Interpersonal psychotherapy for complicated grief - an introduction for family physicians

Kimberly KY Yip 葉健欣，Joseph PY Chung 鍾沛然

HK Pract 2022;44:69-75

Summary

Complicated grief is a condition that is commonly encountered in the primary care setting. It is often overlooked, yet it can cause significant impairments in those who are grieving. Family physicians are often the first medical professional to come across bereaving patients, and some of these patients may be suffering from complicated grieving. Family physicians can refer them for appropriate treatment.

Interpersonal psychotherapy (IPT) is one evidencebased psychological treatment of complicated grief. It is a time-limited therapy to facilitate the griever to mourn for the loss, and rebuild social support through improving communication and interpersonal effectiveness.

This report is an educational article with an aim to give family physicians a glimpse of one evidence-based psychological treatments of complicated grief.

Keywords: Interpersonal psychotherapy, IPT, complicated grief, pathological grief, grief, bereavement

摘要

Introduction

Grief is a psychological and behavioural response to bereavement, or any kind of loss.¹ It has highly variable presentations across different cultural groups. It is an almost inevitable experience for most people, and is commonly encountered in the primary care setting.

Different models

Various models have been used to describe the clinical features and course of grief. Most of these models are based on the stage theory of grief, dividing it into different stages with specific emotional and behavioural responses.

One of the first theories developed was the four phases of grief by Bowlby² and Parkes³, based on Bowlby’s attachment theory. The four phases are (i) shock and numbness, (ii) yearning and searching, (iii) disorganisation and despair, and (iv) reorganisation and recovery. Another well referred to model would be the Kubler-Ross model⁴ originally used to describe the grief faced by patients with terminal illnesses. The stages include (i) denial, (ii) anger, (iii) bargaining, (iv) depression, and (v) acceptance.

The duration of grief again varies greatly, usually from 6 to 12 months. In Maciejewski and colleagues’ study⁵ of 233 individuals who were grieving deaths caused by natural causes, the authors found the indicators of their grief, (i) disbelief, (ii) yearning, (iii) anger, (iv) depression, ending with (v) acceptance, all peaked within 6 months.

Complicated grief is characterised by a prolonged and abnormally intense grief reaction, with a prevalence of 6.7% after major bereavement.⁶ Though there are no definite diagnostic criteria for complicated grief, ICD-11 describes one condition ‘Prolonged Grief Disorder' that illustrates the features of complicated grief.⁷ To meet the diagnostic criteria, one needs to experience persistent and pervasive longing for the deceased, and/or preoccupation with the deceased, combined with 10 additional grief reactions for at least 6 months after bereavement. Similarly, DSM V has also considered persistent complex bereavement disorder as a condition for further study. Persistent complex bereavement⁸ disorder also includes key features of persistent yearning and longing for the deceased, and preoccupation with the deceased in their diagnostic criteria. The only major difference would be the duration of the disorder being at least 12 months for DSM V, compared to only 6 months in Prolonged Grief Disorder.

Treatment for complicated grief should be given promptly as it affects the person’s quality of life⁹, and has impact on both psychiatric and physical well-being. 55% of those suffering from complicated grief together with comorbid depression.¹⁰ It is also associated with increased cardiovascular accidents and elevated cancer risks.¹¹ Therefore, psychological treatment to grievers and early identification of complicated grief in the primary care setting are important in order to improve quality of life and to prevent further complications.

Current treatment for complicated grief include both pharmacological treatment with antidepressants, and any one of the psychological treatments such as the complicated-grief therapy, cognitive-behavioural therapy and interpersonal psychotherapy.

The choice of psychotherapy depends on the availability of local expertise. Whereas complicatedgrief therapy and cognitive-behavioural therapy require more training, IPT techniques are easier to learn.

The goal of IPT in grief patients is to facilitate mourning and to increase social support, thus reducing depressive symptoms. The effectiveness of IPT has been shown in randomised controlled trials.¹²

The case below illustrates the use of IPT in the treatment of complicated grief. The clinical and personal details have been changed so that not to identify the patient.

