M . Katherine Shear, M.D.Professor of Psychiatry

Columbia University School of Social WorkColumbia University School of Physicians and Surgeons

“Woody Allen is still making movies, but the kind of psychotherapy he made famous -- lying on a couch, endlessly talking about your mother and your lousy childhood -- is losing its audience. Those who find themselves in a therapist's office these days are likely to encounter a very different form of treatment, one that's short-term, goal-oriented and evidence-based. It will probably involve sitting upright in a chair.”

A Change of Mind Thanks to Managed Care, Evidence-Based Medical Practice and Changing Ideas About Behavior, Cognitive Therapy Is the Talking Cure of the Moment By Cecilia Capuzzi Simon Special to The Washington Post Sept 3, 2002

“Cognitive therapy is practiced around the world, taking hold in places from the Middle East to Japan. The technique has had its greatest acceptance in Great Britain, where it is widely used as a first-line treatment for depression, panic and obsessive-compulsive disorders, and in conjunction with medication to relieve symptoms of schizophrenia and manic depression.”

Capuzzi Simon The Washington Post 2002

WE WILL REVIEW SOME HIGHLIGHTS OF INTERVENTION RESEARCH OVER THE PAST DECADES

AND WHERE WE ARE NOW

EDUCATION1972 - Tufts University Medical College1975 - internal medicine Mt. Sinai Hosp.1976 - infectious disease fellowship MSH1979 –psychiatry Payne Whitney Clinic1980- psychosomatic fellowship MontefioreFACULTY POSITIONS1980-1992 Cornell 1992-2006 –University of Pittsburgh 2006-present –Columbia

NIMH FUNDINGPanic Disorder1983 R03MH3899 – CV reactivity 1988 R01 MH42430 – Efficacy of CBT

Panic Disorder (cont.)1989 R01 MH45964 – Multicenter Comparative Treatment Study1993 R01 MH50902 – Psychological treatment1995 R10 MH45964 – Panic Treatment study Health Services1994 R24 MH53817 – RTGP – Treatment Effectiveness Studies in Women1998 R24 MH56843 – Caring for Moms with children in MH treatmentComplicated Grief2000 R01 MH60783 – CG Treatment study2007 R01 MH070741 – CGT for older adults2008 R25MH084786 – TF-CBT training2009 R01 MH60783 – Optimizing Treatment (multicenter study)

Goal of behavioral intervention research Defining the intervention target Conceptualizing intervention principles, strategies and

procedures Establishing efficacy Achieving effective dissemination and implementation

Complicated grief: A case example

To identify and describe useful, efficient ways to reduce suffering, improve well-being, and foster optimal functioning

To determine how, to whom, where and when to deliver efficacious interventions in the community

Interventions can target behavioral, cognitive, social or emotional problems in an individual, family or group

For example, intervention targets can be Known mental health problems, identified in the DSM (e.g. major

depression) Symptomatic distress not identified in DSM (e.g. problem grief

reactions) Negative health behaviors (e.g. use of chemical substances) Problematic interpersonal behaviors (e.g. interpersonal violence) Dysfunctional ways of thinking (e.g. delusions or hallucinations) Problems with emotion regulation (e.g. “unified protocol”) Family problems (e.g. dysfunctional families) Community problems (e.g. suicide rates)

Intervention can focus on prevention, treatment or recurrence

Intervention development begins with understanding the problem Requires a period of library or laboratory research Underlying theory may exist or not – if not needs to be developed and to

rest on empirical underpinnings Basic assumptions and principles form an important scaffold for

effective intervention Assumptions derive from a theoretical model of the problem and its solution Principles derive from a model of how the target problem can change

Strategies and procedures are the methods by which the intervention acts Clearly described, operationalized and manualized Guided by the underlying assumptions and principles Usually derived from previous research

“After I graduated from the Psychoanalytic Institute, I was eager to validate the psychoanalytic concepts to make them more acceptable tothe scientific community. As depression was the most frequent disorder in my practice, I decided to focus on that disorder. According to the then current psychoanalytic theory, the depressed individual experiences unconscious rage against other close persons but, as the rage is unacceptable, it is repressed and turned against the self.”

