Question 1

How would DBT approach the numbness or dissociation that can be present with complicated grief?

Nicholas Salsman · Accepted Answer

I find it helpful to think of mindfulness as being almost an opposite to dissociation. Dissociation involves the lack of being present and mindfulness is fully focusing your attention on the present moment. As discussed in some of the questions above, I have found that when individuals engage in repeated and pervasive practices of mindfulness, it can be very helpful with the symptoms of Persistent Complex Bereavement Disorder (PCBD) or Prolonged Grief Disorder (PGD) and particularly with dissociation.

Numbness or flatness of emotions can occur for many individuals with PCBD or PGD. A DBT emotion regulation skill that can be very helpful in targeting numbness or emotional flatness is the skill of mindfulness of current emotions. This skill involves practicing close attention to internal experiences. Some individuals are able to describe and label emotions specifically. However, many individuals coming to DBT experience the problem of alexithymia, or inability to describe emotions. Mindfulness of current emotions can be very useful for individuals with alexithymia as it helps people to focus their attention on even small changes in their body sensations. There is not a requirement that the individuals label their emotions, although skills for labelling emotions are also taught so that people can build up their ability to do so. Through being present with the body sensations of an emotional experience, even when these sensations are small, a person can take steps away from numbness and flatness.

A similar problem that can occur with individuals with PCBD is anhedonia, or not experiencing enjoyment in their lives. Accumulating positive emotions is a set of skills that is taught in DBT emotion regulation. I like to use the metaphor of muscle atrophy with regards to anhedonia. I once had an injury to my left leg and I couldn’t put weight on that leg. My left thigh muscles became weaker and atrophied due to not being used. Anhedonia is like your enjoyment muscles have atrophied. Similar to the physical therapy I had for my left leg, with anhedonia people need to have regular exercise to rebuild their enjoyment muscles. The accumulating positive emotions skills are the exercises needed to rebuild enjoyment muscles. Individuals are taught three strategies: accumulating positive emotions in the short term through mindful engagement in pleasant events; accumulating positive emotions in the long term through engaging in actions connected to one’s values; and accumulating positive emotions through nurturing effective relationships. Through engaging in each of these strategies on a daily basis, individuals can experience improvements in anhedonia and increases in fulfilment. Directly treating dissociation, numbness or flatness of emotions, and anhedonia with DBT skills targeted to treat these problems can be very helpful for individuals with PCBD or PGD.

Question 2

How can DBT help someone who has lost a family member to suicide?

Nicholas Salsman · Accepted Answer

This is such an extremely painful situation. Death by suicide is a factor that can increase the likelihood that someone develops Persistent Complex Bereavement Disorder (PCBD) or Prolonged Grief Disorder (PGD). Family members who experience this can go through many difficulties such as preoccupation with how their loved one died, anger and bitterness about the death, difficulty with trusting people, feelings of loneliness, detachment and isolation. They also may have a desire to join their loved one in death and be at greater risk for suicidal behaviors themselves (Mitchell et al., 2004). In our treatment study, we worked with a man whose son had died by suicide. He experienced many of the symptoms of PCBD listed above. As in prior examples, we found that having him practice the DBT skills was helpful for him. A theme in DBT is ‘building a life worth living’. As I mentioned when discussing radical acceptance in a previous answer, individuals practice how life can be worth living even when there is immense pain. For this man, as with most people, the relationships in his life were critical to his life worth living. I will highlight how some of the DBT interpersonal effectiveness skills helped him through his symptoms of PCBD.

