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A Case of Grief using an Eclectic Approach

Author: Jane Barry

Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of each stage will be different for each individual.

It is therefore understandable that an eclectic counselling approach to grief can be beneficial in allowing for the flexibility needed to work with individuals through various stages of the grief process. The following case study is a practical application of a variety of counselling approaches to one client and her experience of grief.

The client’s name is Joan. Joan sought counselling to deal with the unexpected loss of her daughter in a car accident. She received counselling about 2 weeks after her daughter’s death and continued with the counselling process over a period of 8 months.

The key features of Joan’s grief were her feelings of guilt and despair. In these areas, the counsellor worked mainly from a Person-Centered approach (PCT). The counsellor also utilised some techniques from Solution-Focussed Therapy (SFT) and Cognitive-Behaviour Therapy (CBT). A brief analysis of the case study and application of the various techniques are provided below.

Case Information

Joan is a semi-retired accountant, maintaining contract work with a few long-term clients to support herself in retirement. Joan is a divorcee, who lives on her own, in her family home. She is a mother of 2 children, Kirsten and Mathew, aged in their mid 20s. Joan has a supportive network of family and friends, including her sister, father, children, and friends from her gardening club.

Joan’s relatively steady life was overturned with the sudden death of her daughter, Kirsten. Kirsten was 24 when she died from head injuries caused during a car accident. She was admitted to hospital in a coma. Joan spent several anxious days with Kirsten, before she passed away. In the days that followed, Joan arranged her daughter’s funeral and affairs and deferred her work commitments. Joan described this as a whirlwind period, where she operated in a mechanical way. She was completely absorbed in the organisation of Kirsten’s funeral and pushed aside her feelings of grief. Joan said that she found some security in the numbness that filled her during that time.

After a couple of weeks, however, Joan became concerned that she was not coping as she couldn’t move on from these feelings. People had commented that she should try to carry on as usual, however her numbness persisted and she couldn’t motivate herself to “carry on” as if nothing had happened.

Joan thought that there must have been something wrong with her and it was this fear that led her to counselling some weeks after her daughter’s funeral.

For ease of writing, the professional counsellor in this case will be referred to as “C”.

The Initial Stages

(Numbness) In the first session, Joan appeared somewhat vague and tired. She seemed focussed on describing the details of the funeral, the family members who attended and her concern about her daughter not having a will. “C” observed that Joan’s behaviour reflected a need to be in control of the situation and was a useful coping strategy for Joan at this time. “C” used PCT to build an empathetic understanding of Joan’s experience. She did not attempt to move Joan towards experiencing her grief, but trusted that Joan would reach this stage in her own time.

Joan began discussing the rapid way in which the whole event had occurred and the numbness that she was feeling. “C” used paraphrases and encouragers to assist Joan to express herself. “Everything has happened so quickly that you haven’t had time to absorb it all, is that right Joan?” “Yes”, Joan replied, “I’ve hardly had time to miss my little girl.” “You miss her,” responded “C”.

With this encourager, Joan began to cry and express her grief. Joan cried for some time whilst “C” sat with her in silence. At one point Joan apologised for her crying. “C” responded “It seems that you have a lot to cry about Joan. It shows me how much you loved your daughter.”

In the first session, Person-Centered therapy and Active Listening techniques enabled “C” to be guided by Joan’s readiness to express her feelings. The encouragers and reflection of feeling used, demonstrated to Joan that “C” understood her and allowed Joan to experience her feelings of grief, rather than to keep them at arms length.

Whilst “C” could have indicated to Joan that she was avoiding her grief, “C” instead trusted in Joan’s ability to express her grief in her own time. If Joan had not expressed her grief in this session, “C” would not have pressed the issue, although she may have encouraged Joan to have a further session within a few days.

(Grief and Despair) The following sessions were characterised by further experiences of grief and despair. Joan had found that her grief was no longer avoidable and her days were mostly filled with mourning. Joan abandoned her daily routines such as grooming, making meals and other basic self-care practices.

Joan’s disheveled appearance at the counselling sessions were concerning. At this point, “C” became more directive and suggested that Joan might have someone live-in with her for a while. Whilst “C” was encouraged by Joan’s regular adherence to the counselling sessions, she felt that Joan may need some extra support at home.

Joan contacted her sister Kerrie, who was available to stay with her for a month. Kerrie proved to be good support for Joan and provided her with gentle, yet insistent encouragement to face the everyday challenges.

Over several weeks of counselling, Joan had moved further into stages of despair and guilt. She described her life as being swallowed by a black hole and felt that she would never get over her daughter’s death. She felt that every day dragged by with no release from the pain. She had difficulty getting out of her bed in the morning and was constantly tired from lack of solid sleep.

“C” continued to employ PCT to allow Joan to explore and express her feelings and thoughts about her daughter’s death. Joan focussed heavily on her pain and seemed to stay with these feelings for a long time. “C” observed that Joan’s thoughts did not seem to be focused; she quickly moved from one topic to the next. “C” used summarising skills to help Joan highlight the key recurring issues from her thoughts.

“C” continued to trust that Joan would move through her feelings of grief in her own time. “C” did however experience some frustration with Joan’s continual despair. “C” sought the counsel of a colleague, who advised her to maintain her faith in Joan’s ability to grow and heal and reminded “C” of how the resolution of grief can often be a long-term process. The colleague also suggested some role-play techniques that “C” could use to work on Joan’s experience of her feelings.

(Guilt) Guilty feelings about her inability to prevent her daughter’s death were also of concern for Joan. “C” avoided telling Joan that she was not responsible for Kirsten’s car accident, and encouraged Joan to explore her guilt. In many instances grieving people feel guilt in relation to their loss. Often they will be told that they are not at fault, by well meaning people. The concern for counsellors is that grieving people are feeling guilty and will benefit more from expressing their guilt.

