1. 1 Sorg nye perspektiver på livet med døden The Dual Process Model Margaret Stroebe & Henk Schut Department of Clinical & Health Psychology Utrecht University The Netherlands Invited Address to the Danish Association of Palliative Care June 1 st, 2007

2. Scope Differences in ways of coping & adaptation Differences in ways of coping & adaptation Models of coping Models of coping

3. Differences in ways of coping & adaptation

4. Coping with Grief: Assumption (Western Societies) (cf. Wortman & Silver, 1987; 1989) Necessary to confront: Necessary to confront: Grief Work Grief Work

5. Grief Work (M. Stroebe, Omega, 1992) Process of: emotionally confronting the reality emotionally confronting the reality going over events going over events focusing on memories focusing on memories working toward detachment working toward detachment “Grief work hypothesis” “Grief work hypothesis”

6. Coping with Grief: Assumption (Western Societies) (cf. Wortman & Silver, 1987; 1989) Necessary to confront: Necessary to confront: Grief Work Grief Work In C20 th grief theories & therapies In C20 th grief theories & therapies

7. Doubts about “Grief Work” Alternative ways of effective coping Alternative ways of effective coping Cultural patterning Cultural patterning

8. Coping with Bereavement in Non-Western Cultures: Egypt In Egypt the bereaved are encouraged to dwell profusely on their subjective pain in an atmosphere where … others also immerse themselves in tragic tales and expressed sorrow. (Wikan, 1988, p. 455)

9. Coping with Bereavement in Non-Western Cultures: Bali In Bali laughter and cheerfulness fill the air while the bereaved are enjoined to contain their sorrow and may be made to feel they commit an injustice to others should they fail to abide by this demand. (Wikan, 1988, p. 455)

10. Doubts about “Grief Work” Alternative ways of effective coping (non- confrontive) Alternative ways of effective coping (non- confrontive) Neglect of effortful struggle Neglect of effortful struggle

11. Doubts about “Grief Work” Alternative ways of effective coping (non- confrontive) Alternative ways of effective coping (non- confrontive) Neglect of effortful struggle Neglect of effortful struggle Need for “dosage” of grief Need for “dosage” of grief

12. Doubts about “Grief Work” Alternative ways of effective coping (non- confrontive) Alternative ways of effective coping (non- confrontive) Neglect of effortful struggle Neglect of effortful struggle Need for “dosage” of grief Need for “dosage” of grief Benefits of denial Benefits of denial

13. Doubts about “Grief Work” Alternative ways of effective coping (non- confrontive) Alternative ways of effective coping (non- confrontive) Neglect of effortful struggle Neglect of effortful struggle Need for “dosage” of grief Need for “dosage” of grief Benefits of denial Benefits of denial Other sources of stress Other sources of stress

14. Doubts about “Grief Work” Alternative ways of effective coping (non- confrontive) Alternative ways of effective coping (non- confrontive) Neglect of effortful struggle Neglect of effortful struggle Need for “dosage” of grief Need for “dosage” of grief Benefits of denial Benefits of denial Other sources of stress Other sources of stress Lack of empirical evidence Lack of empirical evidence

15. 1. Expression of Emotions & Well- being among Bereaved Persons 1. Expression of Emotions & Well- being among Bereaved Persons (Schut, 1992, Stroebe, Schut & Stroebe, 2005) Longitudinal study, 128 recently-bereaved Longitudinal study, 128 recently-bereaved 4 assessments, 2 years 4 assessments, 2 years Emotional disclosure; adjustment Emotional disclosure; adjustment

16. Expression of emotions T1 Expression of emotions T2 Distress T1 Distress T2 Distress T3 Distress T4 Expression of emotions T3 Expression of emotions T4 Path model of expression of emotions and distress (Schut, 1992, Stroebe, Schut & Stroebe, 2005)

