Dear Kanthi,

I wonder if your clients are suffering from complicated grief with some comorbid conditions. You may want to consider:

• William Worden's classic Grief counseling and grief therapy
• Katherine Shear et al.'s Treatment of complicated grief: A randomized controlled trial
• Julie Wetherrell's Complicated grief therapy as a new treatment approach

Best,

Stephen

http://www.springerpub.com/grief-counseling-and-grief-therapy-fourth-edition.html

http://jama.jamanetwork.com/article.aspx?articleid=200995

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384444/

The best therapeutic treatment for grief/bereavement is undoubtedly EMDR

in my experience, I would use the narrative and above the therapeutic emplotment

Dear All

Thank you very much for your valuable inputs

I understand that tje approach is controversial, but in my experience with well trained therpists is highly effective. I recommend Gestalt therapy.,

There are some papers on grief:

ROOS, S. (2013). Chronic Sorrow and Ambiguous Loss: Gestalt Methods for Coping with Grief. Gestalt Review, 17(3), 229-239.

Smith, E. W. L. (1986). A gestalt therapist's perspective on grief. The Psychotherapy Patient, 2(1), 65-78. doi:10.1300/J358v02n01_08

Barber, P. (2013). In dialogue with "chronic sorrow and ambiguous loss: Gestalt methods for coping with grief". Gestalt Review, 17(3), 240.

Thanks for your references on gestalt therapy for grief, Cosme. I agree with you on that well-trained gestalt therapists can facilitate grief effectively.

It would be worth investigating the article by Michael White, "Saying Hello Again: The Incorporation of the Lost Relationship in the Resolution of Grief" Dulwich Centre Newsletter, Spr 1998, pp7-11

Kanthi, you have received quite a number of good recommendations, which I agree with. In working with unresolved grief as you have referred to, a stage - process is recommended, depending on how long ago the patient has been bereaved - recent or a long time ago. Earlier unresolved grief often makes current/recent grief difficult to deal with; so in history taking and formulation this becomes really important. The relationship with the deceased person is the next important issue that the patient needs to be encouraged to talk about - pathological attachment makes for unresolved grief, particularly when the environment in the developing years was not conducive to grief and mourning, resulting in unresolved, incomplete mourning. Personality issues need to be worked with finally. I hope this helps - developing a theory and fitting the patient to suit the theory is a useful step.

Joan

Having read the above I have little to add. Kathy Shear's paper is still the only treatment that has passed the test of random allocation. If you want to understand the roots of PGD do read my book Love and Loss: The roots of grief and its complications. (Routledge)

Thanks to all Now I can try out one or the other..Well equipped

Hi Kanthi,

Have you considered the use of music therapy? There are numerous studies that have shown that the use of music to address grief and bereavement is highly valuable for young people. 

Music has been reported to provide a less confronting way for young people to engage with the area. I.e. song sharing can provide a passive way for people to express how they are feeling without having to verbalise it to another person. Instrument improvisation has been reported to allow a safe form of emotional expression and outlet. Song composition has also been reported as useful in this area. Furthermore, young people use music a lot, and showing them how to use it as a positive coping resource has been reported as highly beneficial for young people in their daily lives.

I have included some links to references below: Hope they is helpful - or at least interesting.

All the best,

Alex

Article Music Therapy with Young People in Schools: After the Black ...

Article Learning from experiences in action: Music in schools to pro...

Article Music Therapy with Bereaved Teenagers: A Mixed Methods Perspective

Article Tipping the scales: A substantive theory on the value of gro...

It seemed to have already answered. In my experience I would recommend to use the narrative and the therapeutic emplotment as tools to listen and build a new meaning

I think you have already  sufficent answers. In my opnion it is not very easy to handle grief,I would rather call grief as a permanent loss and something that never can be compensated . I would allow the clients to go through the feelings ,once they cope up with emotions then we can begin the therapy. I would suggest ACT( Acceptance and committment therapy) beause finding meaning and hope for the futre life is necessary for the those who undergoes pain in their life.

Gestalt Therapy a technique unfinished business could prove to be helpful, people are not sad of what they did but lots of times of what they never did when they lose a person. other   therapies that can be used are ART based therapies and somatic,EMDR  after checking the appropriateness and comfort of the client

Dear Linda, Boby, Artioli and Crook

Thank you very much for your views

I strongly recommend the constructivist approach provided by Robert Neimeyer.

