10.1192/bjp.138.3.185Access the most recent version at DOI: 1981, 138:185-193.BJP 

D Mawson, I M Marks, L Ramm and R S SternGuided mourning for morbid grief: a controlled study.

Referenceshttp://bjp.rcpsych.org/content/138/3/185#BIBLThis article cites 0 articles, 0 of which you can access for free at:

permissionsReprints/

permissions@rcpsych.ac.ukto To obtain reprints or permission to reproduce material from this paper, please write

to this article atYou can respond http://bjp.rcpsych.org/letters/submit/bjprcpsych;138/3/185

from Downloaded

The Royal College of PsychiatristsPublished by on October 3, 2014http://bjp.rcpsych.org/

http://bjp.rcpsych.org/site/subscriptions/ go to: The British Journal of PsychiatryTo subscribe to

Brit.J.Psychiat.(1981),138,185—193

The concept of loss occupies a central position inpsychiatry (Freud, 1917; Lindemann, 1944; Bowlby,1960). Earlier interest focussed on the motherinfant relationship but more recently attention hasbeen paid to the effect of other losses; for example of ahome (Fried, 1962) or a limb (Parkes, 1972). Loss of animportant relationship through death appears to havethe most extensive sequelae, both to physical (Maddison and Viola, 1968; Rees and Lutkins, 1967) and tomental health (Parkes, 1964).

Much has been written on the process of mourningfollowing such a loss (Parkes, 1964; Averill, 1968;Lindemann, 1944) but few studies have described orcompared treatments for those whose distress is ununduly protracted or profound. Recent descriptions ofa behavioural treatment for morbid grief have beenpromising (Ramsay, 1976; 1977; 1979; Gauthier andMarshall, 1977; Gauthier and Pye, 1979). Theapproach (which we call ‘¿�guidedmourning') likensunresolved grief to other forms of phobic avoidance,which have been treated successfully by exposure tothe avoided situation, as in the treatment of obsessivecompulsive and phobic patients (Marks, 1978). In oneseries (Liebermann, 1978) most of the 19 patientstreated with this approach improved with an unspecified amount of treatment; this study indicated theneed for a controlled investigation which this paperreports.

The present study compared guided mourning witha control treatment in 12 patients with morbid grief (6per condition).

Design and TreatmentsAfter two weeks on a waiting list twelve patients

185

were randomly assigned to one of two treatments.Each treatment consisted of 1—14hour long sessionsgiven three times weekly for two weeks, with subsequent follow-up until 28 weeks after entering thetrial.

There were five therapists: one (psychiatrist)treated six patients (three per condition); two (psychiatrist, nurse therapist) treated one patient each in eachcondition; two further therapists (psychiatrist, nursetherapist) treated one patient each in the differentconditions.

Psychological treatments

Between weeks 2 and 4 patients received either(a) guided mourning or (b) control treatment.

(a) Guided mourning (6 patients). During treatmentsessions the patient was exposed to avoided or painfulmemories, ideas or situations, both in imagination andreal life, related to loss of the deceased. After initialexplanation of treatment aims, the events surroundingthe loss or its consequences were discussed and thetherapist then focussed on those areas which thepatient found difficult to describe, for example asituation associated with great sadness or guilt. Thepatient was then encouraged to describe repeatedlysuch situations until his initial distress was diminished,which was then pointed out to him. Patients whoavoided places such as the hospital where the deceaseddied, the cemetery or that person's last town ofresidence were encouraged to visit those places.

When phobic avoidance mainly concerned the lossitself the patient was encouraged to say “¿�goodbye―tothe deceased aloud in the sessions, in writing during

This Ons

I@UIU@III@II@III@Il@1IIII@I@l@IIIllI@IIIU24XN-GSB-S4N7

Guided Mourning for Morbid Grief

A Controlled Study

D. MAWSON, I. M. MARKS, L. RAMM and A. S. STERN

Summary: During 2 weeks on a waiting list 12 patientswith morbid grief did notimprove significantly. They were then randomly allocated either to guidedmourning treatment, in which they were encouraged to face cues concerningtheir bereavement, or to control treatment in which they were asked to avoidsuch cues. Each treatment comprised six 1@ hour sessions over 2 weeks. Atweek 4 guided mourning patients had improved significantly more than hadcontrols on 3 measures,with a supportive trend on 4 measures. Improvement,though modest, was maintained to 10-28 weeks follow-up. Control patients didnot improve significantly or show any trend to do so.

