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Volume 7, Issue 7, July – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Cognitive Behavorial Therapy: A Case Study
of Breavement Marshall University
Mwuese C. Titor-Addingi
Abstract:- The need for bereavement services to help The times and dates of the meetings were also
support individuals going through grief and heal discussed amongst the co-facilitators and community
successfully is an essential need in the society. This work member, and were set. Additionally, a centralized location,
made use of Cognitive behavioral therapy CBT as a Bayless Memorial Presbyterian Church, was chosen as a
therapeutic module for the group sessions of selected host site. The church provided refreshments for the
group of individuals going through grief. Assessment participants during the session meetings.
incorporates clinical observations, client self-reporting,
evidence based tools/questionnaires, and diagnostic An advertisement campaign within the local
criterion found within the Diagnostic and Statistical community through a podcast, social media, churches, and
Manual of Mental Disorders Fifth Edition (DSM-5), a community organizations was initiated by the community
preliminary diagnosis of Persistent Complex member. Due to the fact that loss does not have boundaries,
Bereavement Disorder (PCBD) was determined and although there was an age limit set, there were no limitations
studied. It is therefore found that there was a significant on gender, race, or ethnicity. The group co-facilitators met
drop below the clinically significant mark of 4.0 by the several times prior to the first group session. During the
end of the 10 week treatment and final submission of the meetings, the co-facilitators discussed evidence based
BGQ, and is further found that given the recommended diagnostic tools, treatment plans (including but not limited
20-25 Cognitive Behavioral Therapy (CBT) sessions, the to goals and objectives), and implementation of Cognitive
group’s score resulted in elimination of all/nearly all Behavioral Group Therapy (CBGT). The co-facilitators also
symptoms of PCBD experienced by group members. decided on which responsibilities each would have during
the initial group session, and how often they would meet to
I. INTRODUCTION debrief and discuss future group sessions.
The development of the “Grief and Healing Support II. ASSESSMENT
Group” came from an extrinsic need for bereavement Assessments are essential to providing adequate and
services within the Grayson, KY community due to an appropriate treatment to individuals and treatment groups
increase in suicide completions and deaths related to the alike. Assessment incorporates clinical observations, client
current opioid epidemic. A community member reached out self-reporting, evidence based tools/questionnaires, and
to Marshall University Professor, Paula Rymer (CSW, diagnostic criterion found within the Diagnostic and
LSW, LICSW), to request assistance in facilitating the Statistical Manual of Mental Disorders Fifth Edition (DSM-
bereavement group. Graduate students who have 5). Using these methods, a preliminary diagnosis of
experienced traumatic loss and understand the bereavement Persistent Complex Bereavement Disorder (PCBD) was
process were chosen to facilitate the group. determined and studied.
It was predetermined that the group would be an open
group for individuals (ages 16 and older) who have Persistent Complex Bereavement Disorder (PCBD) is
experienced a death or traumatic death of a family member, intense grief after the death of a loved one that lasts longer
friend, or loved one. It was also predetermined that the than expected according to social norms and causes
graduate students would facilitate a total of eight to twelve functional impairment. The condition is found in
sessions. Although Cognitive Behavioral Therapy (CBT) theDiagnostic and Statistical Manual of Mental Disorders
was the module used during therapeutic group sessions, Fifth Edition (DSM-5) within the chapter titled, Conditions
research and pilot studies conducted by Dr. Katherine Shear for Further Study (American Psychiatric Association [APA],
indicate that Complicated Grief Therapy (CGT) is an 2013). The proposed five criteria listed within the DSM-5
effective evidence based treatment for complicated grief of include (APA, 2013):
the bereaved (Zagorski, 2015 and Shear & Bloom, 2017). Individual experienced the death of someone with whom
CGT incorporates elements of CBT along with Interpersonal they had a close relationship
Psychotherapy (IPT) and Motivational Interviewing (MI). Since the death, they have experienced at least one of the
However, CGT is conducted at a minimum of 16 weekly following symptoms more often than not to a clinically
sessions, and due to time constraints along with the significant degree persistently for at least 12 months for
predetermination for use of an evidence based modality, bereaved adults and 6 months for bereaved children:
CBT was utilized (2015& 2017).The structural basis for Persistent yearning/longing for the deceased
implementation of CBT within the bereavement group was Intense sorrow and emotional pain
obtained from the book titled, Cognitive-Behavioral Preoccupation with the deceased
Therapy in Groups (Bieling, McCabe, Antony, 2009). Preoccupation with the circumstances of the death
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Volume 7, Issue 7, July – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Since the death, six or more of the following have been per the DSM-5, a diagnosis of MDD and PDD were ruled
experienced at clinically significant degree and have out.
