applying interpersonal phycoteraphy

7/30/2019 Applying Interpersonal Phycoteraphy

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L EE W O LFSO N , M .E D .,C H A R L E S F . R E YNOL DS

Pn .D .P ii . D .

JOU RN AL O F PSY CH OT HE RA PY PR A CT ICE AN D R ESEA RC H

A pp ly in g In terp ersona lP sycho th erapy toB ereavem en t- R ela tedD ep ression F o llow ing L osso f a Spou se in L ate L ifeM A R K D . M I L L E R , M.D . , EL LE N FR AN K ,C L EO N C O R N ES , M.D . , ST ANL E Y D . IMB E R ,B A R B A R A A N D E R SO N , M.S . , L IN EHRENPREIS , L .S .W.JU L IE M AL LO Y , L .S .W. , RE BE CC A SILB ER M A N , PH .D .

JEA N Z AL TM AN , L .S .W.III, M .D .

T he e fficacy o f in te rp ersona l psycho th erapy(1Ff) a s a trea t m en t fo r ou tpa tien ts w ithm ajo r d ep re ss io n has been docum ented in sev-e ra l con tro lled tr ia ls . R ecen tly , IP T has beenadap ted spec ifi ca lly fo r d ep ress ion in la telife. T he au thors report on the ir exper ience inapply ing IP T to ger ia tr ic pa tien ts w ho se de -press io n is tem pora lly lin ked to th e loss o fth eir sp ou se s. D eta iled trea tm en t techn iq uesare illu s tra ted w ith case vigne tte s . P re lim i-n ary trea tm en t ou tcom es are pre sen ted fo r 6sub jects w ho show ed a m ean chang e on th e17 -item Ham ilto n R a ting S ca le forDepres -s ion from 18 .5 2 .3 SD to 7 .2 4 .6 afte ran average o f 1 7 w eekly 1F f se ss ion s . 1F fappears to b e an e ffec tive sho rt-term trea t-m en t fo r b ereavem en t-re la ted depression in e l-d er ly s ub je cts .

(Th e Jo urna l o f P sych o the rap y P racticean d R esearch 1994 ; 3 :149 -1 62)

G rief is no t a d isease , b u t it can deve lopin to on e.

-G eo rge Enge l

T h e know n conseq uences o f be reavem en tin clu de in creased rate s o f dep ress ive and

anx iety d iso rde rs ; inc rea sed con sum ption o fa lcoho l, to bacco , an d tran qu iliz e rs; exace rba -tion of ex istin g m ed ica l illn ess ; d im in ish edim m une com pe tence; an d p rem a tu rem orta lity from inc reased ra te s o f su icid e,acc iden ts , c irrho sis , and ca rd io vascu la r d is -ea se .#{1 76} A year o r m ore a fter w idow hood , a10% to 20% ra te o f m a jo r d ep re ssio n w asn o ted b y C lay ton an d D arv ish , transla tingin to an annu al inc idence of 80 ,0 00 to 16 0 ,000

R eceiv ed Jun e 1 8 , 19 93; rev ised N ovem ber 1 8 , 19 93 ;acc ep ted N ovem ber 2 2 , 19 93 . F rom W estern Psy ch iatricInst itu te and C lin ic , U n iversity of P ittsburgh School ofM ed icine, P i ttsb urg h , P enn sy lvan ia . A ddre ss repr in t re-qu ests to D r. M ille r, W es tern P sych ia tric Inst itu te andC lin ic , U niversity of P i ttsb urg h S chool of M edic ine ,R oom 742 Be lle fie ld T ow ers , P ittsbu rgh , PA 15213 .

Copy righ t 1994 Am er ican Psych iatric P res s, Inc.


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VOLUMES #{149}UM BE R 2 #{149}PR ING 1994

150 B E R EA V EM EN T IN L A T E L IFE

cases o f be reavem en t-re la ted d ep re ssio n . R e -cen tly , Z iso ok an d S chuc te r2 reported ra tes o fm a jo r d ep re ssio n in 3 50 w idow s an d w idow ersas 24% at 2 m on th s, 23% at 7 m on ths , and 1 6%at 13 m onth s a fte r the ir lo ss , com pared w ith a4% ra te o f dep re ssion in 126 ag e -m a tched su b-jects w hose spouses w ere still liv ing .

W e have recen tly repo rted a la rg e declin ein H am ilto n R atin g S ca le fo r D epression(H am -D ) ra ting s in eld erly sub jects w ith b e-reav em en t-re lated m a jo r dep re ssion w how ere treated w ith the an tidep res san t n o rtrip -ty line .34 H ow eve r, the se sam e p atien tsshow ed on ly a sm a ll declin e in g rie f in ten sityas m easu red by th e T ex as Inv en to ry o fG rief .5 T hese da ta su ggest th at alth ough th esom a tic o r vege ta tive sym ptom s of b ereav e-m en t-re lated depre ssion m ay bene fit fromtreatm en t w ith an tidep res san t m ed icatio n ,su ch treatm en t m akes little ch an ge in th ep sycho log ica l d is tre ss a ssoc ia ted spec ifica llyw ith the lo ss o f a spo use . T h is f ind in g a rg uesfo r a psy ch o the rap eu tic com ponen t to th em an ag em en t o f b ereav em en t-re lated m ajo rdep ression .

T h is rep ort w ill o u tline our e ffo r ts inapp ly ing the p rinc ip le s o f in te rpe rsona l psy -ch o the rap y (IPT ) to e lde rly , dep re ssed ,sp ou sally b ereaved pa tien ts in a re search set-ting . T hese e ffo r ts d raw on ou r p rev ious ad -ap ta tion of 1FF fo r the trea tm en t o f m ajo rd ep re ssio n in la te life : IPT /L L .6 Illu stra tivecase ex am ples w ill be p rov id ed , a s w ell assp ecif ic techn iq ues re lev an t to th is p op u la -tion . R esp on se da ta ob ta ined th rou gh in de -pen den t rate rs w ill b e p resen ted in 5 cases.

In terpe rsona l psycho th erapy7 is an in -te rp erson a lly fo cu sed , p re sen t-o r ien ted ap -p roach to the trea tm en t o f a ffectiv e d iso rde r.I t ha s b een estab lish ed as an e ffec tive acu te ,con tin ua tion , and m a in tenance stra teg y w ithun ipo la r d ep re ssed pa tien ts . Itw as deve lop edby K ie rm an e t al.7 a s w ha t w ou ld tod ay becon side red a con tin ua tion th erapy . S ub se -qu en tly , tw o large tria ls8 .9 have dem on-stra ted its eff icacy as an acu te treatm en t, an dF ran k e t a l.2 #{1 76}ave now show n IFF s p rop hy-lactic e fficacy in p reven ting recu rrence o f

m a jo r dep re ssion in a 3 -y ea r m a in tenancetrial.

T he u se o f IPT w ith depres sed o lde r pa -tien ts has b een spec ifica lly ad dres sed bySho lom skas et a l.2 and m ore recen tly b yF rank e t aL ,6 w ho a re cu rren tly usin g it in alo ng-te rm m ain tenance tr ia l o f th erap ie s inla te -lif e d ep re ss io n.

It sho u ld b e ackn ow ledged tha t m os t p a-tien ts w ho lose a spou se in la te life w ill befem a le and tha t the lo ss o ften o ccurs in th econ tex t o f o the r stresso rs a ssoc ia ted w ith th islife stag e . M ed ica l, s en so ry , o r am bu lato ryd isab ility , f inanc ial s train , ad jus tm en t to re -tirem en t, an d lone line ss a re a few of th ee lem en ts tha t se t the stage fo r ou r pa tien tsreac tion s to the ir lo ss .

IP T SPEC IFIC ITYFO R G RIEF

In the seco nd ed ition o f the c la ss ic tex t Grie fC ounselin g and G r ief Therapy , W orden23 ou t-line s fou r tasks o f m ourn in g : 1 ) accep t th erea lity o f the los s; 2 ) w o rk th rou gh th e pa inof gr ief ; 3 ) ad jus t to an env ironm en t in w h ichthe d eceased is m issing ; and 4) em otio na llyrelo ca te the deceased an d m ov e on w ith life .K ie rm an e t a l.7 de fin e cons isten t go als an dstra teg ies fo r u sing 1FF to treat u n reso lvedg rie f a s fo llow s :

T he tw o go als o f th e treatm ent fo r d ep re s-sio ns th at cen ter on g rie f ar e 1 ) to f ac il ita tethe m ourn ing p roc ess , an d 2 ) to he lp thepa tien t ree stab lish in tere sts an d re la t ion-sh ips tha t can sub sti tu te fo r wha t has beenlos t. Th e th erap ists m ajo r task s a re to he lppa tien ts a sse ss the sig n if icance o f th e lossreal ist ical ly an d em anc ipa te them se lve sfrom a c rip p ling a ttachm en t to th e deadperson , thus becom ing free to cu l tiv atenew in te re sts an d fo rm sa tis fy ing new rela -tio nsh ip s. Th e the rap ist ado p ts an d u tiliz esstra teg ie s and techn iq ues tha t he lp th ep atie n t br ing in to focu s m em ories o f th elost person an d em o tio ns re la ted to thep atien ts ex pe rien ces w ith th e l o st p e r so n .(pp . 9 7-9 8)


