapidly recall and report critical details of the highly emotional moment when

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she found her son, who had died some time earlier. Diane’s experience is one of the ways hotspot revisiting can be helpful. In this case, Diane began to recall other critical details and the story became more complete. Sometimes the details don’t change but the emotional intensity decreases anyway simply through repeated telling. Reflection on Imaginal Revisiting After both the standard and hot spot revisiting is completed, reflect on the experience as in prior sessions. Ask the patient, “What was this revisiting like for you?” Briefly discuss her answer. Some patients find the power of hot spot revisiting disconcerting. They feel as if their hearts have “turned to stone” and are uncomfortable feeling less emotional. Hot spot revisiting is more likely to upset the patient if done too early in the treatment, before any successful inroads have been made into feelings of self-blame. In cases of a violent death, for example, hot spot treatment may be needed early on. In those cases, the therapist should help the patient distinguish between the reduction in anxiety she may be feeling, and any decrease in her feelings for the deceased loved one. In either case, it is important to identify and discuss any feelings aroused by the hot spot revisiting. Ask for a SUDS level. Put Away Story Ask the patient if she would like to put the story away. When she is ready, she can close her eyes and describe herself putting away the tape. Ask for SUDS level. Plan A Rewarding activity Ask what rewarding activity she might do. Discuss if necessary. Tell her you would now like to shift to a discussion of avoidance, and then to talk about her goals work. Ask if this is okay. Discuss Situational Revisiting Return to the Situational Revisiting Form. Review the form and discuss the patient’s

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experience with this exercise. Note whether the SUDS levels fell as expected. Discuss as needed. Decide whether to continue to work on this situation or add a third exercise. Discuss Memories and Pictures Return to the Memories Form. Read and discuss the patient’s favorite memories, the deceased’s best traits, what the patient misses most about the deceased, and how she comforts herself when she thinks about them. Tell the patient you want to shift gears, and talk about her. Ask if that’s okay. Aspirational Goals Work Return to goals work. Pick up from discussion at the beginning of the session and discuss progress on goals. Or, if you have been working on values, abilities and satisfactions, consider whether you are ready to return to goals work. Continue to provide support and encouragement to help patient move forward. Plan what she will do during the next interval.

Ending Summarize Session and Elicit Feedback Summarize what you covered in the session. Ask for feedback from the patient. How did the session go? Briefly discuss. Review Interval Plans Form Plans for the upcoming interval include: 1) Grief Monitoring, 2) Goals work, 3) listening to the Imaginal Revisiting tape, 4) Situational Avoidance exercise 5) completing Memories Form-3. Tell the patient you want to review each of these briefly.

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Listening to Tape of Imaginal Revisiting Rewind and give the patient the revisiting tape and form on which to record SUDS levels. Remind her about the reward for herself after she listens. Ask when she is planning to listen to the tape. Plan Goals Work Review the plans for goals work and write them on the Interval Plans Form. Situational Revisiting Plans Review the plan for situational revisiting and write it on Interval Plans Form. Memories Form-3 Tell the patient that you want to continue reviewing memories. Tell her that the next form is about not-so-positive memories and aspects she didn’t really love about this person. It asks about her least favorite memories, their most annoying traits, what the patient might want to be different about them, what she doesn’t really miss and what might be easier now that they are gone. Ask if she is okay working on these less positive memories. Explain that it

is important that these negative memories are accessible and

not blocked, even though the positive ones are more prominent and important and the ones she wants to recall. Review Memories Form-3 with her and give it to her. Grief Monitoring Diary Remind the patient that you want her to complete her GMD. Ask if she has any questions.

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Instructions for Session 9: Full Core Revisiting (3) Pages 139-145

Session 9 SESSION GOALS Discuss Grief Monitoring Diary; review past week interval plans and orient patient to session Continue Imaginal Revisiting Continue Situational Revisiting. Discuss Goals work Discuss Memories Form-3 Continue Grief Monitoring and Interval plans.

SESSION CONTENT Beginning: a) Discuss GMD b) Review past week Interval plans c) Orient patient to session Middle: a) Revisiting exercise (possibly with hot spots) b) Situational Revisiting c) Discuss Memories Form-3 d) Continue Goals work

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End: a) Session summary b) Grief Monitoring and Interval plans

MATERIALS NEEDED Pre-session Questionnaires: Grief-related Avoidance Questionnaire (GRAQ), Typical Beliefs Questionnaire (TBQ) Grief Support Inventory (GSI) Inventory of Complicated Grief (ICG) Therapist review (before session): Session instructions Materials used in session: Imaginal Revisiting Form-Therapist version Situational Revisiting List or optional values exercise Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Interval Notes Form Between Session Imaginal Revisiting Form and Tape Between Session Situational Revisiting Form Memories Form-4

SESSION PROCEDURES Begin, as usual, reviewing Interval activities. Discuss Grief Monitoring, Memories Form- 3, Goals work, situational avoidance list and listening to the Imaginal Revisiting tape. Orient patient to the session. The middle of session 9 includes either an Imaginal Revisiting exercise, or a Revisiting

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exercise with hot spots (as in session 8). As in earlier sessions, you may choose to work on reflection or problem solving instead of Revisiting. The session also includes a discussion of Situational Revisiting, a review of Memories Form-3 and Goals work. The patient is given Memories Form-4.

Beginning Review Grief Monitoring Diary Ask the patient for the diary and look at it. Discuss the pattern and the triggers. Ask if the patient has noticed any changes. Ask About Other Interval Activities Ask about the Situational Revisiting exercise and Memories Form-3. Review these briefly and postpone further discussion until later in the session. Ask about goals. Comment briefly and postpone more discussion until later in the session here too. Ask about listening to the tape. Review the Imaginal Revisiting Listening Form. Discuss how the listening has been going. Discuss the SUDS pattern and talk about what it was like to listen to the tape. Ask what thoughts she is having about the death. Provide support and encouragement. Orient Patient to Session Tell the patient you want to do another revisiting exercise. Ask if this is okay. Provide feedback on the progress of the revisiting, and explain that today will probably be the last time she will do the Imaginal Revisiting in session. She will proceed in the same way she has done it so far—this time including a hot spot revisiting if her SUDS level is still spiking. After you put the story away and discuss rewards, you will talk about the situational revisiting exercise and goals. You are also going to introduce a memories form at the end of this session. Ask if this sounds okay and if she has any questions.

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Session 9 Middle Do Imaginal Revisiting Exercise Do the revisiting as it was done in session 7, or with hot spots, as in session 8. Discuss Situational Revisiting Return to the Situational Revisiting Form. Review the form and discuss the patient’s experience with the exercise. Note whether the SUDS levels fell as expected. Discuss as needed. Decide whether to continue to work on this situation or add a fourth (or additional) one. Discuss Memories and Pictures Read and discuss Memories Form-3. It includes her least favorite memories, the deceased’s most annoying traits, qualities about their loved one the patient might want to be different, aspects of them she doesn’t really miss and what might be easier now that they are gone. Ask how she felt answering these questions. Discuss the memories and her response to them. In general, this form elicits varied responses. For some people, the experience isn’t interesting; they either say they don’t have many negative memories of the deceased or that they don’t care about the negative memories. Accept this unless you know it to be blatantly untrue. Note that it is unusual for someone with CG to have had a conflicted relationship with the person who died. Some people have been ignoring annoying characteristics of the person who died, and for this group, the negative memories form can be very helpful. Sometimes a person who has been very focused on how much she needs her deceased loved one starts to recall that there were times when they were very difficult, demanding, controlling, or burdensome. Therapists need to remember that recognition occurs against a background of deep love and caring and it does not indicate

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that the “true” story is now emerging. Rather, the patient should be encouraged to see that remembering the negatives as well as the positives about a loved one can help her feel more connected to the real person. You might comment that almost everyone we love has some traits that we are not so fond of and sometimes this just makes us love them more. Goals Work Return to goals work. Return to the discussion at the beginning of the session and discuss progress on goals. Continue to provide support and encourage the patient to move forward. Plan what she will do during the next interval.

Ending Summarize Session and Elicit Feedback Summarize what you covered in the session. Ask the patient for feedback. How did she feel about the session? Briefly discuss. Review Interval Plans Form Plans for the upcoming interval include: 1) grief monitoring, 2) goals work, 3) listening to Imaginal Revisiting tape, 4) doing situational avoidance exercise, 5) completing Memories Form-4. Tell the patient you want to review each of these briefly. Plan Goals Work Review the plans for goals work and write them on the Interval Plans Form. Situational Revisiting Plans Review the plan for situational revisiting and write it on Interval Plans Form.

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Memories Form-4 Discuss Memories Form-4. It asks about memories of the deceased that are positive and those that aren’t so positive. It asks her to imagine their most endearing or admirable traits and their most annoying ones, qualities she loves most and least and misses most and least. You might remind the patient that you know the positive characteristics of her loved one far out- weighed the negative ones, but we want to be sure she can think about her loved one realistically. Thank the patient for telling you about these qualities and ask if she feels okay about talking about them. Grief Monitoring Diary Remind the patient that you want her to complete this. Ask if she has any questions. Ask if there are any other questions before you stop.

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Phase III: Midcourse Review (Session 10) Pages 146-161

Session 10 Midcourse Review Midcourse Review The third phase of CGT consists of taking stock and planning the closing sequence that is used to complete and consolidate the work and to plan for ending treatment. Most of the time, the decision is to continue work on the primary CG-related loss. Alternatively, the therapist may decide to shift to work on a second loss, or the focus may shift to work on an interpersonal dispute or a role transition using a brief IPT approach (see below). As a part of the midcourse review, the therapist returns to the formulation developed in session 2 and reviews and revises this as necessary. Additionally, an estimate of progress is made regarding the overall objectives of resolving grief complications and facilitating natural adaptation processes. The midcourse review is guided by questions such as: what thoughts, feelings and behavior have blocked the progress of grief? How well have these been addressed so far? What has helped? What has changed? What work remains to be done? How much progress has been made with aspirational goals? How much with situational revisiting? In doing this review during session 10, you include both a discussion with the patient and a review of questionnaires. Prior to the session the patient is asked to complete the Grief-related Avoidance Questionnaire

(GRAQ), the Typical Beliefs Questionnaire (TBQ), and the Inventory of Complicated Grief (ICG) that were also done at the beginning of the treatment. You should review changes on these assessments, as well as changes in the GMD. Ideally, the forms are available before session 10 so you can review them prior to the session. The clinical interview is used to elicit the patient’s view of the treatment to date, and to engage in a collaborative discussion about the next phase of treatment. In most cases the work remains focused on the CG-related loss that brought the patient to treatment.

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Session 10 Midcourse Review As the therapist, you also evaluate the possibility of shifting the focus of the last six sessions to do work on a second CG-related loss or to work on an interpersonal problem to address an especially difficult role transition or an important interpersonal dispute. About twenty-five percent of patients we have seen report a second loss for which they have threshold level symptoms of Complicated Grief. For those patients who have a second difficult loss, the session 10 review should include an assessment of CG symptoms regarding this loss. If CG is still present, it may be useful to shift the loss-focus of the next six sessions to deal with this second loss. Some patients struggle with a role transition or interpersonal dispute that affects their mood. Bereavement often results in role transitions that are difficult to navigate. Role transition problems can occur with any loss, but occurs most commonly following the death of a spouse or partner. The bereaved person must make the difficult role transition from being a couple to being a single person. Often the bereaved person must take responsibility for tasks that were previously done by the partner and this can be uncomfortable. For example, a woman who has been staying at home and taking care of the household may need to find a job.

A man may need to take on

homemaking activities that are difficult for him and unfamiliar. Social activities may feel strange and uncomfortable because they are attended alone instead of with a partner. Other bereavement situations may also be associated with difficult role transitions. Sometimes an interpersonal problem is interfering with the progress of grief. Close companionship is important in navigating the rocky waters of grief and if a close companion is not available because of an ongoing dispute, this can be distracting and problematic. As with role transitions, any loss can be accompanied by an interpersonal dispute, but most commonly there are interpersonal disputes between family members after the loss of a child. Mothers and fathers may grieve differently and may find themselves in conflict over whether to talk about the child or not talk about her or him, whether to confront the pain or try to keep it at bay. One parent may be very troubled by seeing the other upset and the other parent may find it difficult that her partner

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Session 10 Midcourse Review seems cold and uncaring. Sometimes the relationship between the parents was already strained, even before the death of the child. When you identify an important interpersonal dispute, session 10 should include a brief interpersonal inventory in order to stage and outline the features of the conflicted relationship that the patient might work to improve. In summary, session 10 is used to review, summarize treatment to date, and to plan the closing sequence. The review entails a discussion with the patient and review of relevant rating scales. In addition to work on treatment termination and continuing work on aspirational goals, possibilities for the closing sequence include: 1) continuing work on the primary loss, attending to resolving complications and facilitating adaptation processes with respect to both loss and restoration, 2) a shift in loss-focused work to a second difficult bereavement episode, while continuing the restoration-focused work, or 3) brief interpersonal work on a role transition or interpersonal dispute.

Topics for Consideration During the Midcourse Review Indications for Continuing Work on the Primary Loss Most people treated in our program continue to work on the primary loss during the last phase of treatment because there is a need for more work coming to terms with the loss. This is especially true if one of their difficult times has occurred during the treatment. Therapists need to take time out to deal with a difficult time. Work on difficult times is discussed earlier in the manual and in a section below related to planning for the future. Work on the primary loss continues when the patient shows evidence in session 10 of being partially treated. There is evidence that CG is still present, though there is usually also evidence that progress is being made. As the therapist, you can use several indicators to estimate the level of CG symptoms. These include the Grief Monitoring Diary, the GRAQ and TBQ. Clinically

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Session 10 Midcourse Review significant problems that remain in any of these ratings are an indication that more work on the primary loss should be considered. However, it is also important to get a sense from the patient of treatment gains and how confident they feel in these gains. The goal of CGT is to free and revitalize a natural instinctive grief process. People who leave treatment on a path consistent with successful mourning differ with respect to grief intensity levels, though in general these are noticeably lower than at the beginning of the treatment. The clinical interview in session 10 is also used to make this decision. People who are partially treated show some overall improvement in grief intensity on the grief monitoring diary, but average levels are still regularly above 5 and there are still spikes in grief intensity on three or four days of the week and these spikes are not noticeably shorter lived than in the beginning of the treatment. There has been some change in avoidance of situations that evoke strong emotions, but there are still restrictions in activities and some feeling of hesitancy about addressing this. There is still indication of distracting or preoccupying thoughts on the TBQ. In addition to the information from the rating scales, use discussion with the patient. This discussion includes exploration of the way the patient is thinking about the death and whether this has changed since the beginning of treatment. Here is an example of a case where the therapist decided there was more to do. This patient, Beth, developed complicated grief after her husband Michael died after a long battle with severe diabetes. Michael had died at home shortly after returning from a hospitalization. Beth had been out of town visiting her elderly mother at the time and was plagued with thoughts that she could have saved Michael if she had been home. The following excerpt includes parts of the session 10 review: T: We have completed the main part of the therapy, and now we have this last segment we call the closing sequence that focuses on finishing treatment and consolidating gains. Our first job is to go over some ratings. You filled out some forms and we want to review those. Then we have to decide what to do in our last six sessions.

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Session 10 Midcourse Review P: I am getting stronger, not denying my feelings. It’s like dealing with it—I

an onion, peeling off the layers. I wasn’t

put myself in a cocoon. People told me to get over it, but I couldn’t. When I

started coming to treatment I found I had to face things, gently, every week, and I wasn’t running from it. Each time I got stronger. I had to deal with you again and again, and each day I had to deal with things. I was afraid for the part I didn’t play in saving his life, and now I see that these things are life’s trials. I’ve gotten stronger again. I can deal with it. Before I couldn’t talk about it without breaking down. You have to be strong to survive, and I’m not going to quit. I’m not a quitter. I could not have done it on my own. You asked me if I thought the world is unjust. I don’t think so. I would have thought so six months ago. I was angry at the world, angry with myself. I’m not now. T: Lets look at your grief over the past week P: It’s about right for where I am. I don’t feel it’s overwhelming and ruling my life. Michael wasn’t ready to die. Sure he was worn out. He told them a year ago not do anything more to him. He wasn’t a quitter, and he wasn’t old like my mom. He always wanted treatment. He said let me be a guinea pig if I can help someone else or live a month longer. They explained there wasn’t much they could do because he couldn’t survive an operation because of his diabetes. T: (reviewing forms) You still think that you’re holding on too much and should be coping a bit better. P: Yeah, a bit. Not as much. He’ll always be close, but I am much better than what I was. T: Okay, but we’re not done here yet. Let’s go over the avoidances. You have his ashes in your living room. P: The box.

