Running Head: PSYCHOTHERAPY: U3c.

Therapy in Special conditions

UNIT 3c)

Therapy in Special conditions: Suicide and related behaviours, Loss and Bereavement,

medical conditions such as cancer, HIV/AIDS, and other terminally ill conditions.

Submitted to:

Ms. Anjali Talreja

(Visiting Faculty)

R. D National College

Affiliated to Mumbai University. Mumbai

December 16th, 2018

SUICIDE AND RELATED BEHAVIOUR

Introduction:

Suicide is act of intentionally killing own self. Suicide ranks among the 10 most common

causes of death among adults and among the three most common causes among adolescents.

About 90% of suicidal attempts are unsuccessful and 10% of suicidal attempts are successful.

About 70 percent of successful suicides are among adults, most occurring in the syndrome of

major depression and in alcoholics experiencing periodic depressed states. A disproportionate

number of suicides are found among professional persons such as lawyers, physicians,

dentists, and military men.

The therapist should be alert to the warning signs. These signs can lead to suicidal act. The

signs are:

1. Old age: Symptoms of severe depression especially in males over the age of 55,

suicide can be attempted due to reasons like social isolation, recent divorce or

widowhood, unemployment, alcohol or drug abuse, and physical illness of a chronic

or painful nature are predisposing factors.

2. History of suicide: At any age those who have made serious suicidal attempts, or

where there is a history of suicide or of affective disorder in the family, these should

be considered danger signals.

3. Dysthymia and Personality: Dysthymia resulting from broken or unhappy love affairs,

disharmony in marriage, serious fights with parents among the young, bereavements

in the elderly, and severe physical ailments may initiate a suicidal attempt. Personality

problems of a psychopathic or hysterical nature with poor impulse control and peaks
 of violence and aggression may register themselves in suicidal gestures or in suicidal

equivalents like reckless driving and dangerous sports.

4. Depression during early stage of treatment: Most likely to commit successful suicide

are severe depressions during early stages of treatment when retardation and

indecisiveness are replaced by a slight release of energy. Here prescribed psychotropic

drugs and hypnotics may be massively incorporated.

Therapist should also identify whether the suicidal attempts are for attention seeking or

situational in nature.

The sign, situation and symptoms are pointed to potential suicidal risk in patient:

1. Loss of appetite, severe weight loss, insomnia, listlessness, apathy, persistent expressions

of discouragement and hopelessness, loss of sexual desire, extreme constipation,

hypochondriac ideas, continuous weeping, and general motor retardation which are

present at the start or appear in the course of therapy.

2. Irrespective of diagnosis, any patient who has made a suicidal attempt in the past, or who

has a history of severe depression, or who is taking antihypertensive and other

medications and drugs that are having a depressive effect.

3. A patient who, during therapy, insistently threatens suicide.

4. Dreams of death, mutilation, and funerals.

Therapist should always take precaution when the patient mention about suicide in the

session. Talking openly and seriously help therapist to investigate hidden feelings and

whether the threat is real or dramatic gesture. Talking frankly about suicide often serves to

rob it of its awesome or appealing quality. Where suicide seems imminent in spite of anything

the therapist can do or where an abortive attempt is actually made, there is no alternative than

to advise responsible relatives to get the patient hospitalized immediately in a closed ward of
a psychiatric hospital. Suicide prevention centres do exist and they have been used by

depressed individuals and their families in crisis.

There are several conditions that can cause suicidal attempts. Some of the conditions are as

follows:

1. Hysterical personality: Suicidal attempts in hysterical personalities are common and

consist of histrionic gestures calculated to impress, frighten, or force persons with

whom the patient is in contact to yield attention and favours. Such attempts are incited

by motives for display rather than by genuine desires to take one’s life. Dramatic

performances of an ingenious nature are indulged, during which there is a superficial

slashing of the wrists, or feigned unconsciousness with stertorous breathing while

placing an empty bottle of sleeping pills alongside the bed, or the gulping of tincture

of iodine, or the impetuous opening of gas jets.

In treating hysterical cases with suicidal threatenings, therapist must

demonstrate to the patient that we are neither intimidated by nor angry at the actions

of the patient. Interpretation of the purpose of the patient’s frenzied behavior should

be made in terms of the broader neurotic patterns.

