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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. Scope.

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slide1

Sorgnye perspektiver på livet med dødenThe Dual Process ModelMargaret Stroebe & Henk SchutDepartment of Clinical & Health PsychologyUtrecht UniversityThe NetherlandsInvited Address to the Danish Association of Palliative CareJune 1st, 2007

scope
Scope
  • Differences in ways of coping & adaptation
  • Models of coping
coping with grief assumption western societies cf wortman silver 1987 1989
Coping with Grief:Assumption (Western Societies)(cf. Wortman & Silver, 1987; 1989)
  • Necessary to confront:
  • Grief Work
grief work m stroebe omega 1992
Grief Work(M. Stroebe, Omega, 1992)

Process of:

  • emotionally confronting the reality
  • going over events
  • focusing on memories
  • working toward detachment
  • “Grief work hypothesis”
coping with grief assumption western societies cf wortman silver 1987 19896
Coping with Grief:Assumption (Western Societies)(cf. Wortman & Silver, 1987; 1989)
  • Necessary to confront:
  • Grief Work
  • In C20th grief theories & therapies
doubts about grief work
Doubts about “Grief Work”
  • Alternative ways of effective coping
    • Cultural patterning
coping with bereavement in non western cultures egypt
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)

coping with bereavement in non western cultures bali
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)

doubts about grief work10
Doubts about “Grief Work”
  • Alternative ways of effective coping (non-confrontive)
  • Neglect of effortful struggle
doubts about grief work11
Doubts about “Grief Work”
  • Alternative ways of effective coping (non-confrontive)
  • Neglect of effortful struggle
  • Need for “dosage” of grief
doubts about grief work12
Doubts about “Grief Work”
  • Alternative ways of effective coping (non-confrontive)
  • Neglect of effortful struggle
  • Need for “dosage” of grief
  • Benefits of denial
doubts about grief work13
Doubts about “Grief Work”
  • Alternative ways of effective coping (non-confrontive)
  • Neglect of effortful struggle
  • Need for “dosage” of grief
  • Benefits of denial
  • Other sources of stress
doubts about grief work14
Doubts about “Grief Work”
  • Alternative ways of effective coping (non-confrontive)
  • Neglect of effortful struggle
  • Need for “dosage” of grief
  • Benefits of denial
  • Other sources of stress
  • Lack of empirical evidence
1 expression of emotions well being among bereaved persons schut 1992 stroebe schut stroebe 2005
1. Expression of Emotions & Well-being among Bereaved Persons(Schut, 1992, Stroebe, Schut & Stroebe, 2005)
  • Longitudinal study, 128 recently-bereaved
  • 4 assessments, 2 years
  • Emotional disclosure; adjustment
slide16

Path model of expression of emotions and distress

(Schut, 1992, Stroebe, Schut & Stroebe, 2005)

Expression

of emotions

T1

Expression

of emotions

T2

Expression

of emotions

T3

Expression

of emotions

T4

Distress

T2

Distress

T3

Distress

T4

Distress

T1

slide17

Structural path-analysis of expression of emotions and distress

(Schut, 1992, Stroebe, Schut & Stroebe, 2005)

.45***

Expression

of emotions

T1

Expression

of emotions

T2

Expression

of emotions

T3

Expression

of emotions

T4

.61***

.42***

.63***

Distress

T2

Distress

T3

Distress

T4

Distress

T1

.64***

.63***

.41***

.31*

.17*

Note: * = p<.05, ** = p<.01, *** = p<.001

slide18
2. Grief Work Through Diary Writing: The Pennebaker Paradigm[e.g. Pennebaker & Keough, 1999; Pennebaker et al., 2001)
pennebaker s writing paradigm effects
Pennebaker’s writing paradigm: Effects
  • Reduces physician consultations
  • Improves some immune functions
  • Increases grades among students
  • Improves mood
  • Effective among unemployed, prisoners, chronically-ill patients, etc.
  • Bereaved persons???
the utrecht diary study cf stroebe stroebe schut zech van den bout jccp 2002
The Utrecht Diary Study(cf. Stroebe, Stroebe, Schut, Zech, & van den Bout, JCCP, 2002)
  • 157 recently bereaved men & women
  • Writing & non-writing conditions
  • Assessed mental & physical health (inc. visits to doctor)
slide21
Results

Symptoms decrease over time, but:

No effect of writing on:

  • Emotional intensity
  • Health (“subjective” or “objective”)
conclusions so far
Conclusions so far:

The grief work model needs revision to…

…define when and for whom - and what type of – working through / disclosure is efficacious

grief work models
Phase Model

(Bowlby, 1980)

Shock

Yearning/protest

Despair

Restitution

Task Model

(Worden, 1991)

Accept reality of loss

Experience pain of grief

Adjust to life without deceased

Relocate deceased emotionally & move on

Grief Work Models
dual process model of coping with bereavement stroebe schut death studies 1999
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
  • Analysis of coping: strategies & appraisal
  • Dynamic process of oscillation
slide26

The Dual Process Model of Coping with Bereavement

Stroebe & Schut (Death Studies, 1999)

Everyday life experience

Loss-

oriented

Restoration-

oriented

Attending to life changes

Doing new things

Distraction from grief

Denial/avoidance of grief

New roles/ identities/ relationships

Grief work

Intrusion of grief

letting go-continuing-relocating bonds / ties

Denial/avoidance of restoration changes

oscillation

slide27

Caregiving & Bereavement AdaptationSchulz, Boerner, & Herbert (in Stroebe et al., Handbook of Bereavement Research: 21st Century Perspectives, in press)