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Session 10 Midcourse Review T: The box. Your plan is to bury that. P: Which I will, and if I don’t this winter I will this spring. It’s definite in my mind. I don’t have time right now. T: That’s great. And do you think that somewhere in there you aren’t ready to bury his ashes? P: I’m sure. I’m sure it will be a hard day for me, and I have to get ready for it. I can hurry and do it and be done with it. I’d rather not do it that fast. T: Tell me what you mean when you say that. P: I don’t want to hurry. I don’t want to cut off my feelings. I want to, make a date, plan a dinner or lunch, make it an occasion, do it nicely, and put him to rest. I don’t want to do it in a hurry or by myself; I want to do it with family. T: That sounds so good. My sense is that this is a finality that you don’t feel quite ready for yet. P: Right. It would be final but he will always at the house with me, and everywhere I go. Our relationship has made me who I am. T: He became a part of you and you him. P: We always talked about each other because our lives were intertwined. But he wasn’t restricted by being with me. If he wanted to go somewhere…

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Session 10 Midcourse Review T: You’d let him go. And now he has gone someplace else, and I know it’s painful because it’s permanent. P: Yeah in a way. T: So once his ashes are in the ground, you’re not going to get them out again. They’re going to be there. There is finality, and it may be good for us to think about that as a goal over the next coming weeks. P: I think so too. His birthday is coming up. I’m sure there will be feelings there, and I don’t feel ready for it. I’m not ready to clean house. I can give more away. T: So you’re more comfortable with it, but not completely comfortable with it? P: No. T: That may be something we can talk about, challenging but doable. P: I think that’s a good part to this program. I have to do some challenging and physical things. I think before I couldn’t because my grief was so strong. T: You said you would know you were there if you could accept Michael’s death. P: Right. I’ve accepted the fact that he died. I still have a little baggage about it, the fact that I didn’t call the hospital.

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Session 10 Midcourse Review Revisiting the Treatment Formulation Part of the process of deciding whether and how to continue work on the primary loss entails revisiting the treatment formulation. In session 2 you developed a preliminary formulation and discussed this with the patient. At session 10 you revisit the formulation. Not infrequently, the formulation has changed. Sometimes the change is that there were several issues that were blocking the progression of grief and now there is just one. Sometimes you have gained a new perspective. Sometimes there are just more details so the formulation is clearer and makes more sense to the patient. Here are some examples of these different situations: When Beth came for treatment, she was feeling angry at the unfairness of Michael’s death, overwhelmed with thoughts that she could not manage without him and plagued with guilty ruminations about why she had gone to visit her mother at a time when her husband clearly needed her. As she worked through Imaginal and Situational Revisiting exercises, she began reflecting on her reaction to Michael’s death. As illustrated above, by session 10 she was not so angry anymore, and she was actively considering burying his ashes. She had made considerable progress on her personal goal to get a new job in a field that she had always wanted to enter. She was beginning to recognize that Michael might have been ready to die. There is the interesting sequence above where she contradicts herself. She says “Sure he was worn out. He told them a year ago when he was up here to not do anything more to him. He wasn’t a quitter, and he wasn’t old like my mom. He always wanted treatment.” The therapist recognizes this and understands it as an indication that Beth is actively grappling with the question of whether she thinks Michael was ready to die. The therapist sees this as the core remaining problem and revises her formulation. The therapist now saw Beth as a person who has always prided herself on her care- giving and who was, in fact, a very effective caregiver. She had learned this role during her childhood when

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Session 10 Midcourse Review dealing with a chronic family stress had depleted her mother’s resources and required Beth to train herself to “be a good girl” and a helper. When she expressed her own needs or had emotional outbursts she was roundly criticized by her irritable over-stressed mother. Beth learned that she must always control her emotions and one way she did this was by focusing on taking care of others. Over the years that Michael struggled with a chronic debilitating illness Beth usually accompanied him to the hospital or medical appointments where she buried her own feelings, and served as his staunch and vocal advocate. However, as Michael’s condition deteriorated and he weakened and struggled with losing his vision, developing kidney failure and hypertension and underwent amputation of his left lower leg, he had begun to prepare himself to die. He was getting ready, but Beth was not. She felt terrified by the idea of being on her own after so many years of feeling Michael’s loving support. This had been by far the most rewarding relationship of her life, and she did not want to lose it. Her reaction to his deteriorating medical condition was to redouble her determination to save him and resist his efforts to help her see his preparations for dying and to help her prepare her as well. Her diligence and courage in the treatment confirmed that Beth had the inner resources to come to terms with this painful loss, and also that she had a solid support system to help her. Her remaining avoidance symptoms and guilty ruminations represented her continued difficulty fully recognizing that Michael was ready to go and that she did not really need to hold him back —either for his sake or her own. Here is another example: Emily entered treatment four years after her only child died in a car accident. Alyson was twenty-two when she died in a car driven by her boyfriend who was intoxicated and drove off the road. Alyson was not wearing a seat belt and she was thrown out of the car and hit her head on a stone. She died instantly. Her boyfriend survived. Emily was devastated. She felt her world had come to an end. She was fifty-five years old and divorced when Alyson died. She had been raised in a family with an abusive alcoholic mother and a passive father. She said she and her brother raised each other. They had a favorite aunt who they could call if things got really bad, but if their mother found out there was “hell to pay.” Emily decided that when she grew up she would marry a kind man like her father and have 6 children and a loving family, like “the Brady

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Session 10 Midcourse Review bunch”—a television show she loved. As things turned out, she married a man who seemed to be passive and sweet like her father, but he didn’t want children. She got pregnant anyway, neglecting to tell him she had discontinued her birth control pills. He was angry but did not insist that she end the pregnancy. However, he was never supportive of her during her pregnancy and seemed to have little interest in the new baby. Their relationship began to deteriorate and shortly after Alyson’s 2nd birthday she found out that her husband had been cheating on her. She was furious and asked for a divorce. She raised Alyson as a single mother and found this deeply satisfying. She and her daughter became very close. Part of their closeness seemed to derive from the fact that Alyson was a spunky and independent child who began getting into trouble at a young age. Emily’s mothering skills were often challenged and she found it deeply gratifying that she succeeded in meeting the challenges almost every time. Her friends told her she was the best mom they knew. Most recently, Alyson had gotten involved with a man that Emily did not like. She saw him as wild and irresponsible, but Alyson said she loved him. This had become a source of conflict, but Emily thought they would find a way to resolve it. At the time of her death, Alyson was Emily’s closest confidant. When she presented for treatment Emily was distraught. She alternately berated herself, railed against the boyfriend or bitterly condemned her daughter. She was convinced that this death was unfair and that Alyson never should have died. At the beginning of treatment, the therapist identified grief complications as counterfactual, second-guessing ruminations that alternately assigned blame to herself, someone else, or an unfair world. During the first ten sessions the patient made progress, but still seemed caught up in feelings of being lost and unable to find her bearings. She did the revisiting exercises diligently and did get benefit from this. However, in reflecting on the loss, she increasingly focused on thoughts about how empty and pointless her life was without her daughter. In one session she talked about her childhood promise to herself that she would have lots of children and be a wonderful mother. She explained that she had ultimately coped with the fact that Alyson would be her only child and that she would raise her without a partner. She made the adjustment to this reality even though she considered it a “watered down version” of what she really wanted. But Alyson’s death was more than she

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Session 10 Midcourse Review could handle. The therapist noted that Emily was mourning the loss of her daughter and also the loss of her lifelong dream of redemption from a difficult childhood. She was coming to terms with losing Emily but she could not imagine her life without some version of her dream. The therapist formulated this as the central problem for the last phase of the treatment. The patient agreed and said she felt a kind of relief. Even though she did not see how she could solve this problem, she said she hadn’t seen that this was bothering her so much.

Indications for Work on a Second Loss Not infrequently, patients who present for treatment of CG have a second loss for which they developed CG. This is not the majority, but for those who do, CGT can help. Patients may benefit from working on a second loss if there is one that is causing CG symptoms. As the therapist, you check the loss summary for any other losses that met criteria for CG at baseline. For each deceased person for whom the patient endorsed ICG score equal to or greater than 30, you ask the patient if she is still struggling with feelings about the deceased person. If so, you need to conduct a formal CG symptom assessment using a semi-structured interview or the ICG. Assessment of CG symptoms should be repeated before beginning work on a second loss since sometimes improvement in the primary loss leads to a reduction in CG symptoms for other losses as well. If another loss still meets criteria for CG, it makes sense to do some work on that loss. Work on a second loss is indicated if the patient shows evidence in the mid-course review (session 10) that she has made good progress working on the primary loss. Work on a second loss usually proceeds quickly when the patient has already worked successfully on the primary loss. It is especially important to do work with a second loss when there was a close relationship between the two deceased people. We refer to this as a “linked loss” meaning that the relationships amongst the bereaved person and the two deceased people were intertwined. When there is a linked loss that is also a trigger of CG, work with the second loss may be needed in order to achieve optimal

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Session 10 Midcourse Review treatment of the primary loss. In some cases what emerges is that the second loss is the more difficult one. If the two deceased individuals did not know each other, the losses may still have links within the bereaved person’s mind. Here is an example: Jane was grieving the loss of her husband Mark. She had lost Steve, her favorite uncle, to whom she was very close, when she was twenty-two. He had never met Mark, who Jane began dating when she was twenty-eight. However, Jane had often thought how much Mark was like her uncle Steve. When her husband became ill at age fifty-seven, she was flooded with memories of her uncle Steve’s terminal illness. Uncle Steve had been a major support during a very stressful childhood, and she had not felt like herself again until she met Mark in a community theater group that she had begun attending to try to get herself out of her funk. Although she had never before been interested in acting, her uncle had been an amateur thespian and going to the theater group helped her feel closer to him. When she met Mark she felt that Uncle Steve had sent him to comfort her. Jane found that her grief over her uncle had gradually subsided as she and Mark grew close. They had many wonderful years together, though they had not had any children. When Mark became ill, she found herself thinking constantly of Uncle Steve, asking herself why he had to die at a young age, feeling angry and bitter and yearning for his comforting presence. When Jane sought treatment, her complicated grief symptoms were almost as intense for her uncle as for her husband Mark. Prominent among them was a nagging feeling of guilt that she had never really shaken. Jane had been looking forward to a party weekend when she got the news that her uncle was diagnosed with cancer. She had decided not to go home to be with him and then found herself dreading the moment she would have to see him. She told herself that she shouldn’t go until after finals and because she was feeling stressed and very upset, she didn’t call or write either. When she finally went to visit him it was about 4 months after the initial call. She was horrified by his appearance and burst into tears. This seemed to affect her uncle deeply but he was too weak to comfort her. He had squeezed her hand and whispered something she could not understand. Jane kept a vigil by her uncle’s bedside after that, but he never regained enough

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Session 10 Midcourse Review strength to have a conversation. She started to think that he was disappointed in her and angry that she wasn’t a support to him, even though she knew this was not like him. At session 10, CG symptoms related to her husband Mark had improved. Jane and her therapist decided to focus on Uncle Steve.

Work on a Troubling Interpersonal Dispute or Role Transition The overall objective of CGT is to resolve grief complications and facilitate the natural healing process. The most common complications are related to thoughts and feelings about the circumstances of the death that are troubling and derail the process of reflection on its finality and consequences. However, restoration is also an important treatment focus and restoration of a satisfying life entails both oneself and other people. Sometimes there is an important problem with sense of purpose in life, self-acceptance and social role. Sometimes there is a serious dispute in an important relationship. Either of these can interfere with restoration related goals. When there is either a significant problem with social role or an ongoing disruptive dispute with a significant other, the last 5 sessions of CGT should be used to resolve these as well as possible. Social role is often a source of sense of purpose and meaning and of self-esteem. People undergo transitions in social role at various points in life, including transition to adulthood, transitions in and out of romantic relationships and marriage, transitions into and out of school and jobs and transition into parenthood or into an empty nest stage. Close relationships are usually important aspects of a person’s social role, because being a spouse, parent, child, or close friend defines role expectations and contributes to social status and sense of purpose. The death of a loved one ushers in a period of role transition that often entails changes in sense of purpose, in practical daily tasks, in relationships with other people and the community at large, and changes in status and expectations. A role transition must be successfully navigated in order to restore a sense of purpose and meaning and the capacity for joy and satisfaction. Most people, even people with

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Session 10 Midcourse Review CG, find a way to do this. However, sometimes a person with CG does have difficulty with role transition. Successful navigation of a role transition entails meeting challenges and being open to opportunities. The challenges entail coming to terms with the loss of the old role and solving problems that are presented by the new role. Being open to opportunities entails being able to identify things that were stressful or unsatisfying about the old role and to benefit from relief from the stresses or frustrations, and also being open to possibilities for growth and positive experiences in the new role. People with CG have usually lost someone very close with whom they had an unusually positive, loving and rewarding relationship. This adds to the difficulty with the role transition. Role transition problems can be practical in nature—like the need to learn new skills or to take over new household or financial responsibilities; or they can be perceived changes to status or freedom or sense of identity. The therapist works on a role transition by systematically addressing the patient’s feelings, providing support and encouragement, and helping her tackle some of the practical and social problems. Another problem that may interfere with restoration of a satisfying life is conflict with an important person. Close relationships, especially marriages, are prone to difficulties. It is easy to find testimonials from famous people about marital conflict. A favorite of ours is from Socrates who said, “My advice to you is to get married. If you find a good wife you’ll be happy; if not, you’ll become a philosopher.” And H.L. Mencken who said, “The longest sentence you can form with two words is I do.” We like these quotes because they highlight the fact that people who are very talented and thoughtful and wonderful in many ways can experience interpersonal conflict. There is no shame in struggling with someone close, but there is pain when this occurs. According to the tenets of interpersonal psychotherapy (Markowitz & Weissman, 2004; Weissman, Markowitz, & Klerman, 2000, 2007), most disputes are based on communication problems, often ones that entail non-reciprocal role expectations. A husband and wife may fight because he expects her to take care of things that she expects to be shared responsibilities, or vice versa. Similarly, a

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Session 10 Midcourse Review parent’s expectations of a teenage or adult child may differ from that of the child, and vice versa. It is helpful to identify mutual expectations and help people to communicate about this and other issues in their relationship.

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Instructions for Session 10: Midcourse Review Pages 162-175

Session 10 Session 10 Instructions SESSION GOALS Review Grief Monitoring diary and interval plans Orient patient to session Take stock of treatment progress Discuss the patient’s reasons for coming to treatment and expectations at the beginning of the work and her view of treatment progress Review and revise CG formulation from session 2 and discuss progress with the patient Compare baseline and week 8 (pre-session 10) scores on grief measures including avoidance and cognitive problems (GRAQ and TBQ) and discuss with the patient Review and discuss other difficult losses (Loss Summary form) and consider repeating the ICG for another loss Review and discuss status of current relationships with respect to identifying dis- putes with significant others or role transition problems Summarize session and formulate plans for remaining sessions with patient, including plans to discuss termination, difficult times, and to continue Goals work Review memories (Memories Form-4), situational revisiting interval work, and interval goals work Discuss interval plans

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Session 10 SESSION CONTENT Beginning: a) Review Grief Monitoring diary and Interval Plans b) Orient patient to the session Middle: a) Mid-treatment review and discussion b) Continue Situational Revisiting c) Review Memories Form-4 d) Continue Aspirational Goals work End: a) Session summary and feedback b) Grief Monitoring and other Interval Plans

MATERIALS NEEDED Pre-session Questionnaires: GRAQ from baseline and administered at weeks 8 or 9 (before session 10) TBQ from baseline and administered at weeks 8 or 9 (before session 10) Repeat ICG for losses that were found to have ICG equal to or greater than 30 at baseline Therapist review (before session): GRAQ and TBQ from week 1 and week 8 or 9

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Session 10 Loss summary and ICG’s that meet criteria for CG (score equal to or greater than 30) Therapist formulation worksheet Materials used in session: Situational Revisiting List Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Memories Form-5 Interval Notes Form Between Session Situational Revisiting Form (if applicable)

SESSION PROCEDURES This session begins with an interval review, as usual. The middle of the session focuses on a midtreatment evaluation of progress used in planning for the last 6 sessions. The therapist discusses the patient’s reasons for coming to treatment, her expectations at the beginning of the work and her view of treatment progress. Review and update the CG formulation from session 2 and discuss progress in addressing complications. Share with the patient her weeks 1 and 8 or 9 scores on GRAQ and TBQ. Discuss with the patient whether there are important remaining interpersonal problems. This includes identification of other difficult losses for which the patient has experienced CG symptoms, and any current problems with role transition issues or interpersonal disputes that are affecting the patient’s mood or grief progress.

