Documente Academic
Documente Profesional
Documente Cultură
D.
MILLER,
ELLEN
FRANK,
Pn.D. P
ii
.
CORNES, ANDERSON,
MALLOY,
D.
EHRENPREIS,
IMBER,
D.
LIN
REBECCA JEAN
L.S.W.
PH.D.
SILBERMAN, ZALTMAN,
LEE CHARLES
WOLFSON,
L.S.W.
F.
REYNOLDS
III,
M.D.
The efficacy of interpersonal psychotherapy (1Ff) as a treat ment for outpatients with major adapted
life. applying
Grief
into
is not a disease,
one.
but
it
can develop
depression
has
been
documented
in sevhas been
-George
Engel
trials.
report
Recently, depression
IPT
in late in
on their experience
T
anxiety
pression
their
IPT to geriatric patients whose deis temporally linked to the loss of Detailed with treatment case vignettes. techniques Prelimi-
spouses.
are illustrated
nary treatment outcomes are presented for 6 subjects who showed a mean change on the 17-item Hamilton Rating Scale forDepression from 18.5 2.3 SD to 7.2 4.6 after an average of 17 weekly 1Ff sessions. 1Ff appears to be an effective short-term treatin elment for bereavement-related derly subjects.
and (The Journal of Psychotherapy Research 1994; 3:149-162) Practice
alcohol, tobacco, and tranquilizers; tion of existing medical illness; immune competence; and mortality accidents, 10% noted into
Received accepted Institute Medicine, quests Clinic, Room
ease.#{176} A year
widowhood,
incidence
1993; 22,
to 160,000
18, School reprint Institute of Medicine, PA 15213. Press, Inc. 1993; of reand
depression
Psychiatric
1994
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BEREAVEMENT
IN LATE
LIFE
of bereavement-related Zisook depression at 2 months, after and Schucter2 23% their in 350 widows loss,
in
a 3-year depressed
with
at 7 months, compared
specifically
addressed
at 13 months
in 126 age-matched were still living. reported a large for Depression subjects with depression
Sholomskas et al.2 and more Frank et aL,6 who are currently long-term late-life tients female maintenance depression. late trial
by in a in
in Hamilton Rating Scale (Ham-D) ratings in elderly reavement-related were treated with the tyline.34 However, showed only a small by data as measured Grief.5 These major
It should be acknowledged who lose a spouse in and that the loss often
occurs
context of other stressors associated with this life stage. Medical, sensory, or ambulatory disability, tirement, elements reactions financial and that strain, adjustment to reloneliness are a few of the set the stage for our patients loss.
SPECIFICITY FOR GRIEF
of bereavebenefit from medication, change in the specifically argues to the major our efforts in
to their IPT
with the loss of a spouse. for a psychotherapeutic management depression. This applying chotherapy spousally
In the
second
edition
of the
classic
text
Grief
Counseling and Grief Therapy, Worden23 outlines four tasks of mourning: 1) accept the reality of the loss; 2) work through the pain of grief; 3) adjust to an environment in which the deceased relocate the Kierman is missing; and 4) emotionally deceased and move on with life. define 1FF consistent to treat goals unresolved and
principles of interpersonal psy(IPT) to elderly, depressed, bereaved patients in a research seton our treatment IPT/LL.6 previous adof major Illustrative
et al.7
ting. These efforts draw aptation of 1FF for the depression in late life: case examples will specific techniques tion. Response data pendent raters Interpersonal will
be provided, as well as relevant to this populaobtained through indebe presented psychotherapy7 in 5 cases. is an in-
for depresare 1) to facilitate the mourning process, and 2) to help the patient reestablish interests and relationships that can substitute for what has been
goals of the on treatment that center grief lost. The therapists major tasks are to help
present-oriented apof affective disorder. as an effective acute, strategy with Itwas developed would today be
patients
considered a continuation therapy. Subsequently, two large trials8.9 have demonstrated its efficacy as an acute treatment, and Frank et al.2#{176} have now shown IFFs prophylactic efficacy in preventing recurrence of
assess the significance of the loss realistically and emancipate themselves from a crippling attachment to the dead person, thus becoming free to cultivate new interests and form satisfying new relationships. The therapist adopts and utilizes strategies and techniques that help the patient bring into focus memories of the lost person and emotions related to the patients experiences with the lost person. (pp. 97-98)
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GRIEF PROBLEM
AS AREA
Focus
IN
IPT educated illness, the of the probexpects to interpersonal invenof earlier of curmay fathe the to ena patient down:
the spouses illness the death a welcomed was the the 1FF history therapist
1FF nature
patient
has
been
of their
recognizing
tendency to idealize a lost mate, specific questions will allow for useful inferences. How were decisions shared? Were and there diffiresponsibilities cult times any periods marriage?
