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CASE STUDY ON PROLONGED GRIEF DISORDER

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CASE STUDY ON PROLONGED GRIEF DISORDER

1. Introduction

Bereavement comes with a complex set of emotions and feelings that requires a unique

approach as grief is processed in phases and stages that are not definite. The therapist has to

implement humanistic approach and along with that must have sound knowledge of the

socio-cultural context of how grief is processed and identify the resilient proponents in the

character of the client both inherited and acquired. This case study includes treatment plan,

provides insight into the grieving process and reconnection with the deceased one that is

instrumental in shedding light into the gleaming resilience inherent in humans.

2. Case Context and Method

This case study includes detail description of the treatment process of the client who was

struggling with bereavement and grief due to loss of his grandmother. The case study used

audiotapes and case notes of the therapist to compile the data to make this case study. The

client came with his parents and so the parents were asked to wait outside throughout the

session. A consent and confidentiality form was signed by the client regarding the audio tapes

and publication of this case study. The name and significant details about the client has been

carefully removed from this case study and any relevant information that can disclose his

identity are excluded. The client was shown this case study so that any information that is not

preferred is included.

3. Case Description
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Primary Complaint

Mr P, 20 has lost his best friends to suicide at age 13 and one year ago lost his grandmother.

He was left shaken by the sudden deaths of the two significantly important people in his life

at an early age. He has hallucinations of his grandmother and is unable to fall asleep. His

grandmother passed away in sleep and so he believes that sleep may take his life as well. His

academics have suffered and is finding it hard to concentrate in his studies. He frequently

wishes to die and discusses afterlife with his parents. He has pain in his chest since a month.

Constipation has been prevalent along with diarrhoea since 8 months post his grandmother’s

demise.

Personal History

He is the youngest among the 3 children of his parents. His father is an accountant and

mother is education counsellor. His grandparents shifted from India to Canada in 1990. His

father is the second child who soon after getting the bank job shifted to Vancouver. His

mother is also Indian. Being the youngest he received a lot of affection and care from his

parents and siblings. He is more close to his elder sister (23) than his eldest brother (28). He

spent most of his time with his grandmother who lived with them.

Mr. P is well-dressed young man, with an inaudible voice and his words mingle together

making them indecipherable at times. He is frightened to go back to sleep and so he keeps

himself awake. He mentions his grandmother often while discussing his symptoms. He asks

about afterlife and the pain that may take life. He has stopped talking to his friends and has

become hostile to teachers and to his parents. He keeps himself enclosed, reading online

about death mostly. He has broken up with his 3 years girlfriend last month. He has

discontinued his piano lessons since 3 months.

Medical history
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He had asthma at the age of 7 which was cured using homeopathy. He doesn’t have any

symptoms now. He has developed chest pains and the test results are clear. He has taken

medication for his digestive issues for 2 months and went through dietary changes.

Biopsychosocial model for GRIEF

The diagnostic symptoms of grief and depression according to ICD-11 and DSM-5 are

different. But they have shared associations in several cases. ICD-11 includes prolonged grief

diagnosis with differential diagnosis with major depressive disorder and PTSD (ICD-11,

2019). As Mr. P’s case mentions significant loss and bereavement after his grandmother’s

demise. Literature review suggest that grief and bereavement has differences based on the

type of loss that results in distinguished unhealthy coping to grief. The biopsychosocial

model of Kübler-Ross, although lacks validity, has conceptualized grief extensively.

According to a study, yearning is an important factor in the grieving process. It states that

yearning cannot be equated to loss of relationship but it essentially indicates a change in the

relationship dynamic.

The neuro-affective pathways of grief

Panksepp and Watt define grief as a persistent feeling of despair that has ensued after social

loss. Mr. P. did experience. The studies show that separation from social relationships can

activate the neuropathway from the dorsal periaqueductal gray matter (PAG) to the anterior

cingulate cortex. This pathway is aroused by glutamate and corticotropin-releasing factor

(Watt et al., 2009). Oxytocin and prolactin discontinue this activation as they promote social

bonding. Lack of these two neuropeptides can lead to separation distress.

