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Summer Study Guide Week 4 (Interventions and risk factors)

Both readings for this week describe, in great detail, each of the 6 “R” processes and include
how-tos for assisting the client to progress through each. I hope you find this to be helpful.

Part I: Facilitating Mourning/ Use of 6 “R”s

Facilitating Mourning, Ch 12 Intervening in the Six “R” Processes of Mourning Ch 9
How to conceptualize treating complicated mourning
 One way of conceptualizing the treatment of Complicated mourning is to view the
mourner’s problems as arising from some:
o compromise
o distortion
o Or failure of one or more of the uncomplicated mourning processes (see previous
weeks)
 This perspective provides an overall context for treatment
 And enhances the likelihood that interventions will be appropriate and effective.
As noted on the bottom of page 208, 2 different languaging styles are used to describe Rando’s 6
“R” processes.
 The first, found in your Rando book uses more professional language and is designed for
mental health professionals.
 The second is less technical and is more user friendly, for clients. I list both below.
“R” Phase Professional language Client/user friendly terms
1 Avoidance Phase Recognize the loss Recognize the loss
2 Confrontation React to the separation React to the separation
Phase
3 “ Recollect and re-experience the Recollect and re-experience
deceased and the relationship your loved one and the
relationship you had.
4 “ Relinquish the old attachments Relinquish your old attachment
to the deceased and the old to your loved one and your old
assumptive world assumptive world.
5 Accommodation Readjust to move adaptively into Readjust to move adaptively into
Phase the new world without forgetting the new world without forgetting
the old the old.
6 “ Reinvest Reinvest

There are many reasons traumatically bereaved clients may have more difficulty with the
mourning process than those who lose loved ones through natural causes. (p 208-209)
 Those who experience sudden traumatic death of a loved one have far more difficulty
accepting the death and its many ramifications
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 Since mourners had no opportunity to prepare for the loss, the initial weeks and months
following the death can be more agonizing.
 Often difficult for survivors of traumatic loss to call up memories of the deceased
because these are often accompanied by disturbing images of the death-----
 Moreover, survivors of sudden traumatic losses are mourning the loss of the world as
they knew it (e.g. they don’t feel safe now), in addition to the death of their loved one.
 For all of these reasons, it is easy for traumatically bereaved clients to get stuck in the
mourning process.
 As you assist the client in moving form acute grief through these [R} processes, you
facilitate healthy accommodation of a loved one’s death.
Each “R” is divided into sub-processes, to clarify salient elements within each process. Further
presented are particular reasons for complications in each of the mourning processes as well as
suggested therapeutic interventions to facilitate progression through the process.
[In other words, each “R” process reviewed here will cover 3 things (items 3 and 4 are similar
just in different books)
1. Sub-divisions of each “R” Process
2. Reasons for the complications in each “R” Process
3. Therapeutic intervention suggestions
4. Ways to facilitate the progression through that “R” process.]
The “order” of the processes P 209
 In most cases earlier processes serve as prerequisites for later ones
o Give an example: the main task of the fourth R process (relinquish) is a precursor
to the fifth (readjust)…..
 However there are times when the “R” process can overlap occur simultaneously
o Give an example: the first (recognize) and second (react)
 Because grief is fluid, non-linear, and fluctuates over time, some movement back and
forth is common.
o Give an example: mouner can vacillate between the second and third
 The important issue is tracking whether a client appears to be moving forward. That is, IS
THE MOURNER WORKING TO accommodate the loss? OR IS HE avoiding, resisting,
OR OTHERWISE stuck within ONE OR MORE OF THESE PROCESSES?
First “R” Recognize the loss
 Sub-divisions of each “R” Process
o Acknowledge the death
 Reasons for complications (3)
 The mourner does not have the necessary confirmation of the death
 The mourner has the necessary confirmation of the death but
because of psychological dynamics denies its reality or refuses to
accept it
 The mourner has access to but chooses to avoid the confirmatory
evidence of the death
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 Therapeutic interventions
 The goal at this point is to:
 Interventions involved both a general strategy to help the mourner
actualize the loss and specific strategies based on the mourners
reasons for failure to acknowledge the death
o Describe verbal interventions: having the mourner talk
about what others are calling the death and the
circumstances surrounding it; discussing the absence of the
loved on and how it is interpreted along with the mourners
frustrated needs for that loved one, feelings about the
separation, concerns it generates, and meanings and
implications were the separation to be permanent;
addressing other issues or circumstances that may be
placing demands upon the mourners ego such that it cannot
allow itself to acknowledge the loss; sharing thoughts and
feelings with others who believe the death to have occurred
o Describe behavioral interventions: encompass techniques to
confront the avoidance of the loves ones absence
o Describe cognitive interventions: techniques such as
imagery, visualization, cognitive restructuring, and
cognitive rehearsal
 Treatment for absent, delayed and inhibited syndromes of
complicated mourning may be helpful for: mourners who have
confirmatory evidence but for psych reason cannot accept the
death and for mourners who avoid confirmatory evidence
o Help the mourner to know:
 Appropriate information, no wild goose chases…
this means:
o Help the mourner to know without knowing:
 Why is this difficult? Because of concerns of
abandoning the loved one
 What about fear of abandoning loved one?
Caregiver must acknowledge the fact that the death has
not been confirmed 100% and deal with the mourners
feelings that going o may seem to be giving up
 What psychological issues confront mourners in
assuming a death has occurred prior to its
confirmation?: guilt, self-condemnation, frustration,
anxiety, chronic uncertainty, helplessness, anger,
chronic mourning
o Help the mourner to live without knowing
 Treatment focuses on: developing most effective
coping strategies, processing specific affects,
thoughts, and fantasies, reducing anxiety, and
coping with practical and emotional concerns
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 How might chronic uncertainly lend itself to