186 GUIDED MOURNING FOR MORBID GRIEF: A CONTROLLED STUDY

homework, and sometimes at the cemetery where thedeceased was buried.

Throughout treatment the therapist aimed to maximize exposure to stimuli at a pace tolerable to thepatient, and to minimize discussion of issues notimmediately relevant to this task.

During the first 4 sessions, all patients were given aninstruction card on which was written: “¿�Writeat leastone page daily about your relationship with the deceased, and think about that person as often as youcan. Force yourself to face the grief and you'll feelbetter. Also look at a photo each day of the deceased―.

(b) Control treatment (6 patients). In contrast toguided mourning, the patient was encouraged to avoidthinking of the deceased, and to give as little attentionas possible to such painful memories or thoughts asemerged spontaneously. Methods of distraction weresuggested, and techniques of thought-stopping orrelaxation between sessions were also sometimes used.Emphasis was placed on current issues and on theneed to carry on with life in an industrious andpositive fashion. Advice was given on how this mightbe done with as little reference as possible to thedeceased. In some cases, the subject of the loss wasrepeatedly re-introduced by the patient; this was dealtwith by pointing out the distress caused and the need toconcentrate on less distressing and more positivetopics. The patient was then advised to put out of sightall painful reminders of the deceased such as photographs or possessions.

During the first 4 sessions all patients were given aninstruction card on which was written: “¿�Writeat leastone page daily about your relationships to friends orrelatives who mean a lot to you, and think about themas often as you can. Give yourself a break and you'llfeel better. Also look at photos of your friends orvalued relatives each day'.

The two treatments were both directive, and had incommon the joint co-operation of therapist and patient, and each step was made at a mutually acceptablepace. Each involved outpatient treatment (except intwo cases, one per condition), sessions of similarduration and number, and tasks to be carried out athome or elsewhere after the sessions. All patients weregiven a relevant instruction card at session I.

Patient Selection and CharacteristicsAll patients complained of persistent distress of over

one year's duration which dated from the loss, orwhich had been greatly exacerbated by the loss. Inaddition, suitable patients had to have two or more ofthe features listed in Appendix 1 and not have hadbehavioural treatment for them. Suitable patientswere then randomly allocated into guided mourningor control conditions within two weeks of initial

assessment. Of the 12 patients selected, 11 werewomen, age range was 28 to 61 (median for guidedmourning 42, and for control 54). The loss had occurred between 1 and 10 years prior to treatment (medianfor each condition 3 years). Seven patients had losttheir husband, four their mother and one her aunt.Cause of death was neoplasia in 11 relatives and heartattack in one. Four patients in each condition were onantidepressant medication throughout the study,having been on it for at least 6 months previously.

Case examples: Two case histories are given toillustrate the type of patient involved in the trial.Neither did well.

(a) Guided mourning. A woman of 58 had been depressedand lonely since the death of her second husband fromHodgkin's disease nearly two years previously. Since thedeath she had taken two small overdoses, and often thoughtof suicide. Alcohol and cigarette consumption had increased. Sleep and appetite were poor, and her sleep wasoften disturbed by nightmares of her husband's illness.She avoided one of the hospitals he had been treated at,and could not look at his glasses, although none of hisother possessions distressed her. She felt extremely bitterand angry about the way her husband had been treated inhospitals and by various doctors, who were almost uniformly regarded as callous and incompetent.

She was the oldest of three children, and described herchildhood as very unhappy. Following a row with herfather she left home at 14. She took various secretarialposts and was married at 20. The marriage was unhappyand ended after 10 years in divorce. In contrast, her secondmarriage was recalled as ideal.

At assessment she was depressed, tearful, and very angryabout her husband's treatment. She said she could sometimes feel her husband's presence, often talked to him andhad once since his death felt his hand.

From the first session she was encouraged to describesome of the more painful memories of his illness, e.g. hisdifficulty walking, the brusque treatment by one hospital,the late diagnosis. In this and subsequent sessions she wasgently asked to describe repeatedly one particularlydistressing episode. This occurred when her husband'slegs became paralysed and he asked her for help. Sherecalled his fear and her feelings of powerlessness to helphim.