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Session 10 Based on the review of remaining problems and on progress to date, the therapist and patient consider together how best to spend the remaining sessions. In virtually all cases, the work will include a continued focus on goals and usually also situational revisiting. It may make sense to continue Imaginal Revisiting, or reflection on problems that remain in coming to terms. An Imaginal Conversation should be planned for the final phase (beginning at session 11). Alternatively, the focus may shift to another interpersonal problem. This can be a second important loss, a role transition or an interpersonal dispute. There will be differences in the extent to which patients have completed Imaginal Revisiting and the degree to which they have engaged in reflection when they arrive at session 10. Some will be well along the way in achieving their grief goals, having progressed through the sessions in a very systematic way, doing a revisiting at most, if not all sessions from 4 to 8 or 9 and engaging in productive reflection. Patients vary in the degree to which they are diligent about listening to the revisiting tapes and doing other interval work. Those who do less outside of the session generally need continued revisiting and other loss-focused work on the primary loss in sessions 11-16. Some will have taken breaks from the revisiting in order to work on reflection and may still be struggling with coming to terms with the death. Sometimes the patient’s expectations of the therapy have not been on track, and this is an opportunity to realign them with the goals of the treatment and help the patient understand what she needs to do a little differently in order to get the most out of the remaining time. There will also be differences in where the patient stands with respect to restoration related work. They will have completed differing amounts of situational revisiting and goals work. These differences will usually be mirrored in how much change has occurred. The decision about how to focus the remaining sessions depends on where the person stands with respect to grief symptoms, as reflected in changes in grief intensity, in Grief-Related Avoidance (GRAQ), and changes in Ruminative Thinking (TBQ). Intense grief is usually less tenacious when it does occur. Changes in the target problems from the formulation are especially important. Session 10 is useful in helping patients to focus on changes in how they feel about the death compared

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Session 10 to when they first started the treatment. These changes can be dramatic. Nevertheless, most commonly, work remains on one or another of the grief complications. The usual plan for the last six sessions entails a discussion of the ending of treatment along with some combination of Imaginal exercises, work on reflection, situational avoidance, and goals work. In order to decide whether to shift to a second loss or to an interpersonal problem, the therapist again reviews the loss summary. If there is a second loss associated with CG symptoms, the therapist asks the patient if she is still feeling upset by the loss. If so, ask the patient to complete another ICG for this person. Though a second episode of CG is present in about twentyfive percent of people, in our experience so far, we have also found that work on a second loss will not be appropriate for all of these people. It is only a good idea to turn to a second loss if the patient has made good progress on the first loss. Work on one episode of CG usually has carryover effects making work on the second loss go more quickly. Sometimes the carryover is sufficient to alleviate fully CG symptoms related to the second death. Work on an interpersonal problem area should be considered if it appears that solving the interpersonal problem is integral to further progress in treating the grief, or if good progress has been made on the CG symptoms and there is a problematic relationship that is now of central concern to the patient. There may be a long-standing interpersonal dispute that now becomes a focus of the treatment. Alternatively, a dispute or role transition may be integral to restoration of a fulfilling life. In summary, the last six sessions are used either: 1) to focus primarily on restoration-related work, 2) to continue CGT focused on the primary death using some combination of reflection about the death, continued Imaginal exercises, either Revisiting (with or without hot spots) or Imaginal Conversation, Situational Avoidance and Goals work, 3) to shift the focus to a second difficult death, or 4) shift to work on a Role Transition or Interpersonal dispute. Following the review, guide the patient in a discussion of plans for the last six sessions. The session ends with a discussion of goals as well as other ongoing interval work, such as situational revisiting or memories and pictures.

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Session 10 Beginning (About 5 Minutes) • Review Grief Monitoring Diary and other interval activities Ask the patient for the diary and review it. Discuss the pattern and the trig- gers. Ask if the patient has noticed any changes. Ask about the Situational Revisiting exercise, Memories Form, and Goals. Review these briefly and postpone further discussion to later in the session. If an Imaginal exercise was done in session 9, ask about listening to the tape. If appropriate, review the Imaginal Revisiting form. Discuss how the listening has been going, including SUDS pattern and the patient’s experience with listening, including thoughts about the story and the experience of listening to it. Discuss as needed. • Orient the patient to the session Tell the patient you want to spend this session taking stock of what you have done so far and deciding how to spend the remaining 6 sessions. Ask if this is Okay. You want to spend most of the session today talking about where things stand compared to when you started working together and then revisit the question of what to do from this point forward. Ask if this sounds okay. You will also review Memories Form-4 and discuss ongoing work on situational avoidance and goals.

Middle (About 35 Minutes) • Introduce the review of progress and plans Tell the patient that you’d like to use this session in order to highlight and support the gains people have made, and to plan work to finish and secure progress they have made. You will also begin a discussion of how they are feeling and thinking about ending the treatment. You want to review their initial expectations of the treatment, your mutual understanding of their problems and what progress has been made toward meeting their expectations and addressing the problems. You want to discuss anything that is still

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Session 10 troubling about the death, and also to think about whether there are other interpersonal issues to address, including other important people who have died, whether there are remaining role transition issues or problems with current relationships. As part of this process, you will review some of the questionnaires the patient filled out as a part of the review of progress. • Review treatment expectations and how well these have been met Ask the patient to think back to when she first came to the clinic. How did she feel? What was she hoping and expecting to get from the treatment? Explore this a little, including what she wanted or expected to accomplish and also how she thought this might occur. Ask her where she thinks she stands now with respect to her grief and its effects on her life. Ask what she thinks she would still like to work on—what she would like to change at this point. Sometimes people have had the experience that the therapist is the first person to understand their suffering, and this seems almost miraculous since so many others have not seemed to understand. These patients may have a related idea that the therapist will be able to relieve the suffering in the same kind of miraculous way, if they just come to treatment. CGT requires a strong commitment to working with the therapist in the various exercises that are included in this treatment. People must not only confront one of the most painful experiences in their life, but they must also think about it. A central goal of Revisiting exercises is to help people feel less fearful of acknowledging the finality of the loss and coming to terms with this. Some people find this too difficult and continue to avoid it. Some do the exercise in sessions but do not listen to the tape at home. Some even resist doing the exercises in the sessions, or keep themselves emotionally distant. Some are over-engaged emotionally. In each of these situations the full sixteen weeks is usually needed to achieve the best results for the primary loss. These often fall short of full response. For therapists with more flexibility, a longer period of work (beyond the

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Session 10 sixteen weeks) on the loss focus can be helpful. • Review progress in CG symptoms Tell the patient you want to review her CG symptoms, focusing primarily on typical beliefs and on avoidance. Review the main kinds of beliefs she had in the beginning of the treatment and ask if these have changed. How does she see this issue now? Use the baseline TBQ to identify the beliefs she had at the beginning of the treatment. Use the repeat version of the TBQ in the discussion of changes, but also ask the patient to think about her progress and discuss this with you. Do the same thing with avoidance behavior, supplementing the discussion with a review of the initial and repeat answers on the GRAQ. It is not necessary to discuss each item, or even each item that started at a high level. Make a general comment about whether and how much the scores have changed and give some examples of what has and has not changed. Choose examples that you recognize to be clinically relevant. Ask the patient if she has been aware of these changes, or lack

of changes. Ask her if these results surprise her at all. Briefly review

the list of avoided situations on the Situational Revisiting List. Discuss where you stand in addressing these. Discuss her progress as well as any unfinished or incomplete work. • Discuss other interpersonal problems Review the loss summary and baseline ICG’s for any other important loss. If there is another loss associated with ICG score of 30 or greater at baseline, ask the patient how she is feeling about this loss. Ask if she thinks your work so far on her primary loss has affected her feelings about this second loss. Ask how it is related, if at all, to the loss you have been working with. Tell her that you can consider working on this second loss as one of the things you want to do moving forward. Tell her that people often find it very helpful to work on a second loss that has also been very difficult and that it is possible to do this work in the remaining sessions. Talk about the patient’s current relationships and her social role functioning. Discuss the

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Session 10 changes she has needed to make in her social role since the death. How is this going? What has she observed? Examples of role changes include the need to do new things— concrete things—such as taking care of the house or the car or paying the bills or doing the shopping or being the one to make social plans. A man who has lost his wife who has young children at home may need to attend to all kinds of things in their lives that his wife had previously done. He may need to do this while he is continuing to go to work and perform at his usual level. He may find this stressful and burdensome and he may be resisting this or he may feel incompetent in doing this job. A woman who has lost her husband and has young children may have the reciprocal problem of needing to find a way to support the family while continuing to take care of the household. She may be struggling with feeling incompetent to do this or anxious about how she will find a job. She may resent the need to give up her exclusive focus on her children and the family. Older widows and widowers may have different role transition issues. They may feel that their partner was needed to ensure their safety and sense of well-being. They may feel incompetent to take care of themselves or to have fun or socialize without their spouse. Men whose wives have always been homemakers may struggle to take on this role. Even when the wife has worked, it is frequently been the wife who has taken care of the dayto-day management of the household and her husband may feel lost without her. In like manner, a widow may feel that her husband was the love of her life and the source of her sense of safety and protection. She may feel uneasy in the world without him. She may feel that there is no way to experience happiness or to have fun without him. Parents may have role transition problems related to interactions in the world that include activities involving children. They may feel they are different and that others shun them or that they cannot feel comfortable in social situations where there are children or discussions about children. They often struggle with the idea that they are still the parent of the child who died. One aspect of a role transition for a parent is the question of how one can or should take care of a child who has died. Other role transition issues

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Session 10 pertain to participation in discussions about children. A parent who has lost an only child may struggle with the transition to being a childless adult again. A parent who has other children may feel that parenting the other children is suddenly different and more difficult. For people who have lost parents or close friends, there may be role transition issues related to being alone in social situations in which this person was usually present or feeling alone in situations in which the deceased was usually a support. Sometimes bereaved people are struggling with an interpersonal dispute that is affecting their mood or making it difficult to come to terms with the death or to restore their interest and capacity for satisfaction in ongoing life. Sometimes the dispute pertains to the manner in which they are mourning. Disputes that entail differences in grief are most common among parents who have lost a child. Many men are more comfortable distancing themselves from the emotions that occur with grief and avoiding emotional triggers. Some feel that emotional displays are childish or unmanly. They may feel that it is their role to be strong for their family and to be the protector. Those who do may be struggling mightily with caregiver self-blame related to the fact of the child’s death or related to their own strong emotional reaction which they see as interfering with their ability to be a protector. These guilty feelings may affect their mood and make them feel irritable. Such a man may be especially irritable with his wife if she is very emotional or is in some way triggering sad feelings in him. However, this irritability can estrange him from the person he most needs as a support and the person who could be the most helpful companion in his grief. From the wife’s point of view, it often seems important to confront painful emotions and to be sure to remember the deceased child. Mothers are often uncomfortable distancing themselves from their feelings and they may resent their husbands for doing so. They

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Session 10 may feel unsupported and isolated by the husband’s distancing. Couples who previously had a good relationship may find themselves at odds over this issue and this can be a source of an interpersonal dispute between them. They may find themselves accusing each other of being childish and “wallowing” in the grief, on the one hand, or being cold and heartless on the other. Some women even conclude that their husbands loved their children or even loved them (the wife) less than she had previously believed. Interpersonal disputes may also occur among people who have lost a partner, a parent or a close friend. Sometimes these disputes resemble those described above that occur between parents. A person mourning the loss of a partner may find that other important people in her support network are also grieving this person and they may do so differently than she does. A widow may feel that her best friend or confidant is not as supportive as she wishes because she does not understand. Close friends may disappoint a bereaved person by being less available and supportive than the widow would like. Many bereaved people feel they should not be the one to reach out. They need others to take the initiative and if this does not happen the widow can feel hurt, frustrated or angry. A widow may feel that others do not understand her and are not providing the comfort she needs and this may engender resentment. Sometimes she may have the experience that whenever she tries to talk about her grief, her friend or sister or close confidant changes the topic to her own pain. The widow may resent this. A widower may feel that friends are not interested in his feelings and he may be overly sensitive to small slights or inconsideration. Sometimes there are disputes with other family members who may be cold or blaming in the wake of a loss. When these disputes arise, they can be very painful and preoccupying and distract the person from dealing with the death. Interpersonal disputes may need to be addressed in order to free the person to focus and come to terms with the death.

• Summarize the information from the session

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Session 10 Summarize for the patient your observations about the progress of grief resolution and the current state of important relationships with others—use the information just obtained to comment on how much grief intensity has been reduced, progress in feeling connected to the deceased in a more comforting way, reduction in dysfunctional beliefs, and improvement in maladaptive behaviors. Summarize the state of important relationships with others. Ask the patient if they agree with this summary and what they believe might still need to be done. Discuss this with them, asking if they would like your opinion about how to spend the remaining time together. • Plan the remaining six sessions Discuss other plans for the remaining sessions. Remind the patient that you have six more sessions to work together. Tell the patient that a part of each session will be devoted to discussing their thoughts and feelings about ending the treatment. You have now started to think about what she has achieved, about what is still troubling her. You will continue to think about this in the upcoming sessions. You want her to think about what she expects in the future. How will she continue to move forward after the treatment ends? What rough spots does she anticipate? How will she handle them? How will she feel about ending her work with you? Does she feel ready to end? If not, what does she still need to do? This will be a part of the interval work for the remaining sessions. In addition, you will continue to work on goals during the remainder of the sessions. You will do an Imaginal Conversation, in the next segment of the treatment. The rest of the time can be used more flexibly. One possibility is to do more Imaginal work. This might entail revisiting that continues to focus on the story of the death or revisiting focused on other parts of the bereavement experience, such as the funeral or memorial, or the time of diagnosis. You may include on additional Imaginal Conversations. Another possibility is to focus primarily on other aspects of the treatment, including focused work on reflection, or on situational avoidance. Occasionally you might decide to focus primarily on goals work. Discuss these possibilities with the patient and make a recommendation. Get the

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Session 10 patient’s thoughts and agreement. Then, tell the patient you would like to shift gears and talk about Situational Revisiting. • Discuss Situational Revisiting Return to the Situational Revisiting form. Review the form and discuss the patient’s experience with this exercise. Note whether the SUDS levels fell, as expected. Discuss this as needed. Decide whether to continue to work on this situation or add a second one. • Goals Work Return to Goals work. Return to the discussion at the beginning of the session and discuss progress on goals. Continue to provide support and encouragement and help her move forward. Plan what she will do over the next interval.

Ending (About 5 Minutes) • Summarize the session and get patient feedback Summarize what you covered in the session. Ask for feedback from the patient. How did the session go? Briefly discuss this. • Review interval plans form Plans for the upcoming interval include: 1) Grief Monitoring, 2) Goals work or Values work, and 3) Continuing Situational Revisiting. Review each of these briefly. • Give patient Grief Monitoring diary Remind the patient that you want her to continue to monitor her grief. Ask if there are any questions about this. Ask if there are any other questions before you stop

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Phase IV: Closing Sequence (Sessions 11-16) Pages 176-183

Sessions 11-16 Overview

The final six sessions are used to conclude the work and tie up any loose ends. The closing sequence includes a discussion of thoughts and feelings about ending treatment, including tracking progress and thinking about future plans. The final memories forms and the Imaginal Conversation are done in the closing sequence. Goals work is always continued and situational revisiting is usually continued, and these may become the main focus of the remaining treatment. Additional Imaginal Revisiting and reflection on the circumstances of the death or its consequences may be continued into the closing sequence The following discussion includes the approach to the main content for the closing sequence including: 1) discussion of treatment termination, including thoughts and feelings about ending and plans for the future, including difficult times, 2) continued memories work, 3) continued Goals work, and 4) continued Situational Revisiting. In addition, there is information about the approach to each of the possible areas of focus included in session 10. Note that sometimes more work is still needed with Imaginal Revisiting, for example if the patient has struggled with this, has had a late start or has been doing the revisiting exercises only intermittently.

Discussion of Treatment Termination Beginning with session 10 the patient is reminded at each session of the number of sessions that remain. Studies have shown that one of the benefits of short-term therapies is to keep the time limit in focus for much of the treatment. This both motivates the patient to work as hard as possible to achieve her goals during this agreed-upon time frame and also helps her to identify and work through feelings about ending with a therapist who has “listened deeply” and with whom the patient with CG may have had the first experience of feeling she was understood. Ending this highly valued relationship can be difficult, and discussion of the thoughts and feelings related to ending can be very productive.

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Sessions 11-16 Overview

The strategy for discussing termination is to begin by inviting the patient to think about termination, including how she is feeling about it and how she plans to deal with her feelings about leaving as well as her continued grief. Make it clear that this treatment is not expected to result in completion of grief, but rather is focused on getting the natural grief process back on track. It is expected that the patient will continue to grapple with her feelings about the loss but that this will progress over time and that grief will become integrated into the rest of her life and her thinking. We expect people to feel freer to engage in their ongoing life in a way that has the potential for joy and satisfaction. Ask the patient if she has had any thoughts about the treatment ending. The response varies with some people saying that they have had a lot of thoughts and worries about the ending to others saying that they haven’t really been thinking about this. Depending upon what the patient says, you will explore these thoughts and feelings and encourage continued reflection on these. If the patient has not thought about her feelings about ending encourage her to do so. The interval notes form for the last six sessions includes a section of notes about ending the treatment. If there are strong feelings about ending, you can suggest using some of the time over the next weeks to work through the feelings about the loss of the therapy. The approach to discussion of termination in CGT follows an IPT role-transition approach. The outline of role transition work is described below. In the case of transition out of therapy, the discussion centers around: 1) the ways in which the therapy has been supportive and helpful and feelings about losing this helpful support, 2) the parts of the therapy that have been difficult, including things like the time it requires and travel and other inconveniences, ways that the therapy has been difficult and time consuming, other things that may have been distressing or problematic, 3) problems the person foresees in the future, including managing difficult times and other problems that the patient may anticipate. This may include issues the person feels are not yet resolved and might not be resolved by the end of the treatment, 4) opportunities and positive aspects of ending the treatment, including having more time, having the opportunity to test new learning and develop a sense of confidence in having assimilated something new that remains even when the meetings with the therapist are over. A range of positive aspects of the future

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without treatment should be explored. The four topics outlined above are not all addressed in each session. Instead, one or two of these is addressed. Over the course of the six remaining sessions, each of the four areas is discussed. The discussion of termination follows the patient’s lead to some degree, but generally proceeds from (1) and (2) above to (3) and (4). The last area pertaining to the positive aspects of the future without the therapy is generally introduced at session 15 and discussed at session 16. In each discussion, the patient is helped to anticipate and problem-solve difficulties and to recognize, “own” and appreciate the positives. The therapist works to integrate specific aspects of progress in the treatment into this discussion. For example, when talking about sadness or anxiety related to leaving the supportive relationship with the therapist, the patient can be encouraged to consider her very real achievements in the treatment and how she will take those with her. When discussing the problems she faces in the future, she can be encouraged to think about how her achievements in the treatment will help her deal with these problems.

