Sorg nye perspektiver p

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Sorgnye perspektiver på livet med dødenThe
Dual Process Model Margaret Stroebe Henk
SchutDepartment of Clinical Health
PsychologyUtrecht UniversityThe
NetherlandsInvited Address to the Danish
Association of Palliative CareJune 1st, 2007
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Scope

• Differences in ways of coping adaptation
• Models of coping

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Differences in ways of coping adaptation
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Coping with GriefAssumption (Western Societies)
(cf. Wortman Silver, 1987 1989)

• Necessary to confront
• Grief Work

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Grief Work(M. Stroebe, Omega, 1992)

• Process of
• emotionally confronting the reality
• going over events
• focusing on memories
• working toward detachment
• Grief work hypothesis

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Coping with GriefAssumption (Western Societies)
(cf. Wortman Silver, 1987 1989)

• Necessary to confront
• Grief Work
• In C20th grief theories therapies

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Doubts about Grief Work

• Alternative ways of effective coping
• Cultural patterning

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Coping with Bereavement in Non-Western
CulturesEgypt

• In Egypt the bereaved are encouraged to dwell
  profusely on their subjective pain in an
  atmosphere where others also immerse themselves
  in tragic tales and expressed sorrow.
• (Wikan, 1988, p. 455)

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Coping with Bereavement in Non-Western
CulturesBali

• In Bali laughter and cheerfulness fill the air
  while the bereaved are enjoined to contain their
  sorrow and may be made to feel they commit an
  injustice to others should they fail to abide by
  this demand.
• (Wikan, 1988, p. 455)

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Doubts about Grief Work

• Alternative ways of effective coping
  (non-confrontive)
• Neglect of effortful struggle

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Doubts about Grief Work

• Alternative ways of effective coping
  (non-confrontive)
• Neglect of effortful struggle
• Need for dosage of grief

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Doubts about Grief Work

• Alternative ways of effective coping
  (non-confrontive)
• Neglect of effortful struggle
• Need for dosage of grief
• Benefits of denial

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Doubts about Grief Work

• Alternative ways of effective coping
  (non-confrontive)
• Neglect of effortful struggle
• Need for dosage of grief
• Benefits of denial
• Other sources of stress

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Doubts about Grief Work

• Alternative ways of effective coping
  (non-confrontive)
• Neglect of effortful struggle
• Need for dosage of grief
• Benefits of denial
• Other sources of stress
• Lack of empirical evidence

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1. Expression of Emotions Well-being among
Bereaved Persons(Schut, 1992, Stroebe, Schut
Stroebe, 2005)

• Longitudinal study, 128 recently-bereaved
• 4 assessments, 2 years
• Emotional disclosure adjustment

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Path model of expression of emotions and
distress (Schut, 1992, Stroebe, Schut Stroebe,
2005)
Expression of emotions T1
Expression of emotions T2
Expression of emotions T3
Expression of emotions T4
Distress T2
Distress T3
Distress T4
Distress T1
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Structural path-analysis of expression of
emotions and distress (Schut, 1992, Stroebe,
Schut Stroebe, 2005)
.45
Expression of emotions T1
Expression of emotions T2
.61
Expression of emotions T3
Expression of emotions T4
.42
.63
Distress T2
Distress T3
Distress T4
Distress T1
.64
.63
.41
.31
.17
Note plt.05, plt.01, plt.001
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2. Grief Work Through Diary Writing The
Pennebaker Paradigme.g. Pennebaker Keough,
1999 Pennebaker et al., 2001)
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Pennebakers writing paradigm Effects

• Reduces physician consultations
• Improves some immune functions
• Increases grades among students
• Improves mood
• Effective among unemployed, prisoners,
  chronically-ill patients, etc.
• Bereaved persons???

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The Utrecht Diary Study (cf. Stroebe, Stroebe,
Schut, Zech, van den Bout, JCCP, 2002)

• 157 recently bereaved men women
• Writing non-writing conditions
• Assessed mental physical health (inc. visits to
  doctor)

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• Results
• Symptoms decrease over time, but
• No effect of writing on
• Emotional intensity
• Health (subjective or objective)

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Conclusions so far

• The grief work model needs revision to
• define when and for whom - and what type of
  working through / disclosure is efficacious

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• Models of coping

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Grief Work Models

• Phase Model
• (Bowlby, 1980)
• Shock
• Yearning/protest
• Despair
• Restitution

• Task Model
• (Worden, 1991)
• Accept reality of loss
• Experience pain of grief
• Adjust to life without deceased
• Relocate deceased emotionally move on

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Dual Process Model of Coping with Bereavement
(Stroebe Schut, Death Studies, 1999)

• A taxonomy to describe ways people come to terms
  with the loss of a close person
• Two categories of stressors
• Analysis of coping strategies appraisal
• Dynamic process of oscillation

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The Dual Process Model of Coping with
Bereavement Stroebe Schut (Death Studies, 1999)
Everyday life experience
Loss- oriented
Restoration- oriented
Attending to life changes Doing new
things Distraction from grief Denial/avoidance
of grief New roles/ identities/
relationships
Grief work Intrusion of grief letting
go-continuing-relocating bonds /
ties Denial/avoidance of restoration changes
oscillation
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Caregiving Bereavement AdaptationSchulz,
Boerner, Herbert (in Stroebe et al., Handbook
of Bereavement Research 21st Century
Perspectives, in press)

• Caregivers at high risk
• Most adapt well to bereavement
• But a few have adverse bereavement outcomes

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Comparison of Models

• Task Model
• (Worden, 1991)
• Accept reality of loss
• Experience pain of grief
• Adjust to life without deceased
• Relocate deceased emotionally move on

DPM (Stroebe Schut, 1999) Accept reality of
loss and accept reality of changed
world. Experience pain of grief and take time
off from pain of grief. Adjust to life without
deceased and master the changed (subjective)
environment. Relocate deceased emotionally
move on and develop new roles, identities,
relationships.