Beck AT Nature Medicine 2006

To his surprise, Beck discovered the opposite was true: dreams of depressives had less hostility than non-depressed control group

Dream content of depressives (rejected, deserted, thwarted) similar to waking descriptions

A model based on negative internal representations of self and others explained the symptoms

Patients could be helped to evaluate the validity of these cognitive distortions and re-evaluation was associated with symptom resolution

Beck AT Nature Medicine 12: 1139-1141 2006

12

Cognitions

MoodBehaviors

SCHEMAEvents

• Schema-related• Maladaptive• Irrational

•Avoidant•Other dysfunctional

Behavior

Emotion

CognitiveAppraisalEvent

Wright, Basco and Thase Learning Cognitive Behavioral Therapy

Rush et. al. Cognitive Ther Res. 1: 17-37 1977

Hollon et al. J Clin Psych 66:455-468, 2005 * Significant advantage for combined Rx.

Developed from studies of treatment problems in depression studies….a subgroup of depressed older adults were bereaved and exhibited symptoms that did not respond to standard efficacious treatment

1. Preoccupation with the person who died

2. Memories of the person who died are upsetting

3. The death is unacceptable4. Longing for the person who died5. Drawn to places and things associated

with the person who died6. Anger about the death7. Disbelief8. Feeling stunned or dazed9. Difficulty trusting others10. Difficulty caring about others

11. Avoidance of reminders of the person who died

12. Pain in the same area of the body13. Feeling that life is empty14. Hearing the voice of the person who

died15. Seeing the person who died16. Feeling it is unfair to live when the other

person has died17. Bitter about the death18. Envious of others19. Lonely

Rated 0 (never) – 4 (always) Score > 25 (30) “defines” CG

Prigerson et al., 1995

SCORE > 30 IDENTIFIES A PROBLEMATIC GRIEF RESPONSE

http://www.google.com/search?hl=en&q=funeral+images

MORE THAN 2.5 MILLION PEOPLE DIE EVERY YEAR IN THE UNITED STATES

ON AVERAGE1-5 CLOSE FRIENDS AND RELATIVES ARE BEREAVED BY EACH DEATH

ABOUT 7% OF BEREAVED PEOPLE DEVELOP COMPLICATED GRIEF

BEREAVEMENT: Experiencing the death of someone close GRIEF: the response to bereavement

▪ Acute grief – the early response that can be intense and all-encompassing, that heals over time

▪ Integrated grief – the permanent residual grief after healing occurs

▪ Complicated grief – a lasting form of acute grief that does not heal

MOURNING: the psychological healing processes set in motion by bereavement aimed at acknowledging the finality and consequences of the loss and re-envisioning life without the deceased person

21

Hofer M Monogr Soc Res Child Dev, 59, 192–207; Antonucci et al 2004; Feeney J Pers Soc Psych 631 -648 2004; Hazan and Ziefinan Cassidy & P. R. Shaver (Eds.), Handbook of attachment (pp. 336–354) New York: Guilford Press. 1999

ADULT ATTACHMENTRELATIONSHIPS OCCUR

IN

MANY

SPECIES

The underpinning of attachment behavior is a biobehavioral motivational system, closely linked to motivational systems for exploration and caregiving.

Mikulincer, et.al., 2002; Mikulincer, et.al., 2003; Pereg & Mikulincer, 2004; Collins & Feeney, 2004

Like other animals, we are biologically programmed to seek, form and maintain close attachment relationships…. and to resist separation from these individuals

Biobehavioral motivational systems are guided by brain circuitry that is linked to both positive (reward) and negative affect centers as well as cognitive systems for memory and planning

These systems operate across the lifespan using similar processes for maternal-infant and adult romantic relationship, though adult systems are more mature and complex

Suryia the organutan and Roscoe the hound

Mastery and performance success Learning and performing Relationships with others Cognitive functioning Coping skills and problem solving• Self esteem• Emotion regulation• Sleep quality• Pain intensity (physical and social)

http://www.suryiaandroscoe.com/On average, people have 1-5 attachment

relationships at any given time

Bell & Ainsworth, 1972; Grossmann, et.al., 1999; Cassidy, 1999; Carmichael and Reis 2005; Roisman 2005; Kim et al 2008; Mikulincer, et.al., 2002; Mikulincer, et.al., 2003; Pereg & Mikulincer, 2004; Collins & Feeney, 2004; Antonucci et al 2004

➠Bereavement results in loss of regulatory functions

Recurrent pangs of sadness and yearning A mix of other emotions, both positive and

negative Preoccupying thoughts and memories of the

deceased Behavioral tendencies to seek proximity or avoid

reminders of the deceased Sense of disconnection from ongoing life, feelings

of incompetence

Each person’s grief follows a unique trajectory, guided by circumstances of the death characteristics of the bereaved person and her/his relationship to the deceased consequences of the loss context in which the bereaved person mourns

It is a tribute to the human spirit that most people weather the storm of loss, often absorbing this most unwanted reality in a way that deepens their humanity and opens their hearts to the suffering of others.

