Follows Section 23 on Map 1A
Appears at the top of Map 5

You can expect a range of treatment issues to appear, depending on the person’s personality and the nature or meaning of the loss to that person. The meaning of the loss may vary according to whether it is the person’s own loss of function or status, symbolic loss, or loss of another person. Within each of those categories, there is a wide range of meanings of the lost person or function, and thus a wide range of possible reactions.

Treatment issues to be on the lookout for include:

• sadness
• anger, often at the perceived cause of the loss
  • the person who died
  • the person who fired the patient
  • the government
  • God
  • oneself
  • possibly together with prohibitions against its expression, or even against feeling it.
• guilt, for all sorts of reasons, including
  • not having done enough
  • believing that one is the cause of the loss or death
  • at feeling relieved that the other person finally died
  • survivor guilt
• dealing with changed circumstances
  • loss of the other person’s role and function
  • loss of one’s own ability to function as before
• reminiscences
• obsessive thoughts, eg: about the way the other person died or was injured, the way one was treated
• rituals
• giving up the old goals and dreams

Treatment frequency should be addressed immediately, and not be assumed. Commonly, a person in crisis due to grief will benefit from frequent sessions at first, directed primarily toward symptom relief.

Whether the form of treatment should be more supportive, interpretive, cognitive or behavioral will depend on a number of things, including

• the extent of the patient’s prior dependence on the person, object or situation that has been lost.
• the degree and severity of cognitive and emotional disturbances that are triggered or exacerbated by the loss

Supportive psychotherapy can be helpful in providing…

• information about the normal grief process.
• an opportunity to talk about loss.
• encouragement for the patient to take better care of him/herself, through exercise and good eating habits

A grieving patient may not be motivated for self-exploration. Typically, grieving patients want to focus on their loss, and not on any inappropriateness or self-defeating qualities of their own reactions.

It should be noted that grief in itself is not considered a treatable condition by insurance companies, under the assumption that it is a natural reaction and best helped by involvement with family, friends or community resources.
Example: A woman presents herself to a psychologist with the following symptoms: she has been grieving the death of family members for over a month, crying, having trouble sleeping, obsessing. People tell her it’s time for her to move on. What’s the matter with her?
Therapist: Who died?
Patient: my mother, sister and cousin were in a car accident going to my cousin’s wedding. There was a head-on. I was meeting them there. They were all killed. Why can’t I get over it?
Therapist: What you are going through is perfectly normal. If you weren’t grieving, something would be seriously wrong. Other people might not like to hear about it because they want to ease your pain, and they can’t. They care about you and it comes out sounding critical.
Patient: What should I do?
Therapist: You are doing it. Let yourself have your grief. Get support wherever you can. Over time, you will be able to move on, but your loss will never go away completely, and they will always be a part of you. We can talk about your symptoms, or the people who died, or your memories of life with them, or how to deal with the people who want you to stop having feelings, if you want.
But she didn’t want anything more than permission to be who she was and do what she had to do. She thanked the therapist and left. One-session cure.

6e. Formal Diagnosis

Earlier revisions of the DSM listed V62.87: Bereavement as a legitimate diagnosis; however, it was not included in the DSM IV.

If depressive symptoms last a long time, a diagnosis of major depression may be justified.

6f. Psychotherapy for a Grieving Patient With Insurance

Calling grief normal may not make it manageable for a patient who is grieving, but it may allow some insurance companies to refuse payment for psychotherapy.

This can put a therapist in a dilemma if the patient clearly needs help and his/her insurance refuses to cover it. You can…

• call the insurance company for clarification, and possibly convince them to cover it in some way.
• see the patient without insurance, possibly at a reduced rate.
• give a tentative diagnosis of depression or another condition until you are convinced that your patient’s issue is simple grief.
• find an adjunctive care that will work as a primary form of treatment.

6g. Adjunctive Care

Other resources for the treatment of patients who are grieving are discussed in Section 7, where they are treated as adjunctive to individual psychotherapy. However, in many instances they can become primary, either because they provide the most effective forms of treatment or because the patient can’t afford individual work.