Counselling and Psychotherapy: Suicide Grief - Essay Example

Each year there are an estimated 6, 000 completed suicides in the UK (Samaritans, 2006). Each suicide has a dramatic impact on family and friends who are bereaved. The loss of someone of close attachment induces intense grief and mourning, although amongst suicide survivors it appears that a unique emotional response occurs as compared to bereavement for non-violent deaths (Reed & Greenwald, 1991). In general, it has been found that bereavement by suicide tends to be prolonged, and that feelings of shock, self-blame, guilt and social isolation may exist. These facets of suicide bereavement are thought to be due to the thematic content of the grief, the socio-cultural context that the survivor is a part of, as well as the negative impact that suicide has on the functioning of a family/social group itself (Jordan, 2001). There are important clinical implications if suicide bereavement requires a different set of clinical counseling approaches to that of other mourning. However, there are research studies that contend that differences between grieving states do not always occur, and that when they do they are only slight is only slight (Jordan, 2001). A popular bereavement model utilised in counselling is the Kubler-Ross Model (1964) (as cited in Kelly, 1997). Kubler-Ross constructed an eight stage model during her work with dying patients, observing their different way of coping with their impending death. Her theory has been drawn on to provide a framework for interventions with people who are experiencing personal loss, such as through bereavement. The fist stage of the model is denial and isolation, and the bereaved make statements such as, "No, not me". The second stage is that of feeling s of anger, so that the bereaved accept that they are experiencing loss. At the third stage the bereaved try to bargain or postpone the full experience of grieving and mourning for their loss. Stage four, they let go of the anger only to feel an intense sense of loss that results in depression. Finally, during the fifth stage the bereaved accept their loss and the need to grieve, and come to feel at peace with the way things are. In contrast, Kelly (1997) argues that a Kubler-Ross's theory assumes that a person will always experience shock and denial during bereavement, and that letting go and acceptance is necessary to be able to cope eventually following a meaningful loss. Also, he continues, her theory ignores the important contribution of the bereaved cognitive development stage. Instead, he suggests a Cognitive Equilibrium Model (CEM) for the grieving process, which has four phases. Phase one is when the bereaved awareness of loss changes their reality, and their attempts to deny their new reality place them in a sate of cognitive disequilibrium. In phase two, the bereaved may experience ambivalence about their change in reality, as they attempt to avoid accepting their new reality, and to remain in the past. During phase three a person lets go of the past and accepts their new reality, as well as the pain of loss, and begins the process of cognitive change (cognitive equilibrium). In the final phase, the bereaved renegotiates their attitude toward their loss, and relocates it within their life as they adapt on biosychosocial levels to their new reality. Complicated grief has been found to occur following major personal loss, such as bereavement (Shear, Frank, Houck, & Reynolds, 2005). It can be characterized by a person's disbelief and denial; feelings of anger or bitterness; reoccurring painful emotions, with intense yearning; and preoccupied thoughts, which in the case of bereavement may include intrusive and distressing thoughts related to the death of the loved one (Shear et al., 2005). For those who are bereaved by suicide, the sense of shock and disbelief may be extremely intense. Feelings of anger are not uncommon as the bereaved may feel a sense of 'rejection' or 'abandonment' by their loved one's death (Knieper, 1999). They may have recurrent visions of how they might have intervened and prevented the death. And a reported common element of suicide grief is that or recurring images of the deceased, even if the person was not witness to the suicide. So that it appears that the suicide bereavement can be considered a complicated grieving process. The complicated grief that can be experienced by suicide survivors has complex elements that do not occur in other bereavement situations. For example, if the bereaved did find the body then this will be another indelible and traumatic experience (Samaritans, 2006). Alternatively, realizing that a loved one acted on their feeling of hopelessness may cause the bereaved to fear for their own safety during times of distress. At times, the bereaved may find that they identify with the one who has died, and experience anxiety and be vulnerable to suicide ideations themselves (Samaritans, 2006). Unfortunately, a death by suicide often attracts the interest of the media and public, and this attention can add to the distress of family and friends, especially if the death is reported in an insensitive or inaccurate way. This form of bereavement