Complicated Grief: A Case Study

Treatment of Bereavement Complicated by the Postmortem Discovery of the Secret Life of the Deceased: A Time-Series Analysis of Emotion Focused Therapy

Albert J. Wong and Michael R. Nash

The University of Tennessee, Knoxville

Author Note

Albert J. Wong and Michael R. Nash, Department of Psychology, University of Tennessee, Knoxville.

Correspondence concerning this article should be addressed to Albert J. Wong, 1 H St #203, San Rafael, CA 94901.  [email protected]

Abstract

Although a number of treatment studies have been conducted on complicated grief, many of these studies continue to report relatively modest effect sizes. Additionally, despite numerous randomized control trial (RCT) studies, the mechanisms of change in complicated grief remain unclear. The current study used a time-series approach to examine the effectiveness of Emotion Focused Therapy (EFT) on complicated grief (CG) in a single-subject case study. The CG symptoms of a recently widowed elderly woman were tracked across a 14-session EFT treatment, and the patient demonstrated significant decreases in symptom severity across a variety of measures. Simulation modeling analysis for time-series data was used to evaluate the level change across baseline, treatment, and follow-up phases. This study supports the effectiveness of implementing an EFT approach to the treatment of complicated grief among complex patients and highlights the importance of narrative reconstruction in the treatment of complicated grief.

Keywords: bereavement, complicated grief, Emotion Focused Therapy, EFT, gestalt, time-series

Treatment of Bereavement Complicated by the Postmortem Discovery of the Secret Life of the Deceased: A Time-Series Analysis of Emotion Focused Therapy

1 Theoretical and Research Basis

Purpose

We examine a clinical case study of marital bereavement that is complicated by the postmortem discovery of the secret life of the deceased. Though bereavement is typically construed as a normative response to the death of a loved one, there is increasing awareness within the clinical research community of the phenomenon of “complicated grief,” in which the normal process of mourning is interrupted or derailed. Indeed, the discovery of hidden truths about a loved one after their death can be a complicating factor in the grieving process, especially when what is uncovered threatens to undermine the bereaved’s pre-existing relational attachment narrative regarding the deceased. This paper seeks to highlight the role of narrative reconstruction in the treatment of complicated grief through a time-series analysis and design.

Because of the way in which Emotion Focused Therapy (EFT) appears to incorporate the dominant apparent mechanisms of change implicated in complicated grief, i.e., exposure and cognitive restructuring, EFT was the treatment of choice (EFT; Greenberg, 2004, 2006).

Background

Bereavement is characterized in the DSM-IV as a normative response to the death of a loved one. It is normal to mourn the death of someone that is deeply cared for, and most individuals are able to grieve the loss of a beloved without experiencing serious physical or psychological dysfunction (Bonanno, Wortman, & Nesse, 2004; Middleton, Burnett, Raphael, & Martinek, 1996). Typically, individuals who experience bereavement are able to manage their loss without the use of specific grief interventions (Bonanno et al., 2004; Stroebe, Schut, & Stroebe, 2007; Zhang, El-Jawahri, & Prigerson, 2006). However, not all individuals who experience loss are able to navigate themselves through the mourning process. Some studies estimate that as many as 9% of adults develop complicated grief reactions consequent to bereavement (Middleton et al., 1996; Raphael & Minkov, 1999). Moreover, the consequences of complicated grief (CG) appear to be significant. Numerous studies indicate that prolonged grief can result in diminished psychological and physical well-being across a broad spectrum of dimensions (de Groot, de Keijser, & Neeleman, 2006; Miyabayashi & Yasuda, 2007; Onrust & Cuijpers, 2006; Stroebe et al., 2007). For example, depression, suicide risk, high blood pressure, drug use, and cardiac problems are all positively associated with CG (Agerbo, 2005; Boelen & Prigerson, 2007; Latham & Prigerson, 2004; Stroebe et al., 2007).

Although CG is not a diagnosis that is currently recognized by the DSM, a number of researchers and clinicians have suggested that such a diagnosis should be added to the DSM-V (Dillen, Fontaine, & Verhofstadt-Denève, 2008; Horowitz, Bonanno, & Holen, 1993; Lichtenthal, Cruess, & Prigerson, 2004). Furthermore, multiple studies have indicated that complicated grief is constituted by a distinct cluster of symptoms that is different from normal grief reactions (Boelen & van den Bout, 2008; Dillen et al., 2008). Complicated grief also appears different from mood disorders and anxiety disorders (Lichtenthal et al., 2004).

The proposed diagnostic criteria for complicated grief are, roughly, as follows:

A person may be classified as having complicated grief if, after having been bereaved for at least 6 months, he/she continues to experience culturally non-normative persistent, acute separation distress, as well as maladaptive cognitive, affective, and behavioral impairment (in relation to the bereavement) for a minimum of at least 1 month. Some examples of impairment include debilitating rumination, behavioral avoidance, somatization, etc. (Shear et al., 2011).

Justification for study

Most of the treatment intervention studies for CG have focused on randomized control studies for particular groups of bereaved individuals, e.g., first degree relatives of suicide victims, gay men who have lost a partner to AIDS, or expectant mothers who discover that they have miscarried (Wittouck, van Autreve, de Jaegere, Portzky, & van Heeringen, 2011). Most of these treatment studies have seemed to emphasize the cause of a loved one’s death as a primary complicating risk factor in grief (e.g., miscarriage, suicide, AIDS complications). While it is true that the particular cause of death may be a significant factor in an individual’s development of complicated grief, the case study that will be discussed here suggests that, perhaps, the disruption in the attachment narrative between the bereaved and the deceased may play a more central role than has previously been thought.