When the man began DBT skills training, in addition to experiencing deep sadness, he also was withdrawing, isolating, and experiencing bitterness and reduced trust of others. Similar to some of the others mentioned previously, he found that the mindfulness, distress tolerance, and emotion regulation skills were helpful. Through his work he recognized the importance of the people in his life and he wanted to improve the ways that he was engaging with his friends and family. The interpersonal effectiveness skills helped him to build, re-build, and invigorate the relationships in his life. For example, the skill of clarifying goals in interpersonal situations is about individuals being mindful of and using wisdom to determine priorities when engaging in an interaction. Three priorities considered are: objective effectiveness (what are the results I want in the interaction?); relationship effectiveness (how do I maintain or improve the relationship, even if I don’t get the objective I want from the interaction?); and self-respect effectiveness (how do I keep or improve respect for myself based on how I handle the interaction?). When practicing this skill, individuals pause before engaging in the interaction to consider these three priority areas and how they may rank them in terms of importance. The man who lost his son to suicide utilized this skill to make more mindful decisions in his interactions with his friends and family. He recognized how engaging with relationship effectiveness could help him feel more connected to others. He engaged with relationship effectiveness by using gentleness, expressing interest, validating, and using an easy manner (the DBT relationship effectiveness skills are identified with the acronym G.I.V.E.). He noticed that not only were his loved ones responding in more connected ways, but that he was feeling more connected as well. As he felt more connected, he noticed that some of the symptoms of PCBD also reduced (such as isolation, mistrust of others, and bitterness). Through the treatment, he increased his experience of his life as worth living.

For anyone who has lost a loved one to suicide or in any other way, it is critical for them to validate their own emotions and get support from others who validate their experiences. Having sadness, anger, fear, and many other emotions is perfectly normal and understandable. Sometimes it is absolutely critical to dedicate time and energy to feeling emotions and soothing through the pain. At other times, a key to effective grieving is recognizing that there is a distinction between emotions and actions. One can feel what they are feeling and choose to act in a way that is aligned with their emotion or can actually act in a completely different way. In DBT, we encourage people to practice a mindfulness skill called ‘wise mind’, which is paying attention to the wisdom inside of themselves. Individuals use wise mind to make decisions like when to act in accordance with emotions and when to act in ways that are not in line with the urges of emotions. Those who are grieving after the suicide of a loved one can use their wisdom to navigate effectively through their pain and find the right balance of acceptance and change.

Question 3

Can you recommend how to help a client with guilt and a sense of responsibility over someone's death, especially if their actions did contribute to the chain of events leading to the death?

Nicholas Salsman · Accepted Answer

In my experiences with people with Persistent Complex Bereavement Disorder (PCBD) or Prolonged Grief disorder (PGD), I have worked with individuals who have experienced a sense of responsibility for their child’s death due to their actions contributing to the chain of events leading to the death. For example, a woman in our study sat with her adult daughter in the emergency room for hours due to her daughter experiencing abdominal pain. After waiting, they made the decision to go home and come back in the morning. Tragically, her daughter died at home that night. Death event factors like this can actually lead to an increased likelihood that individuals develop PCBD or PGD. This woman had remained stuck in the problems of PCBD for years after the death of her daughter.

I would like to highlight some DBT skills that may be helpful for individuals in situations like this. As discussed in a previous answer, mindfulness and radical acceptance may be helpful for these individuals. For example, the woman who waited in the waiting room with her daughter began to take mindful walks every evening after practicing this in her second DBT session. These walks helped her to re-focus her attention away from urges to escape through abusing alcohol and cannabis, which she had been doing almost every night. By the end of treatment, she had stopped using alcohol and cannabis. She also practiced radical acceptance, although she had reluctance to use these skills with regards to the death of her daughter. A history of progress using other DBT skills and a strong relationship with her provider helped to motivate her to practice this skill. One of the ways that she practiced was by noticing urges to follow her typical routine on Mother’s Day of isolating and ruminating on how she wished that her daughter was still alive. Instead, she practiced radical acceptance that she would not see her daughter and instead visited with her grandchildren. She got fulfilment from this visit and recognized that she was not incapacitated by sadness as she had been in previous years. With practice of radical acceptance, she moved from being stuck in persistent grief to becoming more free to experience her life as worth living.