Dismissing guilty feelings won’t stop the grieving person from feeling blame and may lead to the increase of these feelings. “C” realised that Joan’s guilt was a means of expressing how fervently she wished to have her daughter with her still. “C” invited Joan to express her sorrow and guilt to Kirsten in a role play activity. Afterwards, “C” encouraged Joan to debrief and talk about the effect of the activity. Joan was able to acknowledge the depth of her love and concern for Kirsten. “C” supported Joan by offering encouraging feedback. “C” was particularly taken with the extent of love and devotion that Joan displayed towards her daughter.

Joan left the session a little lighter for the experience. She said that she had been able to release some of her guilt and that she felt her despair ease a little. After two months of counselling, both Joan and “C” recognised this as a small breakthrough of acceptance.

Middle Stages

Joan’s grief and despair continued into the middle phase of the counselling sessions. Her emotions came in waves, rather than the constant fog of despair that had characterised her earlier sessions. “C” was continuing to utilise PCT with Joan to explore her issues. Joan expressed a readiness to establish goals during this stage. “C” implemented some CBT techniques for this purpose.

(Feelings of Panic) Kerrie had been encouraging Joan to take on small, everyday tasks such as walking to the shops, or posting the mail, in order to get out of the house for a while. Joan said she had done these tasks reluctantly as she was concerned about trying to “put on a brave face” in public.

Joan related a particular incident where she was at the local shop. She explained that when picking items from the shelves, she had selected her daughter’s favourite brand of biscuits. Feelings of panic had come over her as she realised that she no longer needed to buy the item, but she couldn’t bring herself to return the item to the shelf. In this state, she left all her purchases in the shop and walked straight home.

This incident had increased Joan’s anxiety about her ability to cope and accept her daughter’s death. In the session, “C” validated Joan’s experiences as being normal and a legitimate part of her grieving. As a part of the CBT process, “C” clarified and identified the causes and effects of Joan’s feelings of panic. These were as follows:

A realisation that her daughter was absent in her everyday life A rejection of awareness that her daughter was absent in her everyday life Conflicting emotions about acceptance of daughter’s absence

  • Causing anxiety
  • Causing a belief that she will never be able to accept her daughter’s loss
  • Causing a fear of losing control in public places

“C” and Joan discussed the nature of the anxious feelings, and Joan’s associated beliefs and fears. Together they devised a number of goals, including (1) the development of new beliefs, (2) relaxation and (3) taking it one step at a time – otherwise referred to as a graded-task assignment.

Joan’s new beliefs included:

  • It is normal to want my daughter back
  • I am normal to grieve for and miss my daughter
  • It doesn’t matter if I cry in public
  • Time will help me to heal

She kept notes in a personal journal about when she used these new beliefs. The journal writing was also a process that allowed her to identify other problematic beliefs and thoughts. Once identified, she developed more appropriate and accepting beliefs.

In preparation of taking it one step at a time, Joan and “C” devised some relaxation techniques for Joan to use when she felt a sudden onset of panicky or anxious emotions. Joan had used imagery before and found that an effective method of relaxation. Joan was to imagine a warm, white light surrounding her whenever she felt even slightly anxious. They also devised some imagery to help Joan continue to experience the overwhelming nature of her grief.

Joan often referred to her feelings as a fog, and so “C” encouraged her to imagine sitting in a fog, which was black, thick and impenetrable. Little by little, she suggested that Joan should try to make the fog thin out with her mind. (It is important to note that this imagery was to be used at times when Joan felt bogged down in despair, but not during her anxious moments).

Joan was to record her practice of her relaxing imagery (white light) and to note her responses to the technique. She also recorded the times she used her despairing imagery (black fog) and the extent to which she was able to thin the fog with her mind. The purpose of the exercise was to increase her relaxation and to give her an image of her despair and a means to control it as time went on.

The ‘one step at a time’ goal consisted of Joan taking small steps towards running errands and taking on more of her everyday responsibilities. Her tasks involved the following:

  • Plan meals for week
  • Write a grocery list
  • Go shopping with Kerrie.

Using her relaxation imagery, Joan completed the following graded tasks:

  • Imagine walking around the shops
  • Drive with Kerrie to the shop and stay in the car
  • Walk with Kerrie to the shop door
  • Walk with Kerrie around the shop for 10 minutes approximately
  • Start to purchase a small number of items
  • Complete an entire grocery shopping task

Each week, Joan completed a harder task. It took her only 4 weeks to complete a full shopping trip, although she experienced several occasions of feeling overwhelmed. Each time this occurred she gripped the shopping trolley and imagined the white light. Kerrie encouraged her to breathe deeply and relax. A couple of times, they left the shop (abandoned the trolley) when Joan felt she could not cope. They came back the following day to complete the shopping.

The important thing for Joan was to accept the times when she could not cope. Kerrie proved to be a supportive role model for Joan, helping her to accept her reduced ability to cope by offering encouraging comments and faith that Joan would heal.

Joan applied the graded-task technique to other areas of her life. “C” observed Joan’s increasing attention to self-care and other routines of everyday living.

Final Stages

(Acceptance) Joan’s increasing acceptance of the loss of Kirsten became more obvious with the passing of time. By dealing thoroughly with her despair and grief, she naturally moved on with her life and mourned less and less. After six months, the rewards for both “C” and Joan were evident in her long term improvement and growth.

Joan’s ability to develop goals for herself was greatly improved, as was her motivation. Joan was living independently again and without Kerrie around, she took on more responsibility and began to make plans for her life without Kirsten. Joan’s plans included a number of support mechanisms, as well as long-term goals for herself.

Joan had taken to visiting her daughter’s grave on a monthly basis. During her intense despair, she had been unwilling to venture to the cemetary. Due to her increasing acceptance, she was more inclined to visit and found the visits to be a sad, yet calming experience. The visits allowed her the opportunity to tell Kirsten the things she had left unsaid, and to update her daughter about her life, as she would have when Kirsten was alive. Joan found the visits kept Kirsten’s spirit and memory alive within her.

In these stages, “C” continued using PCT, and incorporated SFT to assist Joan to define her goals. “C” complemented Joan on her inventive ways of honoring her daughter’s memory. “C” was encouraged to see that Joan was actively seeking personal ways to express her grief.

