Keywords

1 Introduction

Losing a loved one can be a traumatic and devastating experience that places the bereaved at a heightened risk of psychological suffering and impairments in functioning (Stroebe & Schut, 1999). Bereavement increases the risk of developing other related mental health conditions such as depression and anxiety-related disorder (Zisook & Kendler, 2007) and is associated with poorer physical health as well as increased suicidality. Feelings of grief and its related symptoms (e.g. insomnia, poor appetite and weight lost) during the bereavement process can be reminiscent of a major depressive episode, MDE (Zisook & Kendler, 2007). The dysphoria in grief however, is likely to decrease in intensity over time, and occurs in waves, whereas depressed mood is more persistent (American Psychiatric Association, 2013). In addition, the pain of grief may be accompanied by positive emotions and humour that are uncharacteristic of the pervasive unhappiness and misery characteristics of MDE. Grief and MDE can also be distinguished on other subtleties, for example, the thought content during grieving features a preoccupation with thoughts and memories of the deceased, rather than self-critical pessimistic ruminations as seen in depression. Typically, symptoms of grief resolve and a progress to restoration of a satisfactory, if changed, life is made by the bereaved.

The relationship between the bereaved and the deceased can have an impact on the degree and severity of grief symptoms. Parents who have experienced the loss of a child tend to have more intense and severe grief symptoms, including heightened levels of suicidality, as compared to other types of bereavement (Zetumer et al., 2015). As compared to losing other loved ones, the death of a child violates the perceived order of natural living and often come unexpectedly. Furthermore, being a parent may also engender a sense of identity and purpose (Rubin & Malkinson, 2001). When a child dies, parents not only experience sadness over the loss but may also feel that a part of themselves have died as well (Malkinson & Bar-Tur, 2005), intensifying the grief experience. Parental bereavement and the accompanying grief experience will be explored further in depth in the following sections. The factors affecting the grief experience are described below:

1.1 Demographics of Bereaved

Old age and female gender (Kersting, Brahler, Glaesmer, & Wagner, 2011; Lobb et al., 2010) have been shown to be associated with adverse bereavement outcomes (Cohen-Mansfield, Shmotkin, Malkinson, Bartur, & Hazan, 2013).

1.2 Relationship to Deceased

Mothers face greater difficulties adapting to a death of a child than fathers (Sidmore, 1999). Parents who lose their only child also have a more difficult time (Dyregrov, Nordanger, & Dyregrov, 2003) as compared to parents who have other living offspring.

1.3 Circumstances of Death

Parents who lose their child by a violent or sudden death are at increased risk of poorer bereavement adaptation (Lehman, Wortman, & Williams, 1987; Murphy, Johnson, Chung, & Beaton, 2003a).

1.4 Culture

In the Chinese culture, the death of a child is considered against the law of nature and shameful as it may represent that the family is not blessed. Parents may condemn themselves, believing that the gods have not blessed them for their wrongdoings either in their current or past lives. Traditional Chinese parents also do not attend their deceased child’s funeral, and the subject of the child’s death is considered a taboo topic and commonly avoided.

Chinese parents cope with their child’s death as claiming it as part of their own destiny, and although they still struggle with the loss, the cultural belief can in part relieve them cognitively from self-blame and guilt by assuming the cause of death as due to supernatural forces of which they are incapable of controlling (Ho & Brotherson, 2007). In addition, there is the belief that even if the deceased is no longer on Earth, he or she is alive in the afterlife, and it is the responsibility of the living family members to continue providing care (Yick & Gupta, 2002).

The various cultural beliefs are complex and can both be helpful and unhelpful in the grieving process. On one hand, the cultural stigmatisation and the discouragement of related emotional expression may impede processing of the loss. On the other hand, these beliefs can also aid in making sense of the loss and facilitating an enduring connection with the deceased beyond the physical loss, alleviating grief symptoms to some extent. Hence, it is important to be aware of the impact of these beliefs on each individual and how it could facilitate the treatment process. In addition, culture also impacts on risk and protective factors and when faced with emotional pain and life stressors, whether individuals resort to maladaptive and destructive suicidal gestures or they tap on internal and external resources to cope (Choo, Harris, Chew, and Ho, 2017). People are influenced by their society and culture, so it is important that such cultural mechanisms and meanings are elicited and woven into conversations to help the bereaved make sense of their grief experience.

