guided mourning for morbid grief: a controlled replication

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BEHAVIOR THERAPY 19, 121-132, 1988 Guided Mourning for Morbid Grief: A Controlled Replication LESTER SIRELING St. George's Hospital, London DARYL COHEN Lady Chichester Hospital East-Sussex ISAAC MARKS Institute of Psychiatry and Maudsley Hospital, London Twenty-six patients with morbid grief were randomly assigned to 6 sessions over 10 weeks of either guided mourning (n = 14) or antiexposure (n = 12) with corre- sponding between-session homework; all cases were also supported and encouraged to engage in new activities. Patients did not improve while on a two-week waiting list. Eleven patients completed guided mourning and nine completed anti-exposure; six further patients dropped out prematurely, three from each of the two treatments. After therapy, both groups improved up to 9 months follow-up, but avoidance and distress to bereavement cues had improved more in guided mourning than in antiexposure cases. On other measures, guided mourning yielded only marginally more benefit, gains in these areas being partly independent of reduced avoidance of bereavement cues. Results agreed with those of a previous controlled study. The idea that "work" is needed to resolve grief dates back at least to Freud (1917). The nature and optimal timing of this work are not well defined, though one aspect of grief is avoidance of distressing affect, thoughts, and external cues not relating to the bereavement. Also poorly defined is the point at which this is pathological and requires help. In a series of 23 cases Ramsay (1975, 1979) used an exposure treatment, which reduces phobic avoidance, to decrease distress from and avoidance of bereavement cues in morbid grief. Exposure was given at varying intervals up to 30 years after bereavement. Amongst "high Dr. Cohen was supported by a grant from the Medical Research Council. We are grateful for the time and expertise of Dr. Stuart Lieberman and Dr. Raja Ghosh who acted as blind assessors, and to John Huson for assisting with data analysis. Valuable comments on the manuscript were made by Dr. Janel Gauthier. Requests for reprints should be sent to Isaac Marks, MD, FRC Psych Section of Experimental Psychopathology, Institute of Psychiatry and Maudsley Hospital, London SE58AF, England. 121 0005-7894/88/0121-013251.00/0 Copyright 1988 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.

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Page 1: Guided mourning for morbid grief: A controlled replication

BEHAVIOR THERAPY 19, 121-132, 1988

Guided Mourning for Morbid Grief: A Controlled Replication

LESTER SIRELING

St. George's Hospital, London

DARYL COHEN

Lady Chichester Hospital East-Sussex

ISAAC MARKS

Institute of Psychiatry and Maudsley Hospital, London

Twenty-six patients with morbid grief were randomly assigned to 6 sessions over 10 weeks of either guided mourning (n = 14) or antiexposure (n = 12) with corre- sponding between-session homework; all cases were also supported and encouraged to engage in new activities. Patients did not improve while on a two-week waiting list. Eleven patients completed guided mourning and nine completed anti-exposure; six further patients dropped out prematurely, three from each of the two treatments. After therapy, both groups improved up to 9 months follow-up, but avoidance and distress to bereavement cues had improved more in guided mourning than in antiexposure cases. On other measures, guided mourning yielded only marginally more benefit, gains in these areas being partly independent of reduced avoidance of bereavement cues. Results agreed with those of a previous controlled study.

The idea that "work" is needed to resolve grief dates back at least to Freud (1917). The nature and optimal timing of this work are not well defined, though one aspect of grief is avoidance of distressing affect, thoughts, and external cues not relating to the bereavement. Also poorly defined is the point at which this is pathological and requires help. In a series of 23 cases Ramsay (1975, 1979) used an exposure treatment, which reduces phobic avoidance, to decrease distress from and avoidance of bereavement cues in morbid grief. Exposure was given at varying intervals up to 30 years after bereavement. Amongst "high

Dr. Cohen was supported by a grant from the Medical Research Council. We are grateful for the time and expertise of Dr. Stuart Lieberman and Dr. Raja Ghosh who acted as blind assessors, and to John Huson for assisting with data analysis. Valuable comments on the manuscript were made by Dr. Janel Gauthier. Requests for reprints should be sent to Isaac Marks, MD, FRC Psych Section of Experimental Psychopathology, Institute of Psychiatry and Maudsley Hospital, London SE58AF, England.