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JOURNAL OF PSY CH OT HE RA PY PRA CT ICE A ND R ESEA RC H

MIL L E R ET I4L . 151

GR IE F A S A Fo cu sPRO BL EM A RE A IN IP T

O nce the 1FF pa tien t has been ed ucatedabo u t th e n atu re o f d ep re ssiv e illne ss , th enex t step in trea tm en t, reg ard le ss o f th e p rob -lem area o n w h ich the the rap ist exp ec ts tofocus, is th e com ple tion o f the in te rpe rso na lin ven to ry . A thorou gh in te rp erson al in ven-to ry is e ssen tia l to assess th e q ua lity o f ea rlie rre latio nsh ip s a s w e ll as the ava ilab ility o f cu r-ren t re la tionsh ips and sup ports th a t m ay fa-cilita te th e las t phase o f th e m ourn ingpro cess (rein teg ra tion ). In add ition to thein te rpe rson al in ven to ry , w e have found thefo llow in g serie s o f questio ns to be h elp fu lw ith sp ousally be reav ed o lde r pa tien ts to en -su re a com p lete u nde rstan d ing o f po ten tia la rea s o f con flic t o r o f p o in ts w he re a pa tien tm ay hav e becom e stuck or b ogg ed dow n :

1 .H ow m uch support d id the deceasedp ro v ide in so c ial m atte rs? P rac tica l m a t-te rs su ch as pay ing b ills?

2 . H ow m uch ad ju stm en t is requ ired tom an ag e the p atien ts cu rren t lifesty lew ithou t h is o r h er spou se? M u st ah om e be so ld? W ill incom e d ro p?3 . W ha t p rop ortio n of ac tiv ity w as in de -penden t v ersu s jo in t? D id the pa tien thave hobb ie s o r in dependen t ac tiv itie sin p lace tha t w ill p rov id e a ready -m ad esup port sys tem , o r d id the coup le dov ir tua lly eve ry th in g tog eth er?

4 . W hat w as th e m anne r o f dea th? Achron ic illn es s a llow s m ore tim e fo r ad -

ju stm en t than an acu te illn e ss o r acc i-den t. W as th ere d iff icu ltyacknow ledg ing or accep ting tha t th esp ouse w as dy ing? Su ic ide o bv io usly re-qu ire s ex tensiv e exp lo ratio n .

5 . If the sp ouse had a chron ic illn ess , howm uch careg iv in g burden d id the pa -tien t shou lde r? W as the re a g rea t f inan -c ia l b u rden from m edica l ca re? D om any la rg e b ills rem a in to b e pa id?W ha t changes in th e pa tien ts custom -a ry life sty le w ere req u ired to accom m o-

da te th e spou ses illn ess p rio r to death ?W as the dea th a w e lcom ed end to su f-fer ing?

6 . W ha t w as th e h isto ry o f the ir m arr iag e?W ith the 1FF th erap ist reco gn iz ing aten dency to id ea lize a los t m a te , spe -c ific q uestion s w ill allow fo r usefu l in fer-ences. H ow w ere d ec ision s an dresp on sib ilitie s sh a red? W ere th ere d iffi-cu lt tim es in the m arriag e? W ere th e reany p eriod s o f sep ara tion d uring th em arriage? W as the m arriage , in fact, aseve re bu rd en ? D oes th e p atien t ex pe ri-ence relie f on som e leve l tha t, th ro ughdea th , th e re la tio nsh ip fin ally end ed ?

7 . W ere th ere con tin gency d iscus sionsw ith the sp ouse in th e ev en t tha t o neo r ano th e r pa rtne r d ied firs t? W erew ills and o th e r leg al m atte rs hand ledjo in tly? W ere th ere a rea s o f d is ag ree -m en t? W ere m oney m a tte rs d iscussed ,w ith p lan s in p lace to ad eq ua te ly sup -p ort the rem a in ing p artne r? W ere fu -n era l p lans d is cu ssed? W ere theyim plem en ted as ag reed?

8 . H ow frequ en tly has the pa tien t hadth ough ts abo u t beg inn ing a new rom an-tic re latio nsh ip ? H ad th is pos sib ilityeve r been d iscu ssed w ith the pa tien tsspo use? D oes the pa tien t fee l tha t a pe -rio d of w a iting is p rope r? W ere th e reo th er re la tionsh ips d uring th e m ar-riage th at are p rod uc ing gu ilty rum in a -tion s now ?

9 . W here a re the pa tien ts ch ild ren liv ing ?W ha t is the q ua lity o f th ose re la tion -sh ips? A re the re g rand ch ild ren , andhow o ften is con tac t m ade? Th e nu -c lear fam ily has b ecom e w id ely d is-pe rsed , w ith ch ild ren m ov in g aw ay tofind jo bs. T hu s, a ltho ugh ch ild ren m aym ean w ell, th eir p ractica l av a ilab ilitym ay be an issue . H ave the re been d is -cu ssion s ab ou t m ov in g c lose r to ch il-d ren? W ha t o th er sou rces o f su ppo rta re a va ila ble ?

10 . W ha t o th er lo sse s has the pa tien t sus-ta ined , and w ha t w ere h is o r h e r reac -


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VO LU M E S #{149}U M B ER 2 #{149}PR IN G 1994

152 B E R E A V E ME N T IN L A TE L IFE

tio ns to those losse s? P a rticu la r atten -tio n is fo cu sed on any lo sse s in ea rlylife , w ith ea rly pa ren ta l lo ss clea rly a sso -cia ted w ith inc rea sed risk fo r dep re s-s ion in adu lth ood .2 4

11 . H as the su rv iv in g sp ouse been ab le tod ispo se o f pe rsona l item s of th e d e -ceased , pa rticu la r ly c lo th ing? In our ex -pe rien ce in o ur p ilo t s tu dy , th is act is ap ow erfu l m e tap hor; it is in d ica tiv e o ftrue m ovem en t o r, if the p rocess is p ro -trac ted , o f f ixa tion . L eav ing the bed-room ju st a s it w as is com m on fo rpa ren ts o f a lost ch ild bu t can a lso b eseen w ith loss o f a sp ouse . T hethe rap ists d irec t in qu iry a lon g theseline s can prov ide v alu ab le ind irectc lues ab ou t the pa tien ts stru gg le toh o ld o n at a ll costs a s opposed to let-ting g o in a m easu red w ay th at a llow sfo r e motion al g r owth .

Som e p atien ts m ay bene fit, how eve r,from the ir 1 FF th erap ists ack now ledg-ing tha t a tim e le ss a ttachm en t to th edeceased (a s desc rib ed by B ow lby andP a rke r e t a l. m ay be best fo r them .B ereavem en t th erap ists shou ld n o t betrap ped in to expec ting a ll pa tien ts tog et ov er it and m ov e on . M any p a-tien ts , pa r ticu lar ly th e o ld -o ld (80y ears o r o ld er), m ay be a t a stage inthe ir liv es w here it is b est fo r them toconso lida te the ir m em orie s and d rawon them for su stenance th ro ughou tthe ir rem a in ing years .

12 . If pa tien ts have d iff icu lty g ettin g intouch w ith the ir feelin gs, have they con -side red w riting a fa rew e ll lette r to thedeceased? L eick an d D av id sen -N ie lsen2en co urag e ex ten sive le tter w riting . A l-th ough hom ew ork is no t a focus o f1FF in gene ral, w e have foun d tha t itsuse is ju stified becau se it he lps p atien tsreach deep e r leve ls o f fee ling an d pro -m ote s p rog re ss . S im ila rly , rev iew in gpho to g rap hs o r o th er m em orab ilia m ayp ro v ide fu rth er s tim u lus to deep en lev -e ls o f feelin g .

EX PL OR IN G M A RIT ALQUAL I T Y

To expand fu rthe r o n th e m arital h is to ry , th e1FF th erap ist m us t rea lize th at the qu a lity o fth e m arriage has b een show n to affec t th ep ro cess o f be reavem en t. F u tte rm an e t a l.2 7fou nd tha t be reaved o ld er p e rso ns ra ted the irm arr iag es m ore p ositive ly th an nonbe reavedo lde r p erson s, su ggestin g an idea lizin g b ia s .Th ese au th o rs fu r the r no ted tha t be reavedd ep re ssed o lde r pa tien ts v iew ed th eir m ar-r iages m o re po sitive ly th an d id depre ssedo lde r p a tien ts w ho w ere n o t be reaved .

B ow lby s2 5 a ttachm en t theo ry p ostu late sth at th e q ua lity o f ear ly - life p aren ta l attach -m en ts se ts the stag e fo r a ll fu tu re a ffectio na lb ond ing . S ecu re attachm en ts in ea rly life p ro -m ote a po sitive self-im ag e an d th e rea liza tiontha t o the r sa tisfy ing affec tion al bo nd in g isp ossib le. In co n trast, im p a ired attachm en tsin ea rly life (re su lting from neg lec tfu l, am b iv -a len t, ind ifferen t, o r abu sive pa ren tin g ) canlead to life long d ifficu lty in fo rm in g sa tisfy in gin terpe rsona l rela tion sh ips . T he re fo re, ac-co rd in g to a ttachm en t theo ry , an in d iv id ua lscho ice o f m ate and the d egree o f sa tisfac tiono b ta inab le in the m arita l rela tion sh ip haveroo ts traceab le to the qu ality o f affec tion alb ond ing in early life .