• Phase Model
• (Bowlby, 1980)
• Shock
• Yearning/protest
• Despair
• Restitution

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Complicated Grief

• Deviation in time course and/or intensity from
  the (cultural) norm, poor functioning
• Chronic absent, delayed, inhibited
• Prevalence rates
• Related to other mental health difficulties
• DSM??? (see Special Issue Omega, 2005, ed. Parkes)

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DPM Complicated Grief
Everyday life experience
Loss- oriented
Restoration- oriented
Attending to life changes Doing new
things Distraction from grief Denial/avoidance
of grief New roles/ identities/
relationships
Grief work Intrusion of grief breaking-continuing-
relocating bonds / ties Denial/avoidance of
restoration changes
Disturbed oscillation Traumatic grief
Absent or inhibited grief
Chronic grief
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DPM Gender Differences
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Gender Differences in the DPM
Everyday life experience
Women
Men
Loss- oriented
Restoration- oriented
Attending to life changes Doing new
things Distraction from grief Denial/avoidance
of grief New roles/ identities/
relationships
Grief work Intrusion of grief Breaking bonds/
ties/relocation Denial/avoidance of
restoration changes
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DPM Time
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DPM Time
Everyday life experience
Restoration- orientation
Loss- orientation
oscillation
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DPM Time
Everyday life experience
Restoration- orientation
Loss- orientation
oscillation
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DPM Time
Everyday life experience
Restoration- orientation
Loss- orientation
oscillation
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DPM Time
Everyday life experience
Have I forgot, my Only Love, to love
thee, Severed at last by Times all-wearing
wave? Emily Brönte
Loss- orientation
Restoration- orientation
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DPM Family Grief
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DPM Family Dynamics
?
Restoraiton- orientation
Loss- orientation
Loss- orientation
Restoration- orientation
Restoration- orientation
Loss- orientation
Restoration- orientation
Loss- orientation
?
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DPM Family Dynamics
Restoraiton- orientation
Loss- orientation
Restoration- orientation
Loss- orientation
Restoration- orientation
Loss- orientation
?
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DPM Family Dynamics
Restoration- orientation
Loss- orientation
Brother
Children
Wife
Restoration- orientation
Loss- orientation
Restoration- orientation
Loss- orientation
Grandchildren
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DPM Evidence

1. Gender differences in loss / restoration in
   bereaved couples
2. Gender differences in intervention efficacy
3. Intervention efficacy DPM vs. Traditional

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DPM Evidence

1. Gender differences in loss / restoration in
   bereaved couples
2. Gender differences in intervention efficacy
3. Intervention efficacy DPM vs. Traditional

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Parental Loss of a Child Study(Wijngaards,
Stroebe, Stroebe, Schut, van den Bout, van der
Heijden, Dijkstra (British Journal of Clinical
Psychology, in press)

• Participants Design
• 219 parental couples
• 6, 13, 20 months post-loss
• Interviews / questionnaires
• Own and partners coping (DPM) adjustment

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Parental Loss of a Child Study(Wijngaards,
Stroebe, Stroebe, Schut, van den Bout, van der
Heijden, Dijkstra (British Journal of Clinical
Psychology, in press)

• Results
• Hi LO -gt poor adjustment
• Hi RO -gt better
• Hi RO buffered against impact of hi LO
• For men, having hi RO partner helped adjustment

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DPM Evidence

1. Gender differences in loss / restoration in
   bereaved couples
2. Gender differences in intervention efficacy
3. Intervention efficacy DPM vs. Traditional

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Evaluation Of Grief Counseling Utrecht Study
(Schut, Stroebe, de Keijser van den Bout, 1997)

• Participants
• Widows widowers
• Medium / high distress
• Non-intervention controls
• Counseling
• Client centered vs. behavior therapy
• 7 sessions, 14-17 months post-loss
• Measure
• General Health Questionnaire (GHQ)

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Behav. Treatment
Client centered
Schut, Stroebe, avan den Bout de Keijser (1997)
British Journal of Clinical Psychology
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Levels of Distress by Therapy Type Males(Schut,
Stroebe, de Keijser, van den Bout, BJCP, 1997)
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Levels of Distress by Therapy Type
Females(Schut, Stroebe, de Keijser, van den
Bout, BJCP, 1997)
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DPM Evidence

1. Gender differences in loss / restoration in
   bereaved couples
2. Gender differences in intervention efficacy
3. Intervention efficacy DPM vs. Traditional

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DPM Treatment of Complicated Grief(Shear,
Frank, Houck, Reynolds, JAMA, 2005)

• Participants
• Bereaved men women meeting CG criteria
• Interventions
• Interpersonal psychotherapy (IPT)
• Complicated grief treatment (CGT, based on DPM)

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Treatment of Complicated Grief Study(Shear,
Frank, Houck, Reynolds, JAMA, 2005)
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Small Group Discussion Themes

• To what extent have you used the Phase, Task or
  DPM Models in your work? What is your experience
  with these Models?
• More fundamentally Can one translate the DPM
  for use in palliative health care settings?
• What are the limitations of the DPM?
• Suggestions for adapting or extending the DPM?