chronic mourning?
o Understand the death
 Reasons for complications: when no cause of death can be found
 Therapeutic interventions: caregiver to work with mourner to gather as
much info as possible about the antecedents, context, and events
associated with the death to develop as complete as possible
 Ways to facilitate the progression through that “R” process.
o Help the client thru: recognizing the loss
Second “R” React to the Separation
 Sub-divisions of each “R” Process
o Experience the pain
 Reasons for complications:
 Stem from mourner’s desire to avoid pain-
 Can develop complications form overcompensating for fear of
pain. This presents how? Often center around fears of being
overwhelmed by mental suffering and loss of control
 Mourners minimize the loss to lessen intensity of the pain: “Its no
big deal”
 Therapeutic interventions:
 Exploring the pain and reactions to it. How?
 Deal with fears of losing control and being overwhelmed
o Inform the mourner that he can go as fast or as slowly as he
wishes and can stop whenever he feels overwhelmed
o breaking down the pain into its component parts to make
the distress more understandable and manageable separate
the pain from this loss from that stemming from prior
losses or conflicts that may be resurrected here
o address the mourners fear that he is not strong enough to
undergo the experience of the pain
o redefine the terms lose control or breakdown and
acknowledge the intensity of the feelings and legitimize the
normalcy of such feelings
o help the mourner understand that it is precisely those
emotions that go unexpressed that prompt loss of control
and that there is great value in expressing a little emotion at
a time in order to avoid an accumulation that will explode
later on
o enable the mourner to recognize that he can choose how
and when to process the emotions
o encourage expressions of feelings with those people and in
those places that are comfortable and without threat
o be mindful of the limits and capability of individual
mourners
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o be aware of the possibility of flight

o encourage the mourner to find appropriate ways to take
breaks from morning and replenish
o educate the mourner about the price of mourning if not
properly addressed
o Finally, the need for contending with pain. Interventions
must be geared toward achieving recognition before
dealing with issues of affect.
o Feel, identify, accept, and give some form of expression to all the psychological
reactions to the loss
 Reasons for complications:
 Most frequent complication is the failure to: address and express
the entire range of feelings generated by loss
 Often mourner deems some feelings unacceptable and these are
suppressed, and: given partial expression or avoided entirely
 What about guilt in this situation? the desire to evade the
recognition of feelings thoughts or memories prompts guilt
 Another issue is mourner’s desire to avoid recognition of
dependency on the deceased.
 Fear of being overwhelmed by painful affects.
 Other complications may derive form the Personality and self-
image especially as they affect the mourner’s ability to: accept and
express certain necessary psychological responses to loss
 Therapeutic interventions
 Worker should convey: a desire to understand and process the
entire spectrum of reaction to the mourner sustains and should
communicate that failure to do so leave the mourning complicated
 Take time to establish conditions of_safety and trust
 These are especially important when the following conditions exist
for the mourner:
o effects are unusually threatening or overwhelming to the
mourner
o the mourner is unusually fragile
o effects stem from long term trauma or a traumatic event
which contribute to PTSD mourners history reveals
betrayal or victimization by those in authority who should
have protected the mourner
o the mourners personality self-image conditioning roles
other attributes or desire for social approvers strongly
prohibit the expression of the very emotions that caregiver
seeks to facilitate
 If a client has difficulty processing affects: the caregiver must use
the strategies outlined for the previous subprocesses to enable
confrontation with the painful emotions and stimulate the effects
that are not being addressed
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 Other techniques besides verbal discussions: can put the mourner

in touch with unexpressed effects and include many generic
techniques of the behavioral therapies and therapeutic bereavement
rituals
 Caregiver can give examples of what to expect, but use care
because: in order to avoid the appearance of telling the mourner
what they should be feeling and guilt should not be mentioned so
the mourner does not feel the need to contend
 Intellectualized treatment will do little good because: the mourner
must experience and own the feeling
 Research suggests that merely ruminating does not help the
individual cope with the loss (associated with increased health
problems). To be successful as a cognitive strategy: the intellectual
work of coping with threatening events must depart from the
passive process of ruminating by involving a search for meaning in
the experience, an attempt to gain mastery over one's life, and in an
effort to enhance self esteem
 What is the target of the worker’s interventions and what care must
be taken? promoting expression of access and a must be taken at
the reactions that are not there to begin with because of a
repression or denial conditioning values beliefs prior mental health
status
 In the case of unfinished business: the caregiver may have to take
the mourner back to the time the effect was generated and facilitate
its expression through a cython therapeutic technique of personal
choice
 What are resistances and what can be done? fears of pain, losing
control, or breaking down and processing these emotions, desire to
avoid having to discover and or contend with guilt anger or
dependency or previous personal societal cultural ethnic
generational religious or role related conditioning - the caregiver
must be aware that various sources of conditioning can lead to
resistance or inability to accept certain feelings as tolerable or
normal
o Identify and mourn secondary losses:
 Define this: when a loved one dies the survivor loses much more than that
individual and kiss sustain a number of physical and psychosocial losses
as a consequence of the death
 Reasons for complications: it's similar to those that interfere in the other
morning processes
 How are these similar? because what occurs with regard to
secondary losses tend to be a microcosm of what occurs in the
overall process
 Therapeutic interventions
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 While many interventions in general will be effective, it is