E rikson 28 sim ila rly ou tlin e s th e c ritic a lim portan ce o f ea rly re latio nsh ips in the in i-tial tw o stages o f h is d ev elo pm en t m od el:ba sic tru st, as ve rsus m istru st (eng en de rin ghop e ), and au to nom y, a s ve rsu s sham e anddoub t (engen de rin g w ill). In the ir 15 yea rso f g rie f the rap y ex pe rience , L e ick andD av idsen -N ie lsen2 have n o ted tha t tho se pa -tien ts w ho had d iff icu lty w ith a ttachm en tsten ded to have m o re p ro trac ted g rie f reac -tions. It w as h arde r fo r them to say goodby eand to w e lcom e new con tacts a s w e ll as tom ake u se o f the healin g p ow er o f a sup po rtivenetwork .

P a rke r e t a l.26 recen tly rev iew ed the lite r-atu re tha t exam ines the lin ks b e tw eenpa tien ts p e rcep tion s o f th e q ua lity o f pa ren t-ing they receiv ed and the ir soc ial bon ds in


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A com m on reaso n fo r inh ib ited com ple tionof the m ourn ing p ro cess is am biva lence ,ang er , o r rage (o ften a t b ein g le ft beh ind )

JOU R NA L O F PSY CH OT HE RA PY PR AC TICE AN D R ESEA RC H

MIL L E R ETJ4L . 153

adu lth ood (the concep t o f con tin u ity ) .P a rke r et a l. po in t ou t tha t ex cep tio ns ex isttha t run coun te r to expec tatio ns o f con tinu -ity theo ry ; fo r exam ple , adve rsity in ch ild -hoo d is no t a lw ays assoc ia ted w ith anim p aired ab ility in adu lth ood to fo rm stab le ,sa tisfy ing re la tionsh ips. Tha t is , a pe rv asivenega tive b ia s can be corrected if a secu rea ttachm en t is m ade a t a la te r po in t in life . Itis th is la st po in t tha t fo rm s a link w ith g riefw ork : the rap ists need to reco gn ize tha t thelost sp ouse m ay have p lay ed the ro le o f co r-rec ting tha t p ervasive nega tive b ia s .

P a rke r e t a l.26 repo rt tha t am p le ev id en ceex ists to conc lud e tha t

1 . N ega tive pa ren t-ch ild bo nd in g m ay d is-p ose peop le to ju dge soc ia l bo nd in g inadu lthoo d n ega tive ly , e ithe r d irec tly o rb y shap in g m en ta l m od els .

2 . Th ose w ho h ad ex trem e de ficits inea rly pa ren tal ca re ap pear m o re lik e lyto as soc iate w ith an unca rin g p artne r( if a rela tion sh ip is e stab lished a t a ll) .

3 . In itia l vu ln erab ility as soc iated w ith le ssex trem e d iff icu ltie s in ea rly pa ren talca re app a ren tly can b e m od ified byla te r rela tion al ex pe riences w ith in ti-m ate p artne rs and sign if ican t o the rs .

H orow itz e t a l. h ave w ritten abo u t there la ted concep t o f a p ro fo und loss reac tiva t-ing p rev io usly la ten t, nega tive se lf- im agestha t h ad been coun te rb alanced o r com pen -sa ted fo r b y the liv in g spo use . P a tien ts w ithh isto rie s o f de ficien t ea rly pa ren tin g sh ou ldbe seen as b ein g a t g reate r r isk fo r th e estab -lishm en t o f a dy sfu nc tiona l m arr iag e o r fo rexp erienc ing the lo ss o f the nega tive -b ia s-co r-rec ting spou se m o re acu te ly than tho se w hohad ad eq ua te pa ren tin g .

M A NA G IN G NE GA TIVE O RAM B IV ALENT EM OT IONS

tow ard th e d eceased , G od , o r fa te ; the se em o -tio ns m ay b e in to lerab le to adm it and thu sm ay be b ey ond th e p atien ts aw areness .W hen the 1FF th erap ist h as reached an ap-p rec ia tion of these com m on fee lings fromth e in te rp e rso na l inven to ry and the pa tien tsow n und erstand in g o f h is o r he r d iff icu lty indea ling w ith the spo use s d ea th , the the rap istw ill a sk if the pa tien t ag rees to w ork tow ard agrea te r u nde rstan d ing of th e und e rp in n ing so f the con tinued grief and d ep re ssio n . H av -ing ob ta in ed pe rm ission to focus o n grief , theth e rap ist w ill o ften n eed to m ake som e effo rtto ed ucate th e pa tien t ab ou t com m on pa t-te rns o f ad ju stm en t to loss . Th e the rap ist m ayrem ind the p atien t tha t a ll s ign if ican t re la -tio nsh ips are ch aracte r ized by som e m ixedfee lings and tha t the ag reed -upon ta sk is tolea rn as m uch as p oss ib le abo u t bo th sid es o fth ose m ixed fee lings-nega tive as w e ll a s po s-itive aspects . C a re fu l em pa th ic rev iew of theev en ts su rrou nd in g th e dea th and th e subse-quen t n ecessa ry ad justm en ts w ill p rov id e aninv ita tion to ren ew th e u nfin ished m ourn ingproces s in a safe env ironm en t.

W hen pa tien ts m ak e refe rences to howdifficu lt th eir live s have becom e sin ce th eirspo uses d ied , the 1FF the rap is t a ttem pts toem pa th ize w ith the ir d iff icu lty an d en co ur-ag es th em to ta lk ab ou t the pe rso na l p rob -lem s tha t a rose in respon se to the ir lo ss . Th eth e rap ist m igh t say , H av ing just hea rd ab ou tall the d ifficu ltie s y ouve h ad ad justin g toy our los s , I w ond er if it som e tim es seem sunfa ir to yo u th at y ou now hav e a ll th ese ex trare sp onsib ilities ? T he th erap ist m ig h t fu rthe rsay , In m y expe rience , its n o t u ncom m onfo r p eop le to fee l som e annoyance or an ge rtow ard the d eceased as th e nega tive p a rt o fthose m ixed fee lings w e talk ed abou t ea rlie r .S im ila rly , L e ick and D av idsen -N ielsen 2 usethe inv ita tio n , ...an d w ha t don t you m iss?afte r p atien tly lis ten in g to a ll the p ositiveattr ibu tes the su rv ivo r a sc r ibe s to the de -ceased . W ith gen tle pe rs is ten ce, the 1FF th er-ap ist w ill cla r ify , in te rp re t, an d som etim esco nfro n t th e p atien t w ith the ev idence a l-ready assem bled from the p atien ts ve rb a liza -


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tion s to sug gest tha t fu r the r inqu iry alo ngthese lin es is ind ica ted , at the sam e tim eedu catin g h im or h er ab ou t com m on fee lingsm any peop le ha rb o r in the g rief p ro cess . T h isapp ro ach prov id es rea ssu rance and leg iti-m izes th e state o f m ixed feelin gs as approp ri-a te un de r th e cu rren t c ircum stances. Th eexp e rience o f re lie f o r un burden in g afte r asess ion a lon g th ese line s o ften in stills h ope inthe p atien t tha t h e o r sh e can u se th ethe rap ists ex pe rtise to he lp g et th ro ugh the g rie f and th e accom pany ing d ep re ssio n .

C ase !: C om in g to Te rm s W ith A m b iva len t o rNegative A ffect. M rs . H . w as referred b ecauseo f u n co n tr ol la b le cry ing sp e lls an d inab ility tocon cen tra te a t w ork . H er h usb an d had d ied sud-d en ly o f a h eart a ttack 6 m onths earlie r. S hehad b een p rev io usly d iv o rced an d had en joyedhe r seco nd m arriage fo r 12 years. She spen t th ef irs t se ssio ns ta lk in g abou t he r em barra ssm en t a tb ein g u nab le to con tro l he r em otio ns an d howm uch she had en jo yed he r los t lo ve , e specia llycom pared w ith he r firs t husband .

Th e firs t ta sk o f th erapy w as to g ive he r pe r-m is sion to g rieve , to a llow h erse lf to feel w h at-eve r w as th e re a t the m om en t. S om e tim e w asa lso sp en t in ea rly se ssion s o n practica l m a tte rssu ch as encourag ing he r to re spec tfu lly dec linein v ita tio ns she w as no t u p to and rea lis tic a lly ap -p ra is ing a lte rn ativ e w ays to b ette r h an d le he rem otio na l ou tbu rsts at w o rk .