Together, they worked to build Joan’s miracle picture. Joan expressed an interest to honor Kirsten’s life, by writing a book. Joan wanted to combine her own and Kirsten’s journals to recount the significance of her life and death. The process would also be a means to resolve her grief and offer a parting gift to her daughter.

Joan’s miracle picture included redefining her life goals to determine what was important for her. Kirsten’s death, whilst painful, had also brought growth and changes with it, and Joan was increasingly inclined to shed parts of her life that no longer held meaning for her. She threw out material things such as old furniture, files and boxes of junk and mentally discarded the maintenance of acquaintances that she no longer felt obliged to remain in contact with.

She renewed her bonds with close friends and family. Kirsten’s death allowed her family to grow closer to one another. Joan was buoyed by the love and support of these few, special people during her long months of despair.

Joan accepted that she would never completely ‘get over’ Kirsten’s death and that that was okay. Counselling assisted her to realise that her daughter would remain a part of her forever. She made a pledge to herself that she would continue to learn ways to live with Kirsten’s absence. Her journal writings and the possibility of publishing a book for Kirsten, would provide her with some therapeutic means of coping and expressing her grief. Joan would also draw from the support of her family and friends in times of need, particularly around the times of Kirsten’s birthday and the anniversary of her death.

End of Session

The case study has illustrated some of the stages that clients may experience due to the loss of a loved one. It has also attempted to demonstrate the way in which PCT lent itself to the complex and individual experience of Joan. The key issue from the PCT perspective was “C’s” respect for Joan to grieve and grow to acceptance in her own way and time.

CBT was applied to changing Joan’s negative thoughts about her ability to cope with her daughter’s loss and the fear of losing control of her emotions in public places. The imagery was a technique that Joan had prior experience with and was therefore ideal for her. Another client, may prefer other relaxation methods. It is important to identify strategies that the client is comfortable with.

Graded task assignments, journal writing, role plays, homework and other practical strategies such as developing support networks are also invaluable CBT techniques. Timing is important when introducing strategies, and the client should not be pushed into solutions before they are ready to accept them. Wherever possible, the counsellor should consult with the client about their ideas for, and their suitability to, particular techniques.

Once the client is ready to focus on solutions to their problems, SFT can be an invaluable tool for identifying the client’s goals through development of the miracle picture. The use of SFT has been briefly presented in the case of Joan, to illustrate its effectiveness in drawing out the plans and goals that Joan aspired to.

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  • John Wilson 1 ,
  • Lynne Gabriel 2 and
  • Hazel James 2
  • 1 Saint Catherine’s Hospice, Scarborough, UK
  • 2 York St. John University,UK

This research was part of a multiple case-study, theory-building project, observing the moments of assimilation and accommodation in clients relearning their post-bereavement world. The aim was to chart moments of therapeutic change in the bereavement counselling process, identifying appropriate therapeutic interventions.

The subject, a male client was bereaved by a road traffic death at age 11. He had not effectively grieved until he began counselling 34 years later. The counselling sessions were digitally recorded by the researcher who was also the practitioner. The recordings assisted the practitioner both in observing the client’s struggle between primitive emotions and rational self and encouraging the client to construct new meaning narratives. This approach enabled the client to view his own process; becoming a student of his own psychological change.

During weekly counselling sessions, key moments of assimilation and accommodation were observed. The client was able to take these changes into his real world between sessions, and report back on their significance and effectiveness; self-judged by improvements in his perceived psychological wellbeing. There was practitioner/client consensus on key moments and the client stated that the outcomes were life-changing.

It would be imprudent to draw conclusions from a single case study. However, a theory-building methodology allows each new case study to add a small degree of confidence to the theory being constructed. There is an omnipresent risk of researcher subjectivity in judging the significance of moments of psychological change.

Multiple case studies would allow the theory to be refuted or modified. We call for more counsellors to become practitioner researchers by adopting this observational, theory-building methodology. Working in this way may lead to more focused therapeutic intervention and a concomitant diminution of grief.

https://doi.org/10.1136/bmjspcare-2015-001026.21

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Case Study on Bereavement Counselling: Restoring Confidence and Happiness

Nitin Shah

  • Published: 18 Jul '23
  • Updated: 12 Mar '24

Grief Counselling

Table of Contents

After losing her husband, Meeta was experiencing lack of confidence, lack of interest in her work, family & friends and life in general. She connected with me with a question “Can therapy help me deal with grief?” and if yes then “How?”

After having an initial conversation over the phone, we scheduled an online consultation session.

Bereavement Counselling – Complete Session Flow

Initial consultation or pre-therapy session:.

(We did counselling sessions over video calls online and we met for the first  counselling session as a result of her sister recommending it. Meeta agreed with her sister that she had been feeling low in mood, distant from her friends and family and had lost interest in life over the last one year. She agreed that it was time for her to try and do something about it.)

Meeta :  Akshada, I lost my husband, just like that no warning nothing, everything seemed to be going really fine and one fine day I woke up and he had ended his life. The both of us were really close to each other. It has been one year since this and, you know, all this time that I have been feeling unmotivated, distant, sad, and also I can’t help but blame myself, that I couldn’t see the signs if there were any, I had absolutely no idea, what kind of a wife was I, thinking that everything is hunky dory and we are close to each other? 

As always in the initial consultation session of Bereavement Counselling , after hearing Meeta’s challenges, I began by psycho-educating Meeta about the core concepts behind the process I follow. I suggested Cognitive Hypnotic Psychotherapy (which is an eclectic approach to Psychotherapy) for working through the guilt, shame and lack of interest in work, relationships, and overall life that she was facing. Then I walked her through the pre-coaching process. 

After helping her understand the bereavement therapy process, I added that in her case, once we have defined the current problem and outcome clearly, I will help her with

  • Defining the Existing problem clearly
  • Defining the expected outcome from the sessions clearly.
  • Exploring her feelings towards her husband about the fact he committed suicide, about his passing away and the feelings now she has towards his memory
  • Completely embracing her feelings including grief and then moving on from the grief.
  • Identifying observable changes that will indicate that the client has achieved the expected outcomes or that she is now capable of achieving her expected outcome.