persisted for 12 months after the death for bereaved adults
and 6 months for bereaved children: Given the noted information, coupled with the fact that
Marked difficulty accepting the death. the majority of the group members experienced their loss
Experiencing disbelief or emotional numbness over the over 6 months (for children) and/or 12 months (for adults)
loss prior respectively, and necessaryDSM-5 was met, a
Difficulty with positive reminiscing about the deceased diagnosis of Persistent Complex Bereavement Disorder
Bitterness or anger related to the loss (PCBD) was made. There were no members who expressed
Maladaptive appraisals about self in relation to the that their loss was associated with a trauma, nor were any
deceased or the death group members observed to exhibit specifiers of traumatic
Excessive avoidance of reminders of the loss bereavement. There was also no comorbid diagnosis such as
A desire to die in order to be with the deceased bipolar disorder, schizophrenia, or substance use disorder.
Difficulty trusting other individuals since the death Therefore, comorbid diagnosis such as those previously
Feeling alone or detached from other individuals since mentioned were ruled out per specified criterion listed in the
the death DSM-5 (APA, 2013).
Feeling that life is meaningless or empty without the Prior to the Diagnostic and Statistical Manual of
deceased Mental Disorders Fifth Edition (DSM-5), the Diagnostic and
Confusion about one’s role in life, or loss of one’s Statistical Manual of Mental Disorders Fourth Edition Text
sense of identity Revision (DSM-IV-TR) described Persistent Complex
Difficulty or reluctance to pursue interests since the Bereavement Disorder (PCBD) and/or bereavement in
loss or to plan for the future generally in terms of “other conditions that might be the
focus of clinical attention” (American Psychiatric
The disturbance causes clinically significant distress or Association Diagnostic and Statistical Manual of Mental
impairment in social, occupational, or other important Disorders Fourth Edition Text Revision [DSM-IV-TR],
areas of functioning. 2000).For facilitation of the group, the DSM-5 was used for
The bereavement reaction is out of proportion to or diagnostic purposes.
inconsistent with cultural, religious, or age-appropriate
norms (2013). Further assessment was made of the group through
implementation of the Brief Measure for Screening
Complicated Grief (BGQ) at the onset, halfway mark, and
In addition to the five criteria listed in the Diagnostic termination of the group (Ito, Nakajima, Fujisawa, et al.,
and Statistical Manual of Mental Disorders Fifth Edition 2012). This is an evidence based tool that was developed in
(DSM-5), a specifier is listed along with features supporting 2002 in response to individuals who sought support for the
the diagnosis, development of Persistent Complex September 11, 2001 terrorist attacks in New York. It was
Bereavement Disorder (PCBD), and associated risk factors. developed prior to the DSM-5, however, the BGQ,
For those who are bereaved due to traumatic loss such as continues to be the most widely used evidence based tool to
homicide or suicide, and exhibit persistent distressing assist in assessments of the bereaved. This screening tool
preoccupations regarding the traumatic nature of the death a asks five questions which organize information about the
specifier of traumatic bereavement is assigned. Some individual client. It assesses the individual, self-care
features that may be observed or reported can include practices, need for professional care, andsocialization for a
hallucinations and somatic symptoms. An environmental more holistic view of the client’s environment in light of
risk for PCBD is when the bereaved had increased their loss. The BGQ uses a Likert scale of “Not at all (0),”
dependency upon the deceased individual. If an individual “Somewhat (1),” and “A lot (2).” The questionnaire is a
grieves outside or beyond the cultural norms, they are at brief self-report, and it can be used in all healthcare settings
higher risk of developing PCBD. Clinicians must also be (Ito, Nakajima, Fujisawa, et al., 2012). The five questions
vigilant as those who are diagnosed with PCBD more asked of the bereaved are:
frequently report suicidal ideations (2013). 1. How much trouble are you having accepting the death
of ________?