Grief is both universal and unique to each bereaved person and each lost relationship.

1. Bereavement is a universal experience2. Grief comprises a recognizable group of symptoms3. Because loss is forever, there is a lasting form of grief

even after acute grief heals4. Bereavement sets in motion a natural healing process 5. Healing acute grief requires a sufficiently supportive

environmental context

Our closest relationships are intrinsically rewarding, provide a foundation of security and shared competence, and contribute to physiological and emotional regulation

Brain circuitry, sometimes called internal “working models”, contains information about our close relationships, that includes implicit and explicit memory, positive and negative emotion centers and cognitive monitoring, evaluation and planning processes

➠Healing after bereavement entails learning and emotion regulation

1. We need to understand close relationships in order to understand the effects of their loss

2. Grief symptoms are generated by brain systems entailed in close attachments, e.g. separation response, caregiver self-blame, inhibition of exploratory system

3. Loss is permanent and grief must be integrated so that its intensity and dominance recedes and no longer disrupts ongoing life

4. The natural healing process entails learning and emotion regulation5. The optimal context for adaptive healing includes support from others

who offer a balance of soothing comfort and gentle encouragement to re-engage in ongoing life

The healing process by which information about the loss is fully acknowledged, its consequences considered and assimilated into the working model and future goals and plans redefined, i.e. a learning process

Effective mourning entails emotion regulation in which Attention typically oscillates between confronting the painful information and

turning away (defensive exclusion) There are periods of positive emotions Typically takes place in a social context; companionship fosters learning and

emotion regulation Progress occurs in fits and starts, that are not predictable or controllable and may not

be noticeable as it occurs

30Bowlby Loss Basic Books 1980

◼ Rumination about circumstances or consequences of the loss; the “if only’s” (counterfactual thinking)

◼ Dysfunctional behaviors, e.g. extensive, prolonged avoidance, compulsive proximity seeking, use of substances, negative health behaviors

◼ Ineffective emotion regulation, e.g. over or under-engagement with emotional stimuli , deficiency of positive emotions, physiological dysregulation (e.g. sleep or daily rhythm disturbance)

◼ Social-environmental neglect or toxicity e.g. absence of a close companion (inadequate support) and/or interpersonal toxicity (hostile, aggressive, blaming behavior) or serious external issues

Boelen PA et al. (2003), Boelen PA et al. (2006), Shear K et al. 2007; Shear K et al., unpublished data

Persistent yearning, longing, searching; despairing sadness, other troubling emotions

Preoccupation with thoughts and memories of the deceased; dysfunctional thoughts

Intense reactivity to reminders and avoidance

Feeling life has no purpose, meaning, joy or satisfaction

Acute GriefAcute GriefDoes not progressDoes not progress

COMPLICATED GRIEFCOMPLICATED GRIEF

Information about the death is not processed, due to

Rumination Avoidance Ineffective emotion regulation

Acute grief symptoms are intense and unchanging

Attachment activation persists Inhibition of exploration continues

BEREAVEMENT

Acute grief symptomsAcute grief symptoms

Integrated griefIntegrated grief

Treatment Targets

Grief complicationsNatural healing

Resolve

Facilitate

Dysfunctional thoughts Cognitive therapy strategies used in Grief monitoring Revisiting exercise and

debriefing Imaginal conversation

Excessive avoidance Exposure strategies− Imaginal revisiting− Situational revisiting

Improve emotion regulation using strategies associated with natural healing

Ineffective emotion regulation

Absence of adequate companionship

Provide and encourage companionship

− Companionship alliance− Meeting with significant other

Learn about the death in explicit and implicit memory systems

Utilize effective emotion regulation strategies

Loss and restoration-related problems addressed in tandem

Supportive companionship

Progress may not be easily observable

Encourage confrontation with relevant information about the death (revisiting)

Foster emotion regulation− Oscillation between pain and respite− Self care, rewards, personal goals to foster

positive emotions− Acceptance, reappraisal, problem-solving

Encourage coping with loss and restoration-related problems in tandem

Provide and encourage companionship

Use strategies for review of progress35

“In the process of receiving and evaluating information that stems from major change of any sort a secure person habitually seeks the help of a companion… to negate or verify information, to confirm or disconfirm initial evaluations, to help consider how and why the event should have occurred, what its further implications may be, what the future may hold, and what plans of action, if any, may be appropriate.