tends also to be associated with a prolonged search for answers as to why their loved one took their own life (Cvinar, 2005). And it can be difficult for the bereaved to accept that they may never actually know why the tragedy occurred. Additionally, during the search for answers each family/social group member may find themselves having different reasons for why they think a death occurred, and this can add strain to relationships, especially when people begin to blame each other (Samaritans, 2006). There is also the tendency for social attitudes to add to the psychological distress, as support may be limited due to people feeling awkward about the death, alternatively the silence of others may be to stigmatise or shame the survivors (Cvinar, 2005). Overall, studies point to those bereaved by suicide as experiencing more feelings of guilt, self-blame and self-questioning, as compared to other forms of bereavement. A counselor is in a key position to assist the suicide bereaved to work through their complicated grief (Knieper, 1999). The counseling context can provide opportunities for the bereaved to talk openly without feeling judged, and to be assisted to take pleasure in the memories they have of their loved one. Studies show that counseling assists the survivors of suicide to; put the death of their loved one into perspective; work through family turmoil resulting from the suicide; to enhance their sense of well being; to educate themselves about suicide and its effects; and to understand and cope with the reactions of other people, all within a safe and supportive environment. Furthermore, counseling interventions are able to provide both short and long-term support, and allows the bereaved to proceed at their own pace when a cline-centred approach is used. Studies have explored the differences in grief experiences of suicide survivors and other survivors, so as to establish the most effective and efficient method of counseling intervention. In 1990, Barrett and Scott compared the suicide bereaved with those bereaved by non-violent deaths using the Grief Experience Questionnaire (GEQ). His sample of 57 women and men aged between 24 and 48 years were interviewed two years following their initial bereavement. There were four self-selected groups by form of death: suicide, accident, unanticipated natural, and expected natural). The results found no significant differences between groups in regards to the frequency of grief reactions common to all bereaved (e.g., denial, anger, yearning and rumination). However, it was found that the suicide bereaved were significantly different from all the other groups on the frequency of the grief reactions of feelings of rejection, feelings of social stigma, and searching for answers. A more recent study by Jordan (2001) has supported these findings that suicide survivors can be differentiated from others in regards to their grieving reactions. Although both studies included survivors of other forms of death, it is contended here that their groups were heterogeneous and may have confounded the results. It may be that the suicide group in each study was more homogenous, as a wide variety of accidents, natural and expected deaths can exist. Also, as the samples were small the significant findings are only tentative at best. In 2005 Shear and colleagues compared the efficiency of psychotherapies across groups of bereaved survivors, as well as stratifying for ethnicity. Eighty-five women and men aged from 18 to 85 years took part in the study. Each participant had to meet the criteria for complicated grief, and were then randomly assigned to either interpersonal therapy (IPT), or to a new treatment developed for the study called 'complicated grief therapy,' which focuses on adaption to a change in reality. Over 19 weeks each participant was administered 16 sessions of their assigned counseling intervention. Outcomes were measured on the Clinical Global Improvement scale, and an Inventory of Complicated Grief. Results showed that both treatments resulted in improvements of complicated grief reactions. However, the response rate was significantly greater for the complicated grief treatment, as compare to the IPT. No significant differences were found across ethnicity, gender, age, time since loss occurred, or the bereaved relationship to the deceased. There was also no significant difference between form of death and type of intervention. Limitations of this study were the small sample size, as well as the wide variation in form of death (i.e., violent death included suicide, homicide or accident, while non-violent death included natural and non-accidental death). Hence, the heterogeneous nature of the sample may have confounded the results. It is evident that those bereaved by suicide experience a grieving process may have elements that differentiate it from other grieving responses to death. It also appears that complicated grief therapy may provide a viable alternative to traditional interpersonal counselling interventions for bereavement due to its focus on cognitive adaption processes, rather than guiding the client towards letting go of their loss. The proposed research project will use a survey