121 0005-7894/88/0121-013251.00/0 Copyright 1988 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

Page 2: Guided mourning for morbid grief: A controlled replication

122 SIRELING, COHEN, AND MARKS

risk" widows, preventive intervention along similar lines in the first few months after bereavement reduced their subsequent morbidity compared with nonin- tervention widows to the level found in "low-risk" widows (Raphael, 1977). Of 19 cases with grief lasting more than a year, 16 were helped by a similar exposure approach (Lieberman, 1978).

The only controlled study of the exposure approach in morbid grief was reported by Mawson et al. (1981). Twelve patients were randomized to have either exposure (guided mourning) or antiexposure (instructions to avoid con- tact with distressing situations relating to their bereavement), each approach being given in six 1-1 ½-hour sessions over 2 weeks. One month after treat- ment exposure cases showed less avoidance of bereavement cues and also did better on the Texas Inventory of Grief (TIG); however, the two groups had similar outcomes on other measures and superiority on the TIG did not per- sist at 2 months.

The present study tried to replicate that of Mawson et al. In both studies the major contrast between the 2 groups was instruction of one group to con- front, and of the other to avoid, distressing and avoided bereavement cues. However, we modified the design in some major ways: 1) Instead of six ses- sions over 2 weeks, the present study had 10 sessions over 14 w e e k s - a treat- ment schedule which could be given in outpatients or in general practice. 2) Both our exposure and antiexposure groups had more systematic advice, sup- port, and help concerning relationships, work, and leisure activities. 3) To the avoided bereavement cues used in the earlier study, we added affective and cognitive cues such as anger, guilt, and painful memories and ruminations. 4) To self-assessments we added a blind assessor and a broader range of measures. 5) Follow-up was to 9 rather than 5 months posttreatment. 6) Cue cards were used to monitor and rate homework together with ratings of com- pliance between and within sessions.

METHOD The study was carried out in 2 hospitals in L o n d o n - S t . George's (12 pa-

tients) and the Maudsley (8 patients). Within each hospital the 26 patients were randomized to receive either exposure (n = 14) or antiexposure (n = 12), stratifying with a minimization technique (Taves, 1974) for sex, age (35 + or 34 - ) , and whether the problem had begun less than or more than 6 months after bereavement. One case was treated as an inpatient, the remainder as out- patients. After initial assessment, patients had a baseline period of 2 weeks before starting 3 months of treatment. Patients were assessed at the end of treatment and 1, 3 and 9 months later. Separate ratings were made by patients and by an independent psychiatrist at each center, who were blind to the treat- ment condition.

Sample Inclusion criteria were: age between 16 and 70, presence of morbid grief

(the most prominent symptoms had to relate in time and content to the loss

Page 3: Guided mourning for morbid grief: A controlled replication

MORBID GRIEF 123

of a significant other, having started after it and persisted longer than a year); avoidance of people, objects, places, or conversations concerning the deceased, or of saying a final goodbye to her/him (accepting that s/he would never re- turn to be communicated with as before); no evidence of psychosis.

Patients were referred by psychiatrists or general practitioners. Of the 26 cases who began treatment, six dropped o u t - t h r e e during guided mourning and three during antiexposure, leaving 20 who completed treatment (11 with guided mourning, 9 with antiexposure). Dropouts were excluded from the anal- ysis. In ll cases the problems began within 6 months of bereavement, in 8 cases between 6 months and 5 years, and in 1 case 20 years later. In 16 cases symptoms were clearly grief-related, e.g., depression, anxiety and irritability, half of them (n -- 8) becoming a problem within 6 months of bereavement. Four cases had symptoms additional to grief that were less obviously grief- r e l a t e d - one had agoraphobia exacerbated by the bereavement, one had obsessive-compulsive disorder, one had a cancer phobia, and one had psy- chogenic trismus. The bereavement among the 20 completers was of s p o u s e - six, parents-f ive, s ibl ings-four , ch i ldren-four , (data on this was missing for one patient). Loss among the dropouts was of a similar range of relatives.