Difficult Times Calendar dates that trigger surges in grief intensity are difficult times for bereaved people. Most bereaved people react to certain times of the year that serve as reminders of the deceased. This occurs when grief is progressing normally and is often especially intense for people suffering from complicated grief. Most bereaved people find the winter holidays difficult—the period between Thanksgiving and New Year. This is typically a time when families get together and it is a stark reminder

of the loved one’s absence. Other difficult times include birthdays, wedding

anniversaries, and the anniversary of the death. For some people the anniversary of a diagnosis can be difficult. For parents, the first day of school, graduation ceremonies or other child-oriented dates can be especially difficult. For people with CG, it may be difficult to anticipate these periods and to plan for them because they just want the day to be over. They want to hide and hope for the best. CGT includes an approach to difficult times that entails planning, self-care, allowing others to provide care, and activities to honor the deceased person. There is a simple handout that outlines this approach and provides some concrete examples of what can be done. In addition, the

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Sessions 11-16 Overview therapist includes a discussion of these plans as a part of the last six sessions of the treatment. Discussion of difficulties the patient foresees in upcoming months and years (3) includes anticipation and planning for difficult times. The patient is given the Difficult Times handout in session 12 so that this can be discussed in sessions 13 and following. The approach to discussion of difficult times is to begin with a generic review of the handout in session 13 and to get feedback from the patient about the ideas expressed and whether they make sense. Encourage the patient to raise any questions she might have about the helpfulness of the difficult times handout. What makes sense? What does not? Discuss this. Either problem-solve any resistance to the approach in the handout or come up with a different approach to difficult times with the patient. In sessions 14-16 ask the patient to identify one or more specific times that they are anticipating as difficult and to begin the planning process for these times. This can entail discussion of just one upcoming date over the 3 sessions or discussion of as many as 3 dates—one at each session. Whichever way this is done, ask the patient to think about how they will develop and implement plans using the approach you have decided on with them. For example, if the patient plans to use the approach in the handout, you may begin now to plan how she will spend the next holiday. How will she decide whether or not to celebrate, who to celebrate with, and how to celebrate. How will she take care of herself? Who else can help take care of her and how will she get them to do it? What does she need to do in order to accept the help of someone else? How will she honor the person who died? Does she want others to join her in this? If so, how can she make that happen?

Continued Memories Work and Imaginal Conversation The closing sequence continues the final memories form in which the patient is asked to recall both positive and negative memories. Session 11 usually also entails an Imaginal Revisiting exercise. Under some circumstances the Imaginal Revisiting is continued into this phase and the conversation is delayed. Another variation is to repeat the Imaginal Conversation in more than one session in the closing sequences. Instructions for the Imaginal Conversation follow.

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Sessions 11-16 Overview

Describe Imaginal Conversation Tell the patient that you want to do another kind of Imaginal exercise. This one differs from the other revisiting exercises. You want to invite her to imagine that she is with her loved one not long after they died. For example, you might invite her to be at the bedside a few minutes after they stopped breathing. Tell the patient that she knows they have died, but you want her to imagine that she can speak to her loved one and they can respond. Tell her she can tell or ask them anything she wants. After she has spoken for a while (usually about five minutes), you would like her to pretend that she is the loved one and answer. Then, she can become herself again and respond to that answer. The loved one may have to answer again. This “back and forth” conversation, conducted entirely by the patient, should go on for about 15-20 minutes. Tell the patient that just as with the Revisiting exercise, you want her to try to visualize her loved one in the room. You want her to imagine that she is really talking with them and, if possible, hear what they would really say, even though this exercise is imaginary. Ask if the patient has any questions. Ask if she is ready to do the exercise. Ask for SUDS level. Turn on audio recorder. Tell her that when she is ready she can close her eyes and visualize her loved one not long after their death. Tell her to take a moment to visualize the room—imagine the scene as vividly as possible, using all her senses. What was she hearing at the time? Smelling? Seeing? Let her then begin to speak to or ask the loved one anything she wishes. Ask for SUDS level. Record the time that you begin and end the Imaginal Conversation. Make a note of the patient’s comments. At the end of the conversation, ask the patient to open her eyes and tell you her SUDS level. Reflect on Imaginal Conversation Ask patient, “What was this like for you?” Briefly discuss her answer. Ask, “What did you observe or note while you were telling the story? Or as you are thinking about it now?” Discuss her response and ask what else she noted. Ask for a SUDS level.

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Discuss whether there is more she would like to “discuss” with the deceased using this technique. Invite her to think about your question and say that you will also think about it, and together, you will decide whether she will do the Imaginal Conversation again. Tell the patient you would now like to shift gears and talk about Situational Revisiting. Ask if that’s okay.

Continued Goals Work A main focus of CGT is on restoration of the capacity for joy and satisfaction in life. Aspirational Goals work is a central procedure for achieving this goal and this work continues uninterrupted throughout the treatment. In general, about a third of the patients we see have been harboring a secret goal and take to this component easily. They may have had secret plans to do something daring for them, but ordinary in the grand scheme of things—like a patient who dreamed of owning a car although she did not have a driver’s license. Another person had worked all his life in a mid-level white-collar corporate position and longed to own his own retail store. After his wife died, he decided to take steps to realize his goal. Another common type of goal is to activate some longstanding ambition to learn or be part of a field of interest. Examples include a patient who had always wanted to be a museum docent and finally decided to realize this goal after her son died. Or a woman who had been a devoted housewife had secretly wanted to learn how to program computers and she decided to take the needed classes. Another woman had struggled through school with an undiagnosed learning disability. She had dropped out of college to get married and had a lifelong wish to get a college degree. When her sister died, she determined to realize this goal. Another kind of goal pertains to doing something adventuresome that the person had always been afraid to do. Examples of this are taking a hot air balloon ride, swimming with dolphins, or traveling to Antarctica. Any of these goals can be anticipated with pleasure and excitement and experienced with a sense of deep satisfaction. Sometimes a person’s goals center around caretaking. One person wanted to learn how to make chocolate sculptures for children.

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Sessions 11-16 Overview

Another wanted to start a mentoring program for school aged children. Yet another wanted to learn how to knit so she could make warm mittens and scarves for people who were struggling economically. These goals can also produce pleasure and satisfaction. This is what we are looking for in Goals work. Once identified, goals like the ones described above are implemented to the extent possible in the treatment. However, there is no expectation that the identified goal will be achieved within the sixteen-week time frame. Most of the time, these goals require some planning and often preparation that may be extensive, e.g. going back to school. The work in sessions 11-16 on goals for this subgroup of people entails continuing to plan some specific small project related to the goal for each week of the treatment. This might be researching the topic at the library or on the internet or some other appropriate place or it might entail thinking through a process that will lead to the achievement of the goal. As the therapist, you work with goals during the last phase of treatment by summarizing progress to date, reviewing what was done over the past week, and discussing plans for the upcoming week. In addition, beginning with session 13, introduce a discussion of how the patient will continue her goals work after the treatment ends. Together, you may discuss the process of working on goals, e.g. will the patient continue to track her progress and make weekly “assignments” for herself? Will she engage a friend in discussing her plans, if she has not already done so? How will she feel about working on this after the treatment ends? Help to consolidate the importance of this work and to ensure that it will be ongoing.

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Instructions for Closing Sequence Personalized Sessions (Sessions 11-15) Pages 184-207

Sessions 11-15 Instructions

The strategies and procedures for these sessions are more flexible than for earlier ones. You and the patient make decisions about how to focus the remaining sessions based upon the results of session 10, with respect to the revised formulation and goals and whether the patient is struggling with another troubling loss or with an important interpersonal problem. Each of the loss-focused exercises from sessions 4-9 can be used in this phase. The choice of which to employ is based on the decision about the focus of treatment. The closing sequence includes Memories Form-5 in which the patient is asked to recall both positive and negative memories. Session 11 usually also entails an Imaginal Revisiting exercise. Under some circumstances, the Imaginal Revisiting is continued into this phase and the conversation is delayed. Another variation is to repeat the Imaginal Conversation in more than one session in the closing sequences. Instructions for the Imaginal Conversation follow.

SESSION GOALS Discuss the Grief Monitoring Diary; review past week interval plans and orient patient to the session. Discuss thoughts and feelings about ending treatment. Do Imaginal Exercise as indicated (Revisiting or Imaginal Conversation) (OPTIONAL) Begin work on interpersonal focus as indicated Discuss Situational Revisiting Discuss Aspirational Goals work. Continue Grief Monitoring and Interval Plans.

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Sessions 11-15 Instructions SESSION CONTENT Beginning: a) Discuss GMD b) Review past week Interval Plans c) Orient patient to session Middle: a) Discuss thoughts and feelings about ending treatment b) Conduct Imaginal Conversation or Imaginal Revisiting exercise (possibly with hot spots) as indicated c) Review and plan Situational Revisiting d) Discuss Memories Form-5 (Session 11 only) e) (OPTIONAL) Work on interpersonal focus as indicated f) Continue Aspirational Goals work End: a) Session summary b) Grief Monitoring and Interval Plans

MATERIALS NEEDED Pre-session Questionnaires: None Therapist review (before session): Session instructions Materials used in session: (as needed) Imaginal Revisiting Form—Therapist version Situational Revisiting List or optional values

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Sessions 11-15 Instructions

exercise Audio-recording device for revisiting exercise Therapist gives to patient: Grief Monitoring Diary Interval Planning Form Interval Notes Form Interval Imaginal Revisiting Listening Form and Tape (as needed) Between Session Situational Revisiting Form

SESSION PROCEDURES Begin, as usual, reviewing interval activities. Discuss grief monitoring, check in about Memories Form-5 (session 11 only), Aspirational Goals work, Situational Avoidance list, and listening to the Imaginal Revisiting tape. Orient patient to the session. The middle of sessions 11-15 includes a discussion of treatment termination, a discussion of Situational Revisiting and a discussion of aspirational goals. In addition, you might review memories form 5, do an Imaginal Revisiting exercise, a Revisiting Exercise with hot spots (as in session 8) or an Imaginal Conversation. As in earlier sessions, you may choose to work on reflection or problem solving instead of revisiting or Imaginal Conversation. You might switch to a new loss and you might decide to introduce a focus on an interpersonal problem area. At the end of the session, you summarize the session, get feedback and plan activities for the upcoming week.

Beginning (About 5 Minutes) Review Grief Monitoring Diary Ask the patient for the diary and look at it. Note the pattern and briefly discuss one episode of high grief and one episode of low grief. Briefly comment on any changes in the level or pattern of grief intensity. Ask About Other Interval Activities

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Sessions 11-15 Instructions

Check whether situational revisiting exercise, goals work, and memories form (Session 11 only) were done. Postpone further discussion until later in the session. For sessions that follow an Imaginal Revisiting exercise, ask about listening to the tape. Review the Imaginal Revisiting Listening Form. Discuss how the listening has been going. Discuss the SUDS pattern and talk about what it was like to listen to the tape. Ask what thoughts the patient is having about the death. Provide support and encouragement. Orient Patient to Session Tell the patient you want to begin to talk about ending treatment in six more sessions. Tell the patient what else you are planning for the session (Imaginal Revisiting, with or without hot spots, Imaginal Conversation or no imaginal exercise). Ask if this is okay. Comment about progress related to revisiting, and explain the rationale for today’s plans. If you are doing a hot spot revisiting, explain how this is done. Explain that after you reflect on the story, put it away and discuss a rewarding activity, you will talk about a situational revisiting exercise and aspirational goals. Ask if this sounds okay and if she has any questions.

Middle (About 35 Minutes) Discuss thoughts and feelings about ending the treatment Tell the patient how many sessions you have left and ask how she is feeling about ending. Some people have had a lot of thoughts or worries about stop- ping while others feel ready and even happy to be ending. Depending upon what the patient says, explore the thoughts and feelings and encourage continued reflection on these. If the patient has not thought about her feelings about ending the sessions, you want to encourage her to do so. If the patient has strong feelings about ending, you might suggest using some of the time over the next weeks to work through these feelings.

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Sessions 11-15 Instructions

You want to be clear that this treatment is not expected to result in completion of grief, but rather to help get the natural grief process on track. You expect the patient to continue to grapple with feelings about the loss even though grief intensity is much lower and grief has become integrated into the rest of her life and her thinking. We expect people to feel freer to engage in their ongoing life in a way that has the potential for joy and satisfaction. We also expect that there will always be some calendar days that will be at least a little difficult. As you move through the closing sequence, you want to be sure you spend some time discussing which days these might be and how to manage difficult times. Over time you want to address the positives and negatives of being in the treatment and the positives and negatives of ending treatment. You want to consider ways the therapy has been helpful and feelings about losing this support. Parts of your work therapy that have been difficult, including practicalities like the time it takes, other things that may have been distressing or problematic about the treatment. You want to consider what kinds of problems the person may face the future, as well as opportunities and positive aspects of ending the treatment, such as having more time, the chance to test new learning and develop a sense of confidence in having assimilated something new and see that it remains even when the therapy sessions are over. Other kinds of positive activities and plans that the patient is anticipat- ing can also be discussed.

USUAL PROCEDURE: DO IMAGINAL CONVERSATION IN SESSION 11 OR 12 AND POSSIBLY OTHERS The usual procedure for the closing sequence is to do an Imaginal Conversation in session 11 or 12 and possibly repeat it one more time. The remainder of the session is focused on continuing Situational Revisiting and Aspirational Goals work. If you decide to work on a second loss you will usually want to do an Imaginal Conversation with the person whose loss you have been working

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with and then switch to the second loss. Similarly, if you decide to shift to an interpersonal problem focus, you still want to do the Imaginal Conversation. The checkboxes listed here describe the Imaginal Conversation and the continued work on Situational Avoidance and Aspirational Goals. Alternatives are described below. Describe Imaginal Conversation The Imaginal Conversation is usually done in session 11 or 12 and may be repeated 2 or 3 times. To introduce this, tell the patient that you want to do another kind of Imaginal exercise. This one differs from the other revisiting exercises. You want to invite her to imagine that she is with her loved one not long after their death. For example, you might invite her to be at the bedside a few minutes after they stopped breathing. Tell the patient that she knows they have died, but you want her to imagine that she can speak to her loved one and they can respond. Tell her she can tell or ask them anything she wants. After she has spoken for awhile (usually about five minutes), you would like her to pretend that she is the loved one and answer. Then, she can become herself again and respond to that answer. The loved one may have to answer again. This “back and forth” conversation, conducted entirely by the patient, should go on for about 15-20 minutes. Tell the patient that just as with the revisiting exercise, you want her to try to visualize her loved one in the room. You want her to imagine that she is really talking with them and, if possible, hear what they would really say, even though this exercise is imaginary. Ask if the patient has any questions. Ask if she is ready to do the exercise. Ask for SUDS level. Tell her that when she is ready she can close her eyes and visualize her loved one not long after they died. Tell her to take a moment to visualize the room—imagine the scene as vividly as possible, using all her senses. Let her then begin to tell her loved one or ask anything she wishes. Continue the conversation for about 5 minutes and then, if the

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patient has not changed roles, invite her to do so. Continue for another 5 minutes and invite her to switch again. Continue in this way for about 10-15 minutes and then, ask the patient to open her eyes and tell you her SUDS level. Reflect on Imaginal Conversation Ask patient, “What was this like for you?” Briefly discuss her answer. Ask, “What did you observe or note while you were talking? Or as you are thinking about it now?” Discuss her response and ask what else she noted. Ask for a SUDS level. Discuss whether there is more she would like to “discuss” with her loved one using this technique. Invite her to think about your question and say that you will also think about it, and together, you will decide whether she will do the Imaginal Conversation again. Tell the patient you would now like to shift gears and talk about Situational revisiting. Ask if that’s okay. Discuss Situational Revisiting Return to the Situational Revisiting Form. Review the form and discuss the patient’s experience with the exercise. Note whether the SUDS levels fell as expected. Discuss as needed. Decide whether to continue to work on this situation or add a fourth (or additional) one. Discuss Memories and Pictures Read and discuss Memories Form-3. It includes her least favorite memories, her loved one’s most annoying traits, qualities about them the patient might want to be different, aspects of them she doesn’t really miss and what might be easier now that they are gone. Ask how she felt answering these questions. Discuss the memories and her response to them.