17. Expression of emotions T1 Expression of emotions T2 Distress T1 Distress T2.61***.64*** Distress T3 Distress T4 Expression of emotions T3 Expression of emotions T4.42***.63***.41***.17*.31* Note: * = p<.05, ** = p<.01, *** = p<.001.45*** Structural path-analysis of expression of emotions and distress (Schut, 1992, Stroebe, Schut & Stroebe, 2005)

18. 2. Grief Work Through Diary Writing: The Pennebaker Paradigm [e.g. Pennebaker & Keough, 1999; Pennebaker et al., 2001)

19. Pennebaker’s writing paradigm: Effects Reduces physician consultations Reduces physician consultations Improves some immune functions Improves some immune functions Increases grades among students Increases grades among students Improves mood Improves mood Effective among unemployed, prisoners, chronically-ill patients, etc. Effective among unemployed, prisoners, chronically-ill patients, etc. Bereaved persons??? Bereaved persons???

20. The Utrecht Diary Study (cf. Stroebe, Stroebe, Schut, Zech, & van den Bout, JCCP, 2002) 157 recently bereaved men & women 157 recently bereaved men & women Writing & non-writing conditions Writing & non-writing conditions Assessed mental & physical health (inc. visits to doctor) Assessed mental & physical health (inc. visits to doctor)

21. Results Symptoms decrease over time, but: No effect of writing on: Emotional intensity Emotional intensity Health (“subjective” or “objective”) Health (“subjective” or “objective”)

22. Conclusions so far: The grief work model needs revision to… …define when and for whom - and what type of – working through / disclosure is efficacious

23. Models of coping

24. Grief Work Models Phase Model (Bowlby, 1980) ShockYearning/protestDespairRestitution Task Model (Worden, 1991) Accept reality of loss Experience pain of grief Adjust to life without deceased Relocate deceased emotionally & move on

25. Dual Process Model of Coping with Bereavement (Stroebe & Schut, Death Studies, 1999) A taxonomy to describe ways people come to terms with the loss of a close person: Two categories of stressors Two categories of stressors Analysis of coping: strategies & appraisal Analysis of coping: strategies & appraisal Dynamic process of oscillation Dynamic process of oscillation

26. Loss- oriented Grief work Intrusion of grief letting go-continuing- relocating bonds / ties Denial/avoidance of restoration changes Everyday life experience Restoration- oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/ identities/ relationships The Dual Process Model of Coping with Bereavement Stroebe & Schut (Death Studies, 1999) oscillation

27. Caregiving & Bereavement Adaptation Schulz, Boerner, & Herbert (in Stroebe et al., Handbook of Bereavement Research: 21st Century Perspectives, in press) Caregivers at high risk Caregivers at high risk Most adapt well to bereavement Most adapt well to bereavement But a few have adverse bereavement outcomes But a few have adverse bereavement outcomes

28. Comparison of Models Phase Model (Bowlby, 1980) ShockYearning/protestDespairRestitution Task Model (Worden, 1991) Accept reality of loss Experience pain of grief Adjust to life without deceased Relocate deceased emotionally & move on DPM (Stroebe & Schut, 1999) Accept reality of loss …and accept reality of changed world. Experience pain of grief …and take time off from pain of grief. Adjust to life without deceased … and master the changed (subjective) environment. Relocate deceased emotionally & move on …and develop new roles, identities, relationships.

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

30. Loss- oriented Grief work Intrusion of grief breaking-continuing- relocating bonds / ties Denial/avoidance of restoration changes Everyday life experience Restoration- oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/ identities/ relationships Chronic grief Absent or inhibited grief Disturbed oscillation: Traumatic grief DPM: Complicated Grief

31. DPM: Gender Differences

32. Loss- oriented Grief work Intrusion of grief Breaking bonds/ ties/relocation Denial/avoidance of restoration changes Everyday life experience Restoration- oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/ identities/ relationships WomenMen Gender Differences in the DPM