Treatments After the week 0 ratings were completed, patients were randomized to re-

ceive either guided mourning or antiexposure. Both treatments involved 10 weekly l - l ½ hour sessions, with a four-week interval between sessions 9 and 10. Both treatments included a systematic program of support and education, and had similar session lengths.

Guided Mourning: Patients were encouraged to expose themselves repeat- edly to avoided cognitive, affective and behavioral cues concerning bereave- ment, e.g., writing a letter to the deceased and reading it aloud at the grave- site; encouraging the ventilation of negative feelings; facing avoided and/or distressing situations, objects, or people reminding them of the deceased such as cemeteries and relevant photographs, books and relatives.

Antiexposure: The approach taken with the bereaved by many medical and lay persons was formalized for evaluation by encouraging patients to get on with living, not to think about the 10ss, to avoid anything painful connected with the loss, and to think about the future rather than dwell on the past.

In each session all patients were given appropriate homework tasks to be reviewed in the next session, and were also given cue cards on which were written five instructions encouraging, according to patients' assigned treatment, ei- ther exposure or avoidance. Patients were asked to read these cards three times on encountering bereavement cues, e.g., if they happened to think about the deceased or did something that brought back the memory. They had to record on the cue card each time they used it. An example of each treatment illus- trates the techniques u s e d - b o t h cases did well:

Guided Mourning: A woman of 23 (Ann) became depressed and irritable 9 months after her mother died from cancer. Within a further 6 months she developed frequent panics, attempted suicide, and lost her job. Tricyclic an-

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124 SIRELING, COHEN, AND MARKS

tidepressives and benzodiazepines failed to help. She had spontaneous panics whilst others were cued by looking at a photo of her mother, or by memories of shared activities. She avoided her mother's photo, contact with mother's books, bedroom, and relatives, memories related to the death and cremation, and hospitals in general.

Ann and her mother had been very close. Mother's terminal cancer became manifest 4 months before Ann was married, but was concealed from Ann prior to the wedding, which mother was too ill to attend. The next day Ann learned that her mother might die within a week and visited her in hospital. On her mother's insistence Ann went on a five-day honeymoon. On the 5th day Ann was informed by phone of her mother's death the previous night. She showed no grief for 9 months, and then became apathetic, depressed, irritable with her husband, slept and ate poorly, and during panics thought she would die.

At assessment she was tearful, very tense, guilty at not having done enough for her mother, frightened by recurrent images of mother lying eyeless in the coffin (the eyes having been donated), and often felt mother's presence and talked to her during the panics.

The therapist first explained the features of healthy grief and why Ann's was unhealthy, and reviewed events prior to mother's death. Areas of avoid- ance were noted (the bereavement avoidance profi le)- cognitive (e.g., avoiding thoughts that she should have done more for mother), affective (e.g., blocking resentment that her mother should have confided in her that she was dying), and behavioral (e.g., mother's photo, books, and relatives). At the end of the 1st session Ann was asked to confront some of these avoided cues during the next week. Subsequent sessions began by reviewing the exposure homework, exploring difficulties in carrying it out, and planning the next week's home- work. New activities and relationships were encouraged. In one session Ann was invited to imagine herself seated in an empty chair and to cross-question herself about whether she had realized her mother was dying. In a later ses- sion Ann was asked to relate in the present tense the avoided memory of her final visit to mother, to identify how she would have wished it to be different, and then to describe the revised scene in the present tense (Melges & Demaso, 1980).

Guided mourning tasks were prescribed both within sessions and between sessions as homework. They included facing hitherto avoided situations, e.g., 1) visiting the crematorium to look at smoke emerging from the chimney; 2) asking her grandmother to describe the body's appearance in the hospital chapel; 3) talking about mother's final illness; 4) bringing mother's photo- graph to several sessions and looking at it for prolonged periods; 5) listing mother's positive and negative attributes (to elicit avoided anger with her); 6) writing a letter to mother complaining at not being told the diagnosis, and reading this aloud to mother's photograph; 7) spending fixed periods in mother's bedroom; 8) wearing shoes and jewelry given by her mother.