By acting also as an attachment figure and caregiver the companion may perform an even greater service. For by this very presence, the bereaved’s anxiety is reduced, his morale fortified, his evaluations made less hastily, and the actions taken to meet a situation selected and planned more judiciously.”

Bowlby Loss p.232

1. Effective companionship is important in healing after loss

2. Structure is helpful to people experiencing acute grief3. Positive emotions are physically and emotionally healthy

and foster optimal creativity and problem solving4. Self observation and reflection, are important tools for

both addressing complications and facilitating natural healing

5. Natural healing is facilitated by addressing loss and restoration-related problems in tandem, and oscillating between pain and respite

6. Imagery fosters implicit learning and emotion activation

Grief monitoring

Imaginal revisiting

Situational revisiting

Memories and pictures

Imaginal conversation

Grief monitoring Aspirations and plans Self care and positive emotionsSituational revisiting

Loss-focused

Restoration-focused

• Comfort and help from others• Self-observation and reflection• Structure

INTRODUCTORY PHASE: THE FOUNDATIONDevelop a solid working alliance (safety, mutual goals and expectations) Understand the person’s life history, interpersonal world and the place of bereavement within this contextBegin grief monitoring, weekly plans and personal aspirations/ goals workProvide the bereaved person and a significant other with information and orientation to the treatmentMIDDLE PHASE: THE HEART OF THE TREATMENTLoss Focus: Imaginal revisiting of the death, situational revisiting, memories and pictures, imaginal conversation Restoration Focus: problem solving, aspirations and plans, self care, re-engaging with

othersTERMINATION PHASE: TRANSITION TO ONGOING LIFE Summarize gains and plan for the future Process thoughts and emotions about ending

chi-square=7.56, df=1, p =0.006 chi-square=5.07, df=1, p <0.024

NNT: Completers: 3 ITT: 4

Shear et al JAMA 293:2601 2005

Who does the treatment help? Are there moderators? Gender? Culture? Symptoms? Context?

Who can do the treatment? What training is needed? Professionals? With or without extensive training and

supervision? Lay people? Self-administration

How can it be administered most efficiently? What mediates the treatment effects? What are the principles of change? What are active agents- what procedures are needed? Is there moderated mediation (e.g. some people require a given

procedure and others don’t? What level of fidelity is required? What comprises adherence?

Competence?

Currently being used in Canada, Ireland, Norway, Japan and China Japanese have completed pilot studies of efficacy in people suffering

violent loss Japanese have plans for modifying CG to use in tsunami survivors

▪ We will develop a collaborative project using the basic assumptions and principles from CGT to design a culturally relevant intervention for tsunami survivors with CG

Social Work Ph.D. Candidate in Utah has completed a pilot RCT of group CGT showing significantly greater improvement in CGGT than treatment as usual (K Supiano personal communication)

Anecdotal reports from clinicians across the country report successful implementation of CGT

Clinicians at Kaiser Permanente in San Diego and at a military base in Canada have attended workshops and are using the principles and procedures in daily practice.

Plans are underway to utilize CGT assumptions and principles to educate palliative care clinicians and funeral directors

Behavioral intervention research is in its fifth decade and has matured significantly

It is now clear that it is possible to devise helpful interventions, document their efficacy and disseminate these interventions effectively

We are beginning to learn how to identify moderators and mediators of intervention effects in order to further improve them

The progress is very heartening, but…

“We would be wise to remember the principal lesson coming down to us from the 1960’s. Behavior therapy is not a school of psychotherapy, nor does it reflect some unified worldview of human nature. Rather, behavior therapy is the application of the principles of cognitive behavioral science to human problems and, as such, reflects the never-ending quest of the human race to better itself through the use of human reason and the methods of science. And we have miles to go before we sleep.”

Barlow “Promises to Keep” Behav. Tx 28:589 1997