The case

Presenting problem

Mr. W was a 70-year-old retired driver and was living with a 20-years old son. He was referred to us because he had been having 12 months’ of persistent low mood precipitated by the death of his wife. His persistent depressive mood had limited response to antidepressant treatment.

His wife had committed suicide by jumping off from a height at home. He presented with a pervasive low mood and crying spells, initial insomnia, and loss of interest. He felt guilty for not being able to prevent his wife’s death. He blamed himself for not being able to provide her with a better life. He became withdrawn and stayed at home all the time. His appetite was, however, maintained. He did not have any suicidal ideation, as he felt a responsibility to take care of his son. He would keep the couple’s bed room the same and change the bed sheets for his wife regularly. Every day, he would make visits to the pier where the couple had their first few dates. However, he had not reported any psychotic symptoms.

He was diagnosed with complicated grief and mild depressive episodes. He was prescribed with Mirtazapine 30mg every night, with little improvement in sleep. His mood remained low all the time.

Previous psychiatric history:

Mr. W had previous psychiatric history before. He was diagnosed with Adjustment Disorder with depressive features when he first presented to a psychiatric clinic 10 years earlier. He suspected his wife was having an extra-marital affair which precipitated his low mood. No medication was prescribed throughout. He was only given some hypnotics to improve his sleep and his mood and sleep improved somewhat after a few months along as the couple’s relationship improved. There had been no violence or self-harm history. Mr. W had received regular follow up at the psychiatric outpatient clinic since then till present day.

History

Mr. W is locally born and raised. He received three years of formal education. He had one elder sister and three younger brothers. His mother, a housewife, left home when he was 5 years old due to marital discord. His mother later re-joined the family when Mr. W was in his teenage years for reason that was not known to him.

He had idolised his mother, whose words he considered to be very wise and were still remembered very clearly till this day. His father was a barber who remained distant to Mr. W most of the time. During his teenage years, he was often made fun of by his classmates and colleagues, for being ‘dim’. His mother and his siblings had also told him that he was the “dimmest” in the family. Mr. W worked as a private driver for almost thirty years. He married his wife when he was 50 years old. The couple met through a friend when Mr. W was visiting mainland China. His wife was 20 years younger. While Mr. W was still in China, he offered to marry his wife initially mainly to help her gain Hong Kong citizenship. The couple later fell in love and had a son together. The wife and son came to Hong Kong from China 2 years later. After the wife came to Hong Kong, she was diagnosed with depression and had been prescribed antidepressants.

Personality traits, cultural and religious factors

Mr. W believed that a loyal partner, and an unbroken family as being very important in the Chinese culture, as it signified a man’s success in fulfilling his role to form, and maintain a “complete” family. He also believed that it is solely the role of the man of the family to provide for the family. Mr. W had no religious beliefs.

Diagnosis and management

Clinical assessment was performed in the first few sessions. An introduction to the structure, goals and nature of Interpersonal Psychotherapy was given. This was followed by history taking to establish a diagnosis. The interpersonal inventory and interpersonal formulation would then follow, assessing the social network and attachment style, as well as to identify an area of focus. Goals of the therapy would be set collaboratively with the patient.

Session 1

Session 2 - 4

It became clear after discussion with Mr. W that his view on himself and others showed an avoidant attachment style. . This was contributed by the lack of a maternal figure at a young age when his mother left the home, and how he had been told since young that he was stupid, thus resulted in him avoiding contact or establishing any relationships with others. His insecurity was also evident when he had been in a relationship prior to getting married as he was afraid of being deserted by his partner.

During the third session, Mr. W was asked to fill in the interpersonal inventory: a diagram of 3 concentric circles, representing his interpersonal network ( Figure 1 ). We asked Mr. W to write down 6 - 7 names; the closest ones in the most inner circle, while the not so close ones at the outermost circle. We reminded Mr. W that names of deceased persons should not be written down, as IPT focuses on here and now, and only his current social network should be assessed. We then asked Mr. W to describe the relationship with each of these important people. It is important to ask patients to write down the names on their own, as this would allows patients to open up to the therapist, to reflect on their own relationship with significant others, and to help the therapist identify any interpersonal patterns.