Session 1: Defining Challenge and Desired Outcome

The first session I used the Meta Model*1 in combination with the SOFT SEA framework to help Meeta define her current situation, desired outcome, and expected future. 

I started the first session by asking Meeta to summarise the challenges she wanted to overcome through therapy in her own words. 

Girl experiencing grief in need of bereavement counselling

Meeta : I have lost interest in my life and I constantly feel sad. The sadness keeps growing day by day

I asked Meeta to reframe her problem statement using the following format:

 I feel …………… about…………… when……………

Meeta: I feel guilty about living my life normally when I remember his death and the way it happened

I asked Meeta to read the statement a couple of times and tell me what was the desired outcome that she wanted to achieve at the end of these sessions in the format:

 I wish ……………………….

Meeta :  I wish to be able to make peace with the passing away of my husband and feel free to live my life normally while being happy about the things that I have in life 

I asked Meeta to create a list of all the things in her life that she can be happy about.

Meeta created a list with 5 things that she could immediately identify that she should feel happy about but Meeta said she doesn’t.

So I asked her, What are the things that you enjoyed doing and wanted to achieve in your life?

Meeta : Before my husband passed away, I wanted to have a child and wanted to play with my child. Wanted to be a family and have a normal adult life. But ever since my husband passed away, I can’t even imagine being with another man, so child is out of question

I asked Meeta to write down her desired future as her home assignment.

Session 2: Working with Grief

We began session 2 of the Bereavement Counselling in the next week by asking her about the week and any changes that she noticed in her behaviours, thoughts, or emotions. Meeta mentioned that while she was writing about the future, she actually started believing that it was possible to achieve that, which seemed almost impossible until she put her pen to the paper. 

Future Writing

As I had asked her to do this future writing as homework, below is a small extract of the future she had written: 

  • I am able to move on from my husbands death and forgive him for the suicide and the fact he never shared his pain with me. I am forgiving myself, and without feeling any guilt or shame anymore for what he did, and the fact that I  wasn’t able to see his pain or any signs of whatever it was that he was going through
  • I am slowly able to get back to my career in full swing, taking baby steps towards having a fulfilling social circle of friends and family. I am even considering at least explorieng and meeting if not dating other men 

Further, I helped Meeta experience a deep hypnotic state and then asked her to imagine herself in the moment where she heard the news of her husband passing and then continue the imagination till she witnessed the last rites in her imagination as well. 

I asked Meeta to imagine this till she started getting in touch with anger. Once her body language reflected that she was in touch with the anger, I continued into the next process called “Hypno-Drama“.

I asked who she was angry towards?

Meeta responded by saying “ Him & Myself” for taking his own life, being selfish and at herself for not seeing the signs and being unaware of what her husband was going through. I asked her to imagine him and asked her emotions, her anger, her sadness towards her husband, and have a full blown conversation in her mind 

Meeta started venting out her emotions in her imagination, I encouraged her to vent out everything she was feeling. Slowly Meeta started calming down, I also asked to imagine her husband with her and God

Akshada : I want you to express your feelings to your husband  

Meeta expressed her feelings, her body language depicted both sadness and yet a sense of relief or closure. Once she felt calmer, she said she could let him go with God and she knew that he was happy and at peace with that journey. While she was saying this, she visibly looked happier. 

Akshada : Meeta, I want you to imagine his life going forward. 

Meeta imagined working towards improving her relationships with her family and friends and getting back to work and dating other men

I asked Meeta how she was feeling?

She replied Calm

I asked Meeta to tell me 3 situations in future wherein she would like to experience a similar kind of Calmness.

I further did the NLP Anchoring process with her.

At the end of the session, Meeta looked relieved and said that she feels happy knowing that her husband is happy and at peace.

Session 3: Working on her confidence to move on

In the third session of Bereavement Counselling, Meeta reported that she had started feeling better in the past week. I reminded Meeta that her second outcome was to be able to move on with her life confidently, and start dating other men and be able to get back to her fulfilling social circle of friends and family and that we shall focus on this during today’s session. 

I asked her to list down the things that she needed to be able to achieve this. Once she had listed it all down. We further made an elaborative task list wherein we broke down each and every task into smaller bits. I also asked Meeta to tell me what would be the possible hindrances while working on those tasks.

For her home assignment, I asked her to continue with the list.

Session 4: Working with Task List and Hindrances Cont…

case study on grief counselling

Meeta reported that she had started feeling better in the past week. 

While I was going through the home assignment, she was very well able to break down the tasks. The major emotion that she wanted to feel was Confidence. I asked her to tell me 1 situation in the past where she felt most confident and 3 situations in the future where she would like to feel confident.

After she listed down the 3 future situations I used a combination of Emotional Anchoring and Future Imagination to associate the feeling of confidence in her everyday life tasks . I guided Meeta in the imagination to live her life confidently moving on and being able to date other men

At the end of the session, she informed me that she felt more confident about being able to move on with her life.

For home assignment I ask Meeta to use the anchored confidence in her daily tasks in the coming week and observe how it went closely.

Session 5: Session Closure

In the fifth session of bereavement counselling, Meeta mentioned that her past week went really nice and that she is back to her work in full swing and confident and that one of her close friends has already set up a date for her in the coming week and she is looking forward to meeting this new guy. She has also connected with her friends and family and she is feeling so much lighter, happier and calm making plans with them and feeling connected to them.

In this session, I taught her how to do self hypnosis for future concerns and at the end of the session I informed her that now the both of us could stay in touch with each other.

Over the next couple of weeks, Meeta stayed in touch with me and kept informing me about how things were going. After about a month both of us decided to terminate the sessions as Meeta was doing well and felt she could handle things by herself going forward.