design to determine if bereavement due to suicide differs significantly from that of cancer in regards to counseling interventions. A secondary aim of this study is to provide a cross-cultural comparison in the form of a UK sample, as much of the research in this area has only been done in Northern Europe and North America. The proposed project will build on previous research by; having homogenous groups due to the specific nature of the deaths chosen for the study; and having a much larger sample. It is hypothesised that the suicide bereavement group will be experience a different set of grief reactions as compared to that of the cancer bereavement group. It is also expected that the suicide bereavement group will benefit more from complicated grief counseling, Method Participants A power-analysis had determined that a sample of 187 participants is required to determine a treatment effect if one really has occurred. The convenience sample will be recruited from local hospitals, support groups, and the public by way of a brochure and an announcement in the local newspapers asking for participation. The research selection criteria will require that each participant: 1) be over the age of 18 years; 2) speak English as a first language (so as not to misinterpret the surveys); and 3) be experiencing bereavement of no less than 2 years. The sample will be stratified on form of death, either by suicide or by cancer. It is anticipated that the study will have an equal representation of females and males, and it is hoped that a range of ethnic participants will be recruited. Materials and Interventions The Grief Experience Questionnaire (GEQ) (Barrett, 1989 as cited in Barrett and Scott, 1990) is a is a multidimensional survey that measures; general grief; somatic reactions; stigma; guilt; shame; rejection; loss of social support; search for explanation; self-destructive behaviour; and unique reactions. The self-report instrument has 55 items, with each sub-scale being made up of five questions on 5-point Likert scales. The scales are summed across to give sub-scale scores, and a total score. It has high reliability and validity. Interpersonal psychotherapy (ITP) is a proven method in the counseling of bereavement (Shear et al, 2005). The session for this study will be delivered by a qualified therapist (paid in kind). The intervention will be a three phased process; introduction, middle, and termination. During the introduction, participant symptoms will be identified and an IPT inventory completed. In the middle phase there will be a grief focus, where the relationship between grief and interpersonal issues will be discussed. The participant will be guided to re-assess their relationship with the deceased, and encouraged to let go of their feelings of loss. At the termination phase the intervention will be reviewed, and feelings regarding the end of treatment will take place. The complicated grief treatment will also be delivered by a qualified counselor (paid in kind). There will also be an introductory, middle and termination phase. During the introduction the therapist will provide information about normal and complicated grief, and describe cognitive adaption strategies. In the middle phase the therapist guides the participant to pay attention to loss and restoration of cognitive functioning. At the termination phase there will be a review of the intervention, and discussion of feelings about ending treatment. Design The present research project plans to use a quasi-experimental survey research method. To demonstrate the viability of a survey design, a brief review of available methods and a critique of their strengths and weaknesses will be presented. In experimental research there is the explicit assumption that the universe functions according to causal laws (Bailey, Balley, & Burch, 2002). As such, these laws are considered to be linear in form (generally).The purpose of an experimental design is to establish the cause-effect relationship between sets of variables, by way of isolating assumed casual factors, and controlling suspected confounding or extraneous variables. For this reason an experiment is conducted within a laboratory environment to enable the researcher to isolate the cause, and to control for other factors that may influence the result. It is hypothesized that an independent variable causes changes in a dependent variable, and that alternate hypotheses can be provided by other factors that are able to influence the results. The design uses random selection procedures to recruit a sample and randomly allocates participants to two or more groups (i.e., treatment group/s and a control group). Due to these random procedures, experimental methods allow for generalization of results to a wider population, as the sample is more likely to be representative of that population. Hence, the purpose of an experimental design is to reject the alternative hypotheses through a process of elimination so that finally a solitary independent variable can be identified as the cause. Between-groups, within-groups, repeated measures, correlational and some survey designs are examples of experimental research methods. Alternatively, a