A f t e r several sess ions o f idealiz ing thepa tien ts dead hu sband , the q uestion W here isthe am biv alen ce? a rose in th e m ind of the the r-ap ist . W hy is th is pa tien t un ab le to m ov e fo r-w ard ? G radua lly , a them e began to em ergeconce rn ing h er hu sbands unw illin gness to g etad equ ate m edic al e xam in atio ns . Sh e felt th at ifsh e had been su ccessfu l m aybe h is dea th cou ldhave been preven ted . S he adm itted feelin g en-raged a t th e tho ugh t tha t he m ig h t have con-cea led k now ledge o f m ed ica l illne ss w ith w hichhe d id n o t w an t to bu rd en he r. F in ally , she a lsocam e to ackn ow led ge ang ry fee ling s tha t hem igh t still be he re (fo r h er) if h e had heededhe r adv ice to g e t m ed ica l ev alu atio n . T hesethou gh ts w ere qu ick ly fo llow ed by gu ilty rum in a-tio ns fo r th in k in g so self ish ly .

A p aral le l d eve lopm ent w a s a de cline inhe r hu sband s sex ua l po tency in th e m on ths be -

fo re h is dea th . S he desc rib ed a m utua lly sa tisfy -ing sex life and sa id tha t bo th w ere d ism ay edabou t recen t d iff icu ltie s . S h e w as ve ry ca refu l todow np lay th e loss o f erectile func tion (and ofm issin g he r ow n sexu al p lea su re ) to avo id m ak-ing h im fee l in secu re. They h ad d iscussed thepos sib ility o f ge tting it check ed m ed ica lly b u thad nev er do ne so . T he pa tien t desc r ibed con-siderab le u nburd en ing relie f at th e opportun i tyto discu ss the se issu es in d eta il, p art icu larly he rgu ilty rum ina tions abo u t hav ing self ish ly encour-aged m ed ical eva lua tion fo r a sexual prob lemw hen , in re trospec t, h e really n eed ed m ed ica lh e lp to sav e h is life . O u t o f re spec t fo r he rdead husband sh e had been unab le to d iscu ssa ll th ese ram ifica tions w ith w e ll-m ean ing friendsand fam ily .M rs. H . p ro g res sed , w ith con tinua l cla r ific a tionand con fron ta tion o f these them es, to the po in to f accep tin g p lans to trave l w ith fam ily , and sh ego t th ro ugh the d eath ann ive rsary w ith le ssstre ss th an expec ted . S he w as n o lon ge r cry inga t w o rk no r th in k ing con stan tly abou t he r la teh usb an d , an d she ag reed th a t it w as tim e to ter-minate t reatmen t .

Commen t : Th is case v igne tte is a g oodexam ple o f th e id ea liz ing p ostu re th at b e -reav ed d epre ssed p atien ts b ring to the in itia ls es sions. It is th is pos tu re tha t p ro tec ts themfrom the nega tive o r am biva len t a ffects theyfin d pa in fu l to ackn ow ledge . Th e IPTth e rap ists jo b is , first, to un de rs tan d th iscom m on ph enom enon , an tic ipa te its occu r-rence , an d look fo r ev id en ce to support itsp re sence from the pa tien ts ow n ve rba liza -tio ns, then to ref lect it b ack to th e p atien t ina the rapeu tic m ann e r, a t th e sam e tim e edu-ca ting the pa tien t th at h is o r h er exp erienceis w e ll w ith in th e ran ge of th e norm a l.

A lth ough co nflic t ov er exp re ssin g am biv -a len t o r neg ativ e affec t is com m on in theau tho rs ex pe rience , it is by n o m ean s u n ive r-s al, and 1FF th erap ists a re cau tion ed ag ain sto ve rzea lous in terp re tatio ns a lon g these line s.

C ase 2 : S trugg lin g to D o th e R ig h t Th in g . M r.a construc tion w o rk er , p resen ted w ith a 30 -

pound w eigh t lo ss , ane rg ia , an hedon ia, and p as-siv e su ic ida l id ea tion . H e repo rted seve re g riefreac tion s a f ter h is m oth er , fath er , and fath er-in -


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JOU RN AL OF PSYC H OT HE RA PY PR AC TICE A ND R ESEA RC H

law d ied . H e desc rib ed h is w ife o f 43 years a sm y b est frie nd , love r, an d w ife . S he h ad died aling ering dea th af ter m any yea rs o f il lne ss, thelast 4 of whi ch requir ed her to be bedriddenwith 24 -hour c are. Despite her decline in wei ghtto 76 p ounds , he had no t al low ed him self to an -tic ipate h er de ath . S inc e h er d eath , h e h ad b eensp end ing his tim e at ten d in g M ass, p ray in g , an dv isit ing her grave da ily .

The m os t s trik in g asp ect of h is ea rly ses-sions w as sex ual preoccupa tio n and inappropr i-a te fl irta tio usn ess w ith fem ale sta ff m em bers.W h e n fin ally confronted wi th the interpr etationthat his overzealo us advances must be hi ding agrea t de al of pain , Mr. G. became tearful an dd iscu ssed how m uch he m issed fem a le com pan -io nsh ip ; h ow eve r, h e felt g reat ly con flic tedabou t C ath o l ic re lig ious proh ib ition s aga in st sexouts ide o f m arriag e. A fte r th is con fro n ta tion ,h is f lirtin g toned dow n consid erab ly . H e w asp ain fu lly aw are of h is lo nel ine ss an d em p tin ess .H e said he w ou ld nt be ab le to ge t h is w ife ou to f h is sys tem until an o th er w om an cam e alo ng ,b u t h e felt aw kw ard b ecause he h ad not dated in43 yea rs. H e ta lked at leng th abo ut h is am biv a-lenc e ab ou t fo rm ing new rela tio nsh ips , s ay ingthat h e m is sed h is w ife s openne ss an d t ru st an ddoubted th at he cou ld rep lace h er. H e sa id h ed id nt w an t to h urt any on e he d ated b y bre ak-ing u p w ith them , b u t h e alte rna tive ly d esc rib eda w ish to find a new re lationsh ip h e cou ld na ildow n and count on .

M r . G . de scr ibed a p ara lle l ov era ctiv ity inho bb ies an d spo rt act iv i ties , w hich he said w a sne ces sary to reach a leve l of ex hau stion th atwoul d allow him to sleep at night.

A fte r h is e igh th ses sion , he repor ted th athe h ad put aw ay som e of h is w ifes rem ind ersand h ad beg un rede corating h is ho use in am ore m anly de cor . H e had his fir st da te andta lked of h is st rugg le with the rea lization thathi s exp erience w as bound to be new and d iffer-en t. H e co n tinu ed h is am biva len t strugg le w ithsexua l ac tiv ity . M r. G . rep orted on h is p rog re ssin th erapy , s ay ing : Ive com e th rou gh som e badm on ths; I nev er th ou gh t Id m ake it. H e d e-sc ribed redu cin g h is cem e te ry v isits to o nce aweek , h as jo ined a squ are d ance g rou p , andlooks upon da tin g as a cha lle nge .

Commen t : L eick an d D av id sen -N ie lsen2rig h tly p o in t ou t tha t feelin gs o f g u ilt andsham e tha t fo llow steps o f p rog re ss in fo rm -

in g new re latio nsh ips can be tru ly p ara lyz ing ,a s if any progre ss w ou ld b e be tray in g th ed eceased . M r. G ., to rn by conflic t ove r fo rm -in g new re la tionsh ips since h is w ife s death ,show ed h is de fen ses in h is f lirta tiousness andh is im m ersion in ac tiv itie s tha t le ft h im ex-h au sted . H is 1FF the rap ist he lp ed h im to dea lw ith b o th sides o f th is und e rly in g co nflict andto w ork th ro ugh it, enab ling h im to relo ca tehis d eceased w ife em otion a lly and b eg indat ing .

IN CO M PL FTE M OU RN IN G

G rie f w ork can reach a p la teau , on ly to bereac tiva ted b y su bsequ en t even ts . T he fo llow -ing v ign ette illu stra te s .

C ase 3 : In com plete M ourn ing . M r. P . los t h isw ife in a 2 -y ear b attle w ith b reast cance r. A lm os tim m ediate ly afte r her death , he w as ca lled to ac -tive du ty in th e Persia n G ulf, w h ere h e servedfo r 6 m on ths u n ti l h e reached the m and ato ry re-t i rement ag e. H e becam e depressed 1 4 .m on thsa fte r h is w ife s dea th w hen h e b eg an d ating aw om an 17 years h is ju n io r.

H is in itia l c om pla in ts w e re p oo r s leep ,poo r m otiv ation , a nd p reo ccu pa tion w iththem es o f d eath-for ex am ple , fe elin g tha t hehad now outl ived the 1 0-y ear gu aran te e on hiscard ia c b ypa ss su rge ry ( tw o fr ien ds w ho also h adund erg on e b yp ass surg ery h ad died in the prev i-ous 6 m onth s). H e d id n ot w ant h elp from anym edic atio n b ecause he fe lt h e had to do th ish imself .

M r. P . described feel ing g uil ty abo ut h av-in g fun w ith h is new lady fr ien d , fe eling that i tw asnt fa ir th at i t c ou ld n t be h is w ife. H e ac -kn ow led ged tha t he had n ev er had th e op portu -nity to gr iev e fo r h is la te wife and fel t th at it w a snow unfa ir to b urden h is new frien d w ith h isgr ief . H e w as o bsessed w ith th e thou gh t tha t hem igh t m istak en ly re fer to h is new frie nd by h isw ifes n am e.