1. Psychopathic personality: Individuals with psychopathic personality attempt suicide

which are serious in nature. During episodes of excitement, violence, deep remorse, excessive

drinking, or temporary psychotic outbreaks, the psychopaths may slash the wrists or take an

overdose of sleeping pills. The desire for self-punishment and death are genuine, though

temporary. When their attempt has been aborted and they have been hospitalized, such

patients recover rapidly, evidence no further suicidal impulses, and express great remorse at

their foolishness. When the suicidal episodes are motivated by disturbed interpersonal
relationships, as, for instance, a broken love affair or rejection by a love object, the continued

exploration of the patient’s feelings and patterns is indicated.

In psychopaths’ case, the therapist may have to increase the frequency of visits and insist on

being telephoned when the patient is tempted to indulge in suicide. Where the patient persists

in this impulsive suicidal behavior, after seeming to have acquired insight into operative

patterns, the therapist may have no other alternative than to tell the patient that treatments

will have to be discontinued. It may be suggested that the patient may perhaps want to start

treatment with another therapist. This may give enough of a jolt to the patient to ensure

insistence on the therapists continuing, based on the promise that all further suicidal attempts

will be abandoned.

1. Schizophrenia: In some types of schizophrenia suicide is a grave possibility. It is most

common in acute, excited catatonic states, particularly those associated with panic.

Hallucinations may drive certain patients to mutilate or kill themselves. Fear of homosexual

attack or of being persecuted may also force some paranoid individuals to suicide. The

methods of self-destruction employed in schizophrenia may be bizarre, including such

mutilations as disembowelment and genital amputation.

The handling of the suicidally inclined schizophrenic patient is organized around

administering ample sedation, communicating with the family so that they may assume some

responsibility, and arranging for transportation and admission to a mental hospital.

Electroconvulsive therapy (ECT)is often indicated. Chlorpromazine (Thorazine), thioridazine

(Mellaril), perphenazine (Trilafon), or haloperidol (Haldol) in ample dosage

1. Pathologic depression: Depressed episodes may occur in people due to loss of

security, status, or a love object; however, the depression is rarely of such depth as to inspire
a desire to take one’s life. Where the depressed state is extreme, suicide is always a

possibility. Among the most vulnerable pathologic depressive conditions are major

depression, bipolar depression, depressions in alcoholics, involutional depression, senile

depression, and depressions in organic brain disease.

To manage patient with pathologic depression certain palliative measure are taken.

● Handling of diet with the inclusion of stimulating and appetizing foods and the

prescription of tonics and vitamins may be indicated in anorexia.

⮚ For mild depression:

● A stimulant like Ritalin may be useful temporarily to activate the patient during the

day, while sedation may be required at night for insomnia.

● Here small amounts of a mild hypnotic like chloral hydrate (Noctec) may be

prescribed to prevent the patient from accumulating a lethal quantity.

⮚ For severe depression:

● The patient’s family or a reliable friend should be contacted and acquainted with the

potential dangers.

● Where the patient remains at home while in a deep depression, a trustworthy adult

person should be in constant attendance.

● The patient should not be permitted to lock oneself into a room, including the

bathroom.

● Sleeping pills, tranquilizers, poisonous drugs, razor blades, rope, and sharp knives and

instruments should be removed.

● Window guards are necessary if there is a chance that the patient may destroy oneself

by leaping through a window.

attendants may be essential. The treatment of choice is electroconvulsive therapy,

which may prove to be a lifesaving measure. Antidepressants are second best where

the patient refuses ECT, but the patient must be watched carefully since the early

“lift” from the medication may give enough energy to try suicide.

● Psychotherapy during severe depression is generally confined to supportive measures,

as insight approaches tend to stir up too much anxiety. Difficulties in decision are

greater in the event a patient has mildly threatened to take his or her life, but makes no

active gesture to do so, and has no history of past suicidal attempts. Under these

circumstances the therapist may have to utilize the greatest interviewing skills

1. Miscellaneous suicidal conditions: Sometimes a therapist is consulted by the parents

or friends of a child or adolescent who has made a suicidal attempt. Examination may fail to

reveal hysteria, depression, or schizophrenia, especially when the child is non-communicative

to the point of mutism. It is possible here that the child is internalizing destructive feelings.

Young drug abusers are particularly vulnerable.

