Cognitive Behavioural and Psychodynamic Approaches Essay

Coping with the death of a loved one often means that the bereaved must develop a new way of viewing themselves and the world around them without the presence or influence of the deceased. In general, reactions to the loss of a loved one are considered intense in the initial period following the death, but on average, these feelings lessen over time (Parkes, 1975; Rando, 1993; Sanders, 1989, 1993, cited in Malkinson, 2001). Some bereaved individuals can successfully cope with this transitional phase and are capable of returning to â€Å"an adaptive level of functioning† within the time frames expected (Marwit & Matthews, 2004) without experiencing severe impairments. However, some grievers can experience severe affects to their physical and psychological well-being (Gallagher-Thompson et al., 1993; Ott, 2003; Stroebe & Stroebe, 1987, cited in Marwit, et al, 2004); cases in which the bereaved is demonstrating prolonged irrational beliefs and/or behaviours about the loss can be an indication of an emotional disturbance (e.g. complicated grief). Complicated grief (CG) can be defined as â€Å"the intensification of grief that does not lead to assimilation of the loss but instead to repetitive stereotypic behavior as well as impaired functioning† (Malkinson & Witztum, in press, cited in Malkinson, 2001, p. 672). The discourse of this paper will compare and contrast psychodynamic and cognitive-behavioral theories with examples of models used to facilitate grief work in situations of complicated grief as well as a brief explanation of what is considered grief resolution. Let us begin with a brief explanation of the core principles of each approach. Psychodynamic counseling is concerned with the role of the unconscious, childhood experiences and how they can ultimately effect our mental processes which in turn manifest in our actions. According to this approach in order to deal with conflicts certain defensive actions or mechanisms instinctively come to our rescue whenever we feel vulnerable or as if our view of reality is being challenged. For example in bereavement cases, clients will often use denial as a defense mechanism and coping strategy in order to avoid the intense pain that comes with acceptance of loss. However effective this may be for short-term relief, in the long run, the client runs the risk of developing symptoms of complicated grief (Hough, 2010). Contrariwise, cognitive-behavioral approaches place almost no emphasis on the past and childhood events, unless it directly relates to difficulties of the present day, in such cases it acknowledges but does not focus on this factor. Rather it concentrates on present day thinking/behavioral patterns exhibited by the client, ways to recondition the client’s cognitive processes and how to eliminate unwanted or destructive cognitions and behavior. Additionally, (and specific to aspects of behavior) this approach adheres to empirically sound principles and procedures that have been tested for their effectiveness and reliability (Hough, 2010), whereas the psychodynamic approach is theory based. The rationale behind CBT being, since negative patterns of thinking and behaving are learned they can be unlearned. We now examine established beliefs about grief and grief resolution. Grief has traditionally been seen as a healthy process aimed at decathexis, abandoning or letting go of commitment to one’s relationship to the deceased (Freud, 1917/1957, cited in Malkinson, 2001) as well as the ability to form new relationships (Malkinson, 2001). During most of the 20th century, leaders in bereavement research followed Freud’s (1917/1957, cited in Marwit, et al., 2004) theoretical model of decathecating grief in which he believed that the bereaved invested a great deal of mental energy into maintaining the attachment to the deceased and in order to reach a resolution of grief it was vital to release this attachment, i.e. to exhaust the energy. To facilitate the process of grief work, the survivor must confront the feelings of loss and allow himself to express the emotions associated with the loss by revisiting the events leading up to and during the death. However, the notion held by Freud (accepting the loss is a sign of grief resolution) is not supp orted by empirical evidence (Artlet & Thyer, 1998, cited in Malkinson, 2001). Cognitive-behavioral models have expanded to include treatment of loss and grief, specifically complicated grief (Fleming & Robinson, 1991, 2001; Florsheim & Gallagher-Thompson, 1990; Malkinson & Ellis, 2000; Neimeyer, Prigerson, & Davies, 2002; Reynolds,1996,1999; Stubenbort, Donnelly, & Cohen, 2001, cited in Marwit & Marwit, 2004). Researchers maintain that more consideration must be given to other