Research on complicated grief indicates that treatment effects, in general terms, are positively correlated with the subject’s level of education, motivation for treatment, and completion of treatment (Boelen, de Keijser, van den Hout, & van den Bout, 2011; Zech, Ryckebosch-Dayez, & Delespaux, 2010). Additionally, research has suggested that individuals who have lost a partner or a child may require longer periods of treatment to diminish their CG symptoms (Boelen et al., 2011).

Cognitive Behavioral Therapy, Gestalt Therapy, and Emotion Focused Therapy

Exposure to what is experientially avoided (Foa & Kozak, 1986) and cognitive restructuring (Ellis, 1962) are significant elements of numerous therapeutic traditions and several researchers have done important work in helping to validate the import of these components in the treatment of complicated grief (Boelen, de Keijser, van den Hout, & van den Bout, 2007; Shear, Frank, Houck, & Reynolds, 2005). However, many of these studies continue to report relatively modest effect sizes, especially when compared to the treatment of other psychiatric disorders (Boelen et al., 2007). Additionally, despite numerous RCT studies, the mechanisms of change in complicated grief remain unclear.

Many research studies on CG appear to implement exposure and cognitive restructuring interventions in a piece-wise manner, i.e., as independent, separate, modular interventions. For example, in Boelen et al. (2011), the cognitive restructuring module of the treatment intervention works to identify, challenge and alter negative cognitions created by the bereavement by seeing these negative cognitions as non-rational, whereas the exposure module of the treatment intervention consists of confronting reminders of the loss, again and again, until the patient is (in theory) desensitized to the stimulus. Importantly, these two modules are independent from one another. The piece-wise nature of this implementation, from the perspective of EFT, however, may significantly diminish their effect.

Emotion Focused Therapy (EFT) is an integrative, evidence-based psychotherapeutic approach based on gestalt therapy that combines person-centered, gestalt, existential, and cognitive theory. It incorporates both exposure and cognitive restructuring within an integrative psychodynamic perspective. Within an EFT framework, mere exposure — approach, arousal, and tolerance of avoided feelings — is insufficient when performed as a piece-wise element of a treatment protocol. Avoided affect must not just be aroused and tolerated, it must also be integrated with cognition within the context of a larger narrative framework in order to achieve optimal emotional processing (Greenberg, 2004; Greenberg & Pascual-Leone, 2006).

Additionally, within an EFT framework, attempting to modify cognitive structures through rationality alone is viewed as having limited effectiveness. Effective and enduring cognitive restructuring only occurs, according to EFT when it is also appropriately connected to a person’s emotional life. Within an EFT perspective, “we cannot ‘leave’ a place, until we have fully ‘arrived’ at it” – emotions, cognitions, and all (Angus & Greenberg, 2011).

From an EFT perspective, exposure and cognitive restructuring cannot be piece-wise implemented: It is critical for an individual to learn how to integrate emotions and cognitions, i.e., “to symbolize and express emotions in a narrative context” (Angus & Greenberg, 2011, p. 21) as this process of contextualizing emotions within a larger narrative helps individuals contain their emotions and imbue them with meaning. Clients must learn not merely to tolerate previously overwhelming affect (exposure), nor merely to reprogram their maladaptive beliefs (cognitive restructuring). They must learn to cognitively orient themselves to their emotional experience by reflecting upon, exploring, and making sense out of that experience. A piecewise protocol of exposure and cognitive restructuring is insufficient, from the EFT perspective, as emotion, cognition, and narrative must be integrated with one another for optimal functioning (Angus & Greenberg, 2011).

Though there is significant support for the efficacy of EFT in the treatment of depression (Ellison, Greenberg, Goldman, & Angus, 2009), trauma (Paivio & Pascual-Leone, 2010), and couples distress (Greenberg & Goldman, 2008), currently, there appear to be no treatment studies of EFT applied to complicated grief. Especially because of the primary role that narrative derailment may play in the etiology of complicated grief, EFT’s emphasis on narrative reconstruction may be a particularly important element in effective treatment for CG.

Single Case Studies, Time-Series Design, and Phase Change Analysis

Single-subject research designs in which patient symptoms are tracked over time have been fruitfully utilized in recent years to help elucidate the efficacy and the dynamic mechanisms of change in various therapeutic modalities (Borckardt et al., 2008). Cognitive-behavioral therapies (Elkins & Moore, 2011), therapeutic assessment (Smith, Handler, & Nash, 2010), psychodynamic approaches (Frankel & Macfie, 2010), and other therapeutic modalities have been clarified through this single-case study time-series approach. In the time-series symptom-tracking framework proposed in Borkhardt et al. (2008), patient’s symptoms are measured daily to generate a continuous graph of how the patient’s symptoms change over the course of therapy. A pretreatment and a treatment phase of the time-series graph are often compared to test whether symptoms improve during the treatment phase.