M r. P . felt th at he h ad a g ood marr iageand that he had been there for his wifeth rou ghou t h er d ec line and death . H e ex -p re ssed gra titude fo r the o ppo rtun ity to d iscus sh is fee lings and reported fee ling an d sleep in gbe tte r af te r sev era l s ess ions.

A trag ic co inc idence occurred d urin g the


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th erapy : h is m o the r w as d iag nosed w ith b reastcan cer an d w as n ear dea th on the 2 -yea r an n ive r-sa ry o f h is w ife s d eath . U pon ex p lo ra tion , M r.P . d id n o t feel tha t he had a good re la tio nsh ipw ith h is m othe r , sum m ing h is feelin gs fo r he r a sre spec t fo r raising he r k ids a lone . A s h ism oth e rs co nd itio n d ete r io rated he w as ab le tom ake tim e fo r he r w itho u t resen tm en t o r gu iltfeel ings.

After his mothers death, Mr. P. de alt withhe r esta te an d felt s atisfactio n in h is ab ility tob e the re fo r h e r even th ou gh h is m oth er hadno t been the re fo r h im du rin g h is w ifes b attlew ith cance r. H e w as ab le to fin d sa tisfac tion inthe kn ow led ge tha t he a tten ded w ithou t re se rva -tion to h is m o the r a s w e ll a s h is w ife o n the irdeathbeds.

Commen t : T he firs t ta sk o f 1FF w ith M r. P .w as to p rov ide a safe fo rum in w hich he co u ldre sta rt the m ou rn ing pro cess in te rrup ted b yh is m ilita ry serv ice . T he inh ib ition h e fe lt inh is new re latio nsh ip w as no t go in g to be re -so lv ed u n til h e f in ished the p rocess o f em o-tiona lly re loca ting h is w ife to a p lace he co u ldaccep t. H is 1FF th erap ist w as ab le to a llowhim to ex p lo re a ll th e fee lings h e w as ex pe ri-enc ing w ithou t th e un fa ir bu rd en ing of h isne w f r iend . H is m o the rs illne ss cau sed h imto rev iew realis tic a lly h is re latio nsh ip w ith he ras w e ll a s rev isit h is ro le a s ca reg ive r fo r b o thh is m oth er an d h is w ife. U ltim a te ly , M r. P . w asab le to ack now ledge th a t he h ad been the refo r th em bo th and co u ld now le t them restan d m ove on to new rela tion sh ip s. L e ick an dD av id sen -N ie lsen2 desc rib e the read iness tolove ag ain as b ein g p repa red to live th ro ughth e g rie f o f a new loss.

OT HE R PR OB LE M A RE A S

A lth ou gh g rie f is th e m os t com m on of thefou r p ro b lem areas tha t w e focused o n in o urexp erience w ith be reaved o lde r pe rso ns,each of the o the r th ree 1FF p ro b lem areas(ro le tran sition , in te rpe rsona l con flic t, an din terpe rsona l d efic its ) has com e to bear o nthe m anagem en t o f g rie f reac tions. Ex p lo ra -tion of th e pa tien ts im m ed ia te reac tion s an d

feelin gs abou t the d ea th is c lea r ly requ ired ;h ow eve r, it is a lso th e case tha t ro le transition sa re o ften d ic ta ted b y chang ing c ircum stancesa f ter the dea th o f a spou se ; in te rpe rso na lco nflic ts m ay exacerba te rem ain ing fam ilyre latio nsh ips; an d in te rp erson al de fic its m ays tron g ly in f luence th e w ay a pa tien t goesth rou gh the g riev in g proces s. T he fo llow in gcases illu strate these p rob lem areas.

C ase 4: R ole T ransitio ns. M rs. P .s husband hadd ied 4 m on ths ear lier o f live r cance r. S he w asb rou gh t to treatm en t by her adu lt ch ild ren w ithw hom she had b een l iv in g s eq ue nt ia ll y, e xh au st -in g and f rustra t ing each on e in tu rn . They de -scr ibed h e r a s w eepy , c ling ing , and unw illing tob e lef t a lon e even fo r sho rt pe r iods .

In p riv ate , he r ch ild ren d escr ibed the irla te fa the r a s an abus ive a lco ho lic , and th ey co l-lec tive ly expre ssed the ir am azem en t th at th e irm othe r had stayed w ith h im . A t the in itia l eva lu -a tion , the p a tien t w as sev ere ly depres sed an d re -qu ired 3 w eeks of hosp ita liz atio n tha t includedtre atm en t w ith an tid ep ressan t m edic atio n . Th eho sp ita liza tion brough t con side rab le re lie f tothe ch ild ren , w ho w ere ve ry w illing to b e sup -p ortiv e b u t h ad been ove rw h elm ed by he r d e-p end ency needs .

W hen the psych otherapy re sum ed on anou tpa tien t b asis , the g rea te st fee lin g o f lo ss th a tM rs. P . ex p res sed w as fo r the pas t ob l iga to ry a t-te ndance by grow n ch ild ren at S und ay d inn ersa t he r hom e and h er loss o f sta tus a s the hu bo f fam ily activ ity . I t w as as if sh e w ere w illin g too ve rlo ok or to le rate he r h usb an ds ab usiv en essa s long as she cou ld coun terba lance it w ith sa tis-fac tio n from th e m a te rna l ro le , in w hich eve ry -o ne cam e hom e to he r. O n e d augh ter , inpa rticu lar , revea led h er ow n strug g le s in her psy -cho th erapy and C h ild ren of A lcoho lics supp ortg rou ps to b reak from w ha t sh e te rm ed an en-m esh ed , dys fun c tiona l fam ily .

Th erapy w ith th is p atien t w as c lear ly fo-cu sed o n ro le trans itio n . M any sessions w eresp en t ex p lo rin g the d iffe ren ces b etw een h erw ishes an d m o re realis tic expec ta tio ns conce rn -ing h er g row n ch ild ren s asp ira tio ns an d the ir al-leg iance to he r . S he w as g en tly cha llen ged totak e m ore resp ons ib il ity for he r ow n needs andto lea rn be tte r w ays to cop e w ith th eir indep en -den t ac tiv itie s . S h e som ew hat idea lized her la tehusb and bu t re fe rred fa r less o ften to h im th an


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to the loss o f her p rev iou s li fes ty le .A f ter 3 m on ths o f ste ady p rog res s, M rs. P .

m oved to an ap artm ent bu ild ing an d succ ess -fu lly spread he r dep en den cy need s o ver a w ide rarea by loo k ing in o n o ther w idow s in herbu ild ing and jo in in g a lo ca l sen io r cen te r,w here she served food to less ab le m em bers.H er fam ily con tinued to be in vo lved and sup -po rtiv e a t a lev el w ith w hich they w ere m orecomfor tab le .

Commen t : A s the abo ve case illu stra tes ,p atien ts w ith stro ng d ep en den t traits w how ere heav ily invested in th e support the irspou ses p rov id ed w ill h av e a m uch m ore d if-ficu lt tim e ad ju sting to th e lo ss an d estab lish -ing n ew ro le s fo r them se lves. T ra its o fex cessiv e depend en cy can a lso p rec ip ita te in -terpe rsona l con flic t am ong fam ily m em bers.

Case 5 : N o M ore T im e fo r Exper imentat ion .Mrs. T.s h usband died suddenly following a one-w eek illn ess . S he p resen ted he rself fo r therapy12 m on ths la te r, du ring the m on th that w ouldhav e m ark ed he r 5 0 th w eddin g an niv ersa ry .

M rs . T . desc ribed fee ling g u ilty becausesom ehow she sh ou ld h ave k nown tha t her h us-band w as sick , even tho ugh no clu es w e re avai l-ab le to her . S he ack now ledg ed tha t h erm arriage w as no t g rea t in the la te r years.Upon further e xploration, her ther apist heardhe r describe he r husban d as crabb y , n ega tive ,and alw ays ang ry . M rs. T . desc r ibed spen d ingth e bul k o f their m arriage to le ra ting h erhu sband s m oods bu t fo und it in cre asing ly d iffi-c u lt to do so in th e late r yea rs. S he describ edchan gin g her s ty le from the a ccom m odatin gsoo ther she usual ly w as to on e w ho becam e ju sta s crabby a s he w as , even th ough it se em ed ou to f ch ara cte r fo r he r. She n ow felt gu ilty , a s if h erchan ge in behav ior tow a rd he r hu sband hadb een an ex pe rim en t th at end ed d isas trou slyw ithou t g iv ing h er an y oppor tun ity to re con -s ide r. O n anoth er th em e, M rs. T . rec alle d co n-ve rsat ion s w ith her h usb an d about h isp referen ce tha t h e go fir st and adm itted angryfeel ing s tow ard h im for su cce ssfu lly w il ling it tohappen .