The main challenge for the bereaved during the grieving process is to integrate the loss into their lives, make sense of and find meaning in the loss (Neimeyer, 2006). Finding meaning can be conceptualized into sense-making and benefit-finding in adapting to bereavement (Currier, Holland, & Neimeyer, 2006; Davis, Nolen-Hoeksema, & Larson, 1998). Sense-making refers to the survivor’s capacity to find a benign explanation for the loss, which can often be framed in philosophical or spiritual terms. On the other hand, benefit-finding refers to the survivor’s ability to uncover positive outcomes or value in the personal and social consequences of the loss. Failure to construct a sense of understanding in the child’s death and/or life after the loss could result in elevated distress (Davis, Wortman, Lehman, & Cohen Silver, 2000; Murphy, Johnson, & Lohan, 2003b), whereas successful attempts at finding meaning over the grieving process predicted less emotional distress and healthier adaptation (Davis et al., 1998; Murphy, Johnson, & Lohan, 2003b). Thus, the focus of the treatment would be to guide the bereaved in finding meaning in the loss, both sense-making and benefit-finding, through various techniques.

The dual process model, DPM (Stroebe & Schut, 1999, 2008), is a model of coping with loss as opposed to one aimed at explaining the broad range of manifestations associated with bereavement. The DPM describes two categories of stressors associated with bereavement: loss-orientated and restoration-orientated. Loss-orientated refers to the bereaved person’s concentration on, appraisal and processing of the loss experience itself. Restoration-orientated refers to the bereaved person’s struggle to reorient oneself in a changed world without the deceased, re-thinking and replanning one’s life in the face of bereavement. According to the DPM, the process of attending to or avoiding of these two types of stressors is dynamic and fluctuating. This regulatory process is termed as “oscillation”. In other words, at times, the bereaved would confront aspects of loss and tasks of restoration, and at other times, avoid them. It is posited that this process of confrontation avoidance is central in adjustment to bereavement, and maladaptation occurs when there is an extreme and extensive focus on one orientation and avoidance of the other.

As the DPM is a model of coping, it can directly link to and inform intervention. Following DPM principles, if the bereaved person is suffering from complications in their grieving process, intervening to change his or her pattern of confronting versus avoiding loss and restoration-stressors would lead to better adjustment (Shear, Frank, Houck, & Reynolds, 2005). In addition, both loss and restoration techniques would be focused on meaning finding, both sense-making and benefit-finding. An integrative/ eclectic approach would be undertaken (Corey, 2013). Principles of intervention would be derived from the DPM to aid in the understanding of grief, techniques would be drawn from existential therapy (promoting self-awareness, searching for meaning, facing living and dying), person-centred therapy (promoting therapeutic relationship and inner directedness) and postmodern approaches (meaning making). In view of MC’s prominent grief symptoms and her cultural beliefs around death, this approach could help to promote therapeutic alliance and for MC to make sense of her grief through facilitated conversations and help MC to discover her strengths to cope with the losses.

2 Background

Mrs. Choi is a female client in her early 80s, referred for psychotherapy to address her emotional difficulties after her son’s death, 4 months ago. Mrs. Choi currently lives alone in a two-room flat. Her husband passed away around a decade ago. Her deceased son’s girlfriend, Jane, stays over a few times a week.

Mrs. Choi grew up in a large family; she reported little conflict within the family and got along well with all her family members. She described the family environment as boisterous and warm. As a child, Mrs. Choi did not attend formal schooling as girls in the family were not given the opportunity. Her father taught Mrs. Choi and her sisters daily after work. Her parents and majority of her siblings had since passed away, except her older sister.