By the end of treatment the patient had carried out all prescribed home- work tasks plus others of her own devising, e.g., sitting for 20 minutes in her mother's favorite chair. She was pursuing a new career, getting on well with her husband, and was not depressed or panicky.

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MORBID GRIEF 125

Antiexposure: A woman of 69 visited her GP regularly for 3 years after her mother died. A year after her last visit her husband died too, while away from home. She became severely anxious and took an antidepressant and a minor tranquillizer. A year after her husband's death she had tremor, palpita- tions, churning abdomen, insomnia, and guilty ruminations. She thought she heard him cough or bringing her morning tea, avoided baking pastry (her hus- band's favorite food), kept his spectacles and other belongings, and repeat- edly checked that the clock which had stopped the night he died was ticking. Anxiety worsened on the 7th and 17th of each month - her husband's birthday and date of death respectively. She and her husband had been very close. They had courted from age 14. She never made friends, rarely went out, and had never worked outside the home.

Treatment began with an explanation of normal grief and that she had grieved for long enough. It was now time to put that behind her, to think about the future and not the past, and to engage in new activities. She was encour- aged to join a coach tour and to build new relationships. She was discouraged from discussing her husband's death. When she avoided bereavement cues this avoidance was encouraged to prevent distress. In sessions, avoidance home- work was reviewed and the past week's activities were discussed.

Homework set for the ensuing weeks included: 1) avoid displaying the calendar dates of the 7th and 17th of the month or her wedding anniversary; 2) when radio tunes which reminded her of her engagement came on and dis- tressed her, she was advised to turn them off, to read her antiexposure card, and then to polish her silver; 3) when she was invited to appear on a TV pro- gram on bereavement she was advised to refuse lest it upset her; 4) when packing for a coach tour painful memories were evoked, so she was advised to ask her son to pack for her. She found her antiexposure cue card helpful at times of distress, e.g., when she couldn't sleep, before and after advancing her calendar 2 days to skip painful dates, before visiting her neighbor, or on hearing on the radio the name of the church where she had married.

By the end of treatment she slept well with little anxiety but continued to use her cue card at times. She looked forward to a holiday, played football with her grandsons, and had several new male acquaintances.

M e a s u res

Self-rated: At weeks 0, 2, 14, 28, 54 (except for H and K - see below), given after the assessor rating, before each therapy session.

A. The Wakefield Depression Inventory (Snaith et al., 1971), with three ad- ditional items used by Marks et al. (1980).

B. Physical Symptoms (Mawson et al., 1981): 13 items. Additional common symptoms (Madison and Viola, 1968; Parkes, 1972) were also included: trembling; general aching; skin rashes; marked increases in smoking or alcohol consumption (each "a third more than you used to . . .").

C. Fear Questionnaire (FQ) (Marks and Mathews, 1979): 15 phobias, 5 anxiety-depression items.

D. Anxiety and Social Adjustments: five items: anxiety, work, leisure, rela-

Page 6: Guided mourning for morbid grief: A controlled replication

126 S|RELING, COHEN, AND MARKS

tionships with family, relationships with friends or neighbors (Marks et al., 1986).

E. Attitudes: Two concepts, MYSELF and THE DECEASED (by first name), were rated on bipolar semantic-differential scales as good-bad and unpleasant-pleasant (= EVALUATIVE factor); MYSELF was also rated on angry-calm and placid-irritable (= ANGER factor). The DE- CEASED was also rated for easy to think about-upsetting to think about (= DISTRESS IN THINKING).

E Hostility-anger-guilt ( H A G - M a w s o n et al., 1981): seven questions. G. Texas Inventory of Grief (Faschingbauer et al., 1977): seven items con-

cerning common symptoms of normal grief. H. Bereavement Avoidance Tasks: five tasks to carry out at home and rate

(1) whether performed, and if so, (2) amount of distress experienced while doing so (0 = none, 8 = maximum). Each task involved some aspect of the bereavement, e.g., writing a short letter to the deceased; writing down and then thinking about the deceased's good or bad qual- ities; looking at a photograph of the deceased; throwing away a posses- sion of the deceased. Each task should take 2 minutes. All patients had identical instructions, and were told that the test was not therapeutic and not to persist if a task was too distressing: "If you cannot carry out any task, don't worry; just tick the "no" box on the sheet" (rated as maximally distressing). Rated at weeks 0, 18, 28, and 54.