A fte r M rs . T . had had am p le opportun i tyto exp res s h er negative feel ing s as w e ll a s howm uch she m issed h is com pany , he r attem p ts tograp p le w ith the ro le chang es in h er life cam e

to the fo re fron t. S he d escr ibed h ow strang e itfe lt d o in g th ing s alo ne ra the r than a s a coup le .For exam ple , now sh e had to p ark the ca r he r-se lf, in itia te so cia l co n tac ts , an d go a lon e to thecou n try c lub so cia ls they had a tten ded so oftentog eth er . S h e re ferred to a lis t sh e w as keep ingo f th ese a lon e f irsts. M rs. T . w as acu tely aw areo f m issing th e hu ndreds o f da ily p hys ica ltou ch es from her m ate , no t the lea st o f w h ichw as sleep ing to ge the r.

N o t a ll o f he r chang ed ro le s w ere unp lea s-an t, how eve r. S he realized , fo r exam ple , tha tsh e no lon ge r had to be on e o f the firs t to leavep arties a s he r husband had alw ays d em anded .S he co uld n ow m ake decisions with only o ne seto f p re ferences to cons ide r.

M rs. T . s so cia l ne tw ork w as ex tensiv e , andshe w as ab le to d raw on it fo r cons ide rab le su p -p ort. F o r ex am ple , she o rgan ized a slum berp arty w ith a coh ort o f g rade sch oo l fr ien ds w hoh ad kep t up w ith e ach oth er. Th e pan gs o f re-gre t th at th e p arty h ad to end the nex t d ay an dh er f rien ds retu rn to th eir ind iv idua l liv esporten ded s im ila r d iff icu ltie s w ith ap proach ingterm ina tio n . H er the rap ist n o ted a chan ge insty le to a m o re iso lated , p ro tec tive stanc e. Th isdefens ive p osture w a s sh ort-liv ed , h ow eve r, a ndM rs . T . w as ab le to term ina te successfu lly andhas sh ow n con sid erab le in dep en den t capab ili ty .

Commen t : M rs. T . clea rly felt h erhusbands dea th w as un tim ely . H e d ied a fte ra sho rt illn es s , he d ied firs t (as he sa id he dp refe r) , an d h e d ied in the m id st o f he rexpe rim en t o f chang in g h er app roach to -w ard h im . T he ir life tog e the r w as qu ite in -v o lved so cia lly , and th is req u ired grea tchang es on he r pa rt a fte r h is d ea th . M rs. T .felt the loss o f p ro x im ity to h e r husb and ev enm o re p ro foun d ly . In 1FF she w as ab le to ex -p lo re a ll th ese issu es and w as ab le to use th eresource o f h er soc ia l n etw ork to he lp fill th evo id sh e fe lt. P red ic tab ly , sh e q u ick ly cam e tova lue th e re latio nsh ip w ith h er 1FF the rap ist,and the p ro spect o f te rm in a tio n w as, a t firs t,a d iff icu lt one . Th e fee lings o f need tha t a rosein the co n tex t o f te rm ina tion w ere taken u pand w orked th rou gh ove r seve ra l se ss io ns,and M rs . T . w as ab le to m ake th is transitio nsuccess fu lly as w e ll.

L eick and D av id sen -N ie lsen2 em phasize


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tha t lea rn ing n ew sk ills is a p rom in en t com -ponen t o f g rie f w o rk , a s illu stra ted in the caseo f M rs. T . T a lk ing ab ou t in tense em otion cana lso b e a new sk ill, e spec ially w hen coup ledw ith the ex pe rience o f un burden in g re lie f .

U s ing the soc ia l n e tw o rk can a lso be anew sk ill fo r the be reaved . L e ick an dD av idsen -N iels en 2 su ggest a sk in g , C an youask your frien d /confidan t (ne tw o rk ) no t totry to com fo rt y ou bu t ju st to b e w ith yo uw h ile yo u ta lk abou t h ow you fee l, to to le ra teyour tears?

Feelin g like a se lf rath er th an ha lf ady ad is ano th e r req u ired sk ill dem on stra tedby M rs . T . w hen she rea lized sh e co u ld nowdec id e fo r he rse lf w hen to leave soc ia l fu nc -t ions.

T ER M INA TION ISSUE S INIP T GRIEF WORK

In In te rpersona l P sycho therap y o f D epression ,K le rm an e t al.7 sug gest th e fo llow ing in thefina l th ree o r fou r ses sions to fac ilitate thete rm ina tion process : 1 ) ex p lic it d iscussio n ofthe end o f trea tm en t; 2 ) ackn ow ledgm en t o fthe end o f trea tm en t a s a tim e of po ten tia lg r iev ing ; and 3) m ov em en t tow ard thep atien ts recog n ition of h is o r h er ind ep en-d en t com pe tence .

F o r p a tien ts w ho com e to th erapy fo rh elp w ith spou sa l lo ss , the 1FF the rap ist m u stp ay ca refu l a tten tion to the po ssib ility tha t thep atien t w ill exp e rience the term in atio n o f thep sycho the rapy as an add itio na l lo ss . M uchh as been w ritten ab ou t te rm in atio n in short-te rm the rap ie s b ein g easie r to nego tia te th anin lo nge r te rm th erapy because les s tim e hase lapsed d uring w h ich depen dency can d e-ve lop . Fu rth erm o re , in 1FF , tran sference in -te rp re ta tions a re specif ically avo ided in o rde rto keep the p atien ts con flic ts fo cu sed ons ign if ican t f igu re s in th e ir eve ryd ay live s(w h ich a lso se rves to d iscou rage dependenceo n the th erap ist) . N eve rthe less , 1FF the ra -p ists sh ou ld an tic ipa te g rea ter d iff icu lty w ithte rm ina tion fo r pa tien ts w ho becam e d e -p re ssed in the con tex t o f a loss than fo r p a-

tien ts w ith a p rim ary focus on ro le tran sitiono r in te rp e rso na l con flic t.

F rom our exp erience , w e su ggest the fo l-low ing specif ic techn iques fo r term in atio n :

1 . F rom the beg inn in g , c lear ly state therange of the an tic ipa ted leng th o f the r-apy , g ene ra lly 16 -2 0 w eeks, w ith fre -q uen t rem ind ers o f the approach ingd ate o f term in atio n .

2 . F rank ly d iscu ss the pos sib ility o f a tem -p orary re su rg en ce of sym ptom s n earthe tim e of term in atio n ; tha t is , m akefu ll u se o f an edu ca tion al app roach asw ell a s a the rap eu tic o ne .

3 . F ocus o n exp lo ring a lte rn ativ e co p ingstra teg ie s (such as spec ific p lan s to com -b at lon elin es s). B eg in w e ll ah ead ofte rm ina tion to a llow som e expe rim en ta -tio n o n the p atien ts p art, w ith rev iewand po ssib le rev ision of those p lans insu bsequ en t se ssion s.

4. Encourag e new re la tionsh ips.

E xcep t fo r pa tien ts w ho rem a in sev ere lysym ptom atic , K lerm an e t a l.7 recom m endte llin g pa tien ts w ho report a h igh leve l o fd iscom fo rt w ith the p ro spec t o f te rm ina tiontha t a m in im um 4- to 8 -w eek w a iting pe rio dis requ ired be fo re b eg inn in g fu rthe r trea t-m en t o f a d iffe ren t type . Th is conv ey s a c lea rmessage that this th erapy w ill be com ple ted ,tha t th e th erap ist is co n fidan t o f th e pa tien tsab ility to func tio n ou ts ide o f th erapy , and th atbefo re fu r th er treatm en t is s tar ted the pa -tien t sho u ld firs t m ak e a reasonab le tria l o nh is o r he r ow n .

T e rm ina tion issues in short- term psycho-the rapy have been d iscussed in fu rth er d e tailby o th er au tho rs .303 2

PREL IMINARYRE SPON SE D AT A

W e conduc ted a pre lim in a ry stud y o f 1FFeff icacy in the treatm en t o f d ep re ssed be -reaved spou ses in la te life . In the study , 3 m aleand 3 fem a le pa tien ts , m ean ag e 68 (rang e


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64-7 3) w ere en gaged in 1FF after m ee tingR esea rch D iag nos tic C riter ia fo r m a jo r o rm in or depre ssion . S ub jec ts en te red treat-m en t an av erage of 2 6 w eeks (range 11 -56 )a fte r the lo ss o f th eir spo uses. M ean age w as69 .2 6 .0 SD , an d sub jects had b een m arr iedan av e rage of 42 yea rs (range 2 5-4 9) . In de -p en den t ra ters ob ta in ed pre/p ost H am -Dsco re s o f 1 8 .5 2 .3 /7 .2 4 .6 ; G lob a l A ssess-m en t S ca le3 3 sco re s o f 62 .5 4 .3 /7 8 .39 ;an d Texas R ev ised In ven to ry o f G rie f sco re so f 49 .3 9 .6 /3 9 .2 14 .9 a fter a m ean of 1 7w eek ly 1FF sess ions.

These p relim ina ry d ata sug gest th at 1 FFis an e ffec tive treatm en t fo r be reavem en t-re la ted depre ssion in th e eld erly . W e are cu r-ren tly com parin g th e e ff icacy of IPT ,no rtr ip ty line , and com bin a tion the rap y inth is p opu latio n unde r random ized doub le -b lind p laceb o-co n tro lled cond itions .