    In Mr. W’s case, he had very limited social support. He put the name of his son in the innermost circle. He was only able to put down the name of his elder sister after much prompting in the middle circle. No further names were written down. We have found the establishment of an interpersonal circle to be a very useful tool in the primary care setting, for patients to open up to talk about their relationships.

   In the fourth session, the interpersonal formulation was completed. The interpersonal formulation is based on a bio-psychosocial, cultural and spiritual model, as suggested by S Stuart. (Figure 2)

   Guided by the therapist, the patient was asked to fill in factors under each category that could have contributed to his distress. It is again important for the patient to fill this in on his, or her own, after being guided by the healthcare provider, as it allows them to appreciate the many factors contributing to their current presentation, gaining an insight into their problem.

Referring back to Mr. W, psychologically, he had always felt inadequate and inferior. His low selfesteem had contributed to his depression. His perceived inferiority had also perpetuated the self-blame that he had for not being the “perfect, smart, interesting husband”, and the idea that his deceased wife should have a “deserved better” deal. This had also prevented him from reaching out to his friends and siblings, as he did not want to “bother” others. He perceived himself as “boring”, thus avoided contact with others. Cultural factors would include his value of a “complete family”. The loss of his wife had his family “broken” which he found very difficult to accept, thus leading to his depression and complicated grief. Treatment goals were set by the end of the session 4 with Mr. W, aiming to reduce his depressive symptoms, to build on his social support, and to enhance communication with his son.

The middle work phase

Common techniques used in this phase includes clarification and reconstruction of the relationship with the deceased, communication analysis, facilitating and encouraging expression emotions, and role-playing.

Session 5 - 6

Mr. W’s commitment and efforts put into the marriage were acknowledged and validated in these sessions, to remind him, and to relieve his self-blame of not doing ‘enough’. The therapist also encouraged and assisted Mr. W to express, identify and to verbalise his emotions - which he found difficult to do, possibly due to his low educational level - as he described specific incidents of their relationship.

Session 7 - 10

In sessions 9 to 10, the focus was to build his social support, mainly by working on his relationship and communication with his son. Specific techniques such as brainstorming, communication analysis, and role-play were used. The relationship between his son was clarified again using specific interpersonal incidents to establish the pattern of communication between Mr. W and his son. Specific questions such as “what did you do when your son said that”, “What did you say to him?” were asked, as well as questions about Mr. W’s emotions: “How did that make you feel?” “What was going through your mind then?’ ‘What did you expect him to do, or say?’ The therapist brainstormed with Mr. W different ways to express his love towards, and to start conversations with his 20-year-old son. Communication analysis was performed to identify any ambiguous, indirect, or lack of communication with his son, for example, assuming that his son knows what was on his mind, thus never verbally expressing any of his thoughts or ideas to his son. His belief that traditional Chinese men did not have to be affectionate or expressive, contributed to the lack of communication with his son, and this was discussed during therapy.

Role-play was then used to assist Mr. W to develop new perspectives on his communication style with his son, in order to understand his communication pattern. It is important here to have the patient play the significant other first as it helps them to see from another perspective.

Concluding sessions

Discussion

The framework of IPT in complicated grief includes: (1) obtain a psychiatric history, conduct an interpersonal inventory and interpersonal formulation in the initial 2 - 3 sessions, (2) facilitate mourning and rebuild social support in the middle phase, and (3) review gains in treatment, manage separation anxiety and educate on symptoms of relapse in the concluding few sessions. Common IPT techniques in the middle phase includes clarification, facilitate expression of emotions, communication analysis, role play and decision analysis.

Although conducting a 12-session psychological treatment in the primary care setting may be difficult, many of the techniques in IPT, include facilitating the expression of emotions, building social support, can easily be applied by the family physician in his/her routine clinical setting.

Conclusion

References