Persistent Complex Bereavement Disorder (PCBD) is 2. How much does your grief still interfere with your
distinguished from the normal grieving process through the life?
aforementioned criterion specified in the DSM-5 (APA, 3. How much are you having images or thoughts of
2013). The bereaved experiences severe levels of grief _______ when s/he died or other thoughts about the
responses which persists at least 12 months following the death that really bother you?
death, and their grief responses interfere with their daily 4. Are there things you used to do when ______ was alive
functioning. Some of the symptoms such as depressed
mood, sadness, crying, and suicidal ideations may also be that you don’t feel comfortable doing anymore, that
shared with Major Depressive Disorder (MDD) and you avoid? Like going somewhere you went with
Persistent Depressive Disorder (dysthymia), however, him/her, or doing things you used to enjoy together?
Or avoiding looking at pictures or talking about
PCBD is “characterized by a focus on the loss” of the _______? How much are you avoiding these things?
deceased (APA, 2013). Therefore, due to criterion not met
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Volume 7, Issue 7, July – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
5. How much are you feeling cut off or distant from other it was found that lemon scent had a positive effect on mood,
people since ______ died, even people you used to be and aroma therapy was found to increase functioning in the
close to like family or friends? (2012). parasympathetic nervous system while decreasing
sympathetic nervous system functioning (Komori,
The decision to utilize this tool was based on Kageyama, Tamura, Tateishi, &Iwasa, 2018, and National
recommendations of clinicians within the field and on Center for Complementary and Integrative Health [NCCIH],
evidence found through literary research of peer reviewed 2012).
studies and articles. One such study was conducted in Japan
and the results of the study supported the reliability and Similarly, diaphragmatic breathing has been proven to
validity of the BGQ(Ito, Nakajima, Fujisawa, Miyashita, decrease sympathetic nervous system function while
Kim, et al., 2012). The study was conducted randomly via increasing parasympathetic nervous system responses and
mailed BGQ’s, and examined the responses of individuals studies have revealed that it reduces anxiety, depression,
who were bereaved more than 6 months but less than 10 stress, and emotional exhaustion (Ma, Yue, Gong, Zhang,
years. The study also supports the view that this instrument Duan, Shi, & Li, 2017). Physiologically, even a single
can be utilized in both clinical and non-clinical settings, as breathing practice significantly reduced blood pressure,
well as, the cultural universality of complicated grief as a increased heart rate variability and oxygenation, enhanced
paradigm for which the BGQ is a way in which clinicians lung function and improved cardiorespiratory fitness and
can easily assess complicated grief symptoms associated respiratory muscle strength. This study showed that
with PCBD (2012). diaphragmatic breathing has the potential to improve
cognitive function while reducing negative physiological
Another study which used the Brief Grief consequences of stress (2017).
Questionnaire (BGQ) was conducted with military service
members (Delaney, Holloway, Miletich, United States To empower participants and provide cognitive
Navy, United States Marine Corps, Webb-Murphy, awareness and insight into emotional regulation, they were
&Lanouette, 2017). The study was conducted to help provided an additional tool to monitor their own progress on
identify military service members who suffered from a daily and weekly basis. The Likert 11 point scale was
complicated grief due to their experiences in theater. It was provided to each of the participants and used during check-
determined through the study that a BGQ “can help capture in as a means of self-monitoring, and for the group and
many of those with grief related impairment,” and further facilitator to monitor progress. It has been proven as an
suggested that the grief screen be utilized as a standard effective tool, and by using the 11 point scale, studies have
measure to target and treat symptoms associated with grief indicated a greater validity “in the sense that total scores
(2017). more highly estimated the construct underlying the item set
(Flamer, 1983).
III. TREATMENT PLAN
IV. COGNITIVE BEHAVIORAL THERAPY
Current studies show that Persistent Complex TREATMENT PLAN IN A GROUP SETTING
Bereavement Disorder (PCBD) is best treated with
Cognitive Behavioral Therapy (CBT) (Khashab, Kivi, Long-term Group Goals:
&Fathi, 2017 and (Fields, Johnson, Mears, & Johnson, Reduce triggers and lessen symptoms of Persistent
2018). Cognitive Behavioral Therapy helps individuals Complex Bereavement.
confront their cognitive distortions, emotional issues, and Begin and sustain an emotionally healthy grieving
provides the bereaved with a means to accept grief, increase process around the loss.
their spiritual well-being, and increase emotional Develop an awareness of how the avoidance of
intelligence(2017). Recent studies have found that grieving and the attempts to deny the loss have
individuals with PCBD respond to an Integrative CBT affected life.
treatment similarly to those individuals with Post Traumatic Identify feelings associated with the loss of the loved
Stress Disorder (PTSD) (Rosner, Pfoh, &Kotoucova, 2010). one.