Another distressing image was of her husband's facenear the end of his illness when it was bloated and ugly.These and similar memories were repeatedly presented toher disgust and she was asked to describe the feelings theyevoked. She felt extremely angry with the doctors who had,in her view, treated him casually and perhaps even experimentally. Again, she was encouraged to talk of her angertowards them, as well as towards his relatives whom shethought had neglected her in her loneliness.

At the end of each session she was given homework. Thisconsisted of looking at photographs of her husband, ofwriting letters (not to be sent) to the various doctors whohad treated him, and of letters to her husband, talking ofher feelings. The last she found impossible to begin with but

187D. MAWSON, I. M. MARKS, L. RAMM AND R. S. STERN

later managed to write to him of her loneliness and sadnessat his loss. She could never write a final “¿�goodbye―,despite much encouragement to do so.

During follow-up the sessions gradually became moresupportive and less concerned with the bereavement.Although some of the distress evoked by talking about herhusband was now lessened she remained lonely andembittered when discharged at 10 months follow-up.

(b) Controltreatment.A womanof 58describedherselfas a lifelong worrier. She became depressed three monthsafter her husband's death from lung cancer two yearsbefore entering the trial. In his final illness, which lastedsix months he became cachectic and hallucinated. She fedhim with food she prepared. One day after feeding him hevomited blood and died subsequently during gastroscopy.When she saw the body, she thought she saw his face move,and ran out to tell the nurses there had been a mistake.

During her depression she became insomniac, anorexicand lost weight. She lost interest in life, and was emotionally labile, with frequent crying spells. A year beforeentering the trial she was admitted for two months andimproved slightly. At assessment she was still mildlydepressed, and felt guilty if she ever began to enjoy herself.He was rarely far from her thoughts and, even in thesimplest task such as threading a needle, often asked himfor help in her mind or aloud. She often saw him in herflat when alone and talked to him, but knew the experiencewas imaginary. She also saw his cat which had died shortlyafter her husband.

At the first session it was explained to her that she hadsuffered a great deal and that therapy would concentrate,with her co-operation, on her resuming a normal, activelife. This would comprise resuming previously neglectedinterests and tasks, and perhaps involve new ones. Sheagreed to this and in her homework she made plans for aholiday, wrote a diary of daily activities and undertookmore of the household chores.

In treatment she showed a marked tendency to returnto the subject of her husband which, although said to becomforting, usually made her tearful. This was pointed outto her and ways of distracting herself from sad or painfulmemories were discussed. Again, she understood this butfound it hard to comply. On many occasions the opportunity arose in the sessions to practise such self distractionby talking of neutral topics, but the effect was usuallyshortlived.

During one session family photographs were looked at.

She was encouraged to talk about those of her niece'sfamily, but the briefest attention possible was given tothose of her husband. All mention of him met with agentle reminder that the subject was distressing for herand therefore best avoided.

Follow-up sessions were supportive, with continuedemphasis on pursuit of an active life and discouragement ofintrospective reflection. She improved slightly overall withgreater interest in her job and several activities.

MeasuresPatients rated themselves at weeks 0, 2,4, 8, 12 and

28 (Fig 1). There were no observer ratings. Ratings atweek 4 occurred 2 days after the last treatmentsession. As a few ratings were lost at weeks 8 and 12the two points were pooled to give a score for ‘¿�week10'. Measures were designed to cover four areas offunction which are currently of theoretical interest inthe treatment of morbid grief. This facilitated study ofthe interrelationships among different areas ofpathology when treatment led to change.

i. Pathology of grief itse{f

(a) Bereavementavoidance tests: Five tasks concerning bereavement were given to every patient tocomplete at home, each task to take 2 minutes timedon the patient's watch. The 5 tasks were: to look at aphotograph of the deceased; to hold a possession ofthe deceased's and then throw it in the dustbin; tothink about those qualities of the deceased they likedmost and least; and finally to write a letter to thedeceased. Each was rated according to (1) Performance—¿�whether or not each task could be done (scorerange 0-5) and (ii) Distress—if each task could bedone, how much distress it caused, by marking across on a 10 cm line between the two extremes of‘¿�nodistress' and ‘¿�greatdistress'. (Mean of 5 scoresrange 0—10).