is the
tory is essential relationships rent cilitate process interpersonal following with sure relationships
in the marriage? Were there of separation during the Was the marriage, in fact, a patient experithat, through finally ended? discussions
severe burden? Does the ence relief on some level death, 7. Were the there relationship contingency
questions
helpful
spousally a complete
patients
of potential
with the spouse in the event that one or another partner died first? Were wills jointly? ment? with port and other legal matters handled Were there Were money plans in place the remaining areas of disagreematters discussed, to adequately suppartner? Were futhey had roman-
1.How much support did provide in social matters? ters 2. such as paying bills? How much adjustment manage the patients without home his or her be sold? Will
deceased Practical
mat-
discussed? Were as agreed? has Had the this patient about beginning with patient
a new possibility
tic relationship? ever been discussed spouse? Does the riod other riage of waiting
3. What proportion pendent versus have hobbies in place that support system,
of activity was indejoint? Did the patient or independent activities will provide a ready-made or did the couple A do
is proper?
relationships during the that are producing guilty the there patients children
virtually everything together? 4. What was the manner of death? chronic justment illness than
tions now? 9. Where are What ships? how clear reis the Are
allows more time for adan acute illness or accidifficulty or accepting that obviously the
quality
of those grandchildren,
relation-
dent. Was there acknowledging spouse quires 5. If the much tient cial
often is contact made? The nufamily has become widely disto may
persed, with children moving away find jobs. Thus, although children
spouse had a chronic illness, how caregiving burden did the pashoulder? burden from Was there a great care? finanDo 10. medical
mean well, their practical availability may be an issue. Have there been discussions about moving closer to children? What other losses what sources has were the of support patient susreacare available? What other tained, and
many large bills remain to be paid? What changes in the patients customary lifestyle were required to accommo-
his or her
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BEREAVEMENT
IN
LATE
LIFE
EXPLORING QUALITY
MARITAL
ciated with increased sion in adulthood.24 11. Has the surviving dispose of personal ceased, perience powerful true particularly
further must
on the realize
history, quality
the of
spouse items
the marriage has been process of bereavement. found marriages older These that bereaved more persons, authors older positively suggesting further
shown to affect the Futterman et al.27 persons than an noted rated nonbereaved idealizing bias. that bereaved their mardepressed postulates attachtheir
clothing?
in our pilot study, this act is a metaphor; it is indicative of or, if the process is probedfor also these to to letallows be
movement
tracted, of fixation. Leaving the room just as it was is common parents seen with therapists lines clues of a lost child but can The along indirect struggle loss of a spouse. direct inquiry valuable patients
depressed older patients riages more positively older that patients Bowlbys25 the quality who were attachment
bereaved.
of early-life
ments sets the stage for all future affectional bonding. Secure attachments in early life promote that a positive self-image and other satisfying affectional In contrast, impaired the realization bonding attachments ambivcan is
hold on at all costs ting go in a measured for emotional Some patients from their 1FF ing that deceased Parker
growth.
possible.