important to point out that the worker know the mourner well
enough to identify________ secondary losses
 In case of bereavement overload:
 Ways to facilitate the progression through that “R” process.]
Third “R” Recollect and Re-experience the Deceased and the Relationship
 Sub-divisions of each “R” Process
o Review and remember realistically
 What is involved in this: mourner reviews relationships with the loved one
 Complications:
 Maintaining an unrealistic image: takes a lot of energy to
defending untruths and disrupts the mourner s ability to review and
process feeling and thoughts of that relationship
 Reluctance to address negative aspects: reluctance to address what
she can choose as negative aspects reflects the mourners lack of
appreciation for and knowledge about the existence of some
amount of ambivalen and all relationships
 Rear of recognizing existing dependency: keep some mourners
from remembering the deceased and their relationship fully
 Fear of confronting anger: avoid realistic recollection of the
relationship in order to evade facing her own acts of omission or
Commission and thoughts feelings and fantasies she now feels
guilty about in light of the loved ones death
 Other reasons (10 more)
 Therapeutic interventions
 First task: is to ascertain what the impediment is in the review and
recollection process
 How can mourners be helped (given a rationale for why the
caregiver wants them to undergo these processes
 Normalize sadness: the mourner may experience
o Revive and re-experience the feelings
 What is this: feelings accompanying what has been remembered about the
deceased and the relationship must be reviewed and re experienced - they
must be felt
 Complications:
 Reasons are an amalgamation of others. …worker can expect to
see variations of following causes:
o fear of pain and desire to avoid it
o fear of encountering unacceptable memories feelings or
thoughts
o fear of being overwhelmed by sadness
o desire to avoid doing anything to alter ties with the disease
in order to maintain prior connections and avoid
recognition of the loss and its implications
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 Therapeutic interventions
 These are similar to: to those for others in which emotions are
evoked and memory stimulated
 What is different here is: the unparalleled poignancy of the
subprocess
 Ways to facilitate the progression through that “R” process.]
Fourth “R” Relinquish the old Attachments to the Deceased and the Old Assumptive
World
 Sub-divisions of each “R” Process
o Relinquish the old attachments to the deceased
 What does this entail? Disconnecting attachments from the deceased
 Reasons for complications:
 The major complication interfering with the mourners
relinquishment of former attachments to the deceased is that she
does not want to
o Because: fears that then she will have no connection to the
loved one and that to do so means he is really dead
o Because: it makes her feel insecure and anxious and
because she cannot imagine life without him she does not
think she can manage to do it because her ties to the
deceased defined parts of herself
o Because: she does not want to be different now but she
wants to go back to the old world the old life the old
relationship and the old self
o Because: this was not the way her life was supposed to go
 Therapeutic interventions:
 This process is interwoven with the previous process so
interventions are similar
 To assist the client to develop a new relationship with the deceased
is applicable
 It will be helpful to explain what? the process of relinquishment
and subsequent reformation of a relationship with the deceased
 The following interventions (5) help to actualize each attachment
or groups of attachments
o explicit identification of each of the attachments
o exploration of how each attachment developed
o interpretation of the meanings and significance to the
mourner of each attachment
o discussion and processing of the needs feeling thoughts
behaviors memories and interaction patterns hopes and
wishes vanities dreams assumptions expectations and
beliefs generated by each attachment and of the reactions
and frustrations consequent to their loss
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o discussion of how each attachment has a corresponding

element in the assumptive world
 These interventions are designed to accomplish the following
goals: (4)
o identify precisely what is being lost and encourage the
morning processes
o make each attachment tangible enough so that the feelings
about it can be discussed and plans made for what to do
about it
o illustrate how the needs feelings thoughts behaviors and
interactive patterns hopes wishes fantasy streams
assumptions expectations and beliefs that had mandated or
involved the physical presence of the deceased must be
religious because they can no longer be gratified
o enable the mourner to understand how specific attachments
to her loved one have influenced her global assumptive
world and now mandate alterations in it to reflect his
absence
 If the proper perspective is established, mourners can be receptive
to: the idea of establishing a new relationship with the deceased
and can work towards this and other readjustment goals
o Relinquish the old attachments to the old assumptive world
 What does this entail? based on the loved ones existence and how her
interactions with the mourner maintained the assumptions needs
expectations hopes beliefs and so forth. Such relinquishment involves
major secondary losses. If the mourner continues to operate with an out of
date and invalid construct system healthy morning and necessary
readjustment processes will be complicated
 Reasons for complications
 Arise from several quarters and pose mourners with dilemmas too
often seriously underestimated by their caregivers
 Client’s need for meaning and for cognitive control, understanding
sense security and predictability, cannot be overstated
 Client attached emotionally to
o general assumptions about the deceased
o and to specific assumptions about the needs and desires that
nurture and spring from them
o and about the relationship in particular
 Some global assumptions have been with the client for as long as
he can remember. This is significant because? when these notions
are shattered by the death of a loved one beliefs and expectation
almost as old as the mourner are dissolved
 Assumptions about meaning: when one of the several of these must
be reconsidered after the death of loved one the others may
become suspect as well
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 Therapeutic interventions:
 First, the worker needs to recognize that the mourner has already
lost a great deal,
 Then: the caregiver must acknowledge the losses inherent in
relinquishing the attachments and the older son underworld and
identify them as secondary losses requiring processing
o The process is lengthy because: only by bumping up
against the new world and discovering the old absorptions
expectations and beliefs and the needs feelings thoughts
behavior and interaction patterns hopes wishes fantasy
streams that coincide with them no longer fit does the
mourner learn the lesson that they must be changed

 Ways to facilitate the progression through that “R” process.]

Fifth “R” Readjust to Move Adaptively Into the New World without Forgetting the Old
 Sub-divisions of each “R” Process
o Revise the assumptive world
 This entails what?
 To adjust and accommodate, the client must change what: both
behavior in the altered physical world and elements of the
assumptive world
 Reasons for complications:
 Client’s inclination is to avoid change
 Mourner does not believe she can function without the deceased
 Some mourners feel need to be punished: for previous acts feelings
or thoughts directed toward the deceased and or the mutual
relationship
 Lack of social support may hamper: the mourner in all areas of
readjustment
 Therapeutic interventions:
 Interventions appropriate for relinquishing the old attachments to
the old assumptive world are applicable here. In addition to
implementing these interventions, the worker can clarify: which
elements of the oldest underworld can be retained which must be
relinquished which must be modified which must be added and
why
 Other activities and tasks?
 Redefining the event to be consistent with the assumptive world:
o The benefits of this are: minimizes the threat to the Moors
assumptive world by maximizing the possibility of
maintaining prior theories of reality
 Find meaning by attempting to make sense of the experience
o those who can make sense or find meaning after
victimization tend to be less psychologically distressed and
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better socially adjusted and appeared to have more