We could find no evidence in the literature for a single case study time-series design for the treatment of complicated grief. Because RCT trials typically only attempt to measure pre- and post-treatment effects across experimental and control groups, these studies may overlook important elements in the actual mechanisms of psychological change of complicated grief over time (Borckardt et al., 2008). Additionally, though there have been a number of case studies on complicated grief, these have, in the main, either been strictly qualitative formulations (Kalafat & Lester, 2000) or have (like the RCTs) utilized only pre- and post-measures of efficacy, rather than daily continuous tracking measures (Shear et al., 2005; Wittouck et al., 2011). This time-series case study hopes to fill this gap in the literature and contribute to our understanding of the actual mechanisms of psychological change in complicated grief. It is an attempt to systematically examine how the EFT treatment approach unfolds in an actual clinical practice when dealing with CG. We proposed the following three-part hypothesis:

Hypothesis: An EFT approach will be effective for the treatment of complicated grief. At termination, each of the patient’s three identified symptom clusters (Overall Distress, Lack of Peace, and Difficulty in Building a Routine) will be decreased relative to before therapy began.

2 Case Presentation

Wendy is a 67-year-old Caucasian female who sought therapy at a university-affiliated psychological clinic to treat symptoms of complicated grief. Her husband of six years (Bradley) had passed away several months prior after a prolonged battle with lung cancer. The patient’s normative process of mourning her husband’s death, however, appeared to be derailed by her postmortem discovery that he had had a secret life, e.g., multiple previous wives (and possibly children) as well as financial debt that he had not disclosed to Wendy during their marriage.

3 Presenting Complaints

At the time of intake, Wendy reported experiencing a number of symptoms of complicated grief including ruminative thoughts regarding her deceased, poor sleep, feelings of overwhelming separation anxiety, intense crying spells, debilitating loneliness, persistent intense yearning for the deceased, difficulty engaging in activities of daily living, anhedonia, irritability, and social withdrawal. Certain times of the day were particularly difficult for Wendy, especially when she was alone in her home. “I can’t find any peace,” she said.

For several months prior to commencing treatment, Wendy had been taking Lorazepam to help mitigate some of her symptoms of anxiety. Recently, her depressive symptoms had worsened and her primary care physician had suggested that she commence Lexapro, but Wendy was reluctant to do so.

Wendy was also was battling Stage 4 ovarian cancer at this time and reported a variety of somatic-related symptoms due to the cancer and her chemotherapy regimen, e.g., hair loss, becoming easily tired, needing to move slowly, etc.

Wendy’s goals for therapy were to “find peace” and to “figure out who I am … now that [my husband] is gone.” She also hoped to build a daily routine that could provide her with a feeling of structure in her life, as she currently felt adrift.

4 History

Wendy was born and grew up in a major city in the Southeast as the youngest of three sisters. She was an “unexpected child” and was separated by 13 years from her closest-in-age sibling. Wendy recalls that her parents experienced significant marital difficulties during Wendy’s formative years largely due to her father’s alcoholism and she remembers frequent fights and confrontations at home. However, her parents remained together and never divorced.

Wendy’s father worked at various jobs in several different careers, e.g., for a railroad company, as part-owner of a gas station, etc. Wendy described him as “distant” and “impenetrable.” They had, according to Wendy, “zero relationship.” After one last attempt to have a conversation with him when she was a junior in high school, she decided finally to “give up.” He passed away when Wendy was 17 and left a burden of debt responsibility to her mother.

Her mother worked part-time at a flower shop and, according to Wendy, was a “very strong woman.” Due to the savings that Wendy’s mother had scrapped together from her flower shop job, Wendy was able to attend a respected college in her home town: She intended to become a teacher.

In her early twenties, Wendy met a man who would become her first husband, a research scientist. They married and moved a few times for her husband’s work before settling into a mid-sized Southeastern city where he had accepted a professorship. They had three children (one son and two daughters) and shared the responsibility of raising them. However, their marriage waned in intimacy over the years and two decades into their marriage, her husband began to develop what Wendy calls “an obsessive interest in New Age philosophies” – an interest that Wendy did not, herself, share. He finally divorced Wendy after twenty-five years of marriage when she was in her mid-forties.

Approximately ten years ago, Wendy was diagnosed with Stage IV ovarian cancer. The oncologist’s prognosis at the time was ominous, and she was given only months to live. However, Wendy continued, month after month, to defy the odds. Wendy’s persistent survival, year after year, became viewed as an inexplicable anomaly by her physicians. In the years following her initial diagnosis, her cancer remained active, though it appeared to have receded. She continued to receive ongoing chemotherapy treatment for the cancer to manage its growth.

Approximately seven years ago, at the age of sixty, Wendy met the man who would become her second husband (“Bradley”) through an online dating site. He was about her age, and they began a long-distance relationship. Soon after, he proposed and they got married. “We just got along,” she said. Bradley himself had two young adult children who were in college (and later professional school), and Wendy took them under her wing as her own.

Bradley himself was diagnosed with lung cancer several years into the marriage and it progressed quite rapidly. Though Wendy and Bradley had always thought that she would be the one to die first (due to her own battle with ovarian cancer), this was not to be the case. After months of grueling chemotherapy, Bradley passed away.

In the aftermath of Bradley’s death, Wendy discovered, in going through Bradley’s files, that his financial situation was not as stable as Wendy had believed. She also learned that he had been married, perhaps several times, in his 20s or 30s, and that even though he no longer maintained any apparent ties to his prior wives, he had not disclosed this piece of his history to Wendy – and she felt deeply betrayed. Wendy would oftentimes become overcome with anxiety, trying to make sense of it all. She would attempt to control her emotions when around others, but then would breakdown into uncontrollable crying spells, especially when alone. She began to question her value in life and frequently wondered if she was “just taking up space.”