a timeless
(as described by Bowlby and et al.) may be best for them. therapists should not be to paall patients on. Many
lead to lifelong difficulty in forming satisfying interpersonal relationships. Therefore, according to attachment theory, an individuals choice of mate obtainable in roots traceable and the degree of satisfaction the marital relationship have to the quality of affectional outlines the critical
Bereavement
trapped into expecting get over it and move tients, years particularly or older), where their the may
it is best memories
on them for sustenance their remaining years. 12. If patients have difficulty touch with their feelings, sidered writing a farewell deceased? encourage Leick and extensive
importance of early relationships in the initial two stages of his development model: basic trust, as versus mistrust (engendering hope), and autonomy, as versus shame and doubt (engendering of grief therapy Davidsen-Nielsen2 tients tended who had to have will). In their 15 years experience, Leick and have noted that those padifficulty with more protracted attachments grief reacto say goodbye as well as to of a supportive the liter-
though homework is not a focus of 1FF in general, we have found that its use is justified because it helps patients reach deeper levels of feeling and promotes progress. Similarly, reviewing photographs provide further els of feeling. or other stimulus memorabilia to deepen may lev-
tions. It was harder for them and to welcome new contacts make use of the healing power network. Parker ature patients ing they et al.26 recently
reviewed
between of parentbonds in
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adulthood (the concept of continuity). Parker et al. point out that exceptions exist that ity run theory; is counter for to expectations example, adversity of continuin child-
toward the deceased, God, tions may be intolerable may be beyond the When the preciation the
emothus an apfrom in a
patients
awareness.
not always associated with an ability in adulthood to form stable, relationships. bias can is made that need have be That is, a pervasive corrected if a secure point in life. It forms a link with grief to recognize that the played the role of cor-
interpersonal
patients
own understanding of his or her difficulty dealing with the spouses death, the therapist will ask if the greater patient agrees of the to work toward understanding underpinnings
at a later
is this last point work: therapists lost spouse may recting exists 1.
of the continued grief ing obtained permission therapist to educate will often need the patient
and depression. Havto focus on grief, the to make some about common effort patmay relamixed
that pervasive negative bias. Parker et al.26 report that ample evidence to conclude Negative pose people adulthood by shaping that bonding social either models. in likely may bonding directly disin or
characterized
feelings and that the agreed-upon learn as much as possible about those mixed itive aspects. feelings-negative Careful empathic
2.
Those early
who had extreme deficits parental care appear more an uncaring is established associated
events surrounding the death and the subsequent necessary adjustments will provide an invitation to renew the unfinished mourning process in a safe environment. make have 1FF their references to how become since their therapist difficulty the attempts and encourto When patients difficult their lives spouses empathize the ages lems therapist died, with the
extreme difficulties care apparently can later mate relational partners et al. latent, and
in early parental be modified by with intisignificant others. about loss reactivatself-images or compen-
experiences
have
written
of a profound negative
counterbalanced
all the difficulties your loss, I wonder unfair to you responsibilities? that
say, Having just heard about youve had adjusting to if it sometimes seems you The now have therapist all these extra might further
sated for by the living spouse. Patients with histories of deficient early parenting should be seen as being at greater risk for the establishment of a dysfunctional marriage or for who experiencing recting spouse had adequate
MANAGING
AMBIVALENT
say, In my experience, its not uncommon for people to feel some annoyance or anger toward the deceased as the negative part of those mixed feelings we talked about Similarly, Leick and Davidsen-Nielsen2 the invitation, patiently the With ...and listening what to earlier. use miss? positive
dont you
all the
OR
reason
for
inhibited
completion
mourning or rage
apist will clarify, interpret, and sometimes confront the patient with the evidence already assembled from the patients verbaliza-
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BEREAVEMENT
IN LATE
LIFE
tions these
along time
fore
ing
educating him or her about common feelings many people harbor in the grief process. This approach mizes ate the under provides state the current reassurance feelings circumstances. and legitiThe after hope use through a in the of mixed as appropri-
his death. She described a mutually satisfysex life and said that both were dismayed about recent difficulties. She was very careful to downplay the loss of erectile function (and of missing her own sexual pleasure) to avoid making him feel insecure. They had discussed the possibility of getting it checked medically but had never done so. The patient described considerable unburdening relief at the opportunity
experience of relief or unburdening session along these lines often instills the the patient grief and that expertise the he to or she help can get therapists
accompanying
depression.