effectively integrated the experience with their respective
worlds
 Change behaviors
o can provide victims with the sense of control that can
minimize the perception of vulnerability assist and
reestablishing a view of the world that is not wholly
unresponsive to one's effort and help rebuild a positive self-
image
 Seek social support
o right victim can help be recovered and adjusted by being
the provided the opportunity to talk about the event invent
emotions and received assistance in problem solving
 Cognitive adaptation to threatening events: (Taylor’s work, 1983)
o Develop a new relationship with the deceased
 This entails what?
 There appears to be less resistance to this sub-process…why? It
permits the mourner to have some of what he wants
 It is absolutely crucial (p 437) that caregivers understand the
mourner’s need to maintain a connection to the deceased. Why is
this? because mourners are not provided a means of having a
healthy connection that they continue to hang on in unhealthy ways
 Reasons for complications:
 In addition to failing a previous “R” process, four main reasons
exist for complications here:
o the mourner is unwilling to accept the need to form a new
relationship with the deceased because he wants to return to
the old relationship in which the loved one was physically
present
o the mourner fails and simultaneously meeting the two
criteria for a healthy relationship with the deceased
o the mourner support system or caregivers failed to support
and or passively or actively discourage the development of
a new relationship with the deceased
o the mourner uses identification with the deceased to avoid
appropriate relinquishment or they identification itself is
inappropriate
 Therapeutic interventions:
 If the worker enters the picture after a pathological connection has
already been established, the task will be to : Find a better and
more appropriate way to maintain a tie so that the mourner can
relinquish the inappropriate 1
 In this regard, all therapeutic interventions are built around: the
caregivers educating the mourner about the establishment of a
healthy new relationship with the deceased
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o The caregiver must first: disabuse the mourner of the

prevailing myth that connection to the dead or unhealthy
and provide explicit permission to reconnect with the loved
one under the two conditions necessary for an appropriate
relationship with the deceased
o The caregiver’s next goal is: to promote a healthy new
relationship and those ways that are as personally
meaningful as possible for the mourner
o The result will be increased feelings of: power and control
and decrease some of the helplessness and passivity with
which many mourners struggle
 Describe the process of reorganization the mourner forms a new
relationship based largely on recollection memory and past
experience
 Healthy ways to maintain the connection include: remembering the
deceased as life continues, choosing life promoting rather than
death denying reminisces, and continuing to maintain the
relationship with the deceased without jeopardizing subsequent
reinvestment in others
 If the mourner uses identification, he may experience problems.
Why? And what can be done? when they identification occurs to
intensely, when it is inappropriate to adult functioning, when it
occurs in areas in which the mourner lacks competence, or when it
is incompatible with other roles; caregiver should help the mourner
discover more appropriate ways to identify with the loved one
 What to do about resistance? caregiver deals with the situation in
the same fashion As for all other protests at the loss and wishes for
a different reality; acknowledging, identifying, and labeling the
mourners response as a wish or protest and then reality testing it
 If client is not moving forward adaptively to the new life: the
caregiver must assess the source of the failure then deal with the
situation
o Adopt new ways of being in the world
 This entails what?
 New rules, skills, behaviors, and even relationships must be
undertaken to compensate for the absence if the loved one had
been an integral part of the mourner's life
 Reasons for complications:
 Client resists engagement to deny implications of the loss.
 Frequently magical thinking is involved…this means what? the
mourner believing that keeping the world the same as it used to be
somehow means that the loved one is not really dead
 Another reason for the reluctance to assume new behaviors is: the
feeling that the old ones are the sole ties remaining to the deceased
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Anxiety and poor self-image also may interfere, how? interfere

with the relinquishment of the overlay ship and keep her from
trying out new behaviors in the world without a deceased
 Serious lack of skills (what type: …) psychosocial, behavior,
vocational, and other skills
 Final complication is: concerns the element of time; if an
insufficient amount of time has transpired to allow these changes
to occur and to be integrated no evidence will be seen of new ways
of being
 Therapeutic interventions:
 Ultimately: all will need to be integrated
 Interventions to deal with magical thinking: assist the mourner in
recognizing and ultimately working through reluctance to admit
the reality
 What about anxiety? caregiver needs to investigate the source of
the affect, identify and label its component parts and specific
carriers, process problem solved and work through each part and
each pacific fear, and teach stress management strategies
 Lack of appropriate skills? caregiver can work with the money to
secure proper training in order to develop these skills and gain that
knowledge
 Some general points: as with all other forms of mental health
intervention events and behaviors may have symbolic meaning to
them or
 Adoption of new behaviors requires trial and error progress is often
two steps forward and one step back
o Form a new identity
 This entails what?
 Inevitable change: the death of individual who was an important
part of the mourners life and inevitably will change that mourner
 Change form “we” to “I”
 Identify what has been lost and gained
 Reasons for complications:
 Change can be frightening: frightening for mourner to watch
himself changing
 Refusing to make changes or to integrate those changes when they
have been forced by external reality
 Problems with identification…how so? Occurs in areas in which
the mourner lacks competence whereas congruent with other roles
 New identity may be that of chronic mourner
 Degree of success in previous processes will influence this one
 Therapeutic interventions:
 For new identity: inquiring what needs, feelings, thoguhts,
behavior, and interaction patterns etc. he has had to give up or
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modify and what new ones had to be assumed to readjust to the

death
 For anxiety re: new identity: anxiety over changes in the self must
be acknowledged
 For clients whose personality organizations contribute to problems
with identify formation: caregiver must enable mourning issues to
be addresses as completely as possible
 Difficulty integrating ego-dystonic parts of himself into the new
identity: caregiver should focus on working through these
unacceptable sequelae to the extent possible
 Inappropriate identification with the deceased interferes with
forming an new identity: caregiver must interpret this,
acknowledge the desire to remain connected to the loved one, and
suggest that the mourner discover healthier ways to maintain the
connection
 Lack of social support for new identity: caregiver must work to
identify available resources and then refer the mourner to them
 New identity is based on perpetuation of acute grief: caregiver
must initiate an overall intervention for chronic mourning
 Complications from unfinished business: caregiver must go back
and work through those previous processes
 Ways to facilitate the progression through that “R” process.]
Sixth “R” Reinvest
 This entails:
o This redirection of energies will not replace the loved one. However, it
canreconnect the mourner with new people, objects, activities, roles etc, that can
provide emotional gratification to compensate for what was lost.
o The object of reinvestment may be tangible
 Examples another person, house, art collection
o The object of reinvestment might be psychosocial:
 Examples a relationship, a dream
 The sole requirement for healthy reinvestment is: that the mourner place
the emotional energy and involvement in a source that will return it
 Reasons for the complications in each “R” Process
o Failure in one or more of the previous “R” processes
o A main cause of complications in the reinvestment process is misinformation
 Many clients equate length and amount of their suffering with their love
for the deceased-
 For them, reinvestment suggests what: that they no longer miss the
loved one or that the relationship was not meaningful or important
 Still others believe it is an insult to the deceased to enjoy life again.
 These and other myths block health reinvestment
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 Reinvestment may be avoided my mourners who fear: either being hurt