D I S C U S S I 0 N

In terpe rsona l psy cho th erapy w as sp ecif icallydesig ned as a short-te rm p sycho the rapy fo rdep re ssion , focusing on fo ur m a jo r a reas:g rie f, ro le trans ition , in te rperso na l con flic t,and in te rp erson a l de fic it. T he fo ci o f g rie fand ro le tran sition a re p articu la rly ge rm aneto th e be reaved d ep re ssed pa tien t. T he foc io f in terperson al con flic t an d in terp erson ald efic its m ay a lso req u ire a tten tion in the be -reavem en t se tting . S urv iv in g rela tion sh ip sm ay becom e unba lanced by th e loss , andp atien ts w ith in te rpe rso na l d efic its (g rea terd eg rees o f cha rac te r pa tho lo gy) m ay be a tg rea te r risk fo r inh ib ited o r p ro lo nged grief .

1FF focuses on in te rpe rson al th em es , itin co rp o rate s an edu catio na l ap proach , and itcan be used in con jun ctio n w ith p sycho trop icm ed ica tion . Th e princ ip le s o f 1FF can betaug h t to a v a rie ty o f m en tal health p ro fe s-siona ls (psych iatr is ts , p sy ch o log ists , soc ia lw ork ers , p sy ch ia tric nu rse s), m ak ing it a p rac -tic a l trea tm en t fo r be reavem en t-re la ted de -p ression .

W hen com paring 1FF w ith o the r th era -p ie s fo r b ereav em en t, 1FF does app ear to

o ffer k ey elem en ts com m on to a ll g r ie f th er-ap ie s . T hese a re d efined b y R aphael in he rexce llen t rev iew as 1 ) e stab lish in g a rela tion -sh ip w ith the be reaved , 2 ) exp lo rin g th e los s ,3 ) rev iew in g the los t re la tion sh ip , 4 ) ex p lo r-ing b ackg ro und issu es, 5 ) p rov id ing su ppo rt,and 6) ach iev ing g oa ls (recov ery ) .

B ehav io ra l the rapy , cogn itive the rapy ,and brie f re latio na l/in sigh t p sycho the rapyh av e b een com pared fo r th e trea tm en t o fd ep re ssio n in o ld e r pe rsons (no t n ecessa r ilysecon da ry to be reavem en t) . R esu lts o f thes tudy by G a llaghe r and T hom pson35 sh ow eda s lig htly be tte r ou tcom e fo r the cogn itiveand beh av io ra l g ro ups than fo r the re la-tion a l/in sigh t g rou p , a lthou gh sm a ll num -b ers an d d ifferen tia l d rop ou t rate s m ake thecom parison s le ss th an c lear . G a llaghe r andThom p son a rgue tha t a fo cu s on go als a s w ellas sk ill tra in ing is es sen tia l to e ffectiv e p sycho -th erap ie s fo r dep re ssion . A lth ough 1FF d eve l-oped ou t o f the p sychodynam ic m od el, it iss tro ng ly go al o rien ted an d focused on in te r-pe rsona l th em es. S pec ific h om ew ork as sign -m en ts are no t em ploy ed in 1FF , a lth oughpa tien ts a re encouraged to im prov e com m u-n ica tio n sk ills , to con side r the pu rsu it o f e f-fec tive co p ing stra teg ies , and to d iscuss theim plica tions o f such chang es a t sub sequen tthe rapy session s.

H o row itz et a l. und ertook a de tailedstud y o f d ispo sitiona l an d proces s v ariab le s in52 be reaved p atien ts trea ted w ith psychody-nam ic psycho the rapy . A few po in ts from th iscom plex stud y m erit m en tio n in th e co n tex to f 1FF . H orow itz e t al. foun d tha t ev en p a-tien ts o rd ina rily co nsid ered to be rela tive lypo or cand ida tes fo r b rie f the rap y becau se o flow m otiv atio n or low d ev elo pm en ta l leve lcou ld still b e en gaged in treatm en t b y anac tive , su ppo rtiv e the rap is t. P a tien ts w ith lowm otiva tion had b ette r ou tcom es reg ard in gte rm ina tion is sues w h en m a tched w ith h ig h lyac tive the rap is ts . C onve rsely , h igh ly m o ti-va ted p atien ts had be tter o u tcom es w henth eir th e rap ists too k a le ss activ e s tan ce in thete rm ina tion ph ase. In g ene ra l, h ow ev e r,H orow itz e t al. fou nd tha t m o re exp lo ra to ry


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actio ns by the th erap ist w orked best fo rh ig h ly m o tiva ted or o rgan ized p atien ts andle ss w e ll fo r le ss m otiv ated or les s o rgan izedpa tien ts . S up portive actio ns w ere ind ica tedfo r the latte r g rou p .

1FF is con sis ten t w ith bo th ac tive andsupportive th erap ist ap p roach es and can ac -com m oda te b o th h ig h and low lev e ls o f pa -tien t m otiva tion and o rg an iza tion . 1FF seek sto estab lish a pos itive w ork ing a lliance qu ick lyand to ag ree to a focus ea rly o n . Th e a ttitud eo f th e th erap ist is sup portive , edu catin g , andactiv e. T hose p atien ts cap ab le o f o r m otiva tedfo r m o re in -d ep th exp lo ratio n are en cour-aged by the 1FF the rap ist to und ertake it,how eve r, in our expe rien ce , pa tien ts w ith le ssexp lo rato ry desire can still bene fit f rom th esupportive , educa tiona l, ac tive s tan ce o f th e1 FF th era pis t.

P sy ch odynam ic psycho the rapy and 1FFhave com m on h isto r ical roo ts ; h ow eve r, 1FFd iscourages tran sfe ren ce in te rp re ta tions o rex ten sive exp lo ra tion o f ear ly life expe ri-en ces w hile en co urag ing a fo cu s on in terpe r-sona l them es. Th is d iffe ren ce pe rh apsdecreases the in tensity o f p atien t- the rap istte rm ina tion issues an d al lows 1FF to be u sedeffec tive ly by le ss exp erienced the rap is ts .G ro up the rapy fo r the be reaved has beenstud ied by severa l au tho rs .37 2V achon et a l.,37fo r ex am ple , a ssign ed w idow s rand om ly to aco n tro l g roup or an in te rven tion gro up(w idow -to -w id ow pro gram ) and fo und tha tth e in te rven tio n g ro up re sis ted the em o-tio na l d ete r io ratio n tha t w as no ted in th eco n tro l g ro up af te r po stbe reavem ent suppor tw an ed . E ven thou gh the con tro l g rou p h adcaugh t up to the in te rven tion gro up a t 12m onth s, the in te rv en tion gro up w as clea rlyahead in the re soc ia liza tion pro cess . S im i-la r ly , L iebe rm an and V ideka -She rm an ,com parin g se lf-he lp group partic ip an ts and an orm a tive sam p le o f w idow s , con c luded tha tthe in terven tio ns w ere tru ly the rap eu tic andtha t im p ro vem en t cou ld no t b e accou n tedfo r sim p ly by the passag e of tim e . S u b jects inb o th o f these stud ie s w ere rec ru ited b y a

m ailed so licita tion , how eve r , and th is m e thodm ay have se lected a he lp -seek ing subg rou p .

M arm ar e t a l.4 #{1 76}om pared m u tua l se lf-h elp g roup the rapy w ith b rie f dy nam ic psy -cho the rapy (12 w eek ly in d iv id ua l se ssion sw ith ex pe rienced psychodynam ic p sycho -the rap ists , focused on co nflic ts w ith th e la tesp ou se tha t m igh t im pede m ourn ing ). A l-tho ugh bo th g ro ups exp erienced redu ctio nin sym ptom s o f depre ss ion and anx iety ,M arm ar e t a l. fou nd a la rge r d rop ou t ra te inp artic ipan ts o f g ro up the rapy com pared w ithin d iv id ua l the rapy .

M utu al s elf-h elp g roup s p rov ide co nsen -su a l v alid atio n , a fo rum to expre ss d iff icu lta ffec ts , p ee r supp ort, an d fac ilita tion o f p rob -lem so lv in g . Th ese g ro ups a re bene fic ia l tom any w id ow s and w id ow ers, p ar ticu la rlytho se w ith m ore ou tg o ing o r h elp -seek ingin te rpe rso na l sty le s o r those w ith les s seve redepre ssion . T ho se w ith m o re seve re depre s-sion , m ore com p lica ted in terpe rsona l d iffi-cu ltie s , o r a relu ctance to jo in a g rou p m ayrequ ire a m ore ta ilo red ind iv idua l psy ch o-the rap eu tic ap pro ach .4 #{1 76}

G iv en the dep th and bread th o f ind iv id -ua l d iffe rences am ong w idow s and w id ow ers,it is no t su rp ris ing th a t a v arie ty o f app ro achesa re po ten tia lly ben efic ial. 1FF is on e ap-p roach tha t can p ro v ide a w ork ab le fo rum toaddre ss sy stem a tica lly be reav em en t-rela teddepre ssion and th a t can b e taug h t to a v a rie tyo f m en ta l h ea lth p ractitio ne rs .