Coming to Terms With Ambivalent or Affect. Mrs. H. was referred because of uncontrollable crying spells and inability to concentrate at work. Her husband had died suddenly of a heart attack 6 months earlier. She had been previously divorced and had enjoyed her second marriage for 12 years. She spent the first sessions talking about her embarrassment at being unable to control her emotions and how much she had enjoyed her lost love, especially compared with her first husband. The first task of therapy was to give her permission to grieve, to allow herself to feel whatever was there at the moment. Some time was also spent in early sessions on practical matters such as encouraging her to respectfully decline invitations she was not up to and realistically appraising alternative ways to better handle her emotional outbursts at work. After several sessions of idealizing the patients dead husband, the question Where is the ambivalence? arose in the mind of the therapist. Why is this patient unable to move forward? Gradually, a theme began to emerge concerning her husbands unwillingness to get adequate medical examinations. She felt that if she had been successful maybe his death could have been prevented. She admitted feeling enraged at the thought that he might have concealed knowledge of medical illness with which he did not want to burden her. Finally, she also came to acknowledge angry feelings that he might still be here (for her) if he had heeded her advice to get medical evaluation. These thoughts were quickly followed by guilty ruminaNegative tions for thinking so selfishly. was a decline in A parallel development
Case!:
to discuss these issues in detail, particularly her guilty ruminations about having selfishly encouraged medical evaluation for a sexual problem when, in retrospect, he really needed medical help to save his life. Out of respect for her dead husband she had been unable to discuss all these ramifications with well-meaning friends and family. Mrs. H. progressed, with continual clarification and confrontation of these themes, to the point of accepting plans to travel with family, and she got through the death anniversary with less stress than expected. She was no longer crying at work nor thinking constantly about her late husband, and she agreed that it was time to terminate treatment. Comment: example reaved sessions. from find common rence, presence tions, then a therapeutic cating the is well within Although alent authors sal, and overzealous Case or This case idealizing patients posture vignette is a good
posture that bebring to the initial that protects affects The understand them they IPT this
or ambivalent acknowledge.
first,
therapists
is,
to
to reflect it back to the patient in manner, at the same time edupatient that his or her experience the range of the normal. conflict over expressing affect is common it is by no means are cautioned along these ambivin the univeragainst lines.
interpretations
her
husbands
sexual
potency
in the months
be-
2: Struggling to Do the Right Thing. Mr. a construction worker, presented with a 30pound weight loss, anergia, anhedonia, and passive suicidal ideation. He reported severe grief reactions after his mother, father, and father-in-
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law died.
my best lingering
He described
friend, death lover, after required care. he death. his her time grave
his
and many her
of 43 She of
as died the a
ing as
new if any
can would
be truly be
paralyzing, the
betraying
by conflict over formsince his wifes death, in his flirtatiousness and left him exhim to deal conflict and to relocate and begin
his immersion in activities that hausted. His 1FF therapist helped with both sides of this underlying
his
The
sions ate When was
most
sexual
striking
with
aspect
early inapproprimembers.
ses-
him
flirtatiousness
dating.
a INCOMPLFTE MOURNING
finally confronted
that his overzealous great discussed ionship; about outside deal of pain, how however, Catholic much he religious
compan-
prohibitions
After this
against He was
sex
a plateau, events.
of marriage.
confrontation,
his flirting
painfully
toned
aware of
down
his
considerably.
loneliness and
emptiness.
He said he wouldnt
of but 43 lence that doubted didnt ing up want with to and Mr. hobbies necessary would find he his he years. about missed that to he hurt system felt He until awkward talked forming his
be able
another because at length new wifes
Mr.
P. lost
his
her
with breast cancer. Almost death, he was called to acGulf, where he served
reached the mandatory re-
about relationships,
he
tirement and he after woman His poor themes had now his
openness replace
trust
said by breakdescribed
age.
wifes 17 years initial
He became
death his when junior.
depressed
he began
14.months
dating a
could
anyone but he
complaints and
poor
sleep, with
alternatively he
a wish down
could
nail
the surgery
10-year (two
in
bypass He because
had want he
exhaustion
6 months).
to sleep
at night. he wifes his had his reported reminders house first in date a and that
medication
do
eighth some
session, of his
himself.