33. DPM: Time

34. Loss- orientation Everyday life experience Restoration- orientation DPM: Time oscillation

35. Loss- orientation Everyday life experience Restoration- orientation DPM: Time oscillation

36. Loss- orientation Everyday life experience Restoration- orientation DPM: Time oscillation

37. Loss- orientation Everyday life experience Restoration- orientation DPM: Time “Have I forgot, my Only Love, to love thee, Severed at last by Time’s all-wearing wave?” Emily Brönte

38. DPM: Family Grief

39. Loss- orientation Restoraiton- orientation DPM: Family Dynamics Restoration- orientation Loss- orientation Loss- orientation ♀ ♂ Restoration- orientation Loss- orientation Restoration- orientation

40. Restoraiton- orientation DPM: Family Dynamics Restoration- orientation Loss- orientation Loss- orientation ♀ Restoration- orientation Loss- orientation

41. Restoration- orientation DPM: Family Dynamics Restoration- orientation Loss- orientation Loss- orientation Restoration- orientation Loss- orientation Brother Grandchildren Children Wife

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

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

44. Parental Loss of a Child Study (Wijngaards, Stroebe, Stroebe, Schut, van den Bout, van der Heijden, & Dijkstra (British Journal of Clinical Psychology, in press) Participants & Design: 219 parental couples 219 parental couples 6, 13, 20 months post-loss 6, 13, 20 months post-loss Interviews / questionnaires Interviews / questionnaires Own and partner’s coping (DPM) & adjustment Own and partner’s coping (DPM) & adjustment

45. Parental Loss of a Child Study (Wijngaards, Stroebe, Stroebe, Schut, van den Bout, van der Heijden, & Dijkstra (British Journal of Clinical Psychology, in press) Results: Hi LO -> poor adjustment Hi LO -> poor adjustment Hi RO -> better Hi RO -> better Hi RO buffered against impact of hi LO Hi RO buffered against impact of hi LO For men, having hi RO partner helped adjustment For men, having hi RO partner helped adjustment

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

47. Evaluation Of Grief Counseling: Utrecht Study (Schut, Stroebe, de Keijser & van den Bout, 1997) Participants Participants Widows & widowers Widows & widowers Medium / high distress Medium / high distress Non-intervention controls Non-intervention controls Counseling: Counseling: Client centered vs. behavior therapy Client centered vs. behavior therapy 7 sessions, 14-17 months post-loss 7 sessions, 14-17 months post-loss Measure: Measure: General Health Questionnaire (GHQ) General Health Questionnaire (GHQ)

48. Schut, Stroebe, avan den Bout & de Keijser (1997) British Journal of Clinical Psychology Behav. Treatment Client centered

49. Levels of Distress by Therapy Type: Males (Schut, Stroebe, de Keijser, & van den Bout, BJCP, 1997)

50. Levels of Distress by Therapy Type: Females (Schut, Stroebe, de Keijser, & van den Bout, BJCP, 1997)

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

52. DPM: Treatment of Complicated Grief (Shear, Frank, Houck, & Reynolds, JAMA, 2005) Participants Participants Bereaved men & women meeting CG criteria Bereaved men & women meeting CG criteria Interventions Interventions Interpersonal psychotherapy (IPT) Interpersonal psychotherapy (IPT) Complicated grief treatment (CGT, based on DPM) Complicated grief treatment (CGT, based on DPM)

53. Treatment of Complicated Grief Study (Shear, Frank, Houck, & Reynolds, JAMA, 2005)

54. Small Group Discussion Themes To what extent have you used the Phase, Task or DPM Models in your work? What is your experience with these Models? To what extent have you used the Phase, Task or DPM Models in your work? What is your experience with these Models? More fundamentally: Can one “translate” the DPM for use in palliative health care settings? More fundamentally: Can one “translate” the DPM for use in palliative health care settings? What are the limitations of the DPM? What are the limitations of the DPM? Suggestions for adapting or extending the DPM? Suggestions for adapting or extending the DPM?