Research have found association between inflammation and chronic psychological distress.

Inflammation markers are found along with cortisol become high in case of bereaved

subjects. Interlukin 6, soluble intercellular adhesion molecule-1, and sE-selectin and C-

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reactive protein are high in bereaved subjects (Cohen et al, 2015). The chest pain may be

associated with bereavement of Mr P.

4. Case Formulation and Treatment Plan

Case formulation

Mr P. has the symptoms of Prolonged Grief Disorder due to bereavement. He has

preoccupation with the deceased, inability to feel, difficulty in engaging in social activities,

longing for the deceased. He mentions “losing a piece of his heart” when he interprets the

loss. The symptoms are reported after a year of the actual demise but have shown themselves

progressively. Added to the grief symptoms, Mr P. has developed fear from sleeping as he

witnessed his grandmother pass away in her sleep. There is anxiety related to death as well.

Prolonged grief disorder is a recent addition in ICD-11 (International classification of

Diseases) 11eth edition (ICD-11, 2019). The significant symptoms of Prolonged Grief

Disorder include intense emotional pain, cognitive, behavioural and social functioning within

6 months after the loss (Prigerson et al., 2009).

Treatment plan

REBT can help deal with the intrusive thoughts he has for sleep. It can help identify the

cognitive distortions and then reduce their impact. Once the cognitive distortions to sleep

beliefs can be cleared, a healthy sleep routine can be established. The ABCDE model

discusses the activating event that is the death by suicide of the best-friend and the demise of

grandmother. Beliefs related to death and loss can be then identified.

Goals of the treatment in REBT

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1- Understanding the process of bereavement and grief. It entails developing grief and

bereavement vocabulary. Identifying the emotions and their physical and

physiological sensations. Then develop a plan to handle emotions related to grief.

2- Changing and correcting the irrational beliefs towards grief and loss of loved one.

This will employ ABC model where A is the activating event which has led to

formation of B-beliefs. The relationship between Beliefs and their Consequences can

be identified collaboratively.

3- Calibrating emotions and developing coping mechanisms

Emotions can be measured to scale the changes that will result after interventions.

Identifying healthy and unhealthy coping mechanisms using the ABC model

(Malkinson et al, 2010). This will be implemented by asking the client to fill Belief-

Emotions-Action questionnaire.

4- Decrease grief and bereavement and incorporate healthy coping. This will entail

behaviour modification techniques as Mr. P. isolates himself.

5- Reducing intrusive thoughts during the sleep. This will require Worry worksheet to be

filled where each worry can be Disputed for their rationality. A sleep routine can be

established next.

Session Intervention Result

1- Identifying the sleep Worry sheet was filled. The client learnt to dispute

beliefs Identified believes:- I will his irrational thoughts and

die in sleep just like my beliefs pertaining to death

grandmother. and sleep.

Disputed with evidence-

Questions asked to research He started to try to fall

how many healthy people asleep.

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have died in sleep. In 3 weeks, sleep became

easier.

Belief changed to- People

with severe health

complications and old

people may die in sleep.

2- Identifying the 1- Created a vocabulary The client learnt to articulate

difficult emotions in mother-tongue his emotions and started to

language for grief keep a journal around. This

and associated kept him in contact with his

feelings. Guilt, fear emotions. He stopped

and loss, numbness, feeling the need to shut

sadness, longing. himself in his room. He

2- Rated the emotions decided to talk about his

on a scale of 0-10. emotions with his mother

3- Identified the after 2 weeks.

feelings and bodily

sensations. Fear

(Rated 7) is in the

belly. It is about

uncertainty. Guilt

(rated 9) is in the

throat. It is filled

with unsaid words

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and emotions.

Numbness (9) is like

a heavy blanket over

the emotions of loss.