again by loving another who also could be lost or others perceptions that
they have not loved or mourned the deceased enough
 The type of death experienced by the loved one can have an adverse
impact on reinvestment…how? Some individuals may have been through
long term illness with their loved ones; feel so depleted after devoting
their time to caretaking that they have difficult readjusting
 Therapeutic intervention suggestions
o These issues can be managed relatively easily by the caregiver.
 Misinformation can be corrected by the provision of accurate
psychoeducational information
o Mourner’s specific fears must be identified and dealt with separately
o Interventions with those who are depleted form a loved one’s terminal illness will
center around: redefining new goals, reestablishing the self as a central focus, and
replenishing physical and psychosocial needs
o Finally, the factor of time plays a part, how? In the reinvestment process
 Ways to facilitate the progression through that “R” process.]
Part II: Risk Factors and Clinical Challenges
This part of our week is focused on risk factors and clinical challenges. We will especially be
looking at guilt, anger, and dependency/co-dependency. These are frequent themes and so are
deserving of our scrutiny.
Rando chapter 10 Risk Factors and Traumatic Bereavement chapter 6 Person-related factors
P 453 “The potential for death to bring on complications in mourning depends on the unique
constellation of factors associated with each individual situation.”
P 453 “Despite the range of variables, the literature is remark ably consistent in identifying
factors predictive of complicated mourning.
Rando identifies 2 categories of factors:
 Factors related to the specific death
o Sudden, unexpected death (especially when traumatic, violent, mutilating, or
random)
o Death from an overly long illness
o Loss of a child
o The mourner’s perception of the death as [having been] preventable.
 Factors of antecedent and subsequent variables dependency/codependency
o A premorbid relationship with the deceased that was markedly angry or
ambivalent or dependent
o Prior or concurrent mourner liabilities, including unaccommodated losses and/or
stresses and mental health problems.
o The mourner’s perceived lack of social support
 16

p. 91 There are striking individual differences in response to traumatic death. Similar losses can
be experienced quite differently by different individuals. In essence, “psychological trauma
arises from an interaction between aspects of the event and aspects of the person.
Person Related Factors
In this chapter, the following person-related factors (variables) will be described. These include:
 Gender
 Religion/spiritual beliefs
 Personality and coping strategies
 Kinship relationship to the deceased
 Nature of the relationship with the deceased
 Attachment style
 Additional person-related variables
o History of prior traumatic events
o Family history of psychopathology
o Presence of other concurrent stressors (in addition to secondary losses)
o Death of a child
 Only child
 Less working outside the home
 Less education.

Let’s look at these 2 identified categories. Rando and your Trauma text use similar terms for one
category and different terms for the other, but they are not that different given the examples
offered. See below: (I have lots of blanks in this table. These are NOT for you to fill in, I just
wanted the similar items to line up, to make comparison more visual. I am unclear how to do
that, so lots of extra dots. Sorry.
Trauma Readings: Rando
Aspects of the Event Factors related to the specific death
 (event)
  Sudden, unexpected death, especially when
 the death (event) was
 o Traumatic
 o Violent
 o Mutilating
 o Or random
  Death (event) was from an overly long
 illness
 Death of a child  Loss of a child (event)
 The mourner’s perception of the death
(event) as preventable.

Aspects of the person (Person- Antecedent variables/ Subsequent

 17

related factors) variables

 Nature of the relationship with the  Person’s premorbid relationship with the
deceased deceased [before the death]
 o Angry
 Attachment style o Ambivalent [attachment]
 o Dependent [attachment]
 Presence of other concurrent stressors  Prior or concurrent mourner (Person)
(losses, in addition to secondary losses) liabilities, including
o History of prior traumatic events o Unaccommodated losses and/or
o stresses
o Family hist. of psychopathology; o Mental health problems (of the
personality [disorder] and coping person) [before the death or
style currently]
o o Mourner’s (person’s) perceived lack
o of social support
 Kinship relationship to the deceased [sister,
mother, uncle, spouse, etc.]
 Gender
 Religion/spiritual beliefs

[I think I included everything. So the take-away is that these categories line up. Just because
there are different terms, doesn’t mean they describe different things. Careful reading and
thoughtful consideration are key here, in the lit review. So the question is raised, then, if this unit
is on person related factors (the bottom row of boxes), when will event related factors be
covered? Circumstances related to the event are covered in
 Rando Ch11 Event: Mode of death Trauma readings chapter 5
o Natural death
o accidental
o war
o disaster
o suicide
o homicide
 Rando Ch 12 Event: Circumstances of the death Trauma readings Chapter 5
o Sudden, unexpected death
o Multiple deaths
o Traumatic death
 Rando Ch 13. Death of child
Hope this helps. Now, back to person related factors.]