My Observation

The bereavement counselling process used by me really surprised me by its effectiveness, especially given Meeta’s initial reluctance to even continue the counselling sessions, and the amount of guilt, blame and shame was carrying for herself.

case study on grief counselling

  • Category: Psychotherapy & Coaching
  • Tags: Case Studies , Coaching , For Therapists

Nitin Shah

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Review of Grief Therapies for Older Adults

Charisse colvin.

Montefiore Medical Center, Bronx, NY USA

Mirnova Ceide

Purpose of review.

The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic.

The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic.

Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

Introduction

By 2060, there will be almost 100 million older adults in the United States, who will comprise 25% of the US population [ 1 ]. This is referred to as the “silver tsunami” [ 2 ]. The biggest wave of older adults are the baby boomers. The youngest of that cohort will be 65 by 2030. Grief impacts older adults more than other age groups because they have more family, more connections, and they have lived longer.

In the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV, bereavement was an exclusion for the diagnosis of major depressive disorder (MDD) [ 3 ]. This “bereavement exclusion” was removed in DSM-5 [ 4 ] and triggered concerns for over-diagnosis of MDD in the presence of grief. DSM-5 includes a “persistent complex bereavement disorder”; however it is under further study [ 4 ]. Additionally, in 2018 there was a recognition in International Classification of Diseases (ICD)-11 by the World Health Organization that grief has varying degrees of severity, resulting in significant impairments in social and occupational functioning. The classification of “prolonged grief disorder” [ 5 ] (PGD), which identifies grief lasting longer than 6 months which “exceeds expected social, cultural or religious norms for the individual’s culture and context”, was added to ICD-11, as well” [ 5 ].

Losses Unique to the Geriatric Population

A meta-analysis [ 6 ] identified that approximately 1 out of 10 bereaved adults is at risk of developing PGD and the impact of PGD in older adults is estimated to be higher than that of the non-geriatric population.

Older adults have experienced many losses over their lifetime including parents, siblings, spouses, friends, and even children. In 1986 a study identified up to 10% of adults >60 years old suffered the loss of an adult child [ 7 ] and with life expectancies increasing, the number is surely higher today. A qualitative Belgian study examined the effects of elderly parents losing an adult child to cancer [ 8 ]. A common theme of these participants was loneliness due to the uniqueness of losing an adult child. They also expressed a lack of desire to express their grief, because they did not want to be a burden on the remaining family. They coped by keeping objects, photos, and visiting gravesites, and having conversations with the deceased. This study did not identify any particular treatment that was used to help this population, and even described family’s attempts at protecting the parent from the child’s impending death by restricting visits to hospitals. Some were not allowed to attend funerals or were heavily medicated, increasing the risk for developing PGD. This study highlights the need for better recognition and management of grief in older adults. More recently, the COVID-19 pandemic has created similarly uncommon circumstances regarding grief. The particular challenges of COVID-19 and grief will be discussed later in this report.

Types of Grief

Other than the pervasive feelings of loss, “grief” can have a wide variety of presentations. Identifying different types of grief, informs monitoring and treatment of grief [ 9 ]. Anticipatory Grief or “pre-death grief” is the grief one feels when caring for a person whose demise is impending. Acute Grief is what is experienced when the loss happens. Integrated Grief is the re-organization of attitudes, feelings, outlook after the loss, which is usually 6–12 months after the loss. Complicated Grief, or Prolonged Grief Disorder (PGD), is a failure to adapt to the loss. It includes a pervasive longing for the deceased. The definition is listed in more detail in Table ​ Table1. 1 . In DSM-V, a Persistent Complex Bereavement Disorder (PCBD) is identified, which is a “Condition for Further Study”. It identifies persistent yearning and preoccupation with the deceased as features of this condition.

ICD-11 prolonged grief disorder (PGD) definition

Different Theories of Grief

In order to understand what grief is, we will now examine some different constructs. There are many conceptual frameworks of grief. Notable ones are described below.

Sigmund Freud

Psychoanalytic models of grief involve attachments to parental figures and the mourning process. This process is a gradual releasing of the attachment, or “love object” and is a painful process which must be experienced [ 10 ].

John Bowlby

Attachment theory evolved from psychoanalytic models. It involves the idea that children’s attachments to parents, and then later other adults are instinctual, necessary for survival, and biologically driven. The quality of the attachment can vary between three types: secure, resistant, and avoidant [ 11 ]. When the attachment is broken, an intense struggle between the attachment and the missing object ensues, which goes through three stages: protest, despair and detachment. Experiencing these stages results in a reorganization of the attachment and a return to former interests [ 10 ].

Elisabeth Kübler-Ross

This widely used model of grief evolved by observation of patients that were facing their own impending death. These five stages are experienced, in no particular order, when people experience grief. Unresolved stages can be re-visited until resolved. They are listed here: [ 10 , 12 ]

Irvin Yalom

Existential psychotherapy recognizes four basic human issues that all people struggle with: mortality, “existential isolation”, freedom, and meaninglessness. The basic concepts are that death is inevitable, that we are all born alone and die alone, that we are in charge of our own destinies, and that we are afraid that our life is meaningless unless we make something of it. These struggles around “death anxiety” manifest in different ways depending on personality and innate coping skills [ 13 ].

Commonalities among All Theories

The above identified theories all have some things in common; an expected temporal component that, depending on the type of loss, a clinician can expect the bereaved person to follow. There is an acute phase that can last up to 6 months, or what is culturally accepted as “normal” [ 14 ]. The relationship to the loss is also important, and research shows that losing a child can extend the grief phase up to ten years [ 14 ]. There is a varying course of intensity of grief which is unpredictable, however it is expected to result in coming to terms with the loss and experiencing life normally, without the loved one in it [ 14 ].

Prolonged Grief Disorder

No matter which construct of grief we imagine a patient is experiencing, an unsuccessful return to normal life within a broad time frame is likely to be PGD (Table ​ (Table1 1 ).