This is his best selling "Lessons of loss" good for professionals, families and bereaved individuals

https://www.youtube.com/watch?v=5YlOpcexLXU

http://www.amazon.com/Lessons-Loss-A-Guide-Coping/dp/0978955617

These are very recent books for professionals, very valuable and updated

http://www.routledge.com/books/details/9780415807258/

Grief and the Expressive Arts: Practices for Creating Meaning

http://www.routledgementalhealth.com/books/details/9780415857192/

I would suggest Acceptance and committment therapy.

Depending on the 'type of loss' - for instance, I am currently doing research of my own on 'ambiguous loss' (Pauline Boss) which is a type of loss that has no closure and can result in unresolved grief - some examples include MIA soldiers (die/or never return from combat), military deployment, Alzheimer's/Dementia, & divorce etc. I would recommend first checking out Pauline Boss's on 'ambiguous loss' - over the last 20+ years, she has published many books & journal articles on ambiguous loss/unresolved grieving/closure etc. (I have included her official website link below). Furthermore, in general, a few specific recommendations (some already mentioned above) include of the use of Narrative work (to assist the individual or family in finding meaning or creating meaning for their loss), ACT (Acceptance & Commitment Therapy), Expressive Arts Therapy, & depending on the loss (and also on the clientele - individuals, couples, families) as mentioned above the Ambiguous Loss Theory/Model (focusing on Boss's 6 core therapeutic principles in treatment/intervention - these are outlined in her book,  "Loss, trauma, and resilience: Therapeutic work with ambiguous loss (Boss, 2006). 

FYI: Pauline Boss's Ambiguous Loss Link is attached or linked below. Also please let me know if you have any other questions about loss etc. Good Luck, hope this was helpful! ~ Jenelle

http://www.ambiguousloss.com

I tried to install client strength, for example: during the saddest part of their live what did they do that can make them become stronger person that I meet today. I used to use cognitive behavior therapy for client who survive from Tsunami and conflict in Aceh- Indonesia. 

Thanks to all

Hi Kanthi,

the research suggests that the actual therapeutic technique used has minimal impact on therapeutic outcomes, well approximately 10%. The therapeutic approach  doesn't actually make a huge amount of difference. Far more important (30%) is the quality of the therapeutic relationship, and the capacity of the therapist to support the client to feel safe enough and understood enough to experience and make meaning of the painful feelings of grief, as well as assisting them to identify any barriers the client may have to allowing the feelings to emerge. Denial, shame and guilt come to mind here, but this is specific to each individual. And this brings me to by far the most important area of influence on therapeutic outcomes (50%), and that is factors intrinsic to the clients themselves.  What else is going on or has gone on in their lives, outside the ambit of the therapeutic process? Addressing this requires undertaking a thorough assessment, rather than just focusing solely on the grief issues. One factor that I have found can have a crucial impact that is often not apparent at initial presentation is a history of early psychological trauma. it is also not easy to identify as often clients will be unaware of it themselves, particularly if trauma has occurred preverbally when the neurological structures required for narrative memory have not been established in the brain,. In this case cognitive therapeutic approaches have very limited usefulness because the neocortex the home of cognition would also have been undeveloped at this period of the client's life. In this case some of the experiential and body oriented psychotherapies mentioned above may be of more use to uncover the trauma. However, these need at some point to be amalgamated with more cognitive, meaning making approaches in order to make sense of what can be very disconnected, chaotic and confusing constellations of feelings that come with no story. 

Perhaps most important of all, these issues are best dealt with in your professional supervision.

Good luck with it.

Paul

I am coming to this topic a bit late, but am happy to see that you have received many interesting answers.

In my own experience with difficulties following the death of my wife in 1996, I found good results from my individual practice of transcending, taught in this case by the Transcendental Meditation organization.

The deep and unique state of rest developed by transcending offers a way to accept the difficult feelings that result from the death of a loved one. There is no judgement involved, and no need to find a suitable therapist, in a self-conducted effortless mental process. The addition of this unique state of consciousness and physiology to daily life gradually dissolves and eliminates the whole spectrum of stresses and dysfunctions caused by unresolved or overwhelming feelings and cognitions, so it is not limited to treating bereavement. All of life naturally improves when internal stress is dissolved.

With the recent availability of quality instruction in transcending by written manual, it is now possible to reach isolated patients with this effective procedure. It is also practical to conduct controlled experimentation to document these remarkable results.