Because the youth is non-motivated for therapy and resents having been taken to a

psychiatrist, it may be difficult to treat the patient. Dealing with Inadequate

Motivation, and by indicating to the patient that he or she seems to be angry at

someone, it may be possible to establish rapport. If suicide was attempted with

poisons or drugs, identification of these will permit selection of the proper antidote.

1. Telephone threat: Where a patient telephones the therapist and states that he or she is

about to take a lethal dose of medication or engage in other kind of suicidal act, the therapist
should try to keep communication going especially around any incident that has inspired the

impulse to die. The patient’s name should be repeated to firm up the sense of identity and

some constructive action may be suggested as well as a reminder that the therapist wants to

help as much as possible, and that others care for the patient and want to help. If the patient

had already taken pills, then the therapist should continue talking with the patient and in

meanwhile, another person should call ambulance to escort patient to hospital. Or in case

where the address is not known, then other person should call police to trace patient’s

whereabouts or trace patients call and call ambulance for help. (.R.Wolberg, 2013)

Please attach a small paragraph on Dialectical therapy, CBT and Mindfulness. The

reference for the same is Sadock, Sadock & Kaplan comprehensive textbook of

psychiatry.

LOSS AND BEREAVEMENT

BEREAVEMENT & GRIEF DEFINITION.

1. BEREAVEMENT:

Bereavement or (to be deprived of) is the process of adjusting to the experience of loss to the

death of friends or loved ones. It involves the overall experience of loss.

2. GRIEF:

Grief can be defined as the intense emotional suffering that accompanies our experiences

of loss and mourning refers to the outward expressions of bereavement & grief.

● Mourning Customs
It can be said that most societies have mourning customs to facilitate the expression of grief

(E.g. in the past American widows are seen to be dressed in black and widowers wore

black armbands).

i. Funeral:

The ceremonies and rituals associated with the burial or cremation of the dead -with

particulars varying by ethnicity , cultural norms and religious cannons is referred as

funeral.(E.g. Mexican-American funeral , relatives throw a handful of dirt or mud on

the coffin before the grave is filled.)

● Grief Work:

Grief work can be defined as consisting of the healthy process of working through the

emotions associated with loss, freeing ourselves emotionally from the deceased,

readjusting to life without that person, resuming ordinary activities and forming new

relationships.

i. The grief process can parallel the experience of dying and involves many of the same

stages.

ii. Grief work takes time and sometimes I never fully completed.

iii. There are large individual differences on how people grieve.

● The ways people react to grief

1. Type 1: In type 1 people may react to a person’s death with a sense of shock and disbelief

especially when death occurs unexpectedly.

2. Type 2: In this the persons reaction to death has been anticipated as is the case with

terminal illness , the initial response may be subdued and accompanied by a sense of relief ,

which may then turn to guilt as a result of feeling "relieved" at ones passing.
 3. Type 3: In this the people undergo survivor guilt, which is defined as feeling guilty

because one is still alive while the others are not.

● Symptoms of grief

The emotional intensity of grief in the early stages often appear in physical symptoms, such

as crying, depressed feelings, lack of appetite and difficulties in concentration. Some

common symptoms of grief is lack of interaction with others. Some may also rely on

sleeping pill, tranquilizers and alcohol in order to avoid negative emotions and

physical symptoms while grieving.

● Gender Differences

Gender differences are also present with men dying sooner than women. It is seen that

widowed men between the ages of 55 and 65 die at a 60% higher rate than married

men of the same age, this may be due to the quality of life changes more drastically

for men than woman because of their greater reliance on wives for their emotional and

daily needs . Women tend to have a better support system for coping with their grief.

● Final Stage of grief

In the final stage of grief people begin to accept (acceptance) their loss and resume their daily

lives .this stag may occur from a few months to a year. Around one year is the

required time length for grief to work with negative emotions peaking by six months.

Normal grief can be present for an extended period of time intensifying on specific

events such as birthdays, wedding anniversaries or death date of a loved one.

3. UNRESOLVED GRIEF

Unresolved grief is also known as complicated grief, it is defined as a psychological state in

which a person’s emotional reaction to loss remains repressed, often being manifested in
 unexplained physical or psychological symptoms. It is prolonged and impairing type of

grief which assumes many forms such as anxiety and depression.