(b) Physical symptoms of grief: Score range 0—39.Thirteen symptoms commonly reported duringmourning (Maddison and Viola, 1968) were selectedfor this newly devised scale, and each item was scoredfrom 0 (“Ialmost never have this―)to 3 (“Thisis asevere problem―). (See Appendix 2).

STUDY DESIGN

Week

Fio 1.—Studydesign.

188 GUIDED MOURNING FOR MORBID GRIEF: A CONTROLLED STUDY

(c) Hostility-anger-guilt: Score range 0—10.Thisnewly devised scale comprised 7 questions concerningaffective manifestations of grief. (See Appendix 3).

(d) Texas inventory of grief: This consists of 7commonly-encountered features of normal grief eachrated 0—4(score range 0—28)(Faschingbauer et al,1977. Appendix 4).

(e) Attitude to self and to the deceased: Two concepts (MYSELF and the DECEASED specified byname) were rated on bipolar 0—6semantic-differentialscales. MYSELF was rated on evaluative scales(good—bad, unpleasant—pleasant) and two angerscales (angry—calm and placid—irritable). The DECEASED was rated on 2 evaluative scales (unpleasant—pleasant, good—bad) and one thoughtdifficulty scale (easy to think about—upsetting to thinkabout). Each concept yielded 2 factor scores (evaluative and anger for MYSELF and evaluative andthought-distress for the DECEASED).

2. Depression

(f) Wakefield depression questionnafre. Score range0—36.This self-rating questionnaire (Snaith et a!, 1971)comprises 12 0—3items. It has a test—retest reliabilityof r = 0.68 and correlates r = 0.87 with the Hamiltondepression scale (Marks eta!, 1980).

@. Anxiety,fear, compulsions

(g) Anxiety was rated on a 0—8scale (Watson andMarks, 1971).

(h) Fear questionnaire (FQ). This lists 17 phobicsituations each to be rated on a 0—8scale of avoidance(Total phobia score range 0—136),6 anxiety—depressionfeelings each rated on a 0—8scale (anxiety—depressionscore range 0—48),and a single overall global phobia0—8scale (Marks and Mathews, 1979).

(i) Compulsive activity checklist. Score range 0-117.This consists of a series of 0—3scales concerningavoidance, repetition and duration of 39 everydayactivities (e.g. having a bath, washing clothes). Thescale was modified from that devised by Hallam (seePhilpott, 1975 and Marks eta!, 1977).

4.Socialadjustment (j-n)

Five items (work, leisure, sex, relationships withfamily, relationships with friends or neighbours) wereeach rated on a 0—8scale (Watson and Marks, 1971).

ResultsTable I and Fig 2 summarize the results. All scores

are arranged so that the lowest score of 0 indicatesabsence of pathology. All 12 patients completedtreatment to week 4. One control patient did notreturn at week 10. At week 28 six patients failed to

attend for follow-up (two from guided mourning, fourfrom control). All t-tests reported are two-tailed.

The 2 groups combined: overall change

From weeks 0 to 2 the 12 patients did not improveon any measure; in fact at week 2 they rated thedeceased as significantly less good and pleasant than atweek 0 (P <.02 on analysis of variance). Pooling thescores for weeks 0+2, (i) analysis of variance of thechange to week 4 showed that the 12 patients takentogether improved on 5 measures: Wakefield Depression (P <.03); hostility—anger—guilt (P <.02),global phobia (P <.06), bereavement avoidance—taskperformance (P <.001), difficulty thinking about thedeceased (P <.01). (ii) t-tests showed improvement on7 measures at week 10 Wakefield Depression (P<.03); physical symptoms of grief (P <.1); hostility

anger—guilt (P <.1); Texas inventory of grief (P<.08); anxiety (P <.08); fear questionnaire, anxietydepression (P <.05) and work (P <.08). There was noworsening on any measure.

Between-groups analysis

Guided mourning was compared with the controltreatment by analysis of covariance, which covariedthe pooled means of each condition's scores at weeks0 + 2, and compared these with scores at week 4:After guided mourning, patients improved more thandid control patients on total phobic avoidance (P<.03), bereavement avoidance—task performance (P<.02) bereavement avoidance task-distress (theguided mourning patients did not improve, whilecontrol patients became significantly worse) (P <.03),difficulty in thinking about the deceased (P <.07),Texas inventory of grief (P <.06), anxiety—depression(P <.08), and global phobia (P <.1); at week 10

tests comparing raw scores found guided mourningto be better than control on the Texas inventory ofgrief (P <.05).