Mr. ing fun P. described with his new feeling lady friend, guilty about feeling havthat it
had had
put
begun
redecorating decor. He
manly
of his struggle with the realization that experience was bound to be new and different. He continued his ambivalent struggle with sexual activity. Mr. G. reported on his progress in therapy, saying: Ive come through some bad months; I never thought Id make it. He described reducing his cemetery visits to once a his week, has upon joined dating a square dance group, and
be his wife. He acnever had the opportulate wife and felt that it was his new friend with his
with to his the new thought friend that he by his
he had
there
a good
marriage
looks
as a challenge.
rightly shame
Comment: Leick and Davidsen-Nielsen2 point out that feelings of guilt and that follow steps of progress in form-
throughout her decline and death. He expressed gratitude for the opportunity to discuss his feelings and reported feeling and sleeping better after several sessions. A tragic coincidence occurred during the
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LIFE
his mother was diagnosed with breast cancer and was near death on the 2-year anniversary of his wifes death. Upon exploration, Mr. P. did not feel that he had a good relationship with his mother, summing his feelings for her as respect for raising her kids alone. As his mothers condition deteriorated he was able to make time for her without resentment or guilt feelings. therapy: After his mothers death, Mr. P. dealt with
feelings however,
about
the the
death case
required; transitions
it is also
by changing of a spouse;
exacerbate
circumstances interpersonal
family
remaining
may goes
following
her estate and felt satisfaction in his ability to be there for her even though his mother had not been there for him during his wifes battle with cancer. He was able to find satisfaction in the knowledge that he attended without reservation to his mother as well as his wife on their deathbeds.
had
with
treatment
Comment: was to provide restart the his military his new solved tionally
first
task
Mr. P.
forum
he could
process interrupted by The inhibition he felt in was not going to be reof emohe could
relationship
whom she had been living sequentially, exhausting and frustrating each one in turn. They described her as weepy, clinging, and unwilling to be left alone even for short periods. In private, her children described their late father as an abusive alcoholic, and they collectively expressed their amazement that their mother had stayed with him. At the initial evaluation, the patient was severely depressed and required 3 weeks of hospitalization that included
treatment with antidepressant medication. The
hospitalization
brought
considerable
relief
to
accept. His 1FF therapist was able to allow him to explore all the feelings he was experiencing without the unfair burdening of his new friend. His mothers illness caused him to review as well realistically as revisit his relationship his role as caregiver with for her both
the children, who were very willing portive but had been overwhelmed
pendency When needs. the psychotherapy resumed
feeling
past at Sunday
of loss that
obligatory dinners hub at-
his mother and his wife. Ultimately, Mr. P. was able to acknowledge that he had been there for them both and could now let them rest and move on to new relationships. Leick and Davidsen-Nielsen2 describe the readiness to love again as being prepared to live through the grief
OTHER
of status
as the
of a new
loss.
AREAS
PROBLEM
of family activity. It was as if she were willing to overlook or tolerate her husbands abusiveness as long as she could counterbalance it with satisfaction from the maternal role, in which everyone came home to her. One daughter, in particular, revealed her own struggles in her psychotherapy and Children of Alcoholics support groups to break from what she termed an enmeshed, dysfunctional family. Therapy with this patient was clearly focused spent on role transition. the Many differences sessions between were her exploring
grief
is the
most
common
of
the
on in our persons,
each of the other three 1FF problem areas (role transition, interpersonal conflict, and interpersonal deficits) has come to bear on the management tion of the patients of grief reactions. Exploraimmediate reactions and
wishes and more realistic expectations concerning her grown childrens aspirations and their allegiance to her. She was gently challenged to take more responsibility for her own needs and to learn better ways to cope with their independent activities. She somewhat idealized her late husband but referred far less often to him than
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to
the
loss After
of her 3 months an
previous
to felt
the forefront.
doing things
She described
alone rather
how strange
than as a couple.
it
of steady building
moved fully
to spread
area
by looking and
widows senior
in her center,
For example, now she had to park the car herself, initiate social contacts, and go alone to the country club socials they had attended so often together. She referred to a list she was keeping
of these alone firsts. Mrs. T. was acutely aware
at a level
As
the
case
illustrates,
traits
strong invested
support
who their
spouses provided will have a much more difficult time adjusting to the loss and establishing new roles for themselves. Traits of excessive terpersonal
Case
Mrs. week 12 have
also
precipitate members.