Mrs. Choi married her husband when she was 21 years old. They had an only son, Sam. She described their marital relationship as “easygoing” with little conflict. Her husband, Mr. Choi, passed away 16 years ago due to a heart attack. She reported feeling “depressed” at the time but continually told herself to “be strong for her son”. She reported her relationship with her son becoming closer after Mr. Choi’s death.

Early last year, Sam stopped working due to medical conditions and was subsequently hospitalised multiple times over the duration of his illness. During Sam’s last hospitalisation, Mrs. Choi was also hospitalised at a different hospital for surgery and was hence unable to take care of Sam. Sam’s girlfriend, Jane, was a major pillar of support during Sam’s illness. Shortly after both Mrs. Choi and Sam returned home from their individual hospitalisations, Sam passed away unexpectedly in his sleep. The cause of death was stated to be organ failure.

3 Assessment

Initial assessment interview was focused on eliciting history and circumstances that triggered Mrs. Choi’s symptoms and nature of symptoms. A suicide risk assessment was also conducted.

Following her son’s death, Mrs. Choi started experiencing low mood and constantly ruminated over the details of Sam’s death. She viewed the medical help that Sam received as inadequate and culminating in his death. She also reported having difficulties in falling asleep, as well as interrupted and poor sleep. She reported having low levels of energy and constantly feeling fatigued and withdrew from social interactions from both neighbours and friends. She also felt guilty and blamed herself for Sam’s death. She reported having passive suicidal thoughts of wanting to “join her son”, and when queried by the clinical psychologist in training during suicide risk assessment, she articulated a plan to overdose on her medication, but she did not report active suicide intent. At the time, she was prescribed sleeping pills and was taking more than recommended (i.e. prescribed two but taking three), which seems to be related to lack of medical understanding, that taking this will help her to sleep better, and not a suicidal gesture. She also asserted that she would not commit suicide as she perceived it as a sin and associated with negative repercussions according to her religious beliefs. During suicide risk assessment, she denied suicide intent and denied active suicide plan. She agreed on taking medication as prescribed, and medication review was arranged promptly with her treating doctor; the treating doctor was informed of the alleged overdose.

Health and Nation Outcome Scales (HoNOS) was administered. Mrs. Choi’s symptoms at initial assessment and over the course of therapy were tracked with the HoNOS, a clinician-rated tool used to measure the health and social functioning of individuals. The HoNOS is a quantitative measure assessing behaviour, impairment, symptoms and social functioning.

4 Formulation

Mrs. Choi’s depressive symptoms were precipitated by an identifiable stressor, namely, her son’s sudden death, and could be understood as grief symptoms. Currently, there is insufficient evidence to support any DSM-V diagnosis, her grief symptoms were prominent and triggered by her son’s death, but the intensity is currently abating, and the duration of her symptoms does not meet DSM-V criteria, e.g. for persistent complex bereavement disorder. Successive experiences of the deaths of significant family members and the resultant feelings of loneliness are in stark contrast to her upbringing in a big and lively family and predisposed Mrs. Choi’s emotional vulnerabilities after her son’s death. Her current grief symptoms were precipitated by her son’s sudden death. Chinese cultural and family expectations of a female’s role to be a wife and mother have been imbued in Mrs. Choi since young, and the death of both her husband and her son may have resulted in a perceived loss of identity and role, which perpetuated her symptoms. Her self-blame and guilt for her son’s death, ruminative tendencies as well as social withdrawal also perpetuated her symptoms. Her religious beliefs are a strong protective factor, helping her to make sense of and stay spiritually connected to the deceased. Her older sister and Jane are important pillars of support in her life. Mrs. Choi also spoke fondly of a job that she held when she was younger, drawing focus to her strengths, resilience, assertiveness and interpersonal skills, especially in an era where there are limited occupational opportunities for Chinese females.