Control patients did not improve more than guidedmourning patients on any of the measures at weeks 4or 10.

Within-group change

From weeks 0 to 2, 2 to 4, and 2 to 10 change wasexamined within each condition separately by t tests(2-tailed). Neither group changed significantly fromweeks 0—2. From weeks 2—10 guided mourningpatients improved on the Texas inventory of grief (P<.05). No significant improvement or trend to do sowas found on any measure for the control condition.At 28-week follow-up the 4 guided mourning and 2control patients who attended had improved slightlyfurther on most measures.

ScorerangeWeeks 0 2 4 10

189D. MAWSON, I. M. MARKS, L. RAMM AND R. S. STERN

TABLEIMeans and standarderrors of scores

Mean SE Mean SE Mean SE Mean SE

0-5

0—10

0—39

0—10

0—35GM

CGMCGMCGMCGMC2.2

2.86.24.7

10.09.54.54.5

18.219.70.3

0.61.01.82.63.00.31.01.42.01.5

1.75.74.89.39.55.03.8

19.320.00.3

0.31.41.41.83.00.70.91.31.90.2

1.76.56.57.09.03.33.5

14.319.60.2

0.41.31.31.21.80.51.01.71.60.8

1.84.87.85.88.73.33.6

11.619.50.3

0.51.01.31.41.60.61.32.9

1.90—12

0—12

0—12

0-6GM

CGMCGMCGMC6.5

5.08.75.23.71.35.82.71.4

0.81.12.12.00.60.21.19.0

4.59.16.05.85.74.33.51.1

1.01.01.91.62.01.00.96.8

4.38.36.33.64.82.22.71.9

0.71.31.61.81.91.11.17.0

5.07.04.54.21.92.93.42.1

1.61.90.91.40.71.2

1.50—36GM

C25.5 24.52.4 3.027.0 24.72.0 2.820.8 21.83.8 2.218.8 22.24.63.30—8GM

C5.5 5.01.2 1.15.8 5.00.8 1.15.0 4.30.8 1.14.2 4.51.01.40—136

0-48

0—8

0—117GM

CGMCGMCGMC36.8

34.826.520.3

4.73.7

20.022.58.6

13.01.66.11.21.55.47.744.7

29.225.319.32.73.7

20.328.011.7

10.32.15.71.01.55.9

10.032.2

34.217.821.5

2.23.5

18.832.58.2

12.03.85.90.71.56.3

13.029.2

34.914.220.8

1.74.5

13.523.20.5

15.64.36.40.71.65.6

12.10—8

0—8

0—8

0—8GM

CGMCGMCGMC2.8

4.33.74.34.01.32.22.01.4

1.11.41.31.81.01.21.03.8

2.84.82.82.31.83.32.01.1

0.91.00.91.21.01.60.52.8

4.33.34.32.52.01.82.31.1

1.21.21.21.31.00.90.92.7

4.14.14.82.81.42.23.01.0

1.51.41.41.10.91.21.3

Pathologyofgrief itself(a) Bereavement avoidance tasks

(i) Performance

(ii) Distress

(b) Physical symptoms of grief

(c) Hostility-anger-guilt

(d) Texas inventory of grief

(e) Attitude to:MYSELF(i) Evaluative

(ii) Anger

DECEASED(iii) Evaluative(iv) Thought-difficulty

Depression(f) Wakefield

Anxiety, Fear, Compulsions(g) Anxiety

(h) Fear questionnaire(FQ)(i) Total phobia: avoidance

(ii) Anxiety-depression

(iii) Global phobia

(i) Compulsive activity checklist

Socialadjustment(j) Work

(k) Leisure

(1) Relationship with family

(m) Socialrelationships

GM = Guided mourning; C = Control treatment.