I. Grief activity and avoidance (Lieberman, oral communication): four i t ems- how often do you think about or talk about your dead relative; how often do you visit the grave; how often do you cry over your dead relative; how often do you cry for no apparent reason (0 = less than once a month, 4 = several times a day).

J. Beck Depression Inventory (BDI): (Beck et al., 1974): 21 items. Rated at weeks 2, 18, 28, and 54.

Assessor-rated: At weeks 2, 18, 28, and 54.

A. Hamilton Depression Questionnaire, 17-item (Hamilton, 1969). B. Anxiety and Social Adjustment. Five items, as for D above. C. Global severity of illness. Seven-point scale. D. Global improvement (after week 2). Seven-point scale.

Medication Psychotropic medication was discontinued prior to starting treatment ex-

cept in four cases who had been on antidepressant medication for more than three months prior to screening for the trial, and in whom the drug had seemed useful; 6 patients continued to take up to l0 rags daily of diazepam or its equivalent during the treatment phase.

R ES U LTS For all measures the lowest score indicates absence of pathology. Analyses

Page 7: Guided mourning for morbid grief: A controlled replication

MORBID GRIEF 127

KEY s e v e r i t y

p : * . 05 , ** . 01 , *** .001

p: f r o m w e e k 2 a n t i - -

e x p o s u r e

0

g u i d e d p: f r o m w e e k 2 m o u r n i n g

I t O ~ . . t 18 28 5 4

2 14 w e e k s

B e r e o v e m e n t A v o i d a n c e Tes t s P e r f o r m G n c e

5 - -

T e x a s I n v e n t o r y o f Gr ie f 2 8 - -

14-

\

I I 0 t, == t~ . . t 5 4

B e r e o v e m e n t A v o i d e n c e T e s t s D i s t r e s s

40 -

(between - - g r o u p )

* ~* 0 I

0 ~.~...t 5 4

Crying over deceosed

4---

2

I I 0 ~ . . t 5 4

FIc. 1. Significant changes in ratings of grief.

0 1 I 0 t . = t ~ . . t 5 4

( .59) P h y s i c a l S y m p t o m s

15 - - ~ .

O 1 I 0 t , ~ , t ~ . . t 5 4

of variance (ANOVAs) and two-tailed t tests were carried out using the Gen- stat program. Some variables were rated at week 14, others at week 18; they were not combined for analysis. For convenience both are regarded as post- treatment scores and designated week 14/18.

Pretreatment This analysis refers to completers (ll with guided mourning, 9 with antiex-

posure). On demographic variables the guided mourning (G, n = 11) and anti- exposure (A, n = 9) groups did not differ on age ( m e a n - G 39 years, A 45), male:female ratio (G 3:8, A 3:6), number married (G 4, A 3), social class (class

Page 8: Guided mourning for morbid grief: A controlled replication

128 SIRELING, COHEN, AND MARKS

s e v e r i t y KEY

p : * . 0 5 , * * . 0 1 , * * * . 001

p: f r o m w e e k 2 a n t i - -

e x p o s u r e

g u i d e d p: f r o m w e e k 2 m o u r n i n g

I [ Ot/~llOtm..l 18 2 8 5 4

2 14 w e e k s

B e c k

2 0

1 Q

0

1 5

0

(4.'

2 0

I I 0 0 v'N~'"t 5 4

H a m i l t o n

%

I I Ot~*tmont 5 4

W a k e f i e l d 0

I I 0 t ~ t m e n t 5 4"

C r y i n g f o r n o r e a s o n 4 - -

0 I I 0 t , . , ,~ ,~ t 5 4

FIG. 2. Significant changes in ratings o f affect.