quasi-experimental research design does not use random allocation of participants to groups, instead they are self-selecting (e.g., they have cancer or they do not have cancer) (Jay & Thomas, 2002). As such, the groups are independent of each other in a critical way. The quasi-experimental design is used in studies that are unable to control the independent variable, or when it is considered unethical or unfeasible to attempt to control the IV. The two main types of quasi-experimental designs are: 1) the non-equivalent control group; and 2) the pre-post design. Non-equivalent control group designs have both a treatment and a control group, whereas the pre-post design has no comparison group, as each participants serves as their own control in regards to their pre-test data. Due to the lack of random allocation the results of quasi-experiments cannot be generalized to a wider population with as much confidence as with an experimental design. There is also the non-experimental design in which no treatments (i.e., independent variable/s) are given to participants (Roberts & Ilardi, 2003). There is no random selection or random allocation of participants, and so the results of the study are unable to be generalized at all, as no causal relationships can be predicted. These designs tend to be used to investigate naturally occurring phenomenon in which the independent and dependent variables vary without researcher intervention. Non-experimental methods are generally used when it is unfeasible or unethical to use an experimental method. Examples of these designs include: 1) the case study (i.e., intensive investigation of one person); 2) ethnographic research (i.e., intensive investigation of a group); and 3) archival research (i.e., investigation of historical data). The advantages of experimental research methods are that the use of quantitative levels of measurement (i.e., numerical data), random selection and allocation procedures, and a controlled environment, allow for higher confidence in the results, as well as greater generalisability of the results (Bailey, Balley, & Burch, 2003). The results are more likely to be reliable, in that the study can be replicated and similar results found over time. It is also more likely to have high internal validity, so that the researcher can be confident that the results obtained are a true representation of what is actually occurring. Furthermore, the experiment is more likely to have high external validity, which means that the results can be generalized, allowing them to be applied to other settings and possibly other populations. However, the limitations of experimental methods are that there must be a large enough sample for the results to be representative and so generalised to a wider population. The method is difficult to conduct in real-world contexts due to the need to isolate variables. And, there the methods are often intrusive, so that using a lab-based approach requires creating an artificial situation to obtain high internal validity. Whereas the quasi-experiment can provide a more real-world context in that the groups are self-selecting, a drawback of this is regression to the mean effects, so that alternative explanations of the results can be provided (Jay & Thomas, 2002). Also, the research method may not represent the true differences between groups in regards to variables that are not measured and that may actually be the reason that the results are the way they are. As such, the quasi-experiment has several risks for its internal validity. Alternatively, whilst non-experimental methods can contribute a wealth of information in regards to the description of participant experiences on a more subjective level, they lack reliability and validity as they do not identify causal reasons that for the results that occur (Roberts & Ilardi, 2003). The proposed study for this project has some limitations. Due to the use of survey instruments that measure subjective attitudes and beliefs, the participant's may experience reactivity, in which they think about the question and so change their opinion on a topic (Jay & Thomas, 2002). Alternatively, some participants may have a pattern of response bias in which they tend to answer questions in a standard manner, for example always choosing the extremes of response options or selecting only neutral answers (Jay & Thomas, 2002). At the surface level this may appear to reflect different groups providing different opinions, whereas at the deeper level it is obvious that they are tending to bias their responses. Procedure Participants will choose a day and time that suits their intervention. Over the course of 19 weeks each participant shall receive 16 individual sessions with their therapist. Following the termination phase the participant shall be provided with the GEQ to complete. They will then be debriefed, informed of the true hypothesis and sincerely thanked for their participation. Ethical Considerations Counselling research must align with ethical codes of conduct to protect the rights and safety of the participants (British Association for Counselling and Psychotherapy [BACP], n.d.; Stern & Elliot, 1997). These ethical codes are based on four