Therapist effects Relationships among the measures

The therapist who had most experience with guided The sample was too small for factor analysis.mourning, in that he treated half the sample, for each Product-moment intercorrelations showed no cleartreatment obtained no better results than those of the clusters among the 4 main areas of interest. At weeksother 4 therapists combined. 0, 2 and 4 significant intercorrelations on all 3

waiting list (weeks 0-2)

guided @.urning tzeetaent (weeks 2-4)

@ control ( ‘¿� )

1O.%6@ DIFFICULTY THINKING TEXAS INVENTORY 7.5( HOSTILITY-ANGER—GUILTSF'S ABOUT DECEASED 28 OF GRIEF 5.01

20@ 2.5J.07 10

L (.01) 0 - - (.08)@ ___________________________________________ ______________________ 02) (.1)0 2 4 weeks 10 0 2 4 weeks 10 ) 4 weekslO

BEREAVE@tENT AVOIDANCE TEST

I WAKEFIELDDEPRESSION4 PERFORMANCE DISTRESS ,@

36@

3 6@ 301

2<@-.-@--@@

1 ‘¿�@‘@@\b_—: 2 .03

0 (-@1@ 01 (.03) (.03)

0 2 4 weeks 10 0 2 4 weeks 10 2 4 @ks 10

FEAR QUESTIONNAIRE

8136 4@60 TOTAL PHOBIC AVOIDANCE 6 GLOBAL PHOBIA ANXIETY-DEPRESSION

4O@S@@@

2008.1

.03@ (.06) 01. (.05)0 2 4 weekslo 0 2 4 weeks 10 0 2 4 weekslo

.07, .02 etc. —¿�sig. of diff. between guided mourning and control, weeks (0+2) v. 4

(.07), (.co1) - “¿�“¿�“¿�for improvement of both groups combined, “¿�““ “¿�or 10

(n@6 for all points, except n—S for controls at@ week 10)

Fio2.—Morbidgrief:mean improvementto10weeks.Trendsandsignificanteffects;lowerscores= lesspathology.

191D. MAWSON, I. M. MARKS, L. RAMM AND R. S. STERN

occasions were found among the following measures(n = 12 for each, P at least <.05). Wakefield depression with: hostility—anger—guilt,anxiety—depression(FQ-fearquestionnaire),anxiety,relationships outside the family. Physical symptoms with:hostility—anger—guilt, global phobia (FQ). Hostilityanger—guilt with: anxiety-depression (FQ), globalphobia (FQ), anxiety, Wakefield depression, physicalsymptoms.

Total phobic avoidance (FQ) with: global phobia(FQ) and compulsion checklist. Anxiety with:leisure.Leisurewith:anxiety,relationshipsoutsidethefamily. Two versions of the hostility—anger—guiltscale(linearanalogueversusanchorpoints)correlatedsignificantlywith one anotherat weeks 0, 2 and 4respectively, (r = .68, .72, .75, P <.007).

DiscussionDuring 2 weeks on a waitinglistpatientswith

morbid griefdid not improve significantlyon anymeasure. Over the next 2 weeks those who receivedguided mourning showed significantly more improvement than did controls on 3 measures (behaviouralavoidancetestsconcerningthedeceasedand distressduring them, and total phobic avoidance), with asupporting trend in the same direction on 4 measures(difficulty thinking about the deceased, Texas inventory of grief, anxiety—depression,global phobia).This improvement was maintained at 10 and 28 weeks.

In contrast, control patients showed no significantimprovement or trend to do so on any measure. Thecontrol treatment might be construed as having contained an element of paradoxical intention, but if sothis was not therapeutic.

All measures in this study were self-ratings, butchanges were consistently in the same direction, allfavouring guided mourning over control treatment.Observer ratings were not used in this pilot study, butother systematic comparisons of observer with selfratings for depression, phobias and rituals have foundthese to correlate highly significantly (Marks andMathews, 1979; Marks et al, 1980).

The results suggest that guided mourning is a usefulingredient in the management of morbid grief,although the effect was not as potent as might havebeen hoped from some earlier reports (Ramsay, 1977;Gauthier and Pye, 1979; Lieberman, 1978).Ourpatients had only 6 treatment sessions over 2 weeks.Perhaps more sessions of treatment over a longerperiod would have had greater effects, and this is beinginvestigated.Whether guidedmourning isespeciallyworthwhile

inany particularvarietyofmorbid griefcouldnotbeascertainedfrom our small sample of patients.Parkes (personal communication) suggested that

guided mourning is indicated where grief has beenavoided, repressed or delayed, but is not especiallyuseful where patients can readily express their griefeither in self-punitive fashion or as an excuse to avoiddeveloping a new life style. For the latter a goaloriented programme may be helpful.