(8

4

A n x i e t y _ A s s e s s o r )

\

I I O~=t~°m 5 4

1 + 2 - G 2, A 2; class 3 - G 7, A 5; class 4 + 5 - G 2, A 2), work status (working- G 5, A 5; good/fair record - G 7, A 7), abnormal premorbid person- ality (G 2, A 2), or death of deceased being unexpected or sudden (G 4, A 7). Guided mourning patients had had more past psychiatric treatment (G 0 v A 5) (p < .05).

At week 2 when G and A began treatment, they did not differ significantly on any clinical measure except that G were crying more frequently (p < .05).

After Treatment and at Follow-up Two Groups Combined: Overall Change. Of the 29 variables the occasion

Page 9: Guided mourning for morbid grief: A controlled replication

M O R B I D GRIEF 1 2 9

s e v e r i t y

0

(81

4

(8

KEY

(61 p : * .05 , * * . 0 1 , * * * .001

p: f r o m w e e k 2 a n t i - - .3

e x p o s u r e

g u i d e d p: f r o m w e e k 2 m o u r n i n g

I I 0 O t , ~ , . t 18 28 5 4

2 14 w e e k s

Work ( s e l f - - r a t e d )

I I

(8

4 -

0

G lgba l SeveEi ty k~ssessor)

\ \

~\\~\~~*-*- - * t _ - _ __**

* * * * * *

I I

(8

0 t n l o t m e n t 5 4

Work ( A s s e s s o r )

\

\ *

[ L 0 ~.~..t 5 4 0 ,~,~--, 5 4

F r i e n d s L e i s u r e ( s e l f - - r a t e d ) ( A s s e s s o r )

4

0

FIG. 3.

l I

4

\\

i I 0 t...~..t 5 4 0 t..~..., 5 4

Significant changes in global and social adjustment ratings.

effect of the ANOVA was significant in 18, and showed a trend in 3. t tests showed significant improvements from week 2 (pretreatment) as follows:

to week 14/18 (posttreatment) on 11 variables, with trends on 2 more; to week 28 on 13 variables, with a trend on one more; to week 54 on 13 variables, with trends on 4 more.

Two Groups Compared. On the ANOVA occasion x treatment interaction, guided mourning was significantly superior on only one variable- performance on the bereavement avoidance task (p < .05), with supporting trends (p < .1) on 7 variables-evaluative attitude to MYSELF, physical symptoms (total), relationships with family and friends (both self-rated) and with friends (asses- sor-rated) and leisure and total phobic avoidance (FQ) (both self-rated).

Page 10: Guided mourning for morbid grief: A controlled replication

130 SIRELING, COHEN, AND MARKS

Within Group Analyses. On t tests the number of variables showing signifi- cant improvement were:

week 2-14/18: guided mourning: 11; antiexposure: 4 " 2-28: " 12; " 9 " 2-54: " 10; " 4

From week 2 onwards guided mourning but not antiexposure improved significantly on various occasions on the bereavement avoidance task (perfor- mance and distress), on two other direct measures of grief, "crying over the deceased" and "physical symptoms of grief" (Fig. 1), on "crying for no reason" (Fig. 2), and on friends (Fig. 3).

Both treatments improved significantly on various occasions on the Texas Inventory of Grief, global severity, work and leisure (Figs. 1-3).

Overall, antiexposure yielded fewer significant changes, with some measures tending to be worse at week 54 than at week 28.

Neither group had any variable worsening significantly on any occasion. Therapist-Effect: This was not significant (ANOVA). Compliance Ratings: There was no significant difference (t tests) between

the two treatment groups on with- and between-session ratings, nor on fre- quency of cue card use.

DISCUSSION This study confirms a previous finding (Mawson et al., 1981) that in pa-

tients with morbid grief persisting more than a year, guided mourning led to more improvement than did antiexposure on performance of bereavement avoidance tasks. However, on most other measures both groups improved without significant superiority of guided mourning. On within-group anal- yses improvement from pretreatment to nine-month follow-up occurred in more variables (10) with guided mourning than with antiexposure (4). This superi- ority must be interpreted with caution, as numbers in our study were small due to difficulty in recruiting enough cases. Also, avoiders were identified from the patient's history; some may have been only weakly avoiding, and so less in need of confrontation than of guidance or "permission" from the therapist to get on with living (Gauthier, 1984). In future work it may be worth treating a subgroup of strong avoiders and measuring change with a behavioral avoid- ance test given by an experimenter.