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In general, this form elicits varied responses. For some people, the experience isn’t interesting. They either say they don’t have many negative memories of the deceased or that they don’t care about the negative memories. Accept this unless you know it to be blatantly untrue. Note that it is unusual for someone with CG to have had a conflicted relationship with the person who died. Some people have been ignoring annoying characteristics of the person who died, and for this group, the negative memories form can be very helpful. Sometimes a person who has been very focused on how much she needs her deceased loved one starts to recall that there were times when he or she was very difficult, demanding, controlling, or burdensome. Therapists need to remember that recognition occurs against a background of deep love and caring and it does not indicate that the “true” story is now emerging. Rather, the patient should be encouraged to see that remembering the negatives as well as the positives about a loved one can help her feel more connected to the real person. As the therapist, you might comment that almost everyone we love has some traits that we are not so fond of and sometimes this just makes us love them more. Goals Work Return to goals work. Return to the discussion at the beginning of the session and discuss progress on goals. Continue to provide support and encourage the patient to move forward. Plan what she will do during the next interval.

ALTERNATIVE: IF MORE REVISITING IS NEEDED If more revisiting is needed you can do one or more revisiting exercises, either with or without hot spots, before doing an Imaginal Conversation. If you do this, the conversation will be delayed but should still be done.

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Do an Imaginal Revisiting exercise Do the revisiting as it was done in session 7, or with hot spots, as in session 8.

EXAMPLE OF HOT SPOT REVISITING Beth and her therapist did a hot spot revisiting that helped work through the idea that Michael was ready to die. T: You can close your eyes and begin whenever you are ready. P: I get home and try to call Michael on the phone. He is up in the country. He loved it there. I am calling and nobody’s answering the phone. I think he always seems to drop it or doesn’t hang the phone up right. T: What is your SUDS level? P: Eight. T: You are doing great. P: I make a phone call and try to call him again and there’s no answer, so I call his friend Paul’s number and I call and say he’s not answering the phone. He said he would go over and check. I made another phone call and then I get into the car, not thinking anything about Michael. Just wanting to talk to him and tell him how everyone was and tell him what I have been doing. I get to the house and the phone rings and I pick it up and Paul says, “Beth. I have bad news, Michael is dead.” T: What’s your level? P: Ten. I feel so bad. I’m hurting. I just kicked the wall. I can’t believe he’s dead. Paul said

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he’s cold already. And he’s in his chair and he wants to know what to do. I say, “I don’t know. I don’t know what to do.” Are you sure he’s dead? “Yeah.” (crying) I said, “Call the coroner or somebody.” I didn’t say an ambulance because Paul said he’s already cold. (Crying) And I said, “I don’t know what to do I’ll call you back. Call the coroner.” So, I got off the phone and my aunt is holding me, because she already knew what the call was about. And I’m trying to hold on because I don’t want to break down in front of my mom. If only Michael would’ve been here, he would’ve helped. T: What’s your SUDS level? P: Eight. And then my other cousin walks in and I told her Michael was dead. She said, “Oh no.” She gave me a hug and everything. And I said, “I have to go home. I have to go home. I can’t stay.” She said, “Are you okay? Do you want me to go with you?” I say, “No, I want to be by myself T: What’s your SUDS level right now? P: Ten. I want to go home where I talked to you last on the phone. (crying) I want to go to our house. So I get home and I’m crying, and I’m crying, and I’m crying. I say, “No, no, no, no, no.” T: Beth, I want you to stop now and without opening your eyes, start again. P: okay. I am sitting in my aunt’s house. We’re talking but I am feeling restless. T: What’s your level? P: About a four. So, I told them I’m going home for a while. I went home thinking about Michael and wanting to tell him about my cousins, because he listens to me about

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Sessions 11-15 Instructions everything. And then I get home. I call Michael and there’s no answer. And I call again and there’s no answer. T: What’s your level now? P: Five. And I can’t get through to him and I want to talk to him about mom and my cousins. Michael is my best friend so I call his friend Paul and say, “Hey. Please go or send one of your kids over to Michael’s. Put the phone back on the hook. Michael has it off.” So, he said he would. So, I tried to call Michael again and the line was still busy. So, I was antsy. Now I wanted to get back to my aunt’s house. T: What’s your level? P: Four. So I go back to her house. My aunt hugs me. She tells me I have a phone call, do I want to take it there. I pick it up and it’s Paul. He says, “Beth, I have bad news. Michael is dead.” T: What’s your level? P: Eight. I said, “No.” (crying) He said, “Yes. He’s dead. He had a heart attack. He’s dead in his chair.” I said, “No.” (crying). And I banged the wall and I hit the wall and said, “No, no, no, no, no.” T: What’s your level? P: Nine. And Paul said, (crying) “What do you want us to do?” And I said, “I don’t know.” Paul said he’s cold already. I said, “I want you to help him!” And he said, “He’s already gone, Beth.” So, I tell them to call the coroner. I told him I don’t know what to do. I can’t leave right now. I said just call the coroner and do what you have to do.

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T: What’s your level? P: About seven. I said, “I’ll call you back.” I didn’t want to be on the phone anymore. Then I put the phone down. I was so angry, I was in disbelief. I didn’t even look at my mom or my cousins. I said, “Michael is dead.” And my aunt was standing right next to me, and she held me. And she said, “I know how you feel.” Or whatever. Something stupid like that. T: What’s your level right now? P: Seven. And I said, “I don’t know what to do. I have to go home.” And my other cousin walked in and I told her and she held me and I cried some more. I said I have to go home, and she wanted to go with me. I said no. I want to go by myself. So I hurried and got out of there, and I went home. And I drove home. And I sat on the floor and I cried. I cried (crying), I cried. T: What’s your level? P: It’s an eight. And I called his name. I called him (crying). And I wanted him to be with me. T: okay. I want you to stop there, Beth and start once more P: It’s early in the morning; I’m at my aunt’s house. T: What’s your level? P: It’s about a three or four. I wasn’t comfortable there with my two cousins, all the harsh things that were said. So I decided to go home and call Michael on the phone and talk to him about it and let him know. So, I leave. I drive home and try to call Michael. I want to tell him about mom and the phone is busy. I try again and the phone is still busy. I think about how he doesn’t put it back on the receiver, and the portable phone, how he doesn’t

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shut it off. So, it’s busy. I call somebody else. Then I try to call Michael again, thinking he has it back on. I didn’t want to call too early in the morning because I knew how tired he was last night, and I wanted him to rest. He seemed so tired and weak. So, I call again, it’s busy. And I call Paul. T: What’s your level? P: About a four or five. I ask if he could go up and see that the phone’s back on the hook. He did it before because Michael will knock it off and doesn’t realize it. He said he would. I decide to go back to my aunt’s house. I’ll talk to Michael from there. I knew Paul wasn’t going to get there right away. So I go back to my aunt’s and she says there’s a call for me. I pick it up, and it’s Paul who’s telling me that Michael died. He said Michael is gone, he died. I said, “No. no.” I tell her, “No. He can’t be.” He says, “Yes. He’s gone.” T: What’s your level? P: About a six. And I said, “No, no. He can’t be gone.” He said, he’s cold (crying), what should I do. I bang on the wall and I say, “Oh no.” My aunt was standing next to me and I didn’t even realize it. I…what should we do. And all I wanted to do was the right thing. I said to call the coroner then. Are you sure he’s gone. And he said, “Yes.” And then I think of Michael (crying). He was so tired the night before. T: What’s your level, Beth? P: Eight. (crying) He was still in his chair. He didn’t go into his bed. And he was so tired and he just passed away in his chair. Paul said he was still sitting in his chair. And I said, “I’ll call back. I don’t know what to do.” I had to get off the phone. I told my cousins he was gone. And my other cousin comes in. I told her and I cried. And I said, “I have to leave, I have to leave.” I wanted to run home to our house. She wanted to go with me and I wanted to be

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by myself. I wanted to go to my house, where Michael lived, our house. So I went home, then he wasn’t there. I called his name over and over. T: What’s your level now? P: It’s about a seven. And I said (crying) “Michael, please don’t leave me.” But I knew he did leave me. I didn’t want him to leave me. And I sat on the floor and cried and cried and then I stopped and I knew I had to make calls. I had to call the funeral parlor and make the arrangements. I had to call his sister. I had to call everybody. I had to do things so I couldn’t cry. T: What’s your level? P: About a five. So, he’s still gone. It’s sad. But I can’t change that. So I have to go on. And I will. In reflecting on this exercise, the patient talks about Michael’s readiness to die: P: I have been thinking that I couldn’t do anything to change it. Initially it destroyed me. It was way too much. I didn’t think he was going to die that weekend because he always rallied, but he made the choice. He didn’t want to go to another hospital. Michael did what he thought was right. He was so tired when I talked to him that night. He was just wearing out. He didn’t have any strength left, and I couldn’t change that. I think he was accepting it. When he passed, the blanket was on the floor, and the phone was dropped. This was Michael’s choice. It took me a long time coming to this. I still had this anger and guilt inside of me because I thought I could have changed something. I tried to keep him alive. But it was his time. For two years of my life, I’ve been torturing myself. If I didn’t work on it, I probably would have been fighting with it the rest of my life.

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T: I know how hard it’s been to do this work and I think you need to recognize your courage because it wasn’t easy. P: No, it wasn’t easy. I had to come to understand it, and not cover over it.

ALTERNATIVE: WORK ON A SECOND LOSS If you decide to work on a second loss, you will still do the Imaginal Conversation related to the first loss. Then you want to follow the instructions for sessions 4-7 to do Imaginal Revisiting and re-focus situational revisiting on situations related to the second loss that are being avoided. Then you would do an Imaginal Conversation related to the second loss in session 14 or 15. Aspirational Goals work does not change as you shift the focus to a second loss. Work on a second loss is done following the same procedures as for the primary loss, but in a more condensed form. Begin with a discussion of the patient’s relationship to the deceased and then elicit the story of the death, issues that are most troubling about this death, and a description of current grief symptoms. In some cases this history can be elicited in session 10. If time permits, there is an initial Revisiting exercise in session 11. Revisiting is conducted in a similar way to sessions of revisiting when working on the primary loss. Debriefing includes reflection on the story of the death in a manner similar to later sessions of debriefing revising with the primary loss. Revisiting exercises are repeated in session 12 and possibly session 13. Memories forms 3-5 are given in sessions 12, 13, and 14. An Imaginal Conversation is done in session 14. Summary and consolidation of work on the second loss is done in session 15. Procedures for each of these components follow the relevant procedures outlined in the earlier sections of the manual. Grief monitoring during the period of work on the secondary loss includes notation of whether grief levels pertain to the primary loss or the second loss. Jane described her relationship with Uncle Steve. She had grown up in a family where her mother

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was passive and depressed and her father very busy, often over-worked, and irritable. There were five children in the family and Jane was the second youngest. Everyone said that she and her father “were like oil and water.” She felt like she got on his nerves just by being in the same room with him. She was frequently the butt of his angry outbursts. After several episodes of being beaten when her father was drunk, Jane learned to stay out of his way. She described her mother as being overwhelmed with all the children. Her mother would cry if the children started to fight and frequently took to her bed. Often the children had to make their own peanut butter sandwiches for dinner. At some point, Sara, her oldest sister, took over household management but she and Jane did not get along well and Jane thought Sara was imperious and mean. Jane’s mother’s brother Steve was a bachelor who was easygoing and fun. He loved the theater and he loved playing with the children. Jane was his favorite and he was the only person she could spend time with whose love and affection felt reliable and genuine. He could soothe her hurt feelings after her father yelled at her or Sara bossed her. As she grew older, Uncle Steve became her confidant and the person who helped her navigate a stormy adolescence. She was devastated when he was diagnosed with pancreatic cancer during her senior year of college. Jane had been at her uncle’s side when he died, and she never stopped having intrusive images of him lying in bed in the hospital, wasted and sad. He looked so unlike the uncle she remembered who was never sad and who was strong and lively. She also kept hearing his last breath. He had begun taking strange rattling breaths and seemed to be struggling. She was alone with him when this happened and she rang the nurse’s call button. Then she had held his hand and sung one of his favorite songs. In the middle of the song his breathing stopped and she screamed. Where were the nurses? Why hadn’t they come to help? She shook him by the shoulder and cried, “Uncle Steve. Wake up! Wake up!” She had never seen someone die and it frightened her greatly. Finally the nurse came into the room and told her to calm down. Her uncle had been very ill and now he was at peace. The nurse told her she needed to get control of herself and seemed busy and officious. She asked if Jane would like some water and without listening for the answer, she left the room. Jane told herself the nurse was right and fought to get her torrent of feelings under control. By

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the time the other family members arrived, she was stone faced and numb. During the weeks and months that followed, Jane was plagued by feelings of intense yearning for her uncle, intermixed with feelings of guilt about her behavior during his illness, and anxiety that verged on panic about how she was going to manage without him. She watched, sometimes with envy and sometimes with disdain, as her siblings laughed and recounted stories of Uncle Steve’s antics. Her inability to join in these reminiscences and her struggles to contain the floods of painful emotion created an impenetrable wall between her and her family. She told herself that no one understood her. No one else had really loved Uncle Steve. As the years went on, it was only with great effort that she had gotten herself to look for a job and find some semblance of a social life. She had not felt like herself until she met Mark. Jane did a Revisiting exercise focused on Uncle Steve’s death in session 11. Her SUDS levels went quickly up to a 10 and stayed there until she left her uncle’s bedside after her parents and older sister arrived. Yet in reflecting on this first exercise, she commented that it was hard, but not as hard as it had been to revisit Mark’s death. Jane also observed that she was so young when her uncle died. There was so much she didn’t know or understand. Over the next three sessions, she repeated the revisiting exercises and developed the idea that there was much that she knew now that she had not known then. She realized that her uncle had an illness that was inexorable and that his last days were relatively peaceful, even if he was weak and wasted and unable to communicate much. She thought she could remember that what he had whispered when she came into his hospital room was, “oh buttercup, its so nice to see you.” She realized that they had a very strong bond and that Uncle Steve understood her so well, he would have known how hard it was for her to see him like this and he would not have been angry with her. During the five weeks she worked on this death she was able to work through her guilt about abandoning him and to forgive herself, as she now believed her uncle would forgive her. This feeling was consolidated in an Imaginal Conversation in which she asked her uncle directly how he felt about her staying away so long after he became ill. He “responded” by reassuring her that from the perspective of eternity, the deep love they shared, and all the fun times they had, greatly overshadowed his last days. He

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explained that he had been sorry that he did not have the energy to share with her some of the spiritual insights he had had after he became ill. He said he had worked with a hospice nurse who had helped him a great deal. Jane knew her uncle to be a spiritual person and she realized that he would have surrounded himself with people to help him. She felt relieved after this Imaginal exercise. Diane was a 53-year-old woman who developed CG after her 3-years older sister Alicia died of breast cancer. Her story provides an example of a linked loss. Diane had a hard time after her sister’s death. She missed Alicia more than she thought possible and thought about her constantly. She didn’t understand how God could take someone so loved and needed and so deserving of a rich long life. Diane’s children were worried about her. They could not get her to do any of the things she used to enjoy and she seemed to be crying all the time. Diane found that following the death of her sister, she had also started thinking again about the death of her mother-in-law. Alicia and Diane had been close confidants. Alicia and Diane’s husbands were brothers, and both wives had been very close to their mother-in-law. Alicia died of breast cancer three years before Diane came for treatment. Their mother-in-law had died of heart failure seven years earlier. The sisters had grieved the loss of their beloved mother-in-law together. Diane worked through the loss of her sister with her CGT therapist, making good progress by session 10, though there were some residual symptoms. The therapist suggested they spend sessions 11-15 working on her motherin-law’s death and Diane agreed that this was a good idea. In doing the work with her mother-inlaw’s death Diane realized that she had comforted Alicia during this period, as much as Alicia had comforted her. She had always thought of herself as somehow less important and less capable than her older sister, but she realized in working through this second loss that the sisters had different strengths and also different vulnerabilities. She felt better able to move forward in her life without these two women who had been her best friends.

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Sessions 11-15 Instructions ALTERNATIVE: INTERPERSONAL FOCUS If you decide to work on a role transition or an interpersonal dispute, you will still do the Imaginal Conversation related to the first loss. You may also want to continue Situational Revisiting and Aspirational Goals work. However, the remainder of the session will now focus on the relevant interpersonal problem area. For work on a role transition, explain to the patient that in sessions 11-15 they will work on helping smooth the transition to being single again, to being a couple without a child in the house, to being an orphan, or whatever the new role might be. Explore the patient’s feelings about the old role and her feelings about the new role. Ask the patient to describe behaviors that have changed in reaction to the change in roles. What has the person stopped doing that she used to do? What has she started doing that she did not do before? Ask the patient to think about how the role change has affected her relationships with other people, both directly and indirectly. The goals are to help the patient systematically examine what was positive and gratifying about the old role and what could be positive about the new role. Negative aspects of both the old and new role are also reviewed. When discussing these issues, ask for detailed examples. As the therapist, you work to engender enthusiasm, confidence, and hope so that the patient can see her new role in the most positive light possible while remaining realistic. CGT makes the assumption that social support is an important component of a satisfying and pleasurable life. You also work with the patient to begin to develop or consolidate strong meaningful social ties in her new role. Clearly for someone struggling with CG there has been a life-changing and very sad loss. The patient needs to come to terms with this painful reality, and earlier work with revisiting and reflection as well as memories and pictures and the Imaginal Conversation have hopefully helped in this process. During the last phase of the treatment, the role transition focus helps the patient to develop a sense of confidence and hopefulness about the future in a new role.