Although there can be an overlap between grief and depression, grief is not depression (https://www.dana.org/article/grief-vs-depression/). Freud wrote about the differences in his 1917 essay Mourning and Melancholia . Melancholia can increase suicide risk whereas Mourning eventually resolves as the person adjusts to the loss of attachment (and possibly re-attaches to something else.) Individuals experiencing grief retain their self-worth and are able to experience positive emotions. Shear writes an excellent article on how depression differs from grief [ 14 ]. Table ​ Table2 2 illustrates some of the differences and similarities among these disorders [ 15 ].

Symptom overlap of grief, prolonged grief and major depressive disorder

Measures of Grief

There is still research needed to refine the ICD-11 definition of PGD, and the DSM-V definition of PCBD. This leaves opportunity for screening tools, cutoffs, and sensitivities to vary [ 16 ]. Table ​ Table3 3 identifies many tools, but is not comprehensive. Given the overlap between depression, grief, and PGD, as shown in Table 2, the sensitivity of screening tools is difficult to assess. The importance of identifying PGD is exemplified in a case report of a grieving woman, who on her deceased son’s birthday, was admitted to an inpatient unit with a diagnosis of mania with psychotic features and treated according to those guidelines. After her discharge she made a suicide attempt, was re-admitted and identified as having PGD/PCBD [ 17 ].

Grief screening tools

Out of the study tools identified in the table, ICG, BGQ, and PG-13 seem to be the most commonly used tool in clinical settings. This is a developing field and one can suppose that the length of time of existence, ease of use, and reported sensitivity/specificity, respectively could be responsible for their relative popularity.

Treatments for Grief

Normal grief resolves externally through social support and internally through re-arranging the loss to their daily routine, and it takes time to do so. Each person will move through their bereavement differently, and at a different pace, and have differing needs of social support. Those that have little social support can be helped by adding support through groups, whether in person or online. Individual therapy has been shown to help, as well.

Since PGD can appear from a multitude of causes, researchers have been examining a wide range of populations and situations.

  • Refugees (specifically female refugees)
  • Elderly Spouse
  • Where the remains were never found
  • University Students
  • Cancer, for deceased and for caregiver
  • Cognitive decline
  • In children with PTSD
  • Community-dwelling caregivers
  • Internet-based treatments

When the clinician has determined that PGD is present in their patient, the following section describes some modalities that have been shown to be helpful.

Psychotherapies

There are many talk therapies available to treat PGD. Some are very structured, some are relatively brief, and some are tailored to specific populations or age ranges. A common observation is that there are not many studies on types of therapy nor are they high-powered. This is a call to generate more research in this area.

Cognitive Behavioral Therapy (CBT)

This therapy is adaptable to a range of diagnoses and is a widely accepted, well known treatment. An example is illustrated in a randomized controlled clinical trial from Germany [ 21 ] where CBT was adapted for PGD and administered to a small group of people, mostly widows ranging from 18 to 78 years old. The intervention lasted on average nine months. The intervention used psychoeducation regarding normal grief vs. PGD, used elements from PTSD exposure therapy, and cognitive restructuring. Their results showed the intervention was highly effective in reducing the severity of grief.

Meaning-Centered Grief Therapy (MCGT)

This therapy is a manualized combination of CBT and existential therapy that lasts for 16 weeks. One study on parents with PGD of children under 25 years old who died from cancer showed improvement in PGD, whether the children had recently passed or not [ 22 ]. Interventions were in person or through videoconferencing. Although this study did not focus on geriatric parents, the devastation and likelihood of progressing to PGD is the same and can be applied to geriatric patients.

Interpersonal Psychotherapy (IPT)

This is a structured treatment that has an introductory, middle, and termination phase, which typically spans 12–16 weeks. The introductory phase assesses the relationship with the deceased, and the quality of the relationship. The middle phase addresses the grief and any positive and negative aspects of the relationship. The termination phase assesses the improvements in therapy, future goals and expectations, and feelings regarding the end of the therapy. IPT was originally developed to treat depression and was shown to be effective when used in combination with antidepressants [ 23 ].

Complicated Grief Treatment (CGT)

Developed at Columbia University, this is a 16 week program [ 24 ] that targets PGD and has manualized training with tools and handouts available to patients [ 25 ]. In comparison to IPT, CGT has shown in one study to be superior with almost double the response rate using CGT compared to IPT [ 26 ]. Their research shows that 70% of participants improve after the treatment. This treatment was conducted across age groups.

Specific, PTSD-Related Treatments

The two treatments listed below are identified because PGD has a crossover of symptoms with PTSD. These can help treat the common elements of PGD. Further refinement of PGD is warranted.

Life Review Therapy (LRT)

This is based on Erik Erikson’s developmental theory, where the 8th stage of integrity vs despair is addressed by reviewing past accomplishments and conflicts. Life Review Therapy (LRT) showed improvement of depression and spiritual well-being in bereaved families and patients with terminal cancer [ 27 , 28 ].

Integrative Testimonial Therapy (ITT)

An internet-based writing therapy called Integrative Testimonial Therapy (ITT) was used with German survivors of World War II. It combines cognitive-behavioral therapy and life review elements, and found moderate decreases in PTSD symptoms [ 29 ].

Group/Peer Modalities

A study conducted by the Veterans Administration introduced a group model of bereavement for older veterans, mostly male, who have lost a spouse. This model was based on the dual process model of bereavement and Complicated Grief Treatment (CGT). It consisted of eight guided sessions in a group setting. This therapy showed a significant reduction in grief and depression symptoms [ 30 ].

Other, Non-Pharmacological Modalities

The majority of the current research has focused on developing screening tools and analyzing psychotherapeutic interventions for PGD. Fewer studies have specifically investigated social support, faith based, or non-Westernized interventions. Most studies are conducted in English. There is a tremendous, personalized variety of grief responses corresponding with varying attachments which would be better addressed by researching interindividual and intercultural variations in grieving.

Pharmacology

There is little evidence showing antidepressants alone treating PGD. In 2017 at Columbia University, a randomized clinical trial of Complicated Grief Therapy + Placebo vs. CGT + Citalopram showed that although citalopram improved symptoms of depression, it was ineffective in changing grief scores as measured by the Clinical Global Impression scale [ 25 ].