processes of grieving which allows for a continued connection between the survivor and the deceased as opposed to decathecting. Additionally, modern day research criticizes the need for finality and closure as a sign of resolution, and instead views the bereavement process as an on going modification of preexisting cognitions and emotional reactions to the â€Å"new reality† (Malkinson, 2001). As opposed to severing ties to the deceased, the maintenance of bonds is now being proposed (Malkinson & Bar-Tur, 1999; Rubin & Malkinson, 2001; Silverman, Klass, & Nickman, 1996, cited in Malkinson, 2001). Klass (1999, cited in Marwit, et al., 2004) reasoned that resolution is achieved â€Å"by integration of the deceased into the ongoing life of the griever† (p.852). Research involving grieving parents reveals a common element of prolonged association and connection with the deceased. As a result of this theory Stroebe and Schut (1999, cited in Marwit, et al., 2004) put forward the Dual-Process Model (DPM), which allows the bereaved to confront painful feelings and cognitions involved in mourning, but to avoid them as well. They maintain that clinicians and researchers must understand the cognitive processes experienced by the griever, and also, the regulation of these cognitions during the bereavement process (ibid.). According to this model, there are two types of stressors: loss-orientation and restoration-orientation. Loss-oriented coping focuses on dealing with the actual loss itself and cognitions such as â€Å"He was too young to die†. Also, addressing the aching desire for the person, for example allowing the emotional expressions to flow, i.e. crying over pictures of the deceased as well as recalling happy moments shared. Alternatively, restoration-oriented coping deals with the task of successfully continuing life and developing a new identity without the deceased and at times, even having to take on those duties and responsibilities, which were previously held by the deceased. Some examples of these potential challenges may include, identity shifts such as â€Å"homemaker† to â€Å"employee† or â€Å"daughter† to â€Å"orphan† and new responsibilities such as entering into the work force for the first time and learning to manage finances. In this way the bereaved goes through a process of learning and coping with new cognitions and realities, such as â€Å"I am the breadwinner now.† (Marwit, et al., 2004). The bereaved must learn to process such new cognitions as a part of moving forward. The DPM is concerned with the interaction of a myriad of cognitive process. According to Bower, et al (1998, cited in Marwit, et al, 2004) in this instance cognitive refers to â€Å"the process of actively thinking about a stressor, the thoughts and feeling it evokes, and its implications for one’s life and future†. Cognitive processes taking place among the bereaved can therefore be described as split between implicit and explicit processes (Marwit, et al, 2004). There is evidence to suggest that exposure therapy can do more harm than good, also that complete avoidance is not always successful in grief resolution, Stroebe & Schut (2001, cited in Marwit, et al, 2004) use an approach referred to as oscillation which allows the griever the balance of both confrontation and avoidance in both loss- and reorientation-coping. This is similar to psychodynamic approaches in which the client has control in directing the course of the therapy (we shall see below). Oscillation gives the client a break from dealing with intense painful emotions for a long period of time. To begin the process of grief work in a psychodynamic setting involves establishing an explicit therapeutic agreement between the therapist and the client whereby the client makes the decision to focus on the loss when he is ready (Lamb, 1988). Once the agreement is made, the therapist explains what the client can expect during future sessions and continues to reassure the client that the pace of the therapy, area of exploration and subject matter discussed will be entirely at his discretion (Lamb, 1988). This gives the client a sense of control during a crisis where he may feel helpless. The therapist can now guide the bereaved through the process of actually acknowledging the loss, reawakening reminiscences, adjusting to their existence in the world without the lost one and to experience all of the pain and emotions associated with this actuality (Worden, 1982, cited in Lamb, 1988). This is achieved through interventions such as, instructing the client to bring memorabilia to sessions like pictures, belongings of the deceased and other â€Å"linking objects† (Volkan, 1972, cited in Lamb, 1988); also the application of such techniques as role-reversal, â€Å"the empty chair† and keeping a dream diary (Lamb, 1988). Another way to elicit emotional response is by encouraging the survivor to talk about positive as well as negative features of the relationship with the deceased (Lamb, 1988). It is also important to allow the client the opportunity to tell their story as often as they wish as this not only assists the griever to confront painful feelings associated with the loss, but it also affords the therapist the opportunity to point out underlying issues which may be the source of the pain. Hough (2010) describes a case study in which a young woman, Linda, sought grief therapy after suffering with depression stemming from the death of her grandmother two years prior. During one session Linda mentioned having to move in with her grandparents after her parents divorced and showed avoidance and discomfort at the mention of this point (i.e. left that particular session early, arrived late for next session). Through â€Å"listening, observing, interpreting, linking, giving reflective response and looking at defences and resistance† (Hough, 2010) the therapist was able to address and draw attention to an underlying issue, which was the actual source of the depression; one that Linda had never been able to identify on her own. Wogrin (2008) explains her approach to this process as listening for what she calls the client’s quieter voice, the one that even the client himself is unaware of. Another form of psychodynamic intervention is group therapy, during which grievers are encouraged to try and understand how unresolved conflicts beneath the surface may be hindering their abilities to cope with loss (Kipnes, et al, 2002; MacNair-Semands, 2004; Piper et al, 2001, cited in Para, 2009). Let us consider two operational forms of group therapies: interpretive and supportive groups. Interpretive group therapy provides a forum for individuals suffering from complicated grief, to gain insight into trauma and recurring internal struggles that impede the griever’s ability to mourn in a normal way (Piper, et al, 2001, cited in Para, 2009). This form of therapy also aims to assist the client’s understanding and acceptance feelings of ambivalence toward loved ones lost (Para, 2009). The counsellor refrains from praise with the purpose of promoting tolerance of stress and uneasiness (Para, 2009). The most important objective of supportive group therapy, however, is to enhance acclimatization of the bereaved to their current situation of loss and grief (Piper, et al, 2001, cited in Para, 2009). The counsellor promotes a pleasurable environment for grievers to express shared experiences and emotions common among the bereaved (Para, 2009). During supportive group therapy the counsellor is non-interpretive and less probing as opposed to interpretive therapy(ibid). So far, we have discussed the two approaches separately, but there are occasions where integration of the two may be necessary and beneficial to the client. For instance, in situations where the survivor suffers from nightmares relating to the death, it may be practical in integrate behavioural exposure techniques as well as symbolism and imagery. Reynolds (1996) asserts â€Å"Drawing as well as verbal representation could also be regarded as an effective form of exposure therapy, helping the client to stay with the anxiety-provoking death-related images† (p.1) To conclude According to the cognitive perspective, suffering a loss through death is a very difficult external occurrence that completely changes one’s belief system and consequently all related sentiments and actions. Internal feelings and beliefs are challenged in CBT as the therapist attempts to show the client other ways of thinking about and adjusting to their loss, this is not unlike the psychodynamic approach. However, in psychodynamic models, internal belief systems are challenged with regards to unconscious conflict resolutions. CBT seeks to inform the client of what can happen as a result of grief due to a loss, to identify different reactions which may be normal responses to loss and to reveal new or better coping skills. Again, this is similar to psychodynamic therapies in as much as the therapist explains emotions which may arise during therapy sessions. Additionally, exposure techniques are used by both theories as a way to encourage the client to face the death head-on. This can be achieved by using emotional cues of the loss i.e. sorting through the personal belongings, talking to them in an empty chair this allows the client to experience a sense of connection to the deceased. The aims of psychodynamic and cognitive behavioural approaches to grief are similar and may at times be integrated in order to provide the best possible intervention for the bereaved. 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