5 Assessment

Baseline Measures

Several measures were administered to Wendy prior to the onset of therapy in order to obtain an accurate baseline of her symptomatology as well as to rule out other possible diagnoses. These measures were the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), the Symptom Checklist-90-Revised (SCL-90-R), and the Outcome Questionnaire-45 (OQ-45). Additionally, Wendy completed an intake interview wherein she specified her major symptoms and agreed to track these symptoms over the course of the therapy. She completed 10 days of symptom tracking before her first therapy session, and this time period served as the baseline/pretreatment phase of data collection.

The MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) is a 567-item self-report measure designed to aid clinicians in evaluating psychopathology and providing information related to an individual’s personality profile. The MMPI-2 assesses a wide range of clinical pathology and is widely agreed to satisfy reasonable criteria for reliability, validity and internal consistency (Butcher et al., 1989). Wendy’s results produced a valid clinical profile. Wendy’s responses on the MMPI-2 indicated clinically significant elevations (≥65) on four of the clinical scales: hypochondriasis (Hs, T-score = 80), hysteria (Hy, T-score = 87), psychopathic deviate (Pd, T-score = 66), and schizophrenia (Sc, T-score = 66). Even though Wendy’s MMPI did fall into a classic “conversion V” form, clinical interview indicated that the elevation on hypochondriasis, hysteria, and schizophrenia scales appeared to be due, in large part, to side effects of Wendy’s (very real) cancer and chemotherapy treatment. Additionally, upon further examination of the Harris-Lingoes Subscales and the Supplementary Scales, it became evident that Wendy presented with a strong Need for Affection (Hy₂, T-score = 67) and general Lassitude-Maliase (Hy₃, T-score = 67) that was somewhat masked through repression (Repression: R, T-score = 78) and a strong need to deny dependency (Social Imperturbability: Pd₃ = 63). This presentation appeared consistent with a diagnosis of complicated grief.

The SCL-90-R (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974) is a 90-item self-report inventory of symptoms that has been widely used to track symptom change across multiple dimensions of concern. It has been shown to be sensitive to change in psychotherapy and has demonstrated good reliability. Wendy’s SCL-90-R indicated modest elevation in depression (T-score = 61), which again appeared consistent with symptoms of complicated grief.

6 Case Conceptualization

Though Wendy had been diagnosed by her primary care physician as having co-morbid anxiety and mood disorders (for which she had been prescribed Lorazepam and Lexapro), it appeared that her cluster of symptoms might be more appropriately be characterized as complicated grief. Indeed, though she did exhibit anxiety and mood symptoms, they appeared to predominantly be associated with complications surrounding her bereavement experience. Moreover, she presented with a number of risk factors that suggested that her symptomatology was a consequence of complicated grief. These risk factors include (1) tendency towards self-blame regarding the death, (2) use of the deceased as an undifferentiated extension of the self, (3) having feelings of ambivalence towards the deceased, (4) and having overcontrolled emotional responses (Horowitz et al., 1993). After reviewing Wendy’s case, it became apparent that Wendy did fulfill, to varying degree, all of these above listed risk-factors for the onset of CG, as well as the actual criteria, as previously listed, for complicated grief.

Wendy’s specific CG-related risk factors were as follows:

1. Self-blame: Wendy appeared, at times, to blame herself for Bradley’s death. She believed that her choice to forgo additional (and quality-of-life-diminishing) chemotherapy treatment for her husband, during the later stages of her husband’s illness, was causative in his death.
2. Non-differentiation between self and other: Wendy appeared to have a difficult time separating herself from her husband. Nearly everything about her — from her daily routine to what sports teams she cheered for — appeared to be highly dependent upon Bradley. She had become used to “doing everything” with her husband; he had felt almost like an extension of herself.
3. Ambivalent feelings towards deceased: Wendy discovered after Bradley’s death that he had had a “secret life” including multiple previous marriages and significant unpaid debts. This created feelings of ambivalence and betrayal within Wendy towards her deceased husband that impacted her capacity to grieve in a normative manner.
4. Overcontrolled emotional responses: As previously mentioned, Wendy appeared to try to control her emotional responses, especially so as not to burden or intrude upon others. Because of this, she became limited in her capacity to grieve normatively and became at greater risk for complication in her bereavement response.

Each of these elements certainly contributed to Wendy’s vulnerability to complicated grief.

Within an EFT narrative framework, Wendy was conceptualized as someone who was derailed from her preexisting relational attachment narrative with her husband and who needed to rediscover a coherent narrative framework that could make sense out of her postmortem discovery of his “hidden past.” Whereas prior to the discovery of his secret life, she could maintain a narrative of mutual respect, symbiotic connectedness, and love in relation to her husband, she became hard-pressed to maintain this narrative in the aftermath of the newfound revelations about his life. The EFT treatment protocol would focus on helping Wendy (1) regain a sense of her inner narrative, (2) learn how to differentiate herself from her deceased husband, (3) overcome her guilt regarding the choices she made surrounding his medical care during his final weeks of his life, and (4) learn how to experience her emotions in an adaptive, rather than overcontrolled manner.

7 Course of Treatment and Assessment of Progress

Treatment Measures

The time-series case study was formulated as an A-B outcome design study with two separate phases: a pretreatment phase (Phase A) and a treatment phase (Phase B). During each of these phases, daily measurements of symptomatology were taken. By performing a time-series analysis of symptoms during pretreatment versus treatment, i.e., Phase A versus Phase B, we track the course of improvement and test whether the improvement realized is statistically significant.