5 Treatment

A summary of the interventions completed with Mrs. Choi across 11 sessions is outlined below. The intervention was delivered with the goals of helping her to process her grief, adjust to a world without her son and ultimately to find an enduring connection with her deceased son while embarking on a new life.

  1. 1.

    Goal-setting

  2. 2.

    Suicide risk assessment, suicide risk monitoring and commitment to safety plan

  3. 3.

    Psychoeducation on importance of medical compliance and monitoring of medical compliance

  4. 4.

    Holistic well-being assessment

    • As part of an ongoing process, Mrs. Choi’s sleep, appetite, energy level and somatic health were monitored.

  5. 5.

    Empathic support to help MC to process her grief experience

  6. 6.

    Supportive ventilation facilitating sense-making and benefit-finding:

    • Circumstances of the dying process

    • Frustrations and resentments regarding medical care

    • Guilt regarding not having done enough – “I am not a good mother”

    • Feelings of shame for being “too emotional”

    • Residual anger towards the deceased

    • Dimensions of loss in concrete terms

    • Social impact of loss

  7. 7.

    Facilitating process of reintegration to find an enduring connection with the deceased and rediscover one’s personal meaning and direction:

    • Discussion of positive memories and shared experiences with deceased

    • Discussion of mutual beneficial contributions between bereaved and deceased

    • Facilitation of process of symbolically taking into the self the best parts of the deceased

  8. 8.

    Encouragement of increased engagement in social interactions and leisure activities

  9. 9.

    Linking Mrs. Choi with volunteers to enhance social interactions

Overall, the HoNOS showed a reduction in severity of problems with nonaccidental self-injury (Mild to Minor), depressed mood (Moderate to Minor), sleep (Mild to Minor) as well as relationships (Mild to Minor).

Scale

Score

Pre therapy

Post therapy

1. Overactive, aggressive, disruptive behaviour

1

1

2. Nonaccidental self-injury

2

1

3. Problem-drinking or drug-taking

0

0

4. Cognitive problems

1

1

5. Physical illness or disability problems

2

2

6. Problems with hallucinations and delusions

0

0

7. Problems with depressed mood

3

1

8. Other mental and behavioural problems

H: 2

H:1

9. Problems with relationships

2

1

10. Problems with activities of daily living

0

0

11. Problems with living conditions

0

0

12. Problems with occupation and activities

0

0

Mrs. Choi no longer has active suicidal ideation although she still expressed a passive desire of wanting to join her family members in the afterlife, which reflect her religious and cultural beliefs rather than active suicide intent; such cultural beliefs are typical of elderly Chinese women in the local context. She also asserted that she would not harm herself and would take good care of herself while she still lives.

Mrs. Choi reported mostly being able to get sufficient sleep without the aid of sleeping pills, although she would still have difficulty falling asleep on average once a week.

Mrs. Choi reported increased interactions with her neighbours, attending events and activities on a weekly basis at the nearby church. She has also attended talks addressing physical health concerns organised by the community centre and has made friends during these events. She has also expressed interest in joining a dance course at the community centre but would like to wait till she heals completely from the operation she underwent last year.

6 Discussion and Conclusion

Mrs. Choi held many of the abovementioned cultural beliefs and initially avoided talking about her loss, perceiving the topic as taboo and others as unwilling to talk to her about it for fear of “bad luck”. As such, she withdrew from social interactions and spent much of her time ruminating about her loss alone. Hence, the initial part of therapy was largely focused on normalising her experiences and rapport building to increase her willingness to open and share.

Intervention also had to be tailored to Mrs. Choi’s cognitive, language and physical ability. For example, focus is on facilitated conversations rather than writing as Mrs. Choi is illiterate.

In summary, an integrative approach, with a focus on finding meaning (sense-making and benefit-finding), was chosen as the approach to aid Mrs. Choi in processing her grief, adjusting to a world without her son and ultimately finding an enduring connection with her deceased son while embarking on a new life. Mrs. Choi responded well to the treatment and showed improvements in various domains of functioning.