4. GOOD GRIEF.

There are some positive aspects to grief which takes shape in good grief it can be defined as

one has learned and grown in our bereavement. Bereavement in turn contributes to

personal growth. Thus grief doesn’t just involve mourning but also includes reflecting on

the person who died as well as the anticipated change for the bereaved.

● Positive Expression of grief

There are several ways to make the experience of bereavement more effective such as:

i. Talking it out

ii. Acting it out

iii. Feeling it out

iv. Physical activities such as walking

v. Funeral rituals

vi. Grief therapy which assists in bereavement and coping with the death of a

loved one.

5. GRIEF THERAPY

● In grief therapy the main goal is to resolve the conflicts of separation and

better adapt to death.

● This conflict requires the client to explore or experience their thoughts &

feelings that the individual is avoiding.

client can freely grieve that was majorly lacking at the time of death this

support is part of the therapeutic alliance.

● It is to be noted the greater the underlying conflict with the deceased, the

greater the resistance.

● It is usually a one-on-one therapy and the number of sessions required is 8 to

10, wherein they explore loss and its relationship to the present pain and

distress. (Worden,2009).

MEDICAL CONDITIONS SUCH AS CANCER and other terminal illness??? Please

complete the ASSIGNMENT PLEASE STUDY OTHER TERMINAL ILLNESSES

FROM Wolberg.

The incidence of an intercurrent incurable physical illness constitutes an emergency in some

patients. Cancer is one such medical condition in which the therapist will have to stock the

reality of the situation and revise the therapeutic goals.

● One essential goal is dealing with the emotional impact of the intercurrent illness on

the individual.

● Insight therapy is halted here and more supportive therapy techniques is implemented.

● Persuasive talks and desensitization as well as CBT techniques such as reassurance is

used with terminally ill patients

● Acceptance is important as it helps the patient overcome feelings of helplessness

● They can also engage in stimulative activity such as knitting, and word puzzles they

can also engage in leisure activities such as a walk in the park. As well as providing

guidance to the patient which will help the patient accept this new role in their life.
 ● Severe pain in dying patients’ pharmaceuticals are administered to lessen the pain

(severe cases).

● Passive euthanasia for terminally ill patients is used to help lessen the burden useless

and artificial means and permitting the patient to die with dignity.

HIV/AIDS and other terminally ill conditions

First let us understand the term HIV; it stands for human immunodeficiency virus. It is a

virus that can lead to AIDS or Acquired immunodeficiency syndrome if it isn’t treated. The

body cannot get rid of the virus completely so if one has HIV they have it for a lifetime.

HIV attacks the body’s T cell which help the immune system fight off infections and

diseases. This makes the individual more prone to getting other infections and infections

related cancer. AIDS is the last stage of HIV infection. The medication used to treat HIV is

called antiretroviral therapy. No effective cure exists as of now. In the last 25 years a lot of

people have become affiliated with and died of acquired immunodeficiency syndrome.

The first edition of grief counselling and grief therapy began around the time that the

HIV/AIDS pandemics began (Worden, 2008). There are a large number of women, children

and minorities which have contracted the virus and have died or are living with the HIV

virus. The other affected group is of children who have parents living and dying with the

disease of AIDS.

Individuals suffering from this disease have questions in their minds such as do I live with

this disease, should I stay home or go to work, will I be able to live until a cure is found. Over

a half million people of the United States have died of AIDS and related disorders.
There are various challenges faced by the survivors of those who die of AIDS. Some of them

being it being caused by an infectious virus, there is no cure for it presently, social stigma

attached to it.

CONTAGION

AIDS is a transmitted through body fluids, this leads to the diseased sexual partner being

anxious about it. Physical symptoms are a normal part of grieving process. The partner might

experience insomnia, fatigue, headaches which can be interpreted with symptoms associated

with AIDS related illness. It is the responsibility of the counsellor to educate the survivor of

the physical aspects of bereavement so they do not mistake it as AIDS disease and the anxiety

related to this can reduce in intensity.

When the survivor is HIV positive he/she might feel angry at the diseased due to the fear of

developing AIDS. Guilt is another factor associated with it. Some partners feel guilty for

transmitting the virus to their partner or for participating in the activity or lifestyle which

increased their possibility of transmission. The feeling of guilt need to be addressed and

evaluated. The contagion factors can have an impact on the survivor in forming new

relationships or rejecting new relationships.