Though the overall effects of guided mourning weremodest, in some cases marked improvement occurred,as in a 48 year old woman who since the death of hermother 3 years before had become almost housebound, had drinking episodes and become sociallyisolated. During guided mourning she was encouragedto visit places associated with her mother and to writeletters to her about her mother's irritating habits. Thepatient carried out these activities and in her last weekof treatment visited her mother's grave daily and saidgoodbye to her. At 28 weeks follow-up she wassocially more active, was no longer drinking excessively, was driving a car for long distances, andwas looking for a job.

Bereavement is a normal and important cause ofphysical and mental distress. Grief is regarded asmorbid when unduly prolonged or severe, and thisstudy investigated the alleviation of morbid grief bybrief intervention of two sorts. Guided mourningassumed that morbid grief is to some extent maintained by phobic avoidance of an aspect of cuesconcerning the deceased, and concentrated on encouraging approach (exposure) to avoided cues. Thecontrol treatment was the opposite approach whichdiscouraged exposure and resembled the reassurancefrequently given by friends or relatives of bereavedindividuals, although the control treatment was moreintensive,structuredand administeredina therapeuticsetting.Guided mourning involvedintensiverelivingof

avoidedpainfulmemoriesand feelingsassociatedwithbereavement,and did not attendto socialand biological features of morbid grief, though the latter wereoften a more obvious aspect of psychopathology.Other important features concerned depressed moodand general anxiety, and these were less improved byguided mourning than was avoidance of the deceased. This is in keeping with the nature of the treatment, but the generalization of improvement fromincreased approach to cues about bereavement tolightening of depression was much less than mighthave been hoped for. At the end of treatment thesample still had abnormally high Wakefield depressionscores.

The superiority of guided mourning was mostevident on measures of approach to bereavement cues,and less evident on measures of depression like theWakefield and other measures which correlatedsignificantly with the Wakefield. This suggests that the

192 GUIDED MOURNING FOR MORBID GRIEF: A CONTROLLED STUDY

mood disturbance and the avoidance of bereavementcues are less intimately linked than is commonlythought to be the case. This idea is borne out by thefew significant correlations among measures of thesetwo problem areas, though our sample was too smallfor systematic appraisal of this issue. A relatedphenomenon is the relative independence of depressed mood on the one hand and phobic-obsessiveproblems on the other. The latter responds well toexposure treatment and the former does not (Markseta!, 1980).

Acknowledgements

The project was supported by Grant Nos. G973/775 andPG978/l 178 from the Medical Research Council (to allexcept I.M.M.). Many thanks are due to Mr Andrew Bulland Dr Jeremy Cold for treating one patient each, and toDrs Stuart Lieberman, Cohn Parkes and Ron Ramsay forhelpful comments on the manuscript.

References

AVERILL, J. R. (1968) Grief: Its nature and significance.PsychologicalBulletin,70,721—48.

BOWLBY, J. (1960) Grief and mourning in infancy andearlychildhood.PsychoanalyticStudy of the Child,15,9—52.

FASCHINGBAUER, T. R., DERANT, R. A. & ZISOOK, S.(1977) Development of the Texas inventory of grief.AmericanJournalofPsychiatry,134,696—8.

FRIED, M. (1962) Grieving for a losthome. In The Environ

ment of the Metropolis (ed. L. J. Duhl). New York:Basic Books.

FREUD, 5. (1917) Mourning and Melancholia. In TheStandardEditionoftheCompleteWorksofSigmundFreud(Vol. 14). (ed. J. Strachey). London: Hogarth.

GAUTHIER, J. & MARSHALL, W. L. (1977) Grief: Acognitive-behavioural analysis. Cognitive Therapy andResearch,1, 39—44.

& PYE, C. (1979): Graduated self-exposure in themanagement of grief. Behaviour Analysis and Modification, 3,202-8.

LIEBERMAN, S. (1978) Nineteen cases of morbid grief.BritishJournalofPsychiatry,132,159—63.

LINDEMANN, E. (1974) Symptomatology and managementof acute grief. American Journal of Psychiatry, 101,141—8.

MADDISON, D. & VIOLA, A. (1968) The health of widowsin the year following bereavement. Journal of PsychosomaticResearch,12,297.