Uncontrolled reports (Siggins, 1966; Ramsay, 1978; Lieberman, 1978) spec- ulate that in the longer term guided mourning patients would do b e t t e r - our results do not allow testing of this. It is worth repeating the study in subjects with acute grief, confining it to cases at high risk for morbidity; Raphael (1977) found more benefit in "high-risk" widows from an active treatment including encouragement of exposure ("ventilation") than from doing nothing.

We do not know whether a nonintervention group would have improved to the same extent as our exposure and antiexposure groups. The potential therapeutic ingredients common to both groups included contact with a ther- apist, detailed discussion of the bereavement at the point of initial assessment, active support and encouragement to engage in new activities, and being in

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MORBID GRIEF 131

a study they knew would continue with repeated measurement to nine-month follow-up.

There is evidence that some of our antiexposure cases may have improved partly as a result of exposure to bereavement cues regardless of our instruc- tions. Several patients cried whilst being questioned about their bereavement in the initial screening interview, when a 62-item questionnaire was completed, and in one case continued to cry for days afterward. Both treatment groups improved somewhat (though not significantly) over the two-week pretreatment waiting period, more than over the same period in the Mawson et al. (1981) study, which used a much more limited initial questionnaire. The therapist's initial readiness to ask about the bereavement and to tolerate the distress en- tailed could have tacitly encouraged exposure even in the face of antiexposure instructions. An antiexposure patient came one day to say that given what his therapist "had been telling him" he would spend a few days on the beach of the island where his wife and daughter had drowned before his eyes - "The only way now is for me to go to that beach and sit there." He did this, was much distressed, and then recovered. On the other hand, against the possi- bility that antiexposure patients did well due to their exposure is their inferior outcome on performance of bereavement avoidance tasks. It is possible that patients concealed doing exposure against the therapist's advice.

Gauthier and Marshall (1977) and Gauthier (1984) suggest that after bereave- ment social rewards gradually shift from being given for grieving to being awarded for new activities and recovery. Our study rewarded both groups for new activities more than Mawson et al.'s did, which may explain why our cases improved rather more in work and leisure adjustment, and could have wiped out some differences between guided mourning and antiexposure.

The six-week follow-up of Mawson et al. (1981) can be compared to our four-week posttreatment ratings. The guided mourning groups in the two studies did similarly on most measures, except that our cases did better on self-rated anxiety and on evaluative attitudes to Self and the Deceased. Our antiexposure group improved more than Mawson's did except on the BAT per- formance, where ours did worse. By 9 months our guided mourning group was still better on 4 variables than Mawson et al.'s cases had been at six-weeks post-treatment.

Our antiexposure cases improved to nine-month follow-up despite their con- tinuing to avoid bereavement cues. This supports Shackleton's (1983) conclusion from a single case study that there may be partial independence of bereavement avoidance from other aspects of grief such as depression and preoccupation with the deceased. It does not fit the relationship assumed by Ramsay (1979). An exposure approach yields more limited benefits in morbid grief than in agoraphobia and other phobic disorders and in compulsive rituals (Marks, 1987), playing an adjuvant rather than a key role in clinical management. Nevertheless, even in morbid grief, exposure as guided mourning reduces dis- tressing avoidance behavior; it should be used with sensitivity and sympathy (Ramsay, 1979; Raphael, 1984).

In conclusion, when morbid grief cases had treatment including the en- couragement of new activities, adding guided mourning rather than antiex- posure was better in reducing avoidance of and distress from bereavement cues

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132 SIRELING, COHEN, AND MARKS

but was of only marginal extra benefit for other symptoms up to nine-months follow-up. Avoidance of bereavement cues was at least partly independent of other symptoms of morbid grief. These results accord with those obtained in a previous study.

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tion. Psychological Reports, 34, 1184-1186. Faschingbauer, T. R., Devaul, R. A. & Zisook, S. (1977). Development of the Texas Inventory

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RECEIVED: April 2, 1987 FINAL ACCEPTANCE: July 8, 1987