Gender
 18

 Death of a spouse: Why might men have greater difficulty? Widowed men are more
likely to become depressed and experience greater mortality than are widowed women
 Child loss: although fathers evidence considerable distress, mother report significantly
more distress than fathers
 Gender differences in coping strategies:
o 2 primary patterns for grieving:
 Intuitive grieving entails: involves intense expression of emotions
 Instrumental grieving entails: often experience their grief as waves of
affect
 NOTE: previously, the literature (mostly Golden, T.) called these models
of grief, Masculine and Feminine models of grief. They were not gender
specific, in other words, women could have a masculine grieving style
(e.g. Jacqueline Kennedy) and men can have a feminine style of grieving.
Feminine styles were more emotive (see Intuitive) and Masculine styles
were more cognitive and behavioral (not inappropriate behavior, but
doing something to make improvements) (See Instrumental.) Just to give
you a history of how things have evolved.
Religion/spiritual beliefs
 “Evidence suggests that religious beliefs and practices are widely used and that the
majority regard them as helpful.” P 94
 Caution when looking at the research. Why? This research has been plagued by
methodological problems
 Religious/spiritual resources available:
o Increase in frequency of prayer helpful in coping with the death
o Religious support, including: support from clergy and members of a congregation
o Affecting how survivors cope with the loss.
o Some evidence to support religion assisting people to find meaning in the loss.
o Tedeschi and Calhoun maintain that 5 different types of experiences indicate
personal growth
 The emergence of new possibilities
 Positive change in relationships
 Increased sense of personal strength
 Greater appreciation for life
 Changes in religious and spiritual orientation
o Yet others refute this. What are the challenges clients face in traumatic death?
Personality and coping strategies
 Define: dispositional tendencies toward such states as optimism, self-esteem, anxiety, and
emotionality
o Dispositional optimism: tendency to be optimistic in most cirucumstances
 Self-esteem is associated with adjustment following loss
 Sudden traumatic death has an adverse effect on affect management
 Traumatic bereavement can also impair ego resources such as: intiative, judgement,
ability to manage boundaries, ability to foresee consequences, and decision making
 19

Kinship relationship to the deceased

 Several studies have shown that the death of a child leads to more intense and prolonged
grief and depression than the death of a spouse, sibling, or parent.
 Marshall and Davies (2011) maintain that the loss of an adult sibling is a disenfranchised
loss
 How does the traumatic death of a child affect the siblings? They face wide randing and
enduring consequences following the death of a brother or sister
 Another disenfranchised loss is the loss of a child during pregnancy (miscarriage,
stillbirth)
Nature of the relationship with the deceased
 Well-controlled studies fail to support the idea that ambivalent or conflicted relationships
fare worse in grief.
 Research does support the added risk of overly dependent p 101relationships
Attachment style
 P 102 Mikulincer and Shaver suggests that secure attachments increases the likelihood of
adjustment to a loss.
 What are the therapeutic implications of the various attachment styles? P 103 (Zech and
Arnold) anxiously attached clients are likely to be emotionally hyperaroused where
avoidantly attached clients may be hypoaroused
Additional person-related variables
 History of prior traumatic events enhances vulnerability to complicated grief
 Family history of psychopathology
 Presence of other concurrent stressors (in addition to secondary losses)
 Death of a child
o Only child parents have greatest risk of admission to psych hospital
o Less working outside the home
o Less education.
This chapter 10 of Rando discusses person related factors in terms of treatment suggestions for
dealing with high risk factors pertaining to the:
 Individual
 The relationship with the deceased
 The social system
Specifically, these discussions will include:
 Mourner’s liabilities
 Anger
 Ambivalence
 Guilt
 Dependency
 20

 Co-dependency
 Degree of social support
P 454 “The treatment suggestions presented in this chapter (as well as chapters 11, 12, and 13)
are IN ADDITION TO
 the philosophical perspectives on treatment and the generic treatment discussed in
Chapter 8
 the specific strategies for intervening in the six “R” processes offered in chapter 9.
These earlier chapters must be read first because they form a matrix for understanding the
interventions suggested in this and subsequent chapters.”
INTERRELATIONSHIP AMONG HIGH-RISK FACTORS
 P 454 “In the vast majority of complicated mourning experiences, more than one high-
risk factor exists. Generally, the existence of more factors increases the risk of
complications. Not all factors are equal, however.”
 For example see 2 clients below:
o Alice:
 Lost a child (risk)
 To suicide(risk)
o Barbara:
 Lost a spouse
 To preventable (risk)
 Sudden heart attack (risk)
o Most would say that Alice is at greater risk…but there may be other factors.
o Perhaps Barbara also has:
 Mental health problems (risk) concurrent stress (risk)
 Perceived lack of social support (risk)…
o If so, Barbara may have the high risk.
The research of Andrews, Tennant, Hewson, and Vaillant (1978) proposed that the (p
454) “prediction of risk of psychological impairment after life event stress improves by
taking into account:
 Meaning of the event to the individual,
 Effectiveness of coping style,
 Personality attributes, and
 adequacy of social support during the crisis.”
What is it that results in “pathologizing of many understandable and statistically normal
responses after specific types of death” ? p 455
P 455 “Similarly, the impact of social validation of the loss and/or social support during and after
it also has been seriously overlooked in favor of attributing responses to the influence of the
individual mourner’s psychology” Person in environment: social support MATTERS.
Nevertheless, “These caveats to not belie the importance of what? P 455
 21

P 455 “ Although some factors can be identified as predisposing the mourner to complicated
mourning their interpretation is ALWAYS relative. Factors must be examined in relation to one
another because their potency and impact may vary over circumstances; one factor cannot
always be presumed to be more influential than another.”
Part III: MOURNER LIABILITIES
Overview
Please define: two areas may complicate mourning: 1. The mourners prior and concurrent losses
and stress and 2. The mourners prior and concurrent mental health
Prior and concurrent losses or stresses
Research findings:
Somewhat inconsistent.
 On the one hand, Rando found: the total amount of previous loss judged by the mourner
as having been successfully coped with influenced adjustment after bereavement, the
better bereavement outcomes tending to be associated with fewer previous losses
 On the other hand, Worden found: it is not just the number of life crises that is important,
but which life crises they are and how the
 Stroebe and Stroebe offer 3 hypotheses
o An antecedent bereavement experience would increase risk of poor outcome if it
entailed the loss of a key attachment figure during childhood
o if the antecedent loss occurred during adulthood the experience could prepare the
individuals for subsequent bereavements
o someone who has suffered multiple losses of very close persons possibly in rapid
succession could be at particularly high risk given that cumulative experiences
might lead to the loss of the feeling of control over events hopelessness
depression social withdrawal from others for fear of losing them also and
consequent loneliness
 How to integrate all three findings (Rando, Worden, Stroebe and Stroebe: each loss or
stress must be identified and note must be taken of when it occurred whom it evolved and
what it meant to the mourner
 Differences between a death and a non-death loss or stress: Non death losses or stresses
may pale next to the death of a loved one
Types of Concurrent losses: (Five types exist:
 The first involves an event that happens to coincide with bereavement over the loss of
the loved one
 the second type of concurrent stress occurs when the same circumstances that cause the
death of the loved one cause the mourner to be unable to attend the morning process
 the third is observable in cases of multiple loss where the death of the one of individual
cannot be mourned properly because mourning is also required for others at the same
time
 22