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Alternatively, as a CGT therapist you might use an interpersonal dispute intervention derived from interpersonal psychotherapy for the last six sessions of the treatment. If an interpersonal dispute has been identified, you will begin by staging the dispute and planning how you might address it. You do this using an abbreviated interpersonal inventory. The inventory is focused on the person with whom there is a dispute. It includes a discussion of the following elements: 1) the person’s name and the patient’s relationship to this person, including how long they have known each other; 2) a summary of aspects of the current relationship, including asking about a) How often do you see them? Talk on the phone? Email or otherwise communicate? b) how much time the patient spends with this person and how this time is spent (being together, talking on the phone, electronic communication, etc.), c) What do they do together? How does it go? How satisfying or pleasurable is their time together?; 3) Mutual expectations and how well they are being met, e.g. ask the patient what are some of her expectations of this person and what does she think the other person expects of her? How well does she think they are meeting each other’s expectations? (Note: most interpersonal dispute involves non-reciprocal expectations. Each party has expectations of the other that the other doesn’t know or doesn’t agree to provide.); 4) Ask what is good for the patient in this relationship and what is not good. Then ask what she thinks is good and not good for the other person. Get some examples of this; and 5) Ask the patient what she would like to change about herself in this relationship—what would she like to do differently and also what she would like to change about the other person in this relationship—what she would like the other person to do differently. You will use this information in working on the interpersonal dispute. You are looking for answers to the following questions: What is the frequency of contact with the other person? How often do they see this person? How long do they spend together when they see each other? What is the quality of contact overall? What is satisfying or pleasurable about being with this person? What is unsatisfying or difficult? What are the patient’s expectations of the other person and what does she think are the person’s expectations of her? How well are the two people meeting each other’s expectations? What would the patient like to change about the relationship, including how she would like the other person to change and how she would like to change herself?

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This information is usually interesting to the patient as it is not the way she usually thinks about her relationship. We like to tell patients that this therapy can help the other person change in the way you want them to change. Of course, you need to do things to teach this person what you want, and you need to do this effectively, and there are no guarantees. However, if someone does work on effective respectful communication and the relationship remains distressed or the other person does not respond at all, then this is also useful information. The discussion of expectations in session 11 helps to identify some of the miscommunications that are causing difficulty in the relationship. Therapists working on an interpersonal dispute may wish to review some of the literature pertaining to marital relationship functioning. For example, a paper by Gottman (Gottman, 1998) reviews observations suggesting that communications need to be positive, supportive or validating in a ratio of more than 5:1 in order for a relationship to function effectively. For couples when the ratio of positive to negative communications approaches 1:1 divorce is close to 100%. Couples tend to enter absorbing states in which they reciprocate each other in either a positive or negative way. Once in either of these, they are difficult to exit. This means it will take some effort to improve communications in a faltering relationship. Yet it can be done. There is an interesting body of information about couples’ behavior (DiTommaso, Brannen-McNulty, Ross, & Burgess, 2003; Hellmuth & McNulty, 2008; McNulty & Karney, 2004; McNulty, 2008) that can inform work in this area. Work on an interpersonal dispute focuses primarily on helping people communicate better. Problems in communicating range from not understanding that it is sometimes important to tell another person how you are thinking and feeling to over-communication and aggressive demands. As relationships deteriorate, communication usually gets worse. Sometimes a person says too little to their partner and sometimes they say too much. Very often, when a relationship is in distress the partners do not validate each other or offer positive comments and yet these are critical to effective functioning. Work with communication problems by focusing on examples of these. The

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Sessions 11-15 Instructions patient is asked to report on successful and unsuccessful conversations and the therapist helps the patient analyze what happened in the interaction, both verbally and non-verbally. To do this, a detailed description of the conversation is provided by the patient. You should be certain you have a clear picture of how the dialogue progressed. Then ask the patient to define her goal. What did she want to accomplish in this conversation? Did she want to communicate clearly? Did she want her partner to communicate? Did she want an explanation for something she did not like? Did she want agreement on a plan? Ask her to think about what could have happened that would have made her feel good about the interaction. Then ask her to consider the actual conversation. Was there any way this conversation could have gone differently? Often the patient will notice something right away. She might say, “Maybe I didn’t have to jump on this with such animosity right when he came home.” Or she might say, “Maybe I could have been a little nicer.” Work with her until she can explain clearly how she could have behaved in the conversation and what she thinks the outcome of that difference might have been. Then talk about the issues that she wants to address with her partner. Ask if she is willing to try to have a conversation about this over the next week. Discuss what she might say. Remind her of the need to be validating and positive even when planning to discuss something difficult. Continue this kind of work over the next four weeks.

Ending (About 5 Minutes) Regardless of whether the focus is the usual one, a modification related to doing more Revisiting, or if it entails work on a second loss, or even if the focus shifts to an Interpersonal Problem area, you still want to maintain the basic scaffolding of a beginning, middle and end of the session. In particular, the end of the session remains the same regardless of the focus. Summarize the session and get patient feedback

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Summarize what you covered in the session. Ask for feedback from the patient. How did the session go? Briefly discuss this. Review Interval Plans form Plans for the upcoming interval include: 1) Grief Monitoring, 2) Goals work or Values work, and 3) continuing Situational Revisiting. Consider whether you want to ask the patient to do anything else and if so, record it. Review each planned activity briefly. Give patient Grief Monitoring diary Remind the patient that you want her to continue to monitor her grief. Ask if there are any questions about this. Ask if there are any other questions before you stop.

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Instructions for Session 16: Ending CGT Pages 208-219

Session 16 SESSION GOALS Review Grief Monitoring diary and Interval Plans Orient patient to session Summarize and review treatment progress Review principles, strategies, and procedures of CGT Discuss progress on CG symptoms, including avoidance and cognitive problems If relevant, review and discuss progress on secondary loss or progress on inter- personal work and status of current relationships Identify personal strengths Summarize use of these strengths in the treatment Discuss use of strengths in planning for the future Discuss thoughts and feelings about termination Discuss plans for the future including any upcoming difficult times Say good-bye

SESSION CONTENT Beginning: a) Review Grief Monitoring diary and Interval Plans b) Orient patient to the session

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Middle: a) Summarize and review treatment and progress b) Discuss termination and future plans Ending: Say good-bye

MATERIALS NEEDED Pre-session Questionnaires: Grief-related Avoidance Questionnaire (GRAQ) Typical Beliefs Questionnaire (TBQ)

Therapist review (before session): Pre-session questionnaires Session instructions Materials used in session: GRAQ, TBQ and GIS from weeks 1, 10, and 16 Therapist gives to patient: No forms

SESSION INSTRUCTIONS The final session is a wrap up of the treatment that includes a summary of CGT principles, goals and procedures, and discussion of how the patient understood and used these. There is a discussion of what has been accomplished and what remains, as well as her thoughts and feelings about ending

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treatment and plans for the future. Grief Monitoring and Goals work are continued in session 15 and reviewed for the last time in session 16. Situational revisiting may be continued in session 15 and reviewed for the last time in session 16. If the therapist has been working on a second loss, there may have been a Revisiting or Imaginal conversation in session 15 and this will also be reviewed in session 16. If you are working on an Interpersonal Problem, planned assignments are reviewed in session 16. Note that a substantial minority of patients will not be ready to stop treatment after 16 sessions. In research studies, the patient is referred to another therapist at this point, and this is discussed in the final session. In clinical work, the patient might continue with the same therapist, either using CGT or switching to some other approach. In this case, session 16 should be another midcourse review, similar to session 10, in which progress to date is summarized, new treatment goals are set, and a plan is made for continued work. The most common reason to continue in treatment is that some progress has been achieved but the patient and therapist believe more can be done. Often the limited progress is related to hesitancy about revisiting exercises, such that they are not done frequently enough or the patient has not listened to them between sessions. If the patient is feeling more comfortable returning to these exercises, it is likely that more can be achieved. Additionally, if the revisiting exercises were not done as fully as possible, this could affect the ability to do the work on memories and the Imaginal Conversation, so these may have been very difficult or even omitted. When components of the treatment have been incompletely achieved or omitted and the patient is interested in continuing to work on using these, this is an indication for continuing CGT. For example, a patient who had felt very embarrassed about his emotions had been reluctant to do revisiting exercises, and when he did try them he worked hard to contain his emotions. He refused to do the audio- tapes, insisting that he would not listen to them. He did engage tentatively in situational revisiting and made some gains, but again, more remained to be done. Discussion of termination in sessions 11-15 began with the patient initially stating that he was happy he had

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come and he was ready to leave. However as the discussions progressed, he began to realize that he had indeed made progress but that he had held back because he was uneasy with the intense emotions that he sensed were present. He had become more comfortable with the process and said he experienced the therapist as completely trustworthy and “on my team.” When they explored the possibility of returning to revisiting exercises, he agreed that this could be useful. He wasn’t sure if he would be comfortable taping but he said he would consider that. The therapist contracted with this patient to do ten more sessions of CGT and re-evaluate where things stood. Sometimes there are difficult times that occur in the middle of the treatment and sidetrack the planned process of the treatment. In our research studies we found this to be regularly true for the five to six-week period from Thanksgiving to New Year’s Day. This holiday period is especially difficult to manage when it occurs in the first month of treatment, essentially requiring the therapist to postpone revisiting and to try to work with the patient to manage intense feelings before much has been accomplished. Additionally, we have noticed that it is not unusual for the anniversary of the death to occur in close proximity to some other anniversary, such as the birthday of the deceased, someone else’s birthday, a wedding anniversary, etc. This can again trigger a need to reorient the sessions to deal with the difficult times. When these interruptions occur in the usual flow of the treatment, more time may be needed to complete the usual sixteen-week CGT package. Patients who have experienced multiple losses may benefit from continued work on these. Patients for whom family members have been affected by CG may benefit if the family members begin to participate in the treatment more actively. We have not worked with couples that have lost a child, but this may be an option. Alternatively, a patient’s partner with CG might be referred to a colleague and some joint sessions held. If there is a child in the family, it can be important to help the patient decide if the child is experiencing CG and needs help with this. Sometimes there is more work to be done on situational revisiting, goals, or interpersonal problems and this is a reason to extend the treatment.

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Session 16 There are a number of situations in which it makes sense to continue with the basic approach used in CGT, i.e. using the same principles, strategies and procedures. However, in some cases the patient may do better to switch to a different modality, either with the same therapist or with a referral. The general indication to continue CGT is if the patient is interested in doing so, is partially treated, i.e. has shown some symptom amelioration after sixteen sessions, and the therapist believes she has benefitted from this approach. It may be helpful to add medication at this point, if a patient is still moderately symptomatic and experiencing prominent mood or anxiety symptoms. Sometimes it makes sense to plan a period of one to three months without treatment and to schedule an evaluation session at the end of that time to see how things stand. The patient may have found that her grief has continued to progress, that she is making good use of the gains of the treatment and wishes to continue on her own, possibly with another check-in planned. In other cases, it has become clear that there are still problems the patient wishes to address and a period of therapy is reinstituted. In some cases, it makes better sense to switch to another modality. Virtually

all forms of

psychotherapy available in the community have been used to help bereaved people. Though there is not data on community treatment for CG, it is almost certain that a wide range of different approaches have been useful

for individual patients. If a person does not wish to continue with

CGT or if they have shown little or no progress during the sixteen-week period, the therapist may wish to switch modalities or refer to another therapist who works differently. Another situation in which switching modalities is indicated is if there is a comorbid condition or clinical problem that is now the most important one. For example, there may have been childhood physical or sexual abuse, other important trauma experiences not related to the death, significant interpersonal problems, beyond the scope of CGT, the emergence of a substance use disorder, or other mood or anxiety disorder. Preparation for termination in session 16 will be done somewhat differently depending on the clinical situation and the plans for the next period of time. The discussion of termination provided here focuses primarily on a person who is ending with the current therapist.

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Preparation for termination includes reviewing with the patient what she has learned in the treatment, and discussing progress on loss-related and restoration-related issues. The therapist also helps the patient identify and deal with any feelings, both positive and negative, about ending the treatment and about her future prospects. Plans for using and managing these feelings are discussed. Plans are also discussed for continued work on personal goals and on any other component of the treatment that is not fully completed. Termination can sometimes evoke feelings of loss that can trigger some of the patient’s grief. This usually emerges on the Grief Monitoring diary. If grief intensity rises in the last few sessions in relation to termination of the treatment, this becomes an opportunity to illustrate how different loss experiences may trigger grief about her lost loved one. Knowing that this is a natural process and that it does not indicate “unfinished business” can be very helpful. Termination is also an opportunity for the therapist to summarize and comment on her view of the treatment and the progress the patient has made. It is useful to summarize again the CGT model and the individual formulation and to discuss how the patient has or has not yet come to see things a little differently. It is important to summarize her strengths. Plan to give some examples of how the patient has her strengths in the treatment and also some concrete ways these could be useful to her in the future. The session ends with a genuine statement of your positive feelings about working with the patient, information about availability in the future, and saying good-bye.

Beginning (About 5 Minutes) Review Grief Monitoring Diary and other interval activities Ask the patient for the diary and look it over. Discuss the pattern and the trig- gers. Ask the patient to consider how these have changed since the first week of treatment. If there is any indication of increased grief related to ending the treatment, discuss this. Ask about goals work and (unlike in prior sessions) discuss this. Discuss any other

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interval work that was done in session 15, including situational revisiting exercise, Imaginal Revisiting, a Memories form, or Interpersonal work. Orient the patient to the session Tell the patient you want to spend this session reviewing the treatment and what the two of you have accomplished together and what remains unfinished. You will spend some time talking about where things stand now compared to when you started working together and at the mid-course review, and plans for the patient after the treatment ends. You want to be sure she has a good understanding of her own strengths, how she has used them in the treatment, and how she can continue to use them as she moves forward in her life. You want to continue the discussion of her thoughts and feelings about ending the treatment and about the future. You are interested in both positive and negative feelings and thoughts. Ask if this sounds okay.

Middle And Ending (About 40 Minutes) Introduce the review of the treatment model and the patient’s progress Tell the patient that we like to use this session to review what we did in the treatment and why we did it. We want to make sure she understands the model we are using, the way we see her situation using this model as a framework, and how we have been working together to get her grief back on track. We also want to highlight and support the gains she has made and answer any questions she has about any of this. Discussion of the treatment model Remind the patient that throughout this treatment we have been thinking of her grief as a natural instinctive healing process that is related to attachment, caregiving and

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exploratory systems, and we also see these as inborn biological systems. We also believe that within the broad framework of the instinctive response, people experience grief in a unique way for every loss. Coming to terms with the loss of a loved one is one of the most difficult experiences anyone ever has and there is no right or wrong way—no healthy or unhealthy way to grieve (with the obvious exception of doing clearly unhealthy behaviors like excessive use of alcohol or other substances or not eating or sleeping). What we mean is that there are as many ways of coping as there are people. What we do think is that some kinds of activities and thinking generally help grief progress and some can keep you stuck. In this treatment, we have tried to identify what has kept her stuck and work with those. We have also tried to help energize the healing process. Ask the patient if this makes sense. Ask her what she thinks has gotten her stuck. Let her know if you agree and if not, what you think. Then ask the patient what kinds of things promote healing. Be sure she mentions the oscillation from confronting the loss and setting it aside, getting respite from the pain and taking care of herself. Remind her that healing needs to occur around coming to terms with the loss and also around restoring her own life. Ask if she has any questions about this. Discussion of strategies and procedures Review CGT loss and restoration strategies. Loss-related strategies are designed to help people come to terms with the loss, to understand their enduring sense of connection to the deceased and also to allow the nature of that connection to evolve and change as healing progresses. Loss-related procedures include grief monitoring, the revisiting exercises, memories and pictures, and the Imaginal Conversation. Restoration-related strategies focus on helping people to redefine their life goals and plans in a way that seems hopeful and positive. Sometimes life goals are not greatly changed, but the person feels more comfortable pursuing their goals without the deceased loved one. Sometimes there are new goals that would not have been desirable or maybe even possible if the

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loved one had not died. We want people to feel comfortable either way. Restorationrelated procedures include self- care and rewards, thinking about relationships with other people, including inviting someone to come into a session, and doing personal goals work. Ask if this makes sense to the patient. Talk about her experience of these procedures and their usefulness. Ask if she has any questions. Discussion of treatment progress Talk about the patient’s progress through the treatment. How much did she engage with the treatment and the procedures? How much did she hold back? Be sure that you are honest and non-judgmental in this discussion. Talk about what changed for her and what has not changed and how confident she is in the changes. Talk about what she thinks was most helpful and what was the hardest thing for her in the treatment. Help her see changes she has made. Ask the patient how she views the loss and her grief at this point. Tell her whether you agree and, if not, what you see differently. If relevant, include a discussion of progress on a secondary loss. How have her feelings and thoughts about that loss changed? Alternatively, if relevant, discuss progress on an interpersonal role transition or interpersonal dispute. How are things going in the problem area now? Summarize the work that has been done in this area. Review Progress of CG Symptoms This review is similar to the one you did in session 10. Tell the patient you want to review her CG symptoms, focusing primarily on typical beliefs and on avoidance. Review beliefs she had in the beginning of the treatment and ask if these have changed. How does she see the death now? Focus on the items that were endorsed at a high level. Use the baseline TBQ to identify the beliefs she had at the beginning of the treatment and then compare these to session 10 and session 16. Use the repeat versions of the TBQ in the discussion of changes, but also ask the patient to think about her progress and discuss

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Session 16 this with you. Do the same thing with avoidance behavior, supplementing the discussion with a review of the GRAQ at session 1 and the repeat versions. Make some general observations about whether and how much the scores have changed and discuss some examples of what has and has not changed. Ask the patient if she has been aware of these changes, or lack of changes. Ask her if these results surprise her at all. Discuss her progress as well as any unfinished or incomplete work. Discuss patient’s strengths and resources Tell the patient that you want to talk about her strengths. Let her know what about her has impressed you. Identification of personal strengths and resources is very important in CGT. Strengths are conceptualized as positive attributes that are often rooted in strong personal or cultural values. Many patients with CG pride themselves on their selfsufficiency and ability to care for others. They are often people who have learned to cope with adversity by relying primarily on themselves. This is both a vulnerability for CG and a strength in many other areas of life. The self-discipline and value system that underlies the ability to be a caregiver and to be self-reliant are often used in CG treatment and this should be acknowledged. Strengths can also be identified by being aware of what is going well—what has gone well from the beginning of treatment and things that are going well at the end. Patients should be helped to identify, acknowledge and “own” their own strengths. Point out admirable traits and behaviors and provide examples of how the patient has used these in the treatment and examples of how she can use them in dealing with problems in the future. Discuss plans for the future including any upcoming difficult times This section can be omitted if the patient is continuing in treatment or being referred to another therapist. Otherwise, review the remaining issues just identified that she may still need to attend to. Remind her that she needs to continue to think about her treatment

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Session 16

gains and to practice any changes in thinking or behavior that have accompanied this progress. Discuss plans for the future, including her continued work on goals and any other remaining elements of CGT. Ask about her comfort in doing these things and if she has any concerns about proceeding on her own. Discuss these. Ask when the next difficult time will be. Discuss how she is planning to handle this day. Make suggestions if needed and provide support.