If you are interested in approaches to traumatic bereavement following sudden, traumatic loss, please see our book, Treating Traumatic Bereavement: A Practitioner's Guide (Pearlman, Wortman, Feuer, Farber, & Rando, 2014; Guilford Press). I am giving a webinar on treating traumatic bereavement in adults on Friday. I welcome you to join us. Go to the APA Division 56 web site, webinar series page.

I found that an extremely effective modality is Psych-K. It helps several functions in the brain: (1) Helps the right and left hemisphere to communicate with each other. (2) Allows the conscious mind to harness the untapped energy of the subconscious. Since often, despite what we may consciously want our emotions go in contrary directions, using Psych-K to align the subconscious mind ("I'm on a train wreck") with the conscious mind ("I want to get over my grief") is a good way to deal with entrenched emotions.

Ever since I learned Psych-K, I've been getting results almost instantaneously. Someone with a background in analytical psychotherapy may find it difficult to conceive that an issue can be so quickly overcome, but I've seen it--again and again. However, an analytical background can be very helpful in determining what the core issues are, in order to make an effective statement that the subject uses to effect change. You can do a search for Psych-K and see if you resonate with it.

Another ground-breaking modality is EFT (Emotional Freedom Technique). Clients can learn to do this for themselves, but it's always helpful and empowering to have a guide. This is also on the web; you can download a free manual for it. People have had an 80% success rate dealing with very knotty issues, such as PTSD (war veterans, for example) and sexual abuse.

As a war veteran my experience with EFT is not as it is hyped up to be.  I found it at best Mindfulness wrapped up in new 'tapping' clothes...(as with many other new and miracle cures) when I hear any EFT practitioner informing the world about this miracle cure I take a step back, and wonder if this is based on the experience of the clients or the income generated from such practices (however I am a cynic at heart and I must say that I have never come across anyone that becomes a counsellor  just for the money).

I find that most of the difficulties I have as a counselling practitioner is bound within  ambivalence (most common in individuals with addictions) and although I have not had a client stuck with grief, this may be due to using a pre-therapy technique (not a therapy) of motivational interviewing.  I think at times we think too hard about percentages and quantitative medical model directed approaches to therapies.  Sometimes we forget that our clients are simply vulnerable individuals who need support, at times we become the expert when it is always the client who is the expert of their own experiences.  

However my personal experience of grief lies in the loss of military personnel in war.  I have entered into therapy about my grieving and felt that the therapeutic model reflected the medical model...ahhh you have a problem lets us deal with that by giving you strategies to overcome the thoughts and feelings that you have in the here and now... and the impression I was left with was that I simply had to get over it in some way or another...and when I didn't I felt I had failed...  I also experienced an intense feeling of guilt when I followed the process of 'getting over it'... and this guilt was far stronger, more intense than any dysfunction that my 'grief' gave to my life...so, I knew that I had to process my feelings about my lost Brothers, but I could not do that without the intense feeling of guilt...which I was unaware of what it was at the time...just a feeling of dread...which then used all of my defences to stop the process of 'dealing with it'...

I then attended a person centred counsellor and who used Motivational Interviewing as a pre-therapy... what this did was to simply allow me to give 'me' permission to process my grief in the way I want to process it, to the level I wanted to process it and not to allow the guilt to overwhelm this process.  My grief is now managed, it is still there (maybe one day I will consider getting rid of the guilt - however my experience of my grief gives me an intense sense of closeness to my mates), the major difference my grief does not appear at inopportune moments...I am aware of its beginning its middle and its end (not thinking it was ever going to end was an awful previous thought), I have insight into my processes and I look forward to grieving as it gives me that sense of closeness to my Brothers, which is very important in my life.  I think at times we get wrapped in a scientific world that ignores emotions fears and trivial considerations, when we should keep our feet in the same world as our clients...

http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf 

A poem that reflects the cause and the acceptance of my overwhelming grief:

What I miss most

I miss the lads.

I miss those crisp clear nights,

when the frost glistens in the moonlight.

I miss those lonely exposed hills,

lashed by the rain.

I miss the young and innocent faces,

some of whom we’ll never see again.

I miss the laughter and the crack.

I miss their morbid humour,

the childish pranks and unspoken laws.

I miss the sense of belonging,

that unique bond.

I miss youth at it’s best,

though I’ll grow old, unlike the rest.

What I miss most ?

I miss the lads.

By James 'Jock' Love - a fellow Brother and member of the Class of 82

 Author's comments on "What I miss most" 

I miss the one's that died. I also miss the guys I served in the army with. Some of whom are still alive.