in-
family
of missing the hundreds of daily physical touches from her mate, not the least of which was sleeping together. Not all of her changed roles were unpleasant, however. She realized, for example, that she no longer had to be one of the first to leave parties as her husband had always demanded. She could now make decisions with only one set of preferences to consider. Mrs. T. s social network was extensive, and she was able to draw on it for considerable support. For example, she organized a slumber party with a cohort of grade school friends who
had kept that friends up the with party return each had to other. to their end The the pangs next of reday lives and gret
5: No More
T.s husband illness. months marked She later, her
her
individual
portended
termination. style defensive to
similar
Her a more posture
difficulties
therapist protective short-lived,
with approaching
noted a change stance. however, in This and
isolated, was
Mrs. T. described
somehow band able was to her. she sick, She should even
feeling
have though known no
guilty
that clues that
because
her were her husavail-
to terminate
successfully
and
capability.
considerable
independent
acknowledged
marriage
Upon her and describe always bulk
was
further
not
her
great
husband
in the
her
later
years.
heard negative,
exploration,
therapist
Comment: Mrs. T. clearly felt husbands death was untimely. He died a short prefer), experiment illness, and of he he died first in the her (as he said died changing life and part midst of approach quite
as crabby,
angry.
moods so her in
the
cult
of their
spending her
diffidescribed
husbands to do
it increasingly
the style
accommodating who became it seemed guilty, just out as if her had reconcon-
as he for in behavior
change
husband
been
without sider. versations preference feelings
an experiment
giving On another with that toward her he him her any
that
theme, husband go for
ended
Mrs. T. about and
disastrously
to recalled his admitted willing
felt the loss of proximity to her husband even more profoundly. In 1FF she was able to explore all these issues and was able to use the resource of her social network to help fill the void she felt. Predictably, value the relationship with she quickly came her 1FF therapist, to
opportunity
first
angry
it to
successfully
happen.
After to express much she Mrs. her missed T. had his had feelings company, ample her opportunity as well as how to attempts negative
and the prospect of termination was, at first, a difficult one. The feelings of need that arose in the context of termination were taken up and worked through over several this sessions, transition emphasize and Mrs. successfully Leick T. was able to make as well. and Davidsen-Nielsen2
grapple
with
the role
changes
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LATE
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that
learning
new
skills
comcase can
tients
with
a primary
focus
on role
transition fol-
be a new skill, the experience Using skill the for social the
to
comfort you
tears?
but how
of termination.
talk
Feeling
a self
Frankly discuss the possibility porary resurgence of symptoms the time of termination; that full well use on of an educational one. alternative as specific exploring (such as a therapeutic
required skill demonstrated she realized she could when to leave social
for
herself
3.
Focus strategies
to com-
IN
IPT In Interpersonal
bat loneliness). Begin well ahead of termination to allow some experimentation on the patients part, with review and possible subsequent Encourage Except for revision of those sessions. new relationships. patients who remain plans in
Psychotherapy
of Depression,
4.
Klerman et al.7 suggest the following in the final three or four sessions to facilitate the termination process: 1) explicit discussion of the end of treatment; 2) acknowledgment of the end grieving; of treatment and 3) as a time movement or to of potential toward the her indepenfor must
severely of
symptomatic, Klerman et telling patients who report discomfort with the prospect
patients recognition of his dent competence. For patients who come help with spousal loss, the
therapy
1FF
therapist
that a minimum 4- to 8-week waiting period is required before beginning further treatment of a different type. This conveys a clear message that this therapy will be completed, that ability
before
pay careful attention to the possibility that the patient will experience the termination of the psychotherapy as an additional loss. Much has been written about termination in shortterm therapies in longer term elapsed velop. during Furthermore, the also being easier to negotiate than therapy because less time has which dependency can in 1FF, transference dein-
the
therapist to function
further
is confidant outside
treatment
tient
should
first
make issues
discussed
are specifically avoided in order patients conflicts focused on figures serves in their everyday dependence 1FF difficulty became than for therawith depaWe conducted lives to discourage
PRELIMINARY
RESPONSE DATA
on the therapist). Nevertheless, pists should anticipate greater termination pressed in the for patients who of a loss context
a preliminary
of
1FF
3 female
mean
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were
engaged
after
meeting
offer
key
elements
common
to all grief
ther-
for major or entered treat(range Mean had been 11-56) age married IndeHam-D Assesswas
apies. These are defined by Raphael in her excellent review as 1) establishing a relationship with the bereaved, the 2) exploring the loss, 3) reviewing ing background and and have 6) achieving Behavioral brief been lost relationship, issues, 5) providing goals therapy, (recovery). cognitive for 4) explorsupport, therapy, of the
of 18.5
ment Scale33 scores of 62.5 and Texas Revised Inventory of 49.3 9.6/39.2 14.9 after data weekly 1FF sessions. These preliminary is an effective treatment related depression rently comparing nortriptyline, and
persons
and Thompson35 outcome for the groups than group, although than that dropout clear. a focus
for
relanumthe and
as well
as skill training is essential therapies for depression. oped strongly specifically for areas:
conflict,
to effective psychoAlthough 1FF develmodel, focused homework in 1FF, to improve the pursuit on it is interand
I S C U S S I
out
oriented
was four
are
are
encouraged
skills,
and and
of
fective coping strategies, and implications of such changes therapy sessions. al. undertook and process Horowitz et study of dispositional
patient.