Discuss remaining thoughts and feelings about termination and end the session Ask the patient how she is feeling about ending the treatment? Is she sad? Happy? What other feelings does she have about this? Ask what thoughts she is having and if she has any concerns about continuing on her own. Discuss this. Tell her that you want to share your own feelings and thoughts about the treatment. Ask if that’s okay with her. Assuming she agrees, tell her honestly what your experience has been. Tell the patient you have enjoyed working with her. Again encourage plans for continued use of various strategies and other things she has learned in the treatment. Support her ability to use these tools. Review plans for future contact, either scheduled or as needed. Ask if she has any questions. Respond to any questions. Wish her well. End the session.

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Selected References Pages 220-229

Selected References Some text and video references you may find interesting: Bryant, R. A., Kenny, L., Joscelyne, A., Rawson, N., Maccallum, F., Cahill, C., . . . Nickerson, A. (2014). Treating prolonged grief disorder: a randomized clinical trial. JAMA Psychiatry, 71(12), 1332-1339. This paper reports on a small randomized controlled study of a group CGT for CG that tested the efficacy of 4 adjunctive sessions of imaginal revisiting. Corbett, B. and Colemon, J. (2006). Chapter 1. Base Camp. The Sherpa Guide: ProcessDriven Executive Coaching Thomson. This short chapter helps you understand the core elements of a Companionship approach to grief therapy. Denborough, D. (2014). Retelling the Stories of Our Lives: Everyday Narrative Therapy to Draw Inspiration and Transform Experience. New York: W.W. Norton & Company, Inc. Chapter 8. This chapter is about saying hello again when we have lost someone close. It will help you think about ways to help clients validate and honor their ongoing relationship (continuing bond) with the person they lost. DiTommaso, E., Brannen-McNulty, C., Ross, L., & Burgess, M. (2003). Attachment styles, social skills and loneliness in young adults. Personality and Individual Differences, 35(2), 303-312. This paper (11 pages) presents research on the relationship between attachment styles, social skills and loneliness in young adults. The results indicate that social competence and skills are related to lower levels of loneliness.

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Selected References

Field, N. P., Gal-Oz, E., & Bonanno, G. A. (2003). Continuing bonds and adjustment at 5 years after the death of a spouse. Journal of consulting and clinical psychology, 71(1), 110-117. This 7-page paper provides information on the adaptive nature of continuing bonds based on a longitudinal study examining individuals’ ongoing attachment to the deceased at 60 months post-loss. Gable, S. L., Gosnell, C. L., Maisel, N. C., & Strachman, A. (2012). Safely testing the alarm: Close others’ responses to personal positive events. Journal of personality and social psychology, 103(6), 963-981. This paper (18 pages) helps you understand effective support. Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in psychiatric treatment, 15(3), 199-208. This is a lovely introduction to a compassion-focused approach to a wide range of interventions. You may find it helpful to incorporate some of these ideas into a grief therapy. Gilbert, D. T., & Wilson, T. D. (2000). Miswanting: Some problems in the forecasting of future affective states. In Thinking and feeling: The role of affect in social cognition, edited by Joseph P. Forgas, 178-197. Cambridge: Cambridge University Press. This chapter outlines how individuals tend to neglect the operation of the immune system when they anticipate the future contains unhappy consequences by doing so it only allows individuals to avoid the unwanted event. Gilbert, D. T., Pinel, E. C., Wilson, T. D., Blumberg, S. J., & Wheatley, T. P. (1998). Immune neglect: a source of durability bias in affective forecasting. Journal of personality and social psychology, 75(3), 617. This 21-page primary source paper discusses the concept

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Selected References

of psychological immunity and illustrates ways that people are not necessarily aware of how it functions. Knowing about psychological immunity can help you encourage clients to confront the painful reality of the death. Gilbert, D. T., & Wilson, T. D. (2000). Miswanting: Some problems in the forecasting of future affective states. In Thinking and feeling: The role of affect in social cognition, edited by Joseph P. Forgas, 178-197. Cambridge: Cambridge University Press. This chapter outlines how individuals tend to neglect the operation of the immune system when they anticipate the future contains unhappy consequences by doing so it only allows individuals to avoid the unwanted event. Gottman, J. M. (1998). Psychology and the study of marital processes. Annual review of psychology, 49(1), 169-197. This article discusses the progress of research on the study of marriage. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101(2), 141-148. This is one of the first good descriptions of acute grief and an interesting historical paper (7 pages). It will help you start to recognize symptoms of acute grief and will give you some ideas about the traditional psychodynamic view of the adaptation process. Markowitz, J. C., & Weissman, M. M. (2004). Interpersonal psychotherapy: principles and applications. World Psychiatry, 3(3), 136-139. This brief article provides information about the structure and applications of IPT. McNulty, J. K., & Karney, B. R. (2004). Positive expectations in the early years of marriage: Should couples expect the best or brace for the worst?.Journal of personality and social psychology, 86(5), 729.

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Selected References

McNulty, J. K. (2008). Forgiveness in marriage: putting the benefits into context. Journal of Family Psychology, 22(1), 171-175. This article (5 pages) reports the results of a longitudinal study on the consequences of spouses’ tendencies to forgive their partners over the first 2 years of 72 new marriage. Morina, N. (2011). Rumination and avoidance as predictors of prolonged grief, depression, and posttraumatic stress in female widowed survivors of war. The Journal of nervous and mental disease, 199(12), 921-927. This paper reports results of a research study of 100 Kosovo war-bereaved wives with children conducted 10 years after the end of the war. This cross-sectional analysis found independent effects of rumination and avoidance in predicting CG. Moskowitz, J., Folkman, S., & Acree, M. (2003). Do positive psychological states shed light on recovery from bereavement? Findings from a 3-year longitudinal study. Death studies, 27(6), 471-500. This paper (29 pages) outlines reports of positive and negative emotions in response to bereavement among bereaved partners of men with AIDS. The paper will help you see the surprising frequency of positive emotions, beginning very early after a loss and introduce you to the idea that positive emotions are important to adaptation. Neff, K. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and identity, 2(2), 85-101. This paper (17 pages) describes the self-regulation strategy of self-compassion and summarizes some of the research done on this concept.

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Selected References

O’Callaghan, C. C., McDermott, F., Hudson, P., & Zalcberg, J. R. (2013). Sound continuing bonds with the deceased: the relevance of music, including preloss music therapy, for eight bereaved caregivers. Death studies, 37(2), 101-125. This paper (24 pages) examines the relevance of music therapy and its usefulness in enabling caregivers to connect with their loved one’s who have passed away from cancer. It will help you see how the use of music not only improves an individual’s mood but also comforts those who are grieving. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American psychologist, 55(1), 68-78. This paper (10 pages) provides an overview of the theory of self-determination theory and some of the supporting research. It will help you learn about this natural facilitator of adaptation. Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F., 3rd. (2005). Treatment of complicated grief: a randomized controlled trial. JAMA, 293(21), 2601-2608. This paper (8 pages) reports on the results of a study finding CGT to be an improved treatment over interpersonal therapy (IPT) for CG. Shear, K., Monk, T., Houck, P., Melhem, N., Frank, E., Reynolds, C., & Sillowash, R. (2007). An attachment-based model of complicated grief including the role of avoidance. European archives of psychiatry and clinical neuroscience, 257(8), 453-461. This paper reports on a measure of Grief-related Avoidance administered to 128 individuals being treated for complicated grief and demonstrates a significant impact of avoidance on functional impairment. The role of avoidance in an attachment-based model of CG is also discussed.

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Selected References

Shear, M.K. (2010). Exploring the role of experiential avoidance from the perspective of attachment theory and the dual process model. Omega, 61(4), 357-369. This paper (12 pages) helps you see avoidance as both a self-regulation strategy and also a grief complication. Shear, M.K. (2012). Getting Straight about Grief. Depress Anxiety, 29, 461-464. This very short paper (3 pages) will help you compare and contrast acute, integrated and complicated grief. Shear, M. K., Wang, Y., Skritskaya, N., Duan, N., Mauro, C., & Ghesquiere, A. (2014). Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA psychiatry, 71(11), 1287-1295. This paper (7 pages) reports on the efficacy of CGT compared to IPT in the elderly. Shear, M.K. (2015). Clinical practice. Complicated grief. N Engl J Med, 372(2), 153-160. This short paper (7 pages) will help you compare and contrast acute, integrated and complicated grief and will introduce a rationale for the seven modules in complicated grief treatment. So, J., & Leung, C.M. (2013). Mummification in a Chinese Patient with Grief: A morbid symptom or cultural practice? East Asian Archives of Psychiatry, 23(4), 164-167. This very short paper (3 pages) shows you an example of an extreme version of a culturally acceptable bereavement practice and helps you see the commonalities in the acute and integrated grief symptoms.

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Selected References

Stix, G. (2011). The neuroscience of true grit. Scientific American, 304(3), 28-33. This article (5 pages) provides a short interesting summary of the idea of natural adaptation to loss and to the concept of flourishing, happiness and wellbeing as important goals in life. Turret, N., & Shear, M.K. (2012). Grief Monitoring Diary. In R.A. Neimeyer (Ed.), Techniques in Grief Therapy: Creative Practices for Counseling the Bereaved (pp. 27). New York: Routledge. This very short paper (1 page) will help you consider how self-monitoring can be helpful. Young, H., & Garrard, B. (2015). Bereavement and loss: developing a memory box to support a young woman with profound learning disabilities. British Journal of Learning Disabilities. This case study provides a closer look at helping bereaved individuals with profound learning disabilities. Researchers explore avenues of communication through the use of a memory box: a person-centered, inventive approach to evoke beneficial memories and feelings about the deceased that does not rely strictly on verbal communication and narrative exercises. Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. Basic Books. This book provides guidance in conducting IPT for depression, its adaptation to mood and non-mood disorders, and resources. Weissman, M., Markowitz, J., & Klerman, G. L. (2007). Clinician’s quick guide to interpersonal psychotherapy. Oxford University Press. Guide for busy professionals who are interested in learning IPT.

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Selected References

Zuroff, D. C., Koestner, R., Moskowitz, D. S., McBride, C., & Bagby, R. M. (2012). Therapist’s autonomy support and patient’s self-criticism predict motivation during brief treatments for depression. Journal of Social and Clinical Psychology, 31(9), 903.

Videos Liam Neeson and Anderson Cooper (9 min) A discussion of Liam’s traumatic loss of his wife. Kay Redfield Jamison (6 min) In this Big Think interview, Dr. Jamison, a Professor of Psychiatry at John Hopkins, discusses the loss of her husband, Richard, touching on a number of important issues. Elaine Mansfield (17 min) TED Talk on the experience of grief, love, learning and community. Wellcast Animation (4 min) This is an excellent overview of a big picture way to understand grief and principles for dealing with the pain. Ten years later: Dan Gilbert on life after “The surprising science of happiness. (21 min) This entertaining TedTalk describes the concept of synthetic happiness that will help you see the importance of the stories we tell ourselves and also of having faith in our own resilience. Psychologist Guy Winch (18 min) TedTalk introducing the concept of psychological first aid as a form of self care.

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Selected References

Richard Ryan on self-determination (15 min) Highlights of the Opening Remarks from the 5th Conference on Self-Determination Theory in 2013. New Hope For Complicated Grief (7 min) Introduction to complicated grief and complicated grief treatment (CGT).

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Appendix Pages 230-231

Appendix

I. Session by Session Schedule of Forms II. Forms Used by Patients Between Sessions A. Interval Notes Form B. Interval Plans Form (IPF) C. Grief Monitoring Diary (GMD) D. Grief Monitoring Diary Sample E. Between Session Situational Revisiting Form F. Between Session Imaginal Revisiting Form G. Memories Form-1 H. Memories Form-2 I. Memories Form-3 J. Memories Form-4 K. Memories Form-5 L. Difficult Times Form III. Forms Used by Therapists During Sessions A. Therapist Worksheet- Case Formulation B. Imaginal Revisiting Therapist Form C. Situational Revisiting List IV. Handouts for Patients, Friends and Family Members A. Complicated Grief and Its Treatment (Short Version) B. Managing DIfficult Times (Short Version)

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Initial: _____ Date: _____ -THE CENTER FOR-

CQMPLICATED GRIEF

Session by Session Schedule of CGT Forms Session Number

Tools

Initials

Person Completing Form

LOSS SUM

PATIENT

2. Inventory of complicated grief (Complete one for each difficult loss)

ICG

PATIENT

3. Difficult times questionnaire

DTQ

PATIENT

4. Grief support inventory

GSI

PATIENT

GRAQ

PATIENT

TBQ

PATIENT

Additional Information

Before session 1 1. Loss summary

5. Grief-related avoidance questionnaire 6. Typical beliefs questionnaire 7. CG handout

PATIENT

Session 1 1. Grief monitoring diary 2. Sample grief monitoring diary

GMD

PATIENT

SAMPLE GMD

NA

Pg 1

I ni t i al : Dat e:

I ntervalNotesForm Not esf orSessi on_ _ _ _ _ _ _ _ _ _ _ _ _ _ Thi sf or mi sf orkeepi ngt r ackofanyt hought s youhaveaboutt het r eat ment ,i ncl udi ng quest i onsorcomment sabouti tort hi ngsyouwantt het her api stt oknow.

Initial: ____ Date: _____ - THE CENTER FOR -

COMPLICATED GRIEF

Interval Plans Form (IPF) Completed at the end of session ___

What to do between now and your next session:

D Complete Grief Monitoring Diary (bring form to next session) Planned Activity

Forms for Planned Activity

Initial: _____ Date: _____

-THE CENTER FOR-

CQMPLICATED GRIEF

Grief Monitoring Diary (GMD) Given out at session (Please circle one) 2

3

4

5

6

7

8

9

10

11

12

13

14

15

During the course of Complicated Grief Treatment we would like you to monitor and rate the intensity of your grief. Using a scale where 1 =the least intense, and 1 O=the most intense grief you can imagine, please record the minimum and the maximum intensity of your grief each day and tell us when these lowest and highest points occurred. Then, at the end of the day, rate the average intensity for that day.

DAY

HIGHEST GRIEF

NOTES

LOWEST GRIEF

NOTES

AVERAGE GRIEF

Initial: _____ Date: _____

-THE CENTER FOR-

CQMPLICATED GRIEF

Grief Monitoring Diary (GMD) Given out at session (Please circle one) 2

3

4

5

6

7

8

9

10

11

12

13

14

15

During the course of Complicated Grief Treatment we would like you to monitor and rate the intensity of your grief. Using a scale where 1 =the least intense, and 1 O=the most intense grief you can imagine, please record the minimum and the maximum intensity of your grief each day and tell us when these lowest and highest points occurred. Then, at the end of the day, rate the average intensity for that day.

DAY

HIGHEST GRIEF

Thursday

8

Friday

9

Saturday

7

Monday

9

NOTES Had dinner with friends I haven't seen sinceJ died

Before I went to bed. MissingJ so much

Son-in-law asked me how I am doing. Asked if I wanted him to come over and help go throughJ's things

Phone call from someone who didn't knowJ died. I had to tell him.