STIGMA

Stigma attached to AIDS is often higher than of suicidal deaths, some survivors have a fear of

being rejected or judged if and when the cause of death becomes known. Some may hide or

lie about the cause of death being some other terminally ill disease because of the heightened

fear. This could make them feel angry and guilty and have an emotional toll over them.

Helping the survivors deal with the stigma and assisting them to find ways which are
appropriate in sharing the cause of loss can help in reduction of the anxiety and fear

experienced by them.

LACK OF SOCIAL SUPPORT

Social support has been shown to reduce depression after an AIDS- related death (Ingram,

Jones, & Smith, 2001). Because of the stigma associated with the disease many of the

survivors who have had non-traditional relationships with the diseased have difficulty in

understanding and finding the support they need after death. Folk and Deck (1976) make an

important point about grief that there is an underlying assumption that closeness of a

relationship exist only among spouses and/or immediate kin.

One group which is hit hard by the stigma is the family which learns about the illness and the

lifestyle of their children at the same time. Because of the stigma attached the family often

experiences alienation from the ill family member.

ULTIMATE DEATHS

Many who face the negative force of AIDS related illness are young between the age of 20

and 35. There is an increase in the awareness regarding death and ultimate end of life among

the friends and the family members. The parents outlive the children and many survivors are

faced with the issue at an age when others aren’t confronted by mortality.

MULTIPLE LOSSES

In the gay community many people have lost a number of friends and significant others to

AIDS. It has been noted that multiple loss can lead to Bereavement overload which may lead

to various somatic symptoms and shut down of grieving process. There can be a massive

bereavement leaving people with a sense of being a repeated survivor. There can be survivor
guilt. When grieving multiple losses one isn’t certain about who they are grieving for. The

counsellor needs to be flexible with the client whose grief focus shifts between prior and

current losses (Nord, 1996). Support groups can be easily helpful here. The impact of

multiple deaths can also be a problem for caregivers who are working with large group of

AIDS patients.

PROTRACTED ILLNESS AND DISFIGURMENT

The immune system gets compromised due to HIV virus which makes the body more prone

to infections. Many of such infections lead to physical and mental deterioration. People with

AIDS related illness often feel a waste of their mental and physical capacity. Initially all

youthful and attractive they can change to an appearance of a death camp victim.

NEUROLOGICAL COMPLICATIONS

● Several studies have found that 80 % of AIDS patients suffered from some kind of

damage to the central nervous system. Sometimes there is a little change in their

behaviour and sometimes there is a higher level of impairment, depending on the

area of brain which is attacked by the virus. The reduction of mental function can

seem like an impairment suffered by the Alzheimer’s patient. As the dementia

progresses the friends and family start to lose the person they once knew.

(Worden, 2009)

PROGRESSIVE INCURABLE AILMENTS.

In progressive incurable ailments such as cancer and HIV/AIDS therapist must incorporate

the following in therapy.

may be reassuring.

● The therapist may use the guidance approach to reduce the disturbing effect of

environmental factors and help divert interests towards outlets of distracting

nature. Such patients are told to engage in activities that are new and different

such as taking up poetry or writing novels. Also taking part in communities and

support groups is advised.

● Patients may also be told to engage in self-relaxation such as self-hypnosis or

cultivate religious interests.

● One of the greatest problems of working with a dying patient is the fear of death,

helplessness and guilt the therapist feels.

● For dying patients a great deal can be accomplished by making their final days

more comfortable and meaningful and free from anxiety and pains hospice

provides this comfort to such patients.

● If the patient shows acceptance for their condition which will lead to death much

can be accomplished through emphatic listening by understanding the patients’

anxiety, feelings of guilt and depression. This is also reassuring to the patient.

● Helping the patients’ family members through hostility is a major task for the

therapist. A good relationship with the family help them go through the process of

grief and bereavement much easily. (Worden, 2009)

The techniques of psychotherapy. International Psychotherapy Institute E-Books. (4th edition,

Lewis R.Wolberg, M.D.)(2013).

Psychology for living: Adjustment, growth and Behaviour today (11th edition Pearsons,

Steven J. Kirsh, Karen Grover Duffy & Eastwood Atwater)

Grief Brief Counseling & Grief Therapy: A handbook for the mental health Practitioner (4th

edition, J William Worden, PhD, ABPP)