  • Caregivers at high risk
  • Most adapt well to bereavement
  • But a few have adverse bereavement outcomes
comparison of models
Phase Model

(Bowlby, 1980)

Shock

Yearning/protest

Despair

Restitution

Task Model

(Worden, 1991)

Accept reality of loss

Experience pain of grief

Adjust to life without deceased

Relocate deceased emotionally & move on

Comparison of Models

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.

complicated grief
Complicated Grief
  • “Deviation in time course and/or intensity from the (cultural) norm”, poor functioning
  • Chronic; absent, delayed, inhibited
  • Prevalence rates
  • Related to other mental health difficulties
  • DSM??? (see Special Issue Omega, 2005, ed. Parkes)
slide30

DPM: Complicated Grief

Everyday life experience

Loss-

oriented

Restoration-

oriented

Attending to life changes

Doing new things

Distraction from grief

Denial/avoidance of grief

New roles/ identities/ relationships

Grief work

Intrusion of grief

breaking-continuing-relocating bonds / ties

Denial/avoidance of restoration changes

Disturbed oscillation:

Traumatic grief

Absent or inhibited grief

Chronic grief

slide32

Gender Differences in the DPM

Everyday life experience

Women

Men

Loss-

oriented

Restoration-

oriented

Attending to life changes

Doing new things

Distraction from grief

Denial/avoidance of grief

New roles/ identities/ relationships

Grief work

Intrusion of grief

Breaking bonds/ ties/relocation

Denial/avoidance of restoration changes

slide34

DPM: Time

Everyday life

experience

Restoration-

orientation

Loss-

orientation

oscillation

slide35

DPM: Time

Everyday life

experience

Restoration-

orientation

Loss-

orientation

oscillation

slide36

DPM: Time

Everyday life

experience

Restoration-

orientation

Loss-

orientation

oscillation

slide37

DPM: Time

Everyday life

experience

“Have I forgot, my Only Love, to love thee,

Severed at last by Time’s all-wearing wave?”

Emily Brönte

Loss-

orientation

Restoration-

orientation

slide39

DPM: Family Dynamics

Restoraiton-

orientation

Loss-

orientation

Loss-

orientation

Restoration-

orientation

Loss-

orientation

Restoration-

orientation

Restoration-

orientation

Loss-

orientation

slide40

DPM: Family Dynamics

Restoraiton-

orientation

Loss-

orientation

Loss-

orientation

Restoration-

orientation

Restoration-

orientation

Loss-

orientation

slide41

DPM: Family Dynamics

Restoration-

orientation

Brother

Loss-

orientation

Children

Wife

Loss-

orientation

Restoration-

orientation

Restoration-

orientation

Loss-

orientation

Grandchildren

dpm evidence
DPM: Evidence
  • Gender differences in loss / restoration in bereaved couples
  • Gender differences in intervention efficacy
  • Intervention efficacy: DPM vs. Traditional
dpm evidence43
DPM: Evidence
  • Gender differences in loss / restoration in bereaved couples
  • Gender differences in intervention efficacy
  • Intervention efficacy: DPM vs. Traditional
slide44

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
  • 6, 13, 20 months post-loss
  • Interviews / questionnaires
  • Own and partner’s coping (DPM) & adjustment
slide45

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 RO -> better
  • Hi RO buffered against impact of hi LO
  • For men, having hi RO partner helped adjustment
dpm evidence46
DPM: Evidence
  • Gender differences in loss / restoration in bereaved couples
  • Gender differences in intervention efficacy
  • Intervention efficacy: DPM vs. Traditional
evaluation of grief counseling utrecht study schut stroebe de keijser van den bout 1997
Evaluation Of Grief Counseling: Utrecht Study(Schut, Stroebe, de Keijser & van den Bout, 1997)
  • Participants
    • Widows & widowers
    • Medium / high distress
    • Non-intervention controls
  • Counseling:
    • Client centered vs. behavior therapy
    • 7 sessions, 14-17 months post-loss
  • Measure:
    • General Health Questionnaire (GHQ)
slide48

Behav. Treatment

Client centered

Schut, Stroebe, avan den Bout & de Keijser (1997) British Journal of Clinical Psychology

levels of distress by therapy type females schut stroebe de keijser van den bout bjcp 1997
Levels of Distress by Therapy Type: Females(Schut, Stroebe, de Keijser, & van den Bout, BJCP, 1997)
dpm evidence51
DPM: Evidence
  • Gender differences in loss / restoration in bereaved couples
  • Gender differences in intervention efficacy
  • Intervention efficacy: DPM vs. Traditional
dpm treatment of complicated grief shear frank houck reynolds jama 2005
DPM: Treatment of Complicated Grief(Shear, Frank, Houck, & Reynolds, JAMA, 2005)
  • Participants
    • Bereaved men & women meeting CG criteria
  • Interventions
    • Interpersonal psychotherapy (IPT)
    • Complicated grief treatment (CGT, based on DPM)
small group discussion themes
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?
  • More fundamentally: Can one “translate” the DPM for use in palliative health care settings?
  • What are the limitations of the DPM?
  • Suggestions for adapting or extending the DPM?