 the 4th occurs when the death creates secondary losses or circumstances that interfere
with the mourning of that death
 Another might arise if the current death triggers A stug reaction to a prior loss
Effect of prior and concurrent losses and stresses on mourning (p 459)
 prior loss may exert an impact on the individual subsequent loss responses
 bereavement overload stemming from a number of simultaneous bereavements may
leave the mourner emotionally depleted and often physically exhausted and unable to
mourn the current loss adequately
 a depletion of the ego can occur because of the demands in prior or concurrent losses or
stresses
 a mourners prior experience with losses and stresses may establish expectations regarding
future loss and influence the coping strategies and defense mechanisms adopted
 When other crises impinge on the crisis of bereavement the mourner may be able to do
little more than survive
Prior and concurrent mental health:
 “No other factor so accurately describes and delimits:
o Is affected by loss, how losses experience, or what is available for a response to it
Treatment implications:
 A good loss history must determine what? the timing, cause, location, type, and other
factors circumscribing prior or concurrent losses and stresses as well as pinpoint the
mourners reactions to and lessons learned from them
 Clearly, TX also must take into account: any pre-existing mental health problems
ANGER
 Overview
o P 462 “As used here anger refers to: any amount of hostile or aggressive emotion
whether minor or major
o “In addition to anger as a non-specific issue in mourning and as a characteristic of
the mourner’s personality influencing interpretations of and responses to life” p
462) anger in mourning may be any one of the following:
 Anger as a normal consequence of loss
 An emotional consequence of being deprived of something valued
 There is always some dimension of anger present at some point in
grief. P 463
 Anger following the loss of a dependent relationship
 According to Raphael, (1983) p 463 distorted mourning of the
extremely angry type typically is the result or:
o This reflects the protest at the loss and is often
accompanied by: a sense of desertion and the perception of
threatened survival
o Persistence and intensity of such feelings can eventually
ruin relationships and destroy the mourner’s support system
 23

 The death of the loved one frequently appears to resurrect

insecurity caused by earlier, often childhood, losses
 Although such feelings are normal for a while following a loss,
their intransigence and exclusivity characterize this type of
complicated mourning and differentiate it from uncomplicated
bereavement.
 Anger following particular types of deaths
 Raphael: has observed that intense anger can be expected
following violent deaths sudden or unexpected deaths or deaths
where the mourner sense of desertion is great and deaths where a
very special and irreplaceable relationship is lost
 Anger as a major characteristic of the premorbid type:
 Two complicated mourning syndromes derive form a contentious
premorbid relationship
o conflicted mourning
o distorted mourning of the extremely guilty type
o P 462 “in brief, the worker may be called upon to work with anger of 2 major
kinds:
 Anger stimulated by the particular death and or its circumstances and
consequences
 or anger as a component of the premorbid relationship between mourner
and the deceased
 Treatment implications
o Prerequisites: Caregiver first must understand the purposes of the anger and be
able to promote healthy psychological behavioral social and physiological
processing and management of this emotion
o Components of effective treatment:
 Provide psychoeducational and normative information about anger
 First: clarify that it is normal to have angry feelings
 Share Lifton: conceptualization of anger as a way of asserting
vitality
 Work through the mourner’s individual resistances
 Idiosyncratic
 Ego-dystonic
 Extreme idealization:
 Identify and understand true sources and causes of anger. Such as: Anger
at the deceased may be present along with anger at the type of death
 Process the anger, how: mourner must acknowledge the existence of anger
and feel identify label differentiate into component parts trace gives some
form of expression to and work through all of the emotions that may be
hidden under the facade of anger
 Give permission to ventilate and channel aggressive feelings in
appropriate ways
 24

 Give permission how? encourage the mourner to make anger

constructive by taking the position that anger is energy and can be
put to work for the mourner
 Examples of appropriate ways to channel anger? working for
stiffer drunk driving legislation after an alcohol related crash
 Enable client to work through “R” processes compromised by anger. How:
a certain in which ways anger interferes with the successful completion of
the R processes address it as defense resistance or impediment and work to
promote healthy completion of the specific processes that have been
compromised
 Provide vehicles for resolving unfinished business. How: put current
issues on hold and work through the unfinished business first in order to
decrease the potential for complicated mourning or acting out
 Help mourner minimize secondary victimization. How: providing
information about how to avoid such secondary victimization can help
them mourn or cope
AMBIVALENCE
 Overview
o 5 main problems when ambivalence exists:
 Mourners are often reluctant to acknowledge that negative emotions play
a part in a relationship
 when it comes to emotional issues human beings tend to think discreetly
in a dichotomous either or fashion that belies the complexity of human
relationships
 there's a general failure to appreciate the negative feelings of bond people
together no less than positive ones
 after a death the recognition of the hostility within the ambivalence
prompts guilt which the more new tries to evade by avoiding recollecting
and re experiencing the deceased and their relationship
 intense ambivalence may complicate mourning by leaving the mourner not
knowing the world or unable to adjust to it adaptively without the negative
experiences that may have characterized it previously
 Treatment implications
o Basic strategy involves 4 parts:
 educating the mourner about ambivalence and relationships in general and
in mourning specifically
 stimulating and promoting a full range of affects
 providing opportunities for appropriate expression and channeling of
emotions
 working through and integrating feelings and memories of the deceased
and the relationship to achieve a realistic composite image
o These help work thru last 3 “R “ processes
o Evocative techniques: Useful in provoking affect - maybe verbal or nonverbal
structured or unstructured
 25