3. Coping with emotions 1- Fear of uncertainty has Mr. P started to take regular

been reduced by listing the baths and listen to self-help

things that are certain about and motivational videos.

today. Then feelings of

uncertainty was rated. The He started to do mild

client had to repeat this exercise after 2nd month of

exercise every time he felt the treatment.

fear.

To cope with guilt, the client

was asked to write a letter to

his grandmother.

For numbness, the client

understood that loss has to

be accounted for.

4- Identifying the Psycho-education of the He started watercolor

healthy and grief cycle was done. Then painting. He could discuss

unhealthy coping. ABC model was fond memories of his

implemented to segregate grandmother with his family

healthy and unhealthy by 3rd month.

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coping mechanisms to loss.

Alternates to unhealthy

coping were collaboratively He still had the yearning

discussed. The client rated down to 6, while his

mentioned that writing numbness has reduced to 4,

poetry helps and at times guilt to 4 and fear to 2.

painting helps to access the

emotions safely without

getting overwhelmed.

The client showed concern for his yearning that he couldn’t cope with. He wanted to feel the

connection with his grandmother. This is where the therapist decided to shift another

therapeutic modality after 6th session which was precisely after 3rd month.

Gestalt therapy can help to re-establish the connection that is perceived to be lost since the

death of the loved ones. Gestalt means to become whole which is opposite to loss. The empty

chair technique can be utilised to face difficult emotions of Mr P. associated with loss. The

exaggeration technique can help to identify the emotions behind the somatic chest pain. It can

also help address the digestive issues faced by Mr P.

The client was asked to imagine his grandmother sitting right in front of him in the opposite

chair. He started to speak about the letters he had written. The therapist assumed a passive

role and only observed. The client went from accusing his grandmother for leaving him early.

Guilt and anger was processed. He turned towards therapist and asked if he can hug his

grandmother. Psychodrama is an essential part of gestalt therapy which recreates the

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memories and let the unsaid be said. The client wanted to meet his grandmother before she

goes to sleep the fateful night. In psychodrama, the client says his goodbye and hugs his

grandmother. After the session, the client describes feeling ‘healed’, ‘full’ and having a warm

threat connected to his grandmother. Gestalt therapy also provides insight. The client feels

surprised to know that the connection was never lost in the first place. He mentions that

through this connection he can live his life differently now. The therapist has found gestalt

therapy to be effective in grief and loss especially when clients are struggling at the blame

and guilt stage (Dayton, 2005). Rebuilding the routine becomes easier for clients once they

have found a meaning to their perceived loss of the connection. Mr. P. discusses why he gave

up piano. He mentions that his grandmother was the one who insisted him to pursue piano

lessons. Soon after a week of the empty chair technique, Mr P. resumes his piano lessons. He

visits India to find answers to his spiritual questions.

Positive psychology can be used at this juncture. Gratitude helps to reconnect with ancestors

and decreased loved ones where fond memories replace the sense of loss. Gratitude gives

meaning to the loss (Elfers et al, 2023). Living a meaningful life is considered an integral part

of positive psychology (Seligman & Csikszentmihalyi, 2000). Changing the narrative of the

experience can increase engagement with others and this has occurred in case of Mr P. as he

restarted his life after he understood the significance of his loss (Bezoff, 2011). Clients begin

to discover different and new sources of meaning and Mr P found meaning in writing poetry

and watercolor painting as meaning making activities (Gillies and Niemeyer, 2006).

5. Course of Treatment and Monitoring of Treatment Progress

Inventory for Complicated Grief by Prigerson et al. was administered after the first

consultation. The treatment was scheduled every week on a Sunday and it spanned for 3

months. There was 2 weeks gap between the 7th and 8th session as the client went to India.
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The first session focused on the identification of irrational beliefs and creating healthy coping

mechanisms. Each session started with monitoring the sleep, feelings of uncertainty and

separation distress using a SUD (subjective unit of distress) rated by the client. Then the goal

of the session was discussed. The client was given Situation-Thoughts-Consequences

questionnaire and Worry worksheet to fill and bring to every week. The worksheets were

used to identify the irrational beliefs and track progress.