Since PGD and MDD can co-occur, the study remarks that citalopram would be effective for MDD.

A literature review [ 31 ] of studies using pharmacological treatments for PGD did show some effectiveness of antidepressants in treatment of PGD, yet were underpowered [ 31 ]. Of note some studies have found a benefit with tricyclic antidepressants, as well as paroxetine, which are unwise to use in geriatric population due to excess sedation and risk of falls. The review also mentioned three escitalopram studies that showed improvement, but all of the studies were, again, underpowered and therefore it cannot be said that the results are significant [ 31 ].

The same review article [ 31 ] identified a study that examined the use of benzodiazepines during ITP and CGT, and showed an improvement in the ITP group but interestingly, not the CGT group. Overall, benzodiazepines are contraindicated in the geriatric population due to over sedation and risk of falls, and increase in cognitive impairment and incidence of dementia [ 32 ].

Since there is a clinical overlap of PGD and MDD, the clinician may be tempted to administer antidepressants. In this published geriatric case report, administering an unneeded selective serotonin reuptake inhibitor in an elderly person can cause hyponatremia [ 33 ]. Clinicians should be cautious of potentially inappropriate prescribing leading to side effects and employ non pharmacologic interventions, whenever possible.

The COVID-19 pandemic has caused death on a scale that surpasses most natural disasters in recent history. Research on the COVID-19 pandemic is prolific at this time. Mortality increases with age, and one study identified an age greater than 60 as the threshold for an exponential increase in risk [ 34 ]. The geriatric population has been devastated by the COVID-19 pandemic and has caused a wave of grief among spouses, children, siblings, and friends. Two articles described that isolation measures to slow down the spread of COVID stopped the natural process of grieving. The prevention of “saying goodbye”, along with the added stress/anxiety/isolation surrounding the pandemic has contributed to stresses that may precipitate PGD in large numbers [ 35 , 36 ]. One article described it as “disenfranchised grief”, and cited a greater risk of PGD because of the pandemic [ 37 ].

Anticipation of greater risk of PGD is common. An online research study of Chinese participants after deaths due to COVID-19 by Tang and Xiang showed higher scores on an online assessment of grief for PGD and PCBD [ 38 ]. “Bereavement overload” was identified in another article and it called for “national bereavement response plans” to guide healthcare professionals in times of massive traumatic deaths [ 37 ].

In an online, cross-sectional study of Chinese citizens in 2020 who have lost a loved one due to COVID, found no difference was found in levels of grief symptoms using a 6-month threshold. More severe prolonged grief symptoms were associated with losing a close person by COVID-19, losing a partner, child, parent, and grandparent, feeling more traumatic about the loss, and feeling closer with the deceased. [ 38 ].

The Bereavement Network Europe (BNE) is taking steps to advance mental health support for bereavement across Europe particularly during the COVID-19 pandemic including: improving access to a network to use a common framework for research and care, creating a web-based platform to raise awareness on PGD, and developing a toolkit to implement/regulate best practice standards and evidence-based guidelines for bereavement care. The BNE will hold a conference in 2022 with the aim to unite bereavement researchers, clinicians and organizations in Europe [ 39 ].

The “death anxiety” construct is a feature of many disorders, including PGD. It is an anticipatory grief-like feature that is unique to humans because they know they are going to die. During the pandemic, one paper examined measures of “death anxiety” and showed positive correlation to fears about contracting the virus, and showed an increase due to constant reminders and worries about dying from the virus [ 40 ]. Since anxiety is a common theme in PGD, using the paper’s suggestion of Cognitive Behavioral Therapy may be a future component of PGD treatment.

Prolonged Grief Disorder as a diagnosis is still in the early stages of definition. The geriatric population is in more need than ever to identify and treat this disorder due to the geriatric population boom. More research is needed and being done, and especially now that the COVID-19 pandemic has expanded the need to identify PGD in other than the geriatric population. The overlap between other major diagnoses makes it easy to miss in a clinical setting and it is important to distinguish it due to the different treatment recommendations for each.

Many tools are available, mostly for research at this time however of use to the primary care provider is the Brief Grief Questionnaire. Its simplicity and brevity make it a good start for screening for PGD, with the option for further refinements. For clinicians not doing research, the longer questionnaires can be shelved until there are more refined definitions of PGD.

The ICD-11 relies heavily on what is “culturally normal”. With so many “norms” and cultures, this area is too broad. Therefore, more concrete, measurable identifiers would improve identification of this condition greatly. An assessment based on attachment theory could be beneficial as grief appears to be tightly entwined into the level of attachment with the deceased.

Psychotherapy, in general, is effective for PGD. However, there is little research on PGD therapies, and no modalities has been shown to be superior. The Complicated Grief Therapy is a convenient, manualized therapy with training materials that can be purchased. Any clinician wishing to further their experience with PGD therapy would benefit from this training. Further research with adequately powered studies and different patient populations is needed to determine the effectiveness of structured PGD therapies. There is a lack of research into group therapies, culturally-targeted therapies, and religiously-targeted therapies.

Older adults are disproportionately affected by grief. While the majority experience normal grief, clinicians should screen for PGD and MDD. They are not uncommon and may warrant specific psychotherapies. More research is needed to address PGD to address the “cultural norm” mentioned in ICD-11, especially since COVID-19 has crossed all boundaries into all populations regardless of local “cultural norms”.

Declarations

Dr. Colvin and Dr. Ceide have no financial interests to disclose.

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Geriatric Psychiatry

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Grieving Couple

Sydney Grief Counsellor Explains Therapy

• Grief is our emotional response to a loss, trauma or death.

• We can connect you with a qualified bereavement counsellor who can help you overcome grief.

• One of our grief counsellors explains the process of grief counselling by sharing a story of a client who lost her husband.

case study on grief counselling

Looking help with grief? On this page a grief counsellor tells one clients story of loss, and how they used counselling for support. You can also read this page for a general overview of grief counselling .