T he au th ors th an k D onna M . U lr ich for h er tech - -n ica l ass is tance .

Wo r k wa s s uppor t e d fr yNa t io na l ln s t iMeo fMen ta lH ea lth G ran ts MH43832 , M J-100295 , M 1-13 7869(C .FR Ill), M H 30915 (D r. D .j K upfer) , an d aN atio na lA llian ce forResearch on S ch izophren ia andD ep ression (NAR SAD ) Young In vestig a torAw ard(M .D.M. ) .

This p ap er w as p resen ted in pa rt a t the Confer ence o f th e In te rna tiona l P sychogeria tric A ssoc ia -tion , Berlin , G erm any , Sep tem ber 1993 , and a t theNAPSAD A nnua l S ym po sium , New Yo rk C ity ,Oc tober 1993 .


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1 . Z isoo k S (ed ): B iop sychosocial A spec ts of B ereav e-m en t (P rog res s in P sy ch iatry S er ies, v o l 8 ). W ash in g-to n , DC , A m eric an P sy ch iatric P ress , 198 7

2 . Le ick N , D avid sen -N iels en M : H ealin g p ain : at tach-m en t, lo ss, and g rie f th erap y . L ondon and New Y ork ,T av isto ck /Routledg e, 199 1

3 . V alan is B , Y eaw orth R C , M u lIis M R : A lcoh ol u seam ong b ere av ed and nonb ere aved old er person s.

Jo urn al o f G e ron to log ical N u rsin g 1987 ; 13:26-324 . C alabre se JE , K lin g MA, Gold PW: A ltera tion in im -

m unocom petence d urin g stre ss, bereav em ent , a ndd ep ress ion : focus o f neu ro end ocr ine regu lat ion . AmJ Psychiatry 1 98 7; 1 44 :1 12 3- 11 34

5. Stroebe MS, St roebe W, Han son RO (eds): Hand-bo ok of B ereavement Theory, Rese arch and Int er-v en tion . C am br idg e, Eng lan d , C am brid ge U niv ersi tyP res s, 19 93

6. Ga llagher DE, Thompson LW, PetersonjA: Psycho so-c ial fa cto rs affect ing adap tat ion to bereav em ent inthe elderly. IntJ Aging Hum D cv 1981-8 2 ; 14 :79-95

7 . P ark esC M , B en jam in B , F itz gerald RG: Broken hea rt:a sta tistic al stu dy of increased m or tali ty am ong w id-ow ers. B ri tish M ed ica lJou rn al 1969; 1 :740-743

8 . P ark es C M : R isk fac tors in bereav em ent: im p lic atio nsfor th e p rev en tion and treatm ent of p ath o lo g ic g rie f.P sych ia tric A nna ls 1 99 0; 2 0:3 08 -3 13

9 .Ja cob sS , K im K : P sych ia tric com plicat ion s of b ere ave -m en t. P sych iatric A nnals 19 90 ; 20 :314 -31 7

10 .Jacobs S . O stfe ld A : A n epid em io lo g ic al rev iew of them or tali ty o f be reavem en t. P sych osom M ed 1977 ;39 :344-357

11 . Clayton PJ, D arvish JS: Course of d epress ive sym p-tom s fo llow ing the stre ss o f bereav em ent , in S tressan d M ental D iso rde r, ed ite d b y B arre ttJE . N ew Y ork ,R av en , 1979, pp 121-1 36

12 . Z iso ok 5 , Sch uc ter SR D ep res sion throug h th e firs tyea r a fte r th e d eath ofa spo use . Am J P sy ch iatry 1 991 ;148:1346-1352

13 . P as tern ak R E , R eynolds CF , S ch lern itz aue r M , e t al :Acute o pen -tr ia l nor trip ty l ine the rap y o f bereav e-m en t-re la ted dep res sio n in late life .J C lin Psych iatry1 99 1; 5 2: 30 7- 31 0

14 . H am ilton M A : D evelo pm en t o f a ra tin g sc ale forp rim ary dep res sive illnes s. B ri tish Jou rna l o f So cia la nd C li ni ca l P sy ch ol og y 1 96 7; 6 :2 78 -2 96

15 . Fa sch ing bau er TR , D eV aul R A , Z iso ok S : D eve lop -m en t of th e T exa s Inv en tory o f G rief . A m J Psych iatry1 97 7; 1 34 :6 96 -6 9816. Fr ank E, Frank N, C om es C , e t a l : In te rpe rson alp sy cho the rap y in th e tre atm en t of la te-li fe d epres-sio n , in N ew A pplica tion s of In terperson al Psy cho -therapy , edited by W eis sm an M , K lerm an GL .Washington, DC, Am erican Psychiatr ic Pre ss, 1993 ,pp 169 -1 75

17 . Klerman G L , W e issm an M M , R oun sav ille B J, et al :In te rpe rso nal P sy cho the rap y o f D ep res sio n . N ewY ork , B asic B ooks, 198 4

18 . E lk in I, Sh ea M T , W atk ins JT , e t a l: N atio na l Inst itu teo f M en tal H ealth T rea tm ent o f D epress ion Collab o-ra tiv e R ese arch P rog ram : G en era l effect ivenes s o ftreatm ents. A rch G en P sych ia try 19 82; 4 6 :9 71 -98 2

19 . W eissm an M M , K lerm an G L , P ruso ff B A , et al: D e -p res sed o utp atie n ts : resu lts on e yea r a fte r tre atm entw ith drugs an d/o r in te rpe rso nal p sychotherapy .A rch G en P sych ia try 1 98 1; 3 8: 5 1- 55

20 . F ran k E , K up fer D J, Pe relJM , et a l: Three-yea r ou t-c om es fo r m ain ten anc e th erap ies in re cur ren t de-p res sio n . A rch G en P sy ch ia try 1 990; 4 7 :1 09 3-1 099

21 . Sh olom skasA J, Ch evron ES , P ru sof f BA , et al: S hor t-te rm in terp erso na l th erapy (IVT ) w ith the d epressede lde rly : ca se repo rts an d discus sio n . Am J Psy cho the r1 98 3; 3 7: 55 2- 56 6

22 . R eynolds C F , F rank E , Pe rel JM , e t al: C om bin edpha rm acotherapy and p sychotherapy in th e acu teand co ntinu atio n trea tm ent of eld erly pat ien ts w ithrecu rren t m ajor dep res sio n : a p rel im inary rep or t.Am J P sych ia try 1 992; 149 :16 87 -16 92

23 . W o rd enJW : G rief C oun se ling and G rie f T herapy : AH andbook for the M en tal H ealth P rac titione r, 2n ded itio n . N ew Y ork , S pringe r, 1 99 1

24 . L loy d C : L ife ev en ts and depress ive d iso rders re -v iew ed . A rch Ge n Psych ia try 1 980 ; 37 :52 9-535

2 5. B ow lb y J: The m aking and break ing of af fect ionalbonds . B rJ Psych ia try 19 77 ; 1 30 :201 -209

26 . P arker GB , B arre tt EA , H ickie IB : F rom nurtu re ton etw ork : exam in in g lin ks betw een percep tio ns ofp aren ting rec eiv ed in ch ildho od an d social bo nds inadu lth oo d . A m J Psy ch iatry 19 92; 149 :877-885

27 . F u tterm an A , G allag her D , Thom pson L W : R etro-spe ctive a sse ssm en t of m a rita l a d ju stm ent anddep res sio n du rin g the f irst 2 years o f spousal bereave-m en t. P a th o logy and Ag ing 1990 ; 5 :2 77 -28 3

28 . E rik son EH : Childho od an d Soc ie ty . N ew Y ork , W WN orton , 1 96 8

29 . H orow itz M J, W ilne r N , M arm a r C , e ta l : P ath o lo g ic alg rief a nd th e act ivat ion o f la ten t s elf -im age s. Am JP sy ch iatry 1980; 1 37:115 7-1 1 62

30 . M alan D H : The F ron tie r of B rief P sychotherapy . N ewYo rk , P lenum , 1976

31 . S ifneo s PE : Sho rt-T erm P sycho the rap y : E va lua tionand T ech niq ue. N ew Y ork , P lenum , 19 79

32 . Strupp HH , B inde rJL : P sycho the rap y in a N ew K ey:A Guide to T im e-L im ited D ynam ic P sychotherapy .New Y ork , B as ic B ooks , 19 84

3 3. E nd ic ott J, Spitzer RL , F le iss JL , e t a l: T he G loba lA ssessm en t S ca le : a p roced ure fo r m easuring overa llseverity o f psych ia tric d istu rb ance. A rch G en P sych i-atry 19 76 ; 33 :766-771

34 . R aphae l B : P reven tive in terven tio n w ith th e recen t lybereaved . A rch G en P sy ch ia try 1 97 7; 3 4:1 45 0-1 45 4

35 . G allagher D E , T hom pson LW : T rea tm en t o f m ajo rdep res siv e d iso rde r in o ld er adu lt ou tpa tie n ts w ithbrief p sychotherap ies 19 82 ; 1 9 :4 82-49 0

36 . H o row itz M J, M arm ar C , W e iss D S , e ta l : B rief psycho-


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