o When ambivalence is extreme: the caregiver will have to process with the
mourner the various reasons for conflict normalize such emotions when they are
appropriate and work them through as much as possible in order to diffuse their
intensity and the bonds they serve to perpetuate
o Ambivalence in mourning a conflicted relationship following chronic
victimization
 Generally: those who mourn the death of a loved one with whom they
have had a markedly conflicted relationship
 Sources of conflict form victimization:
 Victimization of a child
o Intervening with the conflicted mourner: p 475-477
 mourning the death of abusive individual does not invalidate the abuse,
lessen the culpability of the perpetrator or victimization of the mourner, or
mean the mourner wishes the deceased were alive to resume the
relationship
 negative ties can bind just as strongly as positive ones with the degree of
bonding being determined by the strength of attachment not its
characteristics
 extremely negative ties can coexist with some positive ties
 all ties whether positive or negative must be relinquished
 contrary to popular assumption mourning negative ties does not mean that
the mourner is sad that the deceased has died or experiences unwanted
deprivation
 much of the morning that must take place after the death of an abuser
focuses on mourning for what that abuser has taken away from the
mourner
 the six R processes of mourning illustrate that much alteration must be
done in the absorptive world, the self, and ones behaviors in the world
after the death
 the consequences of victimization frequently leave PTSD sequelae
GUILT
 Overview
o Defined here, guilt is: p 478 the feeling of culpability deriving from perceived
offenses or a sense of inadequacy
o Guilt has 2 latent functions:
 to defend against helplessness
 to serve as self punishment and a tool for retribution
o Guilt and shame are related but different. Describe: in guilt the individual
perceives her behavior as bad whereas in shame the individual perceives herself
as bad
o Sources of Guilt: 4 general, but clinically there are 6:
 falling short of oneself image
 violation of a conscious or unconscious personal standard
 ambivalence
 imperfection and relationships
 26

 surviving when others have died

 feeling one contributed in some way to the death
o Types of guilt:
 Illegitimate: neurotic; comes from inappropriate self condemnation
associated with vulnerabilities derived from parental admonitions during
childhood or from the sources of guilt cited previously
 Legitimate: appropriate; arises from actual wrongdoing and thus is
appropriate to the situation
o Problems posed by guilt:
 Treatment implications
o 4 goals:
 recognize and accept guilt feelings which are often unconscious
 adopt the proper perspective about ambivalence human error and
imperfection and normalcy of guilt feelings after loss
 process guilt by acknowledging the impact of the emissions commissions
emotions thoughts additude wishes fantasies and impulses giving rise to it
and understand how and why these relations these things occurred and
worked through the origins and the relationship and villa express emotions
that arise
 share the guiltwith another or others in a supportive relationship
o Strategies: (p 487
 help the mourner recognize that although guilt often can be worked
through at times it cannot
 enable the mourner to engage in appropriate symbolic experiences to make
amends provide relief illustrate himself to others and his feelings about the
disease or offer opportunities for atoning behavior
 aid the mourner in discovering constructive ways to make restitution and
expiate guilt
 help the mourner forgive himself
DEPENDENCY/CO-DEPENDENCY
 Overview
o When mourner is extremely dependent on the deceased, it contributes to 3
complicated mourning syndromes:
 distorted mourning of the extremely angry type
 chronic morning
 inhibited mourning
o Second, dependency is strongly associated with: other factors highly correlated
with complicated mourning specifically early prior losses depression and anger
and ambivalence at the dependency
o Third, dependency tends to result in problematic mourning because: of a number
of its inherent elements and associated aspects
o Fourth codependency appears to derive from dysfunctional family experiences
o Three perspectives on dependency and co-dependency:
 Mourner may have experienced and UNUSUALLY dependent
relationship
 27

 Characterized by (p 491)What is the place of rage here?

characterized by overreliance upon another in order to feel secure
achieve gratification and make decisions and manage in life
 Second: Deceased’s dependency on mourner: the mourner may have been
the one upon whom the deceased have been extremely dependent
 Third: dependency or codependency caused by the death:
 Treatment implications
o Treatment for dependency and co-dependency
 Specific interventions include: (bottom p 493 increasing appropriate
autonomy and independence through psychological work and appropriate
skill development
o Treatment for complicated mourning impaired by dependency or codependency
 promote recognition of the reality of the loss especially its permanence
and irreversibility
 identify the meaning of the relationship and why the mourner feels it
cannot be relinquished
 promote identification of aspects of the mourners dependency upon the
deceased expression of feelings about losing each aspect and discussion of
what needs to be done to take care of the self without the help of the
deceased
 identify and work through problems created by the loss of the dependent
relationship
 offer unqualified support in order to build trust and once an therapeutic
relationship has been established gradually shift the emphasis from
support to encouragement discouraging the tendency to claim to the role
of the mourner insisting on and reinforcing forward movement
 place particular emphasis on the last three R processes
 assist the mourner in the sub process of developing a new relationship
with the deceased
 use behavioral strategies to put limits upon chronic mourning
 work on this displacement of anger recognizing that anger at the deceased
for desertion may be particularly difficult for the morning to acknowledge
when the loved ones perceives as having been perfect
SOCIAL SUPPORT
 Overview:
o One of the most consistent findings is the salience of the mourner’s perception of
social support
o Types of social support and relationship to bereavement
 emotional support
 instrumental support
 validation support
 informational support
 support of presence
 relational support
 social activities support
 28

 Research has found what: different sources and different types of support
are useful at different times during bereavement
o Need for social support (many possibilities: exist with regard to availability of
social support
o Disenfranchised grief (VERY IMPORTANT)
 P 498 “a LACK OF social validations AND recogniton OF A LOSS
LEAVES THE PERSON MOURNING A LOSS IN A STATE OF
disenfranchised GRIEF.
 Disenfranchised grief is grief that is experienced when a loss is :
 Not or cannot be openly acknowledged,
 publicly mourned,
 Or socially supported. P 498
 Doka (the expert in this) offers that people are cast into disenfranchised
grief for a number of reasons:
 First the relationship is not recognized
 Second the loss is not recognized
 Third, the mourner is not recognized.
 Support withheld because it is too horrible (so need to defend
against it as a possibility
 Need to punish the griever
 Treatment implications
o First enfranchise the person. How? Enfranchising the mourner requires
legitimatizing his status as a mourner, helping him actualize his loss, and
conveying the importance of undertaking the R processes of mourning
o When the situation is more absent or insufficient support the worker must do
what? Identify the mourners loss as legitimate