Patient symptoms were tracked using an individualized set of ideographically formulated time-series questions and the Outcome Questionnaire 45.2 (OQ-45.2; Lambert, Gregersen, & Burlingame, 2004).

Outcome Questionnaire 45.2

At intake, Wendy was administered the Outcome Questionnaire 45.2 (OQ-45.2; Lambert, Gregersen, & Burlingame, 2004) as a baseline measure of overall distress. The OQ-45.2 is a 45-item measure that, when administered at periodic intervals during treatment, can help track the progress in a patient’s overall constellation of symptoms during the course of therapy. The OQ-45.2 measures symptom status across a variety of dimensions and assesses overall quality of life. The OQ-45 has been demonstrated to be a highly reliable, valid measure of psychological distress that appears to accurately track how the overall severity of a patient’s symptomatology changes during psychotherapy (Lambert et al., 2004; Lambert, Okiishi, Finch, & Johnson, 1998; Umphress, Lambert, Smart, Barlow, & Clouse, 1997). This measure was given to the patient twice during the pretreatment phase – once at the beginning and once at the end of this phase. Thereafter, this measure was given at monthly intervals over the course of the treatment.

Idiographic Time-Series Questions

In order to monitor the patient’s individualized symptomatology, Wendy completed an intake interview wherein she specified the symptoms she would track over the course of the therapy. She completed 10 days of symptom tracking during the baseline/pretreatment phase of data collection (Phase A). The treatment phase (Phase B) consisted of 5 months of once weekly individual therapy, during which time she completed the daily measures without significant breaks.

The questions that Wendy answered daily in order to help her track her symptoms were:

(1) What is my overall level of distress?

(2) How much difficulty do I have feeling at peace?

(3) How hard has it been for me today to build a routine for my life?

These questions were rated on a 9-point Likert scale, with higher numbers indicating more problematic symptomatology. For each of the symptoms, the possible scale responses ranged from 1 = none/not at all bothered by this problem to 9 = extreme/extremely bothered by this problem.

Treatment Sessions

The treatment approach applied was Emotion Focused Therapy. This treatment is an established, evidence-based treatment approach based on gestalt therapy that has been demonstrated to be effective in treating depression, trauma, and couple distress. A manualized form of EFT for depression has been found to be equally or more effective than a cognitive behavioral treatment (CBT) in multiple studies (e.g., see Ellison et al., 2009). Additionally, in each of these studies, EFT was found to be more effective in reducing interpersonal problems than the CBT treatment (Angus & Greenberg, 2011).

Wendy participated in treatment for approximately 4 months for a total of 16 sessions – 2 sessions of intake / assessment and 14 sessions of once weekly individual psychotherapy. Treatment integrated supportive and insight oriented techniques utilizing an EFT therapeutic framework. The therapy was delivered by a clinical psychology doctoral student and supervised by a licensed clinical psychologist in accordance with EFT-procedural guidelines as outlined in Working with Narrative in Emotion-Focused Therapy by Angus and Greenberg (2011).

The Central Question

Wendy’s central, driving question emerged in the context of her first therapy session. During that session, she told a story where, while in the midst of her debilitating distress, her 6 year old grandson had offered her the following words of comfort: “Grandma, I think he loved you.” The grandson’s words encapsulated in a single sentence Wendy’s central longing and her fear – her hope that her husband had, in fact, loved her and her existential dread, in light of the revelations, that it had all been just a sham.

Wendy central question was this: Did he really love me? The love in which Wendy had once felt so secure had, with the revelation of his secret prior life, been summarily torn from her. This question would continue to haunt her through much the treatment, leaving her confused, angry, shaken, and most importantly unable to fully grieve. Mending this derailed narrative would be one of the central objects of the therapy. Until then, grief would come, in bits and spurts, only to be periodically derailed by Wendy’s doubt and confusion over the truth over what she was trying to grieve.

Stages of Therapy

The objective of the initial phase of the therapy was to establish basic trust between Wendy and the therapist by empathic attention to Wendy’s key concerns. Once this environment of trust had been created, a therapeutic space emerged in which some of the hallmarks of grief came to light. Wendy expressed denial (“He can’t be gone. It wasn’t his time.”), anger (“There was a woman who was saying how happy she was and I just wanted to hit her”), and depression (“I’ve been crying for the last two days… I can’t stop and I don’t know why.”) As Wendy’s salient stories emerged, they were attended to with empathic concern thereby creating a “holding environment” for the therapy (Angus & Greenberg, 2011; Winnicott, 1965).

The second phase of the therapy sought to further explore Wendy’s problematic emotions and undo interruptions to her emotional experience. For example, Wendy’s anger, which was initially displaced onto arbitrary others, became more appropriately connected with their actual source: her husband’s non-disclosures and his untimely death. Her crying spells, which were initially experienced merely as overwhelming affect, were contextualized within her overall narrative of bereavement, thereby providing her with an integrated emotional experience: cognition, affect, and narrative. Her guilt regarding her choice to not pursue more aggressive chemotherapy treatment for him (thereby, in her mind, causing his death) gave way to compassion for herself and how she was doing the best she could to handle an overwhelmingly difficult situation.

In the midst of it all, Wendy experienced a classic conflict between wanting to “hurry up and be done with the grief” and “not wanting to let him go.” Somehow, remaining stuck within her grief, in Wendy’s frame of thinking, helped her to maintain a connection with her husband. Eventually, after much “working through,” Wendy was able to synthesize these two polarities and become open to the possibility that she might be able to both grieve the loss of her husband and yet still be able to “hold him inside.”