Therefore, exposure therapy is integrated during the course Gradually but steadily return to level of functioning
of CBT. This allows for cognitive restructuring whereby the that was normal previous to the loss.
individual identifies and confronts dysfunctional thoughts
and provides for them to experience the situation in a safe V. METHODOLOGY
environment (2010).
A. Session 1-Introduction to Bereavement Group
In addition to Cognitive Behavioral Therapy (CBT), a) Session 1 Objective # 1:
aroma therapy, mindfulness and relaxation techniques were Group members will verbalize an understanding of
integrated into the therapeutic bereavement group. In a the concept and process of grief work
controlled pilot study that measured the effects of
mindfulness-based CBT on depressive symptoms of Interventions: CBT/Rapport
bereaved elderly individuals, there was a significant Building/Psychoeducation/BGQ
reduction in symptoms (O’Conner, Piet, &Hougaard, 2014). Group members will complete BGQ(Ito, Nakajima,
In other studies, which looked at aroma therapy whereby Fujisawa, et al., 2012).
different scents such as lavender and lemon were analyzed,
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Volume 7, Issue 7, July – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Group members will introduce themselves and C. Session 3-What is Loss?
share their losses that precipitated them attending a) Session 3 Objective #1:
group therapy. Group members will identify types of losses and the
Facilitator will provide an overview of the grief impact of loss on daily functioning.
process and elicit group discussion.
Group members will identify common emotional Interventions: CBT/Mindfulness
reactions to death of a loved one and participate in Group members will check-in using Likert Scale to
a discussion about the grief process. discuss current stress level.
Group members will discuss what loss means to
b) Session 1 Objective# 2: them.
Group members will establish goals and rules for They will discuss how their loss has changed their
group. daily routines and resulted in further losses.
Interventions: CBT/Rapport b) Session 3 Objective #2:
Building/Psychoeducation Group members will develop an awareness of the
Facilitator will elicit group members’ expectations interconnectedness of thoughts, feelings, and
and/or goals for group therapy. behaviors.
Group facilitator and members will discuss and
establish the group “Rules.” Including: Interventions: CBT/Mindfulness
Confidentiality Group members will be provided education and
Check-in illustration handout of cognitive triangulation
Likert Scale (Vanderbilt University Medical Center, 2011).
Home practice discussion Group members will discuss an experience where
Session discussion their cognitions and emotions were directly
Home practice impacted by their loss. They will then discuss their
Attendance subsequent behavior.
Home Practice Week 1: Review group goals and Home practice Week 3: Group members will list
prepare to discuss stress level using the Likert ways their losses affect their daily lives throughout
Scale during next group session. this week and will share during the next group
session.
B. Session 2-Stages of Grief
a) Session 2 Objective # 1: D. Session 4- I Statements
Group members will verbalize an understanding of a) Session 4 Objective #1:
the stages of grief as a non-linear Group members will explore, develop, and
process(Maciejewski, Zhang, Block, & Prigerson, demonstrate the ability to use “I” statements
2007). (Hansen, 2015).
Interventions:CBT/Psychoeducation Interventions: CBT/Psychoeducation/Mindfulness
Check-in using Likert Scale to discuss current Group members will check in using the Likert
stress level and home practice review (Flamer, Scale to discuss current stress level
1983; Cirino, 2017). Facilitators will provide education and worksheet
The facilitator will provide handout and education to group members on “I” statements.
on Stages of Grief (Corn, 2013).
Group members will discuss how they have b) Session 4 Objective #2:
experienced the various stages and where they are Group members will use “I” statements to discuss
within the Stages of Grief at this time. cognitions, emotions, and behaviors related to the
loss.
b) Session 2 Objective # 2:
Group members will develop an understanding of Interventions: CBT/Mindfulness
how the stages of grief are part of the ongoing grief Group members will discuss home practice activity
process and must be experienced in order to heal. using “I” statements.
Group members will use “I” statements to discuss
Interventions:CBT/Mindfulness ways they feel they have/have not adapted to
Group members will discuss their individual changes surrounding their losses.
coping strategies as they relate to the stages, and Home practice Week 3: Group members will list
will determine if they allowed themselves to stressors they experience this upcoming week and
experience the stage or avoided the stage (Rice, prepare an “I” statement describing one of their
2015). stressful situations to discuss during the next group
Home Practice Week 2: Group members will session.
review the Stages of Grief handout, and note daily
their thoughts and feelings related to their loss and
experienced stages of grief.
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