My research is not in this areana, but as a clinician have dealt with Depressionmany times especially with adolescence.  I found each person's grief a bit different and thus had to dip into my too box of tricks and find one that was right for that particular .  There is a nice Web site: Coping with Loss and grief _http://www.coping-with-loss-and-grief.com/services.html?gclid=CI2EnbXj0MUCFQmTaQodYlAAJQ

You might find some helpful suggestions there - Nice resources and seems to cover the gamut of kinds of depression - Good Luck!

Hi Kanthi,

You received already a lot of answers. As a clinician, I also had some patients with less or none results. I work with short term psychodynamic psychotherapy, Some issues are   deep insight and take more time to get into it, but I am trying EMDR or brainspotting to access the unacessible. Neurobiology working together with psychology... Wish you luck

Dear Kim

Thanks. I also have notices that very personalized psycho dynamic approach works  sometimes

This is about the comments by Kevin Spruce:

Your comments are very sensitive and sincere. Great appreciation!

The approach of our group is based on Personal Construct Theory and has evolved towards a conceptualization of dilemmas in the process of change. We recognize the need for continuity and self-coherence as much as the need for change. Lots of coincidences! We also see clients as experts in their own lifes, as spelled out in this work

http://diposit.ub.edu/dspace/bitstream/2445/48706/3/PCINSP_APA.pdf

For those who have some interest in this dilemma approach:

https://es.scribd.com/doc/147437600/Using-Personal-Dilemmas-for-Case-Conceptualization-Guillem-Feixas

And for a research piece:

http://onlinelibrary.wiley.com/enhanced/doi/10.1111/bjc.12050/

Thanks for your attention

A lot has to do with the nature of what the client is trying to resolve. For example it may be about trying to get some balance back into his or her life, between grieving the loss and continuing with day to day tasks. It may be about finding meaning: in the life of the deceased, in the death and how it occurred and in the life of the client without the comforting presence of the lost loved one. It may be about adapting to life without the deceased. Once you have identified a focus for the work unique to that client's needs, it can be easier for the client to move forward. There is a lot more detail in my book Supporting People Through Loss and Grief: An introduction for counsellors and other caring practitioners. (2014, Jessica Kingsley Publishers)

http://www.amazon.com/Supporting-People-Through-Loss-Grief/dp/1849053766/ref=sr_1_1?ie=UTF8&qid=1433149571&sr=8-1&keywords=supporting+grief+wilson

Dear Kanthi,

I think I am a bit too late, but I just want to add a family perspective thinking of David Kissane´s Family Focused Grief Therapy. It was developed in the context of a life threatening disease such as cancer.

Best regards,

Gregor

Thanks Gregor

Best

kanthi

John Wilson, Finding out what the client wants to resolve, and investigating the actual situation they are in are one valid approach to helping the client.

Another valid approach is eliminating the stored stresses that actually cause dysfunctions when we are exposed to outside challenges.

This second approach, in which the client learns the simple, natural, and effortless mental technique known as transcending (such as taught by TM or NSR), is many times quicker, since no such investigations are needed, and little or no work need be done to help the client solve practical problems, or to resolve psychological issues.

David Spector

President,

Natural Stress Relief./USA

Disclaimer: I take no salary for my work; we are a 501(c)(3) public educational and research charity.

Dear David

Thanks you very much for your answer

Best

kanthi

Hello Kanthi,

I have found that writing is a great release and reveal of issues. Journaling with focus on a positive purpose, best personal result, different possible outcome, or forgiveness.  Fifteen minutes spent at the end of day.  Does not have to be elaborate prose, emotions tend to be 'short words'.  Journals shared with a involved, educated guide tend to open windows for further exploration and healing. 

Mike Nosbisch, Walden University

Dear ichael

Thanks

Kanthi

Have you considered EMDR? For example this link.

http://www.ingentaconnect.com/content/springer/emdr/2012/00000006/00000003/art00007

Have you considered EMDR? For example the below link. It would need to be delivered by an appropriately trained clinician etc, a good place to find out more is http://www.emdrassociation.org.uk .

Regards

Dean

http://www.ingentaconnect.com/content/springer/emdr/2012/00000006/00000003/art00007

Many bereaved individual carry with them their loss AND an view of their own mortality...I use person centred approach starting with the view they have a fear of death...

Hello Kanthi Hettigoda,

I have some experience with children/teenagers, but not with adults.