LOWEST GRIEF

3

7

4

7-8

NOTES Spent time with 4-year-old grand niece. She is very cute and funny

Trying to watch tv (This was a bad day. Home alone all day. No one called)

AVERAGE GRIEF 6

8

Went to ball game to watch oldest grandson play. Pretty good day Spent most of the day with my daughter and her family Someone called from church and asked if I would volunteer to help out next Sunday. I felt a little better but it didn't last Home alone all day again not a good day

8

Initial: ____ Date: ____ - THE CENTER FOR -

COMPLICATED GRIEF

Between Session Situational Revisiting Form

Given out at Session (Please circle one): 1 2 3 4 5

6

7

8

9 1 0 11 12 13 14 15

I. Situation p ra cticed__________________________ Suds: _______ (taken from Situational Revisiting List)

Day

1. 2.

3.

4. 5. 6.

7. 8.

Date

Before Revisiting SUDs

After Revisiting SUDs

Time Spent (min)

Notes

Initial: ____ Date: _____ - THE CENTER FOR -

COMPLICATED GRIEF

Between Session lmaginal Revisiting Form Given out at Session (Please circle one):

2

1

3

4

5

6

7

8

9

10

11

12

13

14

15

Please record the following information related to listening to the lmaginal Revisiting recording.

Date

Time Spent (in minutes)

I I

1.

- - -

2.

- - -

3.

- - -

4.

- - -

5.

- - -

6.

- - -

7.

- - -

8.

- - -

9.

- - -

1 0.

- - -

11 .

- - -

12.

-

I I I I

I I I I I I I I I I I I

I I I I

I-I-

SUDS Beginning

SUDs End

Highest SUDS

Initial: ____ Date: ____ -THE CENTER FOR-

CQMPLICATED GRIEF

MEMORIES FORM-1 1. List

's most likeable characteristics:

a.�---------------------------------C.

2. List the most enjoyable times you had with __________:

a.�---------------------------------C.

3. What are some of the things you loved most about _______?

a.�---------------------------------C.

4. What were the most important things __________ added to your life?

a.�---------------------------------b. �---------------------------------C.

d. �----------------------------------

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Initial: ____ Date: ____ -THE CENTER FOR-

CQMPLICATED GRIEF

MEMORIES FORM-2 1. List additional likeable characteristics of a.

b. C.

d. 2. List other enjoyable times you had with ___________________ : a.

b. C.

d. 3. What are some other things you loved most about ______________? a.

b. C.

d. 4. What are some additional things ___________ added to your life? a.

b. C.

d.

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Initial: ____ Date: ____ -THE CENTER FOR-

CQMPLICATED GRIEF

MEMORIES FORM-3 1. What are some of your favorite memories of ______________?

a.�---------------------------------C.

2. What were _________'s best traits?

a.�---------------------------------C.

3. What did you love most about ______________?

a.�---------------------------------C.

4. What do you miss most about ____________?

a.�---------------------------------b. �---------------------------------C.

d. �----------------------------------

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Initial: ____ Date: ____ -THE CENTER FOR-

CQMPLICATED GRIEF

MEMORIES FORM-4 1. What are some of your least favorite memories of ____________?

a.�---------------------------------C.

2. What were _______'s most annoying traits?

a.�---------------------------------C.

3. What did you wish was different about _______________?

a.�---------------------------------C.

4. Is there anything you don't really miss?

a.�---------------------------------b. �---------------------------------C.

d. �----------------------------------

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Initial: ____ Date: _____ -THE CENTER FOR-

CQMPLICATED GRIEF

MEMORIES FORM-5 1. What are some of your favorite memories of ___________?

a.-----------------------------------C.

2. What are your least favorite memories of ____________ ?

a.-----------------------------------C.

3. What were some of their endearing traits?

a.-----------------------------------C.

4. What did you admire about ____________ ?

a.-----------------------------------b. -----------------------------------C.

d. ------------------------------------

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Initial: ____ Date: __/ __/__ - THE CENTER FOR -

COMPLICATED GRIEF

Difficult Times Plan 1. When is the difficult time?

2. List some ways you can soothe and take care of your self

3. Listsomewaysyoucan I etothershe I ptakecareofyou

4. Whataresomepleasurableactivitiesyoucandoaloneorwithothers?

5. How can you show your continuing love and caring for the person who died?

Initial: ____ Date: ____ -THE CENTER FOR-

CQMPLICATED GRIEF

Therapist Worksheet-Case Formulation PART 1: FACTS ABOUT THE DEATH 1. Who died (brief description of the relationship-quality,

importance, frequency of

contact)

2. When was the death? 3. How did the person die?

PART 2: CG SYMPTOMS A. Prolonged acute grief (circle those that are present and rate intensity on 1-10 scale) •Intense yearning, longing, sorrow, emotional pain, distressing somatic symptoms (e.g. heart palpitations, butterflies in the stomach, frequent yawning, dizziness/fogginess) • Feelings of disbelief, unreality • Insistent distracting thoughts of the deceased, trouble focusing, forgetfulness • Loss of sense of self, sense of purpose, feelings of wellbeing • Feeling disconnected from other people and ongoing life; feeling aimless, loss of sense of purpose, feelings of incompetence, loss of sense of self, loss of wellbeing • Other Pg 1

Initial: ____ ,

Date: ___ ,_ -THE CENTER FOR-

CQMPLICATED GRIEF

lmaginal Revisiting Therapist Form 1. Is this a (please circle one): 1. Revisiting the death: Full Story 2. Revisiting: Hot Spot 3. lmaginal conversation with the deceased 4. 0ther (p I ease specify): ---------------------------------

Baseline Time -- --

-- --

Baseline SUDS

AM or PM

Revisiting notes: (noted during the imaginal exercise)

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Initial: ____ / _ Date: __/__ - THE CENTER FOR -

COMPLICATED GRIEF

Situational Revisiting List SUDS Level 100

0

ACTIVITY OR SITUATION

Complicated Grief and Its Treatment A Handout for Patients, Friends, and Family Members

M. Katherine Shear, M.D. Based in part on an earlier version with Krissa Caroff, B.S. October 2013 Copyright ©2015, Columbia Center for Complicated Grief, The Trustees of Columbia University in the City of New York. All rights reserved. Not to be cited or used without the written permission of the authors

Handout Explaining Complicated Grief

Bereavement, Grief, and Mourning Bereavement is the loss of a loved one. Loved ones are very important in people’s lives. People define themselves in part by their close relationships and these relationships help them feel safe. Close relationships affect people in many ways including some they are not aware of in their conscious mind. The importance of loved ones when they are alive is the reason their death affects people so much. Grief is the reaction to loss and it is different for every person. Yet certain kinds of thoughts and feelings occur predictably. These include feelings of yearning, longing and sadness, frequent thoughts and memories of the deceased, a sense of distance from the world and other people, and a range of different painful emotions. Bereaved people often feel confused about themselves– their identity, what they care about. It can be hard to focus on anything very complex. They may want others around, but it may be harder than usual to contribute to conversation and activities. Painful and disruptive as it is, you can think of grief as nature’s way of giving people time and guidance to work through a mourning process. Loss is permanent and so is grief. However, grief usually changes over time. It starts out as acute grief that is intense and disruptive and sometimes surprisingly strange and unsettling. Over time grief is reshaped into a form that is quieter and integrated into a bereaved person’s life. Integrated grief enables people to remember and honor their loved ones, without disrupting their own lives. Mourning is the process by which acute grief is reshaped and integrated.

How mourning works Acute grief can be so strong that it feels like it is going to last forever, but it usually doesn’t. The changes don’t happen easily and are often imperceptible, but grief is usually integrated more quickly than we expect. It appears that people have an instinctive process that helps them deal with a painful loss. Instinctive mourning, like acute grief, is a process unique to each individual. The way people cope and the time they need is different for each person. However, there are some things most people have in common. People usually learn to dose themselves with the

Complicated Grief Handout

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Handout Explaining Complicated Grief

emotional pain. They usually spend some time with the pain, letting it be there, while they think about their new state of affairs. At some point, their minds naturally turn away from the pain. Bereaved people need to allow this break from the pain and even welcome it, allowing themselves to experience positive feelings. The process of moving toward and away from painful feelings helps the process of learning to live with the loss. It helps if there is someone who can share the pain. The presence of other people can help the bereaved feel connected to the present and feel some hope for the future. People who are very close to each other have a bond that is permanent. Memories of loved ones are stored in a special way in the brain. Right after a loved one dies it seems like this can never be enough. But over time, the deep feelings of connection can become a comfort. People who love each other are not usually together all day, every day. Instead, they come and go in each other’s lives, even when they are very close. People’s minds have a way of staying connected to people they love even during times when they are apart. Mourning can help bereaved people find a way to use this sense of connection after someone dies to feel connected to their loved ones in a new way. Mourning is also a process of adjusting to practical changes the loss has created. People have to find solutions to simple everyday things like who will take out the trash, or do the laundry, things they may not be used to doing and may not want to do. They need to find new ways to spend their time, especially if they have been spending a lot of time taking care of their loved one. They may need to find someone new to confide in. Mentally, they need to find ways that they can think about or “re-visit” memories and feelings about the person who died including their death, and rethink thoughts that are highly painful. Making these changes is not easy, but people can feel a sense of satisfaction and even pride, as they begin to figure this out.

Complicated Grief Having strong feelings of sadness and loneliness, some fear, anxiety, guilt, resentment, anger, or shame is perfectly normal after a loss but people need to pay attention to these feelings

Complicated Grief Handout

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Handout Explaining Complicated Grief

and resolve them. Sometimes that doesn’t happen. Sometimes people continue to feel like they can’t accept the death, even though they know perfectly well that it happened. Sometimes they become afraid of their grief or ashamed of it or mad about being so upset. They think of grief as a problem that is getting in their way instead of a natural human feeling to accept and even respect. Sometimes people focus on grief so much they stop caring about themselves or their own lives. Sometimes sorrow and yearning seem very strong and stubborn, and a person can’t imagine ever being happy again. Another way of saying this is that the person is “stuck” in acute grief and mourning is derailed. W e call this situation “complicated grief”. In medicine a complication is something that gets in the way of a healing process. Think of losing a loved one as something like a serious injury and grief as like the painful inflammation that occurs with the wound. Mourning is like the healing process in which the pain and inflammation eventually lessen. A wound complication such as an infection can make the inflammation and pain worse and get in the way of healing. Likewise, certain kinds of thoughts, feelings and behaviors can make the pain of acute grief worse and get in the way of mourning. Once this happens it can be very difficult to find your way out of it alone.

Grief Complications In order to heal, people need to wrestle with how to understand that a loved one is gone and what the loss means to them. They need to find ways to stay connected to their loved one and also ways to live their own lives in a meaningful way without their loved one. People’s minds automatically start to do this when someone dies, often without our quite realizing it. But people can get in the way of themselves. You might know the term “Monday morning quarter-backing”. It is something people do very naturally when something happens that they wish they could have prevented. If you are a coach and your j ob is to help your team do better in the next game, it is a useful thing to do. But it is not so useful if you are trying to deal with the loss of a loved one or anything else over which you have no control, and which you cannot change. If a person looks back and thinks about what could have been different “if only _____” (you can fill in the blank) it is not helpful. In fact, the more bereaved people do this kind of second guessing, the more they are telling their brain that maybe this death didn’t have to happen, and this can be a signal to put the mourning process on hold. "If only" thinking is one kind of common grief complication. Complicated Grief Handout

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Handout Explaining Complicated Grief

Another common problem is excessive avoidance of reminders of the death. Its natural to want to stay away from pain. The world is full of painful reminders and bereaved people do need to dose themselves with the pain. But they also need to learn what the loss means to them and one of the best ways to do that is to do things that they used to do with the person who died. They need to strike a balance between doing these painful things and trying new things that might not have so many reminders. If they find a good balance they end up gradually doing more and more. W idespread avoidance can block the mourning process. The feelings associated with painful experiences will not go away just by avoiding or ignoring them. Instead, they remain in your mind - a little like land mines in a battlefield, buried under the surface, but still active. If they are triggered, the intense emotions “explode out” and people end up having to use more and more energy trying to make sure this doesn’t happen. In addition, there is usually some ongoing tension from knowing that these feelings are present under the surface. This tension, combined with the unpredictable outpouring of emotions, means that hidden feelings can have a big affect on people’s lives.

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A Poem that Expresses How a Lot of People with Complicated Grief Feel: Anger Don’t tell me that you understand, Don’t tell me that you know. Don’t tell me that I will survive, How I will surely grow. Don’t tell me this is just a test, That I am truly blessed, That I am chosen for this task, Apart from all the rest. Don’t come at me with answers That can only come from me, Don’t tell me how my grief will pass That I will soon be free. Don’t stand in pious judgment Of the bonds I must untie, Don’t tell me how to suffer, And don’t tell me how to cry. My life is filled with selfishness, My pain is all I see, But I need you, I need your love, Unconditionally. Accept me in my ups and downs, I need someone to share, Just hold my hand and let me cry, And say, “My friend, I care.”

- By Joanetta Hendel

Reprinted with permission of Bereavement Publishing, Inc. 1-888-604-HOPE. Complicated Grief Handout

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Managing Difficult Times A Handout for people with complicated grief

M. Katherine Shear, M.D. Copyright ©2015, Columbia Center for Complicated Grief, The Trustees of Columbia University in the City of New York. All rights reserved. Not to be cited or used without the written permission of the authors

Managing Difficult Times

WHAT IS A DIFFICULT TIME? Certain times of the year are especially painful for a bereaved person. This handout is designed to help manage these difficult times. Examples include the family holidays, especially the period between thanksgiving and new years day, the day of the death, the deceased person’s birthday, the bereaved person’s birthday, a wedding anniversary after the loss of a spouse, the first day of school each year, mother’s or father’s day after the loss of a child, parent’s anniversary or mother’s or father’s day after the loss of a parent. Or, if your deceased loved one especially enjoyed the fall, you might find that time of year especially difficult. The anniversary of becoming pregnant might be difficult for someone who has lost a child. The winter solstice might be hard for a person who lost a close friend with whom she had celebrated this date every year.

PRINCIPLES FOR MANAGING DIFFICULT TIMES There is no right and wrong kind of grief, and there is no prescription for managing difficult times. Our principles are simply suggestions about ways you might take a little control of your own life. It is up to you to decide whether and how to do so.

PRINCIPLE 1: ANTICIPATE AND PLAN FOR DIFFICULT TIMES You can probably predict when these times will occur and you might want to make plans for how you want to spend the time. This will help you feel a little more in control even though these times are difficult regardless of whether you acknowledge this ahead of time or not. Think about which times are difficult for you. Make some notes about this. Try to anticipate and accept how you will feel and practice self-compassion.

PRINCIPLE 2: HONOR CONTINUING BONDS TO THE PERSON WHO DIED We have permanent bonds to people to whom we are very close and their death does not bring an end to their influence upon us. It does change the nature of that influence. It is different to love a person who died, but our bond with them continues. You can honor that bond, even as

Managing Difficult Times

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Managing Difficult Times

you miss your loved one terribly. Consider that a deceased loved one has needs that are different from when they were alive. They may need you to honor them, to take time to remember their achievements, their accomplishments, their love and caring, or other admired traits or actions. They may need you to let them be gone, to acknowledge their new status and not try to bring them back. They may need you to visit them at their final resting place, or to tend to that place.

PRINCIPLE 3: FIND PLEASURABLE ACTIVITIES FOR YOURSELF AND OTHER PEOPLE WHO ARE STILL ALIVE. Periods of celebration or of marking a life transition are the very times many people find difficult, and they are also opportunities to find moments of joy for yourself and also to share with loved ones who are still living. Positive emotions help us think more clearly and solve problems more effectively and have beneficial physical effects as well. So, in addition to missing your loved one, try to find ways to allow yourself and your remaining loved ones to experience positive feelings. Enjoy the Hannukah lights, the Christmas tree or the Kwanza celebration. Share the warmth and love of people around you. Plan to go to a special performance or take a walk in the snow. Try to think about things that you can truly enjoy, even if only for a few minutes, in the midst of your sorrow.

PRINCIPLE 4: TAKE CARE OF YOURSELF AND LET OTHERS TAKE CARE OF YOU. Even if you are well prepared, difficult times are just that. They are likely to trigger painful emotions and you need to soothe yourself as best you can. Be sure that you put yourself on the list of people you are planning to take care of. Lower your expectations of yourself and give yourself time and permission to feel sad. Maybe you don’t need to be a cheery host or take on too many obligations. You can accept help from friends and family. Let others take over activities that you find stressful or unpleasant. Maybe someone else can plan the party, take care of the kids, prepare meals, do the laundry. Maybe someone else can help you decide what will help you relax or have fun. Consider asking someone to do one of these things. Try to bring others into your life in a helpful way, even if you are not feeling as connected to them as you have in the past.

Managing Difficult Times

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Managing Difficult Times

WORKSHEET 1: IDENTIFYING DIFFICULT TIMES Below are some examples of times bereaved people find difficult. Think about how you feel on these days, and add others if you wish. Using the scale below, rate how difficult you expect each day to be and make notes about why.

Managing Difficult Times

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Managing Difficult Times

Worksheet 2: Planning activities Identify the difficult time and make a list of how you can plan to do things in each area

Managing Difficult Times

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Managing Difficult Times

Worksheet 3: Monitoring activities List your planned activities and rate the intensity of grief, the level of negative and positive emotions, on a scale from 0-10, where 0= none at all and 10 is the highest you can imagine. Then, list some of your thoughts or reactions, after you do these activities.

Managing Difficult Times

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