When a loved one dies, whether unexpectedly or after a long illness, the emotional impact is always severe. This is especially the case if a person dies before old age. Grief represents our emotional response to the loss, as well as the fear of the dramatic life change that will likely result from such loss.

Everyone experiences grief in their own unique way but emotional support for the grieving party is an essential component for overcoming grief. Support comes from family and friends, but can also come from a professional bereavement counsellor who is able to offer non-judgmental understanding, a listening ear, and a practical way forward.

Here is Naheem’s Story.

Naheem's Story

Naheem was very close to her husband. They had been childhood sweethearts and had been best friends all of their lives. When her husband, Nabill, died at 45 of a sudden and unexpected heart attack, Naheem felt like she had been punched in the stomach. She cried and screamed when the doctor told her that they had done everything possible, but he had not survived. How could she go on with her life?

Naheem sat in her home in stunned silence. She had two children to take care of, all by herself now. Jade and Asia were only toddlers and did not really understand what was happening or why their father was not home. They happily watched the television while their mother sat staring into space. Naheem and Nabill’s families were trying to help her as much as they could, but at the end of the day, she was left to herself in her now empty bed. Naheem would wake in the middle of the night, reaching for her beloved husband, only to find his side of the bed empty. She cried herself to sleep every night for a week.

Naheem had to take care of her husband’s estate and all of the legal issues that accompanied the death of a spouse. Unfortunately, she could not just crawl into a hole and forget about life for a while. She had her children to take care of and raise as a single mother now.

Naheem’s sister suggested was a social worker and suggested she might benefit from seeing a bereavement counsellor. Naheem was quick to take up the suggestion as she felt that her friends were sick of hearing about her despair, and yet she really wasn’t ready to stop despairing. She needed to talk about Nabill, she needed to talk about her grief, she needed to cry. Naheem met her grief counsellor, Rebecca, for the first time about three weeks after Naheem’s death and she continued to see her, each week, for about 2 months.

During this time, Naheem’s sleeping patterns calmed down, and she gradually became used to sleeping in her bed alone. While it took her a long time to feel normal in a social situation, she found she was able to find joy in her children and even go out with friends for dinner now and again.

Naheem continued to touch base with Rebecca on an intermittent basis for about 18 months.

After about a year, and with Rebecca’s encouragement, Naheem was finally able to clear Nabill’s clothes from their home. This was symbolically momentous for Naheem as it helped to bring her a sense of closure. Naheem gave away many of Nabil’s things to his brothers or to charities for people who might need them more than she did now. Naheem found that eventually she could look back on her life with Nabill with happiness and wistfulness at what she had lost and what might have been.

Naheem found that seeing a grief counsellor within a few weeks after losing Nabill really assisted her to overcome the initial shock, and adjust herself to a new life without him. Naheem found grief counselling valuable because it gave her an opportunity to reveal her emotions and talk about her loss in an environment separate to her family and friends. In the counselling room, Naheem felt able to talk freely about her fears of a life without Nabill – fears for her children, fears about financial insecurity, fears about loneliness. Rebecca listened with empathy and without judgment. She helped Naheem to make sense of her emotions and gave her practical advice, as well as emotional support, to help her find a way forward.

Finding a bereavement counsellor for grief and loss

If you or someone you love has suffered a recent loss, they may benefit from talking with a professional bereavement counsellor or psychologist to help them work through their feelings of grief.  If you would like more information or to schedule an appointment, please contact Associated Counsellors & Psychologists Sydney.

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    This manual uses a four stage model, corresponding to the seasons of the year, to help young people work through their unresolved grief issues. Before beginning these sessions, C assisted Tina to come up with some definite goals of counselling. This was an important process as it enabled the two to come together as a team to brainstorm ideas of ...

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    1.1. The present study. A unique situation of bereavement care in Scotland and a newly developed intervention at a Scottish national organization, Cruse Bereavement Care Scotland (CBCS), have presented the opportunity to address these gaps in the research by conducting a naturalistic, longitudinal study on the effectiveness of community‐based, one‐to‐one bereavement counselling.

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    Grief counseling for Muslim preschool and elementar y school children. J . Multicult Couns Dev 2010;38(2):112-24. 3. Fox SS. ... In this case study, index client was an eight years old girl who ...

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    A Case of Grief using an Eclectic Approach. October 15, 2009. Author: Jane Barry. Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of ...

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  11. Complicated grief therapy as a new treatment approach

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    Sue agreed for Tom to join the counselling process at this stage to explore the differences. Once Tom and Sue acknowledge each others thoughts and feeling about the loss of Jill and how this impacted on their thoughts and fears regarding David they were in a better position to co-develop a suitable solution. Once this issue was resolved there ...

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  16. Review of Grief Therapies for Older Adults

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  17. Exploring the Impacts of an Art and Narrative Therapy Program on

    This study has built on previous work demonstrating the use of art and narrative therapy as a therapeutic tool for individuals going through a grief or bereavement process (Case and Dalley, 2014). In general participants felt strongly about the efficacy of the therapeutic AT program in helping them cope with their grief both during the program ...

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    Section Four: Grief and Loss Counselling A Case of Grief and Loss 65 A Person Centred Approach to Grief and Loss 70 A Case of Grief Using an Eclectic Approach 74 A Case of Acceptance and Letting Go 82 Section Five: Stress Issues in Counselling A Case of Stressful Life Change 89 A Case of Low Self Esteem 95 A Case of Mid-Life Difficulties 99 A ...

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    Psychologists Sydney / Grief & Loss / Grief Counsellor. • Grief is our emotional response to a loss, trauma or death. • We can connect you with a qualified bereavement counsellor who can help you overcome grief. • One of our grief counsellors explains the process of grief counselling by sharing a story of a client who lost her husband.

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    Her more recent episodes related to her parents' marital problems and her academic/social difficulties at school. She was treated using cognitive-behavioral therapy (CBT). Chafey, M.I.J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response.

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