I have used also this book, for me was and still be a very useful with some tips:

James, Friedman, Matthews, (2002) "When Children Grieve: For Adults to Help Children Deal with Death, Divorce, Pet Loss, Moving, and Other Losses"

This is not a psychotherapeutic tool per se, but it can help make anything you do, easier. Have any of you tried flower essences? The original formulas were developed by Englishman Edward Bach in 1930, when he quit his medical practice and roamed the countryside to develop the 38 Bach Flower Remedies. You could consider them homeopathic in nature. All except one (made from a rock, intended to treat exceptionally rigid subjects) are comprised of flowers. Bach saw that when emotional imbalances were addressed, physical ailments healed. He spent the rest of his life administering to clients with his remedies, and saw excellent results. Several remedies could be taken together in the same bottle.

In my experience, the emotional healing from these and similar remedies can be quite profound. There are a number of different companies that use these principles. Perhaps even stronger than Bach's remedies are the Australian Bush Flower Essences. You can look them up. Some of the explanations you'll find on the web--as well as the description of what the essences do--may be a bit too esoteric for some of you. However, these essences are worth a try. You can buy, in any good health food store, the Bach combination called Rescue Remedy. I give it to my dogs when they're stressed--for instance, before and during their getting their nails clipped--and they are much calmer. In the Australian Bush Flower Essence system, two comparable remedies (they overlap with each other, but have slightly different properties) are Calm & Clear and Emergency Essence.

There might be a placebo effect in people, but dogs don't know about that. I know these remedies work: I've used them not only for myself, friends and clients, but also my dogs. There's a wonderful, psychologically-oriented book called Advanced Bach Flower Therapy by Gotz Blome, MD, which teaches you how to use the Bach Flower remedies.

 Hypnosis is an excellent way to work with grief. On a longer term there are a variety of grief coaching programs around that use creativity. Essential oils if used properly and safely can also be helpful. Each of these need to have an appropriately trained person. Bach Flower Essences is a homeopathic modalities and I agree it is a great adjunct to almost anything else a therapist wants to use.I have personally used Bach Flower Essences with good success. I like teaming this with hypnosis for grief.

The basic assumption behind this question arises from your use of the term 'unresolved'. This implies that grief is a problem capable of resolution, a problem to be solved. Yet the grief that follows the loss of a loved person cannot be resolved. There is no magical anaesthetic for the pain of grief ... We cannot give to the bereaved the one thing they most want; we cannot call back Lazarus, or Bert or Harry from the dead. The bereaved know that. They know that 'There is nothing you can say.' And they have seen others turn away, embarrassed by their uselessness. But anyone who turns towards the widow and the widower, and gives confidence that they do have something to offer at moments of utter despair, helps to reassure them that all is not lost. Goodness is not gone from the world because one good person has died. Meaning has not gone from life because one who meant so much is no longer present. The loss of one trusted person need not undermine trust in all of those who remain.

Interesting perspective Colin...  I agree that the loss of individual through death raises reactions which sometimes lead to symptoms: anger, despair, depression, sadness etc... that get in the way of returning to normal daily life functioning.... but if this process of grief continues in a way that leads to dysfunction life style, then the individual may remain with "unresolved" grief....  I believe the original question is how to support an individual who gets stuck in the grief process rather than going thru Elizabeth Kubler Ross' stages of loss and reaching acceptance of this loss, so they can move on with with their lives in a more positive way....

While it is true that the pain of the loss of a loved one cannot be prevented or avoided (except for those who are so emotionally dysfunctional that they cannot sense such pain), the suffering that results for most people from that experience of pain is a different matter altogether.

Most therapists have had many patients whose suffering causes dysfunction in life, deeper and for a longer time than is experienced by healthy, self-actualized people from the same pain of loss.

There are people, for example, who cannot work after the loss of a pet, and this effect can last for weeks, months, or years.

Psychological suffering is a very real and sometimes debilitating condition, and deserves deeper consideration and help than simply conseling reassurance.

We researchers need to familiarize ourselves with the clinical field we are studying. Otherwise, we do injustice to the suffering of the people we study.

In my previous postings, I have discussed the limitations and distortions caused by stress stored in the nervous system. I would like to incorporate my essay at http://www.nsrusa.org/about-stress.php into this reply. In my clinical experience, it is possible for anyone to practice techniques that eliminate stored stress, eliminating the suffering associated with pain. The result is that pain is fully experienced, and then let go. Life can continue to be lived functionally and even with peace and happiness following an appropriate period of bereavement. This is part of what is called psychological health.