MAIuc.s, I. M. (1978)Living with Fear. New York: McGrawHill.

—¿� (1978) Chapter 7: Conceptual issues. Chapter 8:

Clinical applications. In Behavior Modification. 2ndEd. (ed. W. S. Agras). Boston: Little, Brown.& MATHEWS,A. M. (1979)Briefstandardself-rating

for phobic patients. Behaviour, Research and Therapy,17,263—7.

HALLAM, R. S., PmLPOTF, R. & CONNOLLY, J. (1977)Nursing in BehaviouralPsychotherapy.London:Royal College of Nursing.

—¿� STERN, R. S., MAWSON, D., COBB, J. & MCDON'ALD,

R. (1980) Clomipramine and exposure for obsessivecompulsive rituals. I. British Journal of Psychiatry,136, 1—25.

PARKES, C. M. (1964) Recent bereavement as a cause ofmental illness. British Journal of Psychiatry, 110, 198—204.

—¿� (1972) Bereavement: Studies of Grief in Adult Life.

Harmondsworth: Penguin Books.PHILPOTT, R. (1975) Recent advances in the behavioural

measurements of obsessional illness. Scottish MedicalJournal, 20,33—40.

RAMSAY, R. W. (1976) A case study in bereavementtherapy. In Case Studies in Behaviour Therapy (ed.H. J. Eysenck). London: Routledge, Kegan and Paul.

(1977) Behavioural approaches to bereavement.BehaviourResearchandTherapy,15,131—5.

—¿� (1979) Bereavement: A behavioural treatment of

pathological grief. In Trends in Behaviour Therapy,(eds. P. 0. Sjöden,S. Bates and W. S. Dochens, III).New York: Academic Press.

REm, W. D. & LUTKINS, S. G. (1967) Mortality of bereave@ment. British Medical Journal, 4, 13—16.

SNAITH, R. P., AHMED, S. M., MEHTA, S. & HAMILTON, M.(1971) Assessment of the severity of primary depressiveillness. Psychological Medicine, 1, 143—9.

WATSON, J. P. & MARKS, I. M. (1971) Relevant vs. irrelevant flooding in the treatment of phobias. BehaviorTherapy,2,275.

Appendix 1

Additional selection criteria: 2 or more of the following:1. Delayed or abnormal onset of grief after the death.2. Increased alcohol, drug or cigarette consumption since

bereavement.3. Identification with deceased.4. Psychoneurotic reactions arising since death.5. Anniversaryreaction.6. Avoidance behaviour concerning the deceased.7. Excessive guilt or hostility towards the deceased, or

those involved with the deceased.

Physicalsymptoms1. Headache.2. Chest pain.3. Vomiting.4. Eat too much.5. Palpitations.6. Shortness of breath.7. Nightmares.

Hostility-Anger-Guilt

Appendix 2

Appendix 3

I. I have let people down since the death.2. Everyone did all they could at the time of death.3. I did all I could for the deceased.

8. Nausea.9. Drowsiness.

10. Unsteadiness of hands.11. Dizziness.12. Sweating more than usual.13. Sexual difficulties

D. MAWSON, I.M. MARKS, L.RAMM AND R.S.STERN 193

4. I get cross at my friends and relatives more than I 2. I still get upset when I think about the person who died.should. 3. I am preoccupied with thoughts about the person who

5. I blame myself for the death. died.6. Certain people are to blame for the death.7. Since the death I have got on with life quite well. 4. lam unable to accept the loss of the person who died.

5. I have pain in the same area as the person who died.6. Sometimes I feel just like the person who died.

7. I seem to get upset each year at about the same timethat the person died.

David Mawson, MB.. B.S., M.R.C.Psycb..Senior Registrar, The Maudsley Hospital, London SE5

* Isaac Marks, M.D., F.R.C.Psych.. Professor of Experimental Psychopathology, Institute of Psychiatry, London SES

Elizabeth Ramm, R.M.N.,Nurse-therapist, Institute of Psychiatry and The Maudsley Hospital

Richard Stern, M.D..M.R.C.Psych.,now Consultant Psychiatrist, St George's Hospital, London SWJ7

* Reprint requests.

Appendix 4Texas inventory of grief

1. At times I still feel the need for the person who died.

(Received 9 July; revised3 October 1980)