over-riding principles: 1) patient autonomy; 2) beneficence for the patient; 3) avoidance of harm to the patient (non-maleficence); and 4) justice (BACP, n.d.). Participation in counselling research must be voluntary on part of the participant, and hey have a right not to be coerced into taking part (i.e., autonomy). The process of gaining informed consent from a participant falls under the principle of patient/participant autonomy. The patient/participant has the right to be informed of what is expected of them during the research, of what the positive and negative consequences of taking part in the research may be, and to be informed of what will happen with the results of the study. Additionally, it is the patient/participant's right to agree to procedures that may affect their body or mind. The researcher is obliged to maximize the benefits of the research to the participant whilst reducing their exposure to harm (i.e., beneficence) (Stern & Elliot, 1997). The Hippocratic Oath of "First do no harm" (i.e., non-maleficence) is closely linked with beneficence, in that a risk-benefit analysis of research procedures needs to be made. In Western society the autonomy of the patient/participant is considered the highest priority, and so once informed of potential risks the patient/participant may choose not to take part in the study. The patient's right to confidentiality of their personal medical details, as well as the information they provide as a research participant allows them to remain anonymous, and to withdraw from the study at any time without penalty or shame (i.e., justice). An ethical dilemma that can arise within counselling research is the process of gaining informed consent while not giving the patient/participant access to the true research hypothesis (i.e., by use of deception). For example, Shear et al. (2005) would not have wanted their participants to know that the true purpose of the study was to determine a link grief experience and mode of death. This is because knowledge of the hypothesis may lead the participants to provide the responses that they believe the researcher wants (i.e., demand characteristics; Bailey, Balley, & Burch, 2002), and so the results would not have been a true representation of the experiences of the participants. Deception in counselling research is acceptable when it does not conflict with the four over-riding principles (BACP, n.d.). Following the use of deception a counselling researcher is required to debrief their patients/participants and so reveal the true hypotheses, except in cases where the debriefing may do more harm than good (e.g., the current debate about debriefing participants in designs that include a placebo group, regarding issues of trust in a therapeutic relationship) (BACP, n.d.). In conclusion, the grieving process for those who are suicide bereaved is argued to be a unique and traumatic experience, although some aspects of the grief reactions overlap with general grieving experiences. To date, a standard bereavement theory does not exist, and as such the ability for counselors to provide the most effective and efficient intervention for suicide survivors is constrained. Furthermore, there is a lack of literature that unequivocally points to a differentiated grieving experience for the suicide bereaved. Also, research that has explored counseling interventions suited to suicide survivors has methodological limitations. It is anticipated that the proposed research project will address the limitations of past studies, and will contribute to the knowledge of suicide bereaved grieving experiences. References Bailey, J. S., Balley, J. S., & Burch, M. (2002). Research methods in applied behavior analysis. NY: Sage Publications. Barrett, T. W., & Scott, T. B. (1990). Suicide bereavement and recovery patterns compared with non-suicide bereavement patterns. Suicide and Life-Threatening Behavior, 20(1), 1-15. British Association for Counselling and Psychotherapy [BACP] (n.d.) Ethical framework for good practice in counselling and psychotherapy. Retrieved June 3rd, 2006, from the BACP website: http://www.bacp.co.uk/ethical_framework/ Cvinar, J. G. (2005). Do suicide survivors suffer social stigma: a review of the literature. Perspectives in Psychiatric Care, 41(1), 14-21. Jay, C., & Thomas, C. (2002). Understanding research in clinical and counselling psychology. London: Lawrence Erlbaum Associates. Jordan, J. R. (2001). Is suicide bereavement different A reassessment of the literature. Suicide and Life-Threatening Behavior, 31(1), 91-102 [Abstract]. Knieper, A. J. (1999). The suicide survivor's grief and recovery. Suicide and Life- Threatening Behavior, 29(4), 353-364. Reed, M. D., & Greenwald, J. Y. (1991). Survivor-victim status, attachment, and sudden death bereavement. Suicide and Life-Threatening Behavior, 21(4), 385-401. Roberts, M. C., & Ilardi, S. S. (2003). Handbook of research methods in clinical psychology. London: Blackwell Publishing. Shear, K., Frank, E., Houck, P. R., & Reynnolds, C. F. III (2005). Treatment of complicated grief. Journal of American Medical Association, 293(21), 2601-2608. Stern, J. E., & Elliott, D. (1997). Research ethics. NY: UPNE. Read More