Additionally, DBT teaches a set of three emotion regulation skills for changing emotional reactions. ‘Check the facts’ is a skill that is used to analyze if an emotion at its current intensity and duration fits the facts. For anyone who is struggling with a sense of responsibility over the death of a loved one this may be an important step. The skill invites individuals to check what assumptions and interpretations they are making about the event. For example, the woman who went home from the waiting room with her daughter believed that she caused her daughter’s death and felt intense guilt and shame. It is not factually true that she caused her daughter’s death. Her daughter’s illness caused her death. Further, even if her daughter might have lived had she been treated in the hospital the night that she died, the mother and her daughter took reasonable and understandable steps when they left the hospital that night. She wanted the best care for her daughter and she took the steps that seemed best to accomplish that goal. When check the facts indicates that an emotion or its intensity or duration do not fit the facts, then the next skill to practice is called opposite action. With opposite action, you observe and describe your emotion and identify the action urges associated with your emotion (for example, shame has the action urge to avoid and hide). You decide that you are not going to do the actions that your emotion tells you to do and you decide to do the opposite of those urges. For the woman in our study, opposite action to shame was to not hide and avoid and instead be social and engage. She did not hide the story of her daughter’s death, but instead talked about it both inside and outside of therapy. A key with practicing opposite action is to act opposite all the way by not apologizing and adopting a posture of someone who has not done anything wrong.

In cases where check the facts indicates that someone’s guilt or shame is justified, the skill that is recommended in DBT is problem solving. The skill starts by non-judgmentally observing and describing the problem situation and your emotion. Then, you identify your goal in problem solving, identify a solution that can help you achieve that goal, and put the solution into action. For example, when you have done wrong and feel guilt, the solution typically involves repairing the harm. When someone has died as the result of the harmful action, repair is not possible. Then the task becomes to work to prevent or repair similar harm for others. Individuals in this set of circumstances can work to make amends through using their actions to prevent the same harm from happening again. For example, someone who killed a loved one due to their drunk driving can engage in advocacy to end drunk driving.

Question 4

What is complicated grieving and how is it different or similar to traumatic bereavement?

Nicholas Salsman · Accepted Answer

While there is not unanimous consensus about terminology, many terms including complicated grieving and traumatic bereavement often are used to refer to a similar cluster of problems. Complicated grieving is a term that is often associated with the diagnosis of Prolonged Grief Disorder (PGD) in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5 TR; American Psychiatric Association, 2022). Prior to the text revision, in the DSM-5 (American Psychiatric Association, 2013) Persistent Complex Bereavement Disorder (PCBD) was included as a condition for further study. The criteria for PGD and PCBD have a great deal of overlap, although PCBD is no longer in the DSM-5 TR. A study by Maciejewski et al. (2016) indicated that the diagnostic criteria for PCBD in the DSM5 and PGD in the International Classification of Diseases 11th Revision (ICD-11; World Health Organization, 2019) were measuring the same disorder. The diagnostic criteria for PGD adopted in the DSM-5 TR include:

Experience the death of a loved one over one year prior
A prolonged grief response as indicated by intense yearning and/or preoccupation with the deceased
At least three of eight symptoms including avoidance, intense emotional pain, emotional numbness, loneliness and more
Evidence of clinically significant distress or functional impairment
Exhibit distress which is outside of sociocultural norms
The symptoms are not occurring due to another disorder

As indicated in the criteria for PGD, complicated grieving involves intense suffering by the individuals who experience it. The American Psychological Association defines traumatic grief as ‘a severe form of separation distress that usually occurs following the sudden and unexpected death of a loved one.’ In other words, traumatic grief or traumatic bereavement are types of reactions that may lead to PGD and be closely associated with a diagnosis of PGD.

Priegerson et al. (1999) were early adopters of the term Traumatic Grief, which was a precursor to the terms Prolonged Grief, Persistent Complex Bereavement, and Complicated Grief. Boelen and Smid (2017) developed the Traumatic Grief Inventory and they state, “In the naming of the instrument, we sought to avoid the terms prolonged, complicated, or persistent” to avoid inferring that the inventory was intended to exclusively measure PCBD, PGD, or Complicated Grief as defined by Shear et al. (2011). Lenferink et al. (2022) have noted that while there are differences in the diagnostic criteria of PCBD in the DSM-5, PGD in the ICD-11, and PGD in the DSM-5 TR, these differences may not be particularly clinically significant when measured by the Traumatic Grief Inventory.

Question 5

How would a DBT approach help a male in his 70s with loss, grief and adjustment? He has been caring for his wife with dementia at home and it's been difficult. She is now in full-time care.