Her loss of internal narrative continued, however, to be problematic. “There’s no place I belong,” she lamented. “It might be better for everyone if I just died.” This process came to a head when, in the second month of the therapy, Wendy discovered a bankruptcy filing that Bradley had made while she was married to him. Though she had discovered other postmortem non-disclosures regarding her husband’s relationships and financial dealings previously, she had not yet discovered a significant non-disclosure regarding something that he had engaged in during the marriage. This newfound information sent Wendy into deep confusion and self-doubt. “Did he love me? Was it real?” she kept asking herself. The third phase of the therapy would seek to help Wendy answer this question and reconstitute a coherent narrative.

Utilizing a modified version of EFT chair work, Wendy engaged in an imagined dialogic process with her deceased husband in which she queried, again and again, “Was it real?” After one prolonged session in the second month of therapy (Day 67 of the study), she was able, finally, to projectively imagine herself within his subjective experience, and completed the following abbreviated gestalt “empty chair” dialogue.

Therapist: So imagine that [Bradley] is here, sitting in this chair.

Wendy: (pause) Ok.

Therapist: Can you see him? I mean really imagine him?

Wendy nods.

Therapist: Ok, now ask him exactly that, that question that you were asking.

Wendy: Which question?

Therapist: The question you had just asked… “Was it real? … Was it real?”

Wendy: Oh yeah…. Ok…

Pause.

Therapist: Are you asking him the question?

Wendy: Uh-huh.

Therapist: How does he respond?

Pause.

Wendy: He’s crying…. He says,“It was real. It was real.”

Pause.

Therapist: Just sit with that for a moment.

Wendy nods.

Therapist: Does that feel true?

Wendy hesitates. Then nods.

Therapist: Is there anything you want to ask him?

Wendy: (pause) Why didn’t you trust me?

Therapist: (softly, echoing) “Why didn’t you trust me?” (pause) And what does he say?

Pause.

Wendy: He says that he was scared and ashamed.

Therapist: Ah. Scared. Ashamed.

Wendy: (angry – directed to imaginary Bradley) You should have believed that I would still have loved you! I would have loved you anyways!

Therapist: And what does he say.

Wendy: He says that he’s sorry. Just so sorry.

Pause. Wendy weeps. Wendy reenters her own experience and speaks as if to imaginary Bradley.

Wendy: (crying) It’s ok. It’s ok. (pause) I forgive you.

In the sessions following this gestalt dialogue, the quality of Wendy’s grief appeared to meaningfully shift. It deepened and seemed more consuming and complete. “I hurt. I hurt. I miss you so much,” she said. She said that she wanted to scream and “keen” – an ancient tradition in which people wailed in lamentation for the dead. Alongside this increased depth of grief, Wendy appeared finally able, in the midst of the grieving, to reclaim her personal narrative of her relationship with her husband. “Those were the best six years of my life,” she said, weeping with a grief that no longer appeared constrained by her cognitive doubt. For a period of time her symptoms appeared to worsen. “I feel like I’m backsliding,” she said. Indeed, from a gross symptomatic perspective, her distress over this period of time significantly increased: She became absolutely unable to follow any routine and had more difficulty finding a place of peace than ever before.

However, within the next few sessions, she reported a slow and gradual improvement. Remarkably, she said that despite the pile of financial responsibilities that she had, she was “not anxious” anymore. She had even stopped taking her anti-anxiety medication. Though her grief was not over, she described herself as cautiously feeling “stronger and in better spirits.” Her outlook on life appeared to improve and she spoke in a moving manner about how she believed that “God is a god of love, not a god of wrath” and that she imagined Bradley in the afterlife “surrounded by love.” She reported feeling more freedom and liberty. Though she had tried volunteering in the cancer center before, she now appeared to embrace her volunteer efforts with increased commitment and vigor. “They look at me and they see hope,” she said.

After another few sessions of “working through,” she stated that she felt finally ready to move on. Her grief had passed and though not completely absent was now very manageable. In the final termination session, she thanked the therapist for his work, and the therapist and Wendy wished each other well. She left him with a gift of cookies she had baked him for the day.

Assessment of Progress

Level change analysis. Simulation modeling analysis (SMA; Borckardt et al., 2008) implements a bootstrapping approach to assess time-series level changes and was applied in this instance to analyze the time-series data to determine if the treatment effect size due to the EFT intervention was, in fact, significant. SMA accounts for the autocorrelation of sequential observations that is inherent in real-world, temporally continuous data streams. In the SMA level-change / phase-effect analysis, the mean scores of pre-treament and treatment phases are compared and an actual effect size from pre- to post-treatment (Pearson’s r) is calculated. The SMA level-change analysis calculates the probability that this effect size would in fact be obtained without treatment, given the length of the data stream and its level of autocorrelation. Significant effect sizes suggest that the reported symptom has decreased in severity due to the treatment intervention. Because SMA is a bootstrap procedure, it generates exact probabilities.