The second to fifth session discussed his journal entries worked with his emotional

vocabulary. Homework after second session was to make a list of the emotions and feelings

that he feels the most. He was asked to write few lines of poetry before trying to sleep. This

prevented him from googling death. In the fifth session Inventory for Complicated Grief by

Prigerson et al was administered again. After his visit to India, he was asked to research on

mourning rituals of Hinduism. This helped him prepare positively for the third death

anniversary. In the fourth session, he had to write a letter to his grandmother. He wrote a

letter every day after that session. Common emotions and themes were identified by the

therapist and counsellor from the letters to get insight into the difficult underlying emotions.

After his visit to India, Mr P. had felt reconnected to his roots. This helped him gain a

different perspective regarding his grandmother. Mr. P discussed his emotions with his

parents. Family support and collective grieving helped him immensely. His father had lost his

father which brought resilience in him. Mr. P felt helped by his father’s resilience and

intended to cultivate it for himself. Resilience can be built in the midst of mental illness as

well (Sreelatha et al, 2018). This insight helped him keep a positive outlook.

6. Treatment Outcome:
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Mr P. has shown remarkable changes since his second session. His numbness reduced to 2

after 4th month as his coping mechanisms became healthy. He resumed his piano lessons and

developed his artistic talent in poetry and watercolor painting. His sleep improved and after

the Gestalt psychodrama, Mr P. significant improvements were noticed. His separation

distress reduced since then. The final sessions included follow-up sessions as he decided to

reconnect with his family in India. After 2 months, Mr P. mentioned that he is able to cope

well. His existential questions are discussed to which the therapist encourages him to find

answers in his culture. Spirituality as a coping mechanism helps to address the inner struggle

and is found to increase hope, optimism and bring positive life outcomes (Snyder et al.,

2015).

7. Discussion and Limitations:

Grief and bereavement comes with challenges both for the client and the therapist. Losing

grandparents with whom the client has shared childhood is difficult. The emotions are

overwhelming and DSM-V allows for 2 years to mourn in case of bereavement.

Prolonged grief, however is accompanied by severe impairment exceeding 6 months and

more in socio-cultural context. Gaining insight from the client’s question, therapy

modalities were deficient in addressing the questions regarding death. The therapist found

that grief provided Mr P an opportunity to reclaim his Indian roots. Due to the emotional

nature of the challenge, an eclectic approach was needed. One single modality was not

sufficient. The client required socio-cultural support which a nuclear family in Canada

was deficient in. Hindu traditions approach mourning and grieving as a community work

(Menon, 2014)

8. Implications and Recommendations

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A comprehensive treatment protocol must be modulated and personalized for the client

dealing with bereavement. Social support is found to be essential in recovering from distress.

The socio-cultural context in dealing with grief brings maximum resolution and it helps to

address the spiritual and existential questions that loss of loved ones evoke. Grief processing

of the entire family brings further healing. Clients must be encouraged to discuss their

feelings once they are capable of understanding their own difficult emotions. Bereavement

may be stuck at a phase when the client had difficult relationship with the loved one.

Restoring or realigning the relationship dynamics between the client and the deceased

becomes important step to fully bring meaning to the loss. Future research is required in

identifying the religious and spiritual aspects of grief and bereavement. There is significantly

less mention of dysfunctional relationship dynamics between the grieving and deceased that

serves an impediment in full recovery in the grieving process.

References

 Berzoff, J. (2011). The transformative nature of grief and bereavement. Clinical

Social Work Journal, 39, 262-269.

 Cohen, M.; Granger, S.; Fuller-Thomson, E. (2015) The association between

bereavement and biomarkers of inflammation. Behav. Med., 41, 49–59

 Dayton, T. (2005). The use of psychodrama in dealing with grief and addiction-

related loss and trauma. Journal of Group Psychotherapy Psychodrama and

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 Gillies, J., & Neimeyer, R. A. (2006). Loss, grief, and the search for significance:

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