Nicholas Salsman · Accepted Answer

Dialectical Behavior Therapy (DBT) is a treatment that was developed by Marsha Linehan (1993) and has been shown to have strong empirical support as a treatment for problems like Borderline Personality Disorder (BPD). It is a skills-based treatment that can be delivered as a comprehensive treatment including weekly individual therapy, weekly skills training, as needed telephone consultation, and provider consultation team. DBT is meant to be a treatment for problems that develop and are maintained because of difficulties with emotion regulation. The skills that are taught in DBT target four areas of skills deficits often experienced by people with pervasive difficulties with emotion dysregulation: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. DBT practitioners seek to dialectically synthesize acceptance and change.

The research on DBT as a treatment for grief related problems is limited. My colleagues and I conducted a small study utilizing DBT skills training and DBT consultation team (that is, not comprehensive treatment) with individuals with Persistent Complex Bereavement Disorder (PCBD) who had a child who died (Barrett, Tolle, & Salsman, 2017). This premise of using DBT skills training with these individuals was based on the idea that at the core of PCBD is problems with emotion regulation. DBT as a full, comprehensive treatment may not actually be an appropriate treatment for all individuals with loss, grief, and adjustment. More research is needed to understand how DBT as a formal treatment may be useful for individuals with PCBD or Prolonged Grief Disorder (PGD) and those without diagnoses who are grieving. However, there are DBT skills which may be useful for individuals who struggle with loss, grief and adjustment, particularly those who experience significant emotion dysregulation.

My heart goes out to the man described in the question, as I am sure that he is in such an incredibly difficult and painful situation. Among the individuals that we treated in our study, there are a number of skills that were helpful to them that might also be helpful to this man and people in similar situations. In DBT, the core set of skills is called mindfulness. Mindfulness practices involve focusing attention in the present moment. In moments, it is critical to fully and mindfully experience the emotions that come with grief, like sadness. Grief can also greatly impact attention in ways that perpetuate problematic effects of the grief. For example, many individuals who are grieving understandably have their attention drawn to the past, but these thoughts may turn to ineffective preoccupation or rumination. By practicing mindfulness skills, individuals can improve their skills in purposefully controlling their attention. In moments when it is wise to reflect on the past, the individual can intentionally allow mindful attention to be on the past. In moments when it is not helpful to attend to the past, the individual can change the focus of their attention to something else (such as mindfully doing the dishes). For many of us, when we focus our attention on one thing it gets pulled away to another. If attention gets pulled back to the past, mindfulness practice involves gently bringing attention back to the present moment (for example, notice attention has been pulled into thoughts and gently bring focus back to observing the movement of hands while doing the dishes). An individual may have many cycles of attention being pulled away and gently bringing their attention back. I find the metaphor of lifting weights useful in these cases. Each cycle of bringing your attention back is like another ‘rep’ with the weights, strengthening your mindfulness ‘muscles’. By repeatedly practicing mindfulness, a person can improve their ability to stay present in their life in ways that reduce suffering.

Another skill that I would highlight as potentially being helpful in this situation is the skill of radical acceptance, which is part of the DBT distress tolerance skills. This skill is based on the premise that suffering comes from non-acceptance of pain. While pain is an inevitable part of life (which is not distributed evenly or fairly), suffering can be avoided through acceptance. The word ‘radical’ is paired with acceptance to indicate that this practice is meant to be complete and total, with mind and body. Acceptance does not mean approval or giving up. Instead, acceptance is focused on anchoring oneself in reality just as it is. By practicing radical acceptance, a person may fully experience their grief, disappointment, and sadness, which is incredibly difficult. However, this practice will help the person to work through their pain instead of being stuck in suffering. With this practice, a person can experience life as worth living even with immense pain in it. I once worked with a man who was a musician with PCBD, who had not visited his son’s grave for months after his son’s funeral. He was stuck and suffering. When we reviewed radical acceptance, he decided to practice by going to his son’s grave and playing a song that he had written about his son. This was incredibly difficult for him to do and he experienced immense sadness. However, after doing this, he experienced an increasing sense of peace and more freedom to make some important changes in his life. With further practice he was able to become unstuck.

For the man described in the question, using skills like mindfulness and radical acceptance may help him if he is struggling with problems like ineffective rumination and/or suffering through the painful reality that he is in. Practicing these skills is not doing DBT per se, as DBT involves a comprehensive treatment. Nonetheless, practicing these skills in targeted ways may help to alleviate suffering.

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