As previously mentioned, three separate daily time-series data streams were compiled during a pretreatment phase (Phase A) as well as over the course of the treatment (Phase B) in order to track Wendy’s symptoms. These data streams were (1) Wendy’s overall distress, (2) her difficulty in finding peace, and (3) her inability to build a routine. Using this method, level-change analyses between pretreatment (Phase A) and treatment (Phase B) were conducted in SMA across all three symptom variables and yielded a significant effect (p ≤ 0.05) for Overall Distress, Difficulty in Finding Peace, and Difficulty in Building a Routine: (Overall Distress: r = −0.562, p = 0.0008; Difficulty in Finding Peace: r = −0.442, p = 0.015; Difficulty in Building a Routine: r = −.388, p = .0336) indicating significant improvement in these symptoms from Phase A to Phase B. These effects are visually represented in Figures 1 to 3. Descriptive statistics are reported in Table 1 and phase effect results are reported in Table 2.

Improvement in general psychological functioning. Monthly OQ-45 assessments were utilized during baseline, treatment, and follow-up phases (see Figure 4). Because the OQ-45 cut-off that demarcates clinical from non-clinical populations is an OQ-45 raw score of 63 and since Wendy’s initial OQ‑45 raw score (47) was below this cut-off value, the severity of her initial symptoms was not considered to be in the clinical range according to the OQ-45 (Lambert, Morton, et al., 2004). However, we could still ascertain via the OQ-45 whether or not reliable change had occurred for Wendy between pre- and post-treatment had occurred using the Reliable Change Index (RCI; Jacobson, Roberts, Berns, & McGlinchey, 1999; Jacobson & Truax, 1991). Previous research has demonstrated that the OQ-45 has an RCI of 14, indicating that changes in the OQ-45 greater than 14 represent reliable change that is not due to chance variation (Lambert et al., 2004). Since the change in Wendy’s OQ-45 score (pre-treatment = 47; post-treatment = 29) was 18, and since this difference from pre- to post-treatment is greater than the RCI value of 14, it appears that Wendy’s symptoms did in fact improve over the course of the therapy (Lambert et al., 2004; Lambert et al., 1998).

8 Complicating Factors

There were two complicating factors in this case: (1) the comorbidity of Wendy’s complicated grief and her Stage 4 cancer and (2) a two-week vacation that Wendy took in the middle of the therapy which interrupted the SMA data stream for one of her symptom response measures.

Due to the comorbity of Wendy’s complicated grief and her cancer it was sometimes difficult to ascertain whether some of Wendy’s physical symptoms were somatic responses to her mood / anxiety issues or actually due to her chemotherapy / cancer. For example, Wendy endorsed the MMPI item that states: “Parts of my body often have feelings like burning, tingling, crawling, or ‘like going to sleep.’” It was at first ambiguous whether this was the result of her chemotherapy or an underlying somatization disorder, and further questioning and clinical interview was required to locate the actual cause of the somatic symptom. Additionally, due to the chemotherapy, Wendy was required to miss one week of psychotherapy during her course of treatment, which may have had a small effect on treatment progress.

Additionally, Wendy went on a family vacation between Day 43 and Day 56 of the study. During this time, although she continued to track her daily symptom measures of Overall Distress and Difficulty in Finding Peace, she did not complete the symptom measure for Difficulty in Building a Routine. (She reasoned that while she was on vacation, she was not trying to rebuild a life routine and so measuring this symptom would not be relevant.) Due to this gap in the data stream, fewer data points were gathered for this symptom. This gap in the data stream may have skewed our results.

9 Access and Barriers to Care Considerations

There were no managed care considerations in this particular case.

10 Follow-Up (How and How Long)

The patient did not complete any standardized follow-up measures. However, during a brief phone interview with Wendy approximately 8 months after the completion of treatment, she reported, that despite a recent physical injury, she was nevertheless, overall, in good spirits. She appeared to be looking forward to spending time with various members of her family and seemed to exhibit positive signs of psychological resilience and emotional health.

11 Treatment Implications of the Case

At the conclusion of EFT treatment intervention, Wendy’s symptoms of complicated grief had largely abated. Her initial symptoms of overall distress, difficulties in finding peace, and inability to build a routine had all decreased. Wendy’s daily ratings pattern reflected, in broad form, these improvements in symptoms. Additionally, her OQ-45 indicated symptom abatement. These results suggest that, in this instance, EFT was effective in treating Wendy’s symptoms of CG.

Additionally, clinical observation indicated that the EFT framework appeared to be successful in addressing the underlying etiology of Wendy’s complicated grief symptoms, not just the overt symptomatology of it. Over the course of treatment, Wendy’s sense of narrative derailment appeared to be replaced by a reconstituted attachment narrative. Wendy was also observed to begin differentiating herself from her deceased husband, replacing her feelings of overwhelming guilt with self-forgiveness, and learning how to adaptively express her previously overcontrolled emotions. These observed changes in Wendy further buttress the research findings that indicate that EFT interventions improve domains of functioning above and beyond mere symptom abatement. At each stage of this EFT treatment, affect, cognition, and narrative remained deeply intertwined with one another. It is unclear whether a therapeutic approach that segments cognitive restructuring and exposure into entirely separate modules would achieve the same result.

Particularly notable in the symptom time-series data is the prominent peak in symptom severity across all three symptom measures that occurred approximately 2 months into the treatment. At first glance, this peak appears related to Wendy’s discovery of Bradley’s non-disclosure of bankruptcy filing during their marriage. However, it is of particular interest to note that this period of symptomatic exacerbation occurred approximately eleven days after this betrayal was discovered, rather than immediately upon its discovery.