and
interpersonal
require
attention by the
Surviving
relationships loss,
unbalanced
with interpersonal deficits (greater of character pathology) may be at risk for inhibited or prolonged grief. it it be
1FF focuses on interpersonal themes, incorporates an educational approach, and can be used medication. taught sionals workers, tical in conjunction The principles of mental with psychotropic of 1FF can health professocial it a prac-
tients ordinarily poor candidates low motivation could still be active, supportive motivation had
considered to be relatively for brief therapy because of or low developmental level engaged in treatment by an therapist. Patients with low better outcomes regarding with highly highly motiwhen when matched Conversely, better
de-
outcomes
their therapists took a less active stance in the termination phase. In general, however, Horowitz et al. found that more exploratory
JOURNAL
OF PSYCHOTHERAPY
PRACTICE
AND
RESEARCH
160
BEREAVEMENT
IN LATE
LIFE
actions
by
the
therapist
worked
best
for
solicitation,
however,
and
this method subgroup. mutual selfdynamic psysessions psychowith the late Al-
have selected a help-seeking Marmar et al.4#{176} compared group therapy with brief weekly individual psychodynamic on conflicts impede
patients. Supportive for the latter group. 1FF is consistent supportive commodate therapist both
both
chotherapy (12 with experienced therapists, spouse that though both in symptoms Marmar participants individual Mutual focused might
tient motivation and to establish a positive and to agree therapist to a focus of the
organization. 1FF seeks working alliance quickly early on. The attitude and educating,
in
with consen-
of or motivated are encourto undertake patients with benefit from stance and however, it, less the
still
sual validation, a forum to express difficult affects, peer support, and facilitation of problem solving. These groups are beneficial to many widows and widowers, particularly or help-seeking with less severe severe depresdiffithose with interpersonal depression. sion, culties, more more outgoing styles or those Those with more complicated
supportive, educational, active 1FF therapist. Psychodynamic psychotherapy have common historical transference of roots; early a focus difference of
allows
discourages
interpersonal
extensive exploration ences while encouraging sonal themes. This decreases termination effectively Group
studied
or a reluctance to join a group may require a more tailored individual psychotherapeutic approach.4#{176} ual Given the differences depth among and breadth of individwidows and widowers, apto
the
patient-therapist to be used
by less experienced therapists. therapy for the bereaved has been authors.372Vachon et al.,37 assigned widows randomly to a
or an intervention group
by several group
for
example,
it is not surprising that a variety of approaches are potentially beneficial. 1FF is one proach that can provide a workable forum address systematically bereavement-related depression of mental The authors and health that can be taught practitioners.
control
to a variety
and
found
that
thank
Donna
postbereavement
nical assistance.
had Work wassupportedfryNationallnstiMeofMental Health Grants MH43832, MJ-100295, M1-13 7869 (C.FR Ill), MH30915 (Dr. D.j Kupfer), and a NationalAllianceforResearch on Schizophrenia and Depression a (NARSAD) Young InvestigatorAward
Even
though
control
at 12 clearly Simi,
self-help
(M.D.M.).
This paper was presented
normative sample the interventions that improvement for simply by the both of these
concluded therapeutic
in a
ence of the International Psychogeriatric Association, Berlin, Germany, September 1993, and at the NAPSAD Annual Symposium, New York City, October
1993.
VOLUME
#{149}
NUMBER
#{149}
SPRING
1994
MILLER
ETAL.
161
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