Indeed, the peak in symptom severity appears more proximally related not to the discovery of the betrayal, but rather to the resolution of the narrative derailment that emerged through the dialogic gestalt process in the aftermath of this discovery. That is, the exacerbation of symptoms may have been caused by the internally experienced narrative resolution that emerged through the processing of the betrayal rather than from the betrayal itself. Indeed, the extreme spike in symptoms of grief and distress appeared to emerge two days after the session wherein Wendy was able finally to unflinchingly state: “Those were the best six years of my life.” It appears that once the doubt about Wendy’s attachment narrative had been resolved, she was able to proceed with her mourning without derailment or distraction – thereby temporarily exacerbating her overt symptoms of mourning as she became finally able to fully experience her grief. This result may have significant implications in future treatment protocols related to complicated grief.

Limitations

It is important to highlight the limitations of the current study. This treatment was short term and supportive in nature. It was designed specifically to address symptoms of complicated grief. However, Wendy’s betrayal by Bradley appeared sufficiently similar to her historic betrayals, e.g., by her father and by her previous husband, that one wonders if Wendy’s archaic schematic representations may have been activated by her discovery of Bradley’s non-disclosures. Due to the short term nature of this therapeutic treatment, this aspect of treatment was not explored within the context of this therapy.

Additionally, Wendy was undergoing chemotherapy concurrent with her psychotherapy treatment. It is difficult to know exactly what level of an impact the chemotherapy may have had on the course of psychotherapy treatment. Certain chemotherapy drugs are known to have significant physical and psychological impact. It is possible that Wendy’s chemotherapy medication treatment may have changed her symptomatology and skewed our results.

Though Wendy did complete an MMPI-2 and the SCL-90-R, neither of these measures was completed after treatment: Neither could therefore serve as empirical evidence for symptom change. Additionally, although Wendy did complete the empirically validated OQ-45.2 and her overall symptoms were shown to have reliably changed, it should be noted that the OQ-45.2 is itself a self-report measure. Finally, the SMA analysis of the patient’s symptom improvement was based on a data stream derived from Wendy’s subjective experience as reported on a self-generated measure. That is, the data stream that was analyzed using SMA was based on Wendy’s self-generated and self-assessed symptom measure scales, rather than an empirically validated measure.

12 Recommendations to Clinicians and Students

As this case study illustrates, the idiographic tracking of individual patient progress using a single-subject time-series research design (Borckardt et al., 2008) can help inform clinicians and researchers about the anatomy of change within psychological processes over time. This kind of study helps to overcome the divide between actual, day-to-day clinical practice and scientific research. The findings in this instance are suggestive and, it is hoped, may promote therapeutic innovation and, ultimately, increase treatment efficacy for the important psychological phenomenon of complicated grief.

In particular, this research provides insight into the dynamic process of change within a single-subject case study of complicated grief using EFT. Importantly, the time-series data suggests that EFT may be an effective treatment for CG. Additionally, it appears that narrative reconstruction may play a more central role in the treatment of CG than has previously been thought. In light of the findings in this study, it is recommended that issues of narrative derailment be particularly attended to in the treatment of CG, both in the context of future RCT research trials on CG as well as for clinicians working with this patient population in the context of psychotherapy.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interests with respect to their authorship or the publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.                  

Bios

Albert J. Wong, MA, is a clinical psychology doctoral candidate at the University of Tennessee, Knoxville. His clinical interests include emotion-focused therapy and mindfulness.

Michael R. Nash, PhD, is a professor of psychology at the University of Tennessee, Knoxville. His clinical and research interests include psychodynamic psychotherapy, hypnosis, and time-series analysis.

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Table 1.
Descriptive Statistics for Time-Series Symptom Measures across Phases.
	Baseline   (N = 10)					Treatment (N = 132)
Daily Measure	M	SD		pAR(lag1)	M		SD	pAR(lag1)
Overall Distress	6.80	0.87		0.58	2.67		1.83	0.61
Difficulty in Finding Peace	7.10	1.30		0.71	3.28		2.22	0.59
Difficulty in Creating a Routine	5.50	0.67		0.56	2.51		1.91	0.57
Note: pAR (lag1) = autocorrelation at lag 1.

Table 2.
Phase Effect Results from Baseline to Treatment
Daily Measure	r	p
Overall Distress	-0.562	0.0008*
Difficulty in Finding Peace	-0.442	0.0152*
Difficulty in Creating a Routine	-0.388	0.0336*

Note: r = Pearson’s R for the Level Change between pretreatment and treatment phases;

p = p-value with statistically significant improvement (p < 0.05) marked by the (*).

Figure 1. Daily ratings of overall distress during baseline and treatment phases. Note: Higher rating indicates more distress (1 = none/not at all bothered by this problem and 9 = extreme/extremely bothered by this problem); — = Phase marker between baseline and treatment at day 10.

Figure 2. Daily ratings of patient’s difficulty in finding peace during baseline and treatment phases. Note: Higher rating indicates more distress (1 = none/not at all bothered by this problem and 9 = extreme/extremely bothered by this problem); — = Phase marker between baseline and treatment at day 10.

Figure 3. Daily ratings of patient’s difficulty in creating a routine during baseline and treatment phases. Note: Higher rating indicates more distress (1 = none/not at all bothered by this problem and 9 = extreme/extremely bothered by this problem); — = Phase marker between baseline and treatment at day 10.

Figure 4. Patient’s scores on the OQ-45 symptom outcomes measure during baseline and treatment phases. Note: Higher rating indicates more distress; — = Phase marker between baseline and treatment at day 10. The square ( ) represents Wendy’s pretreatment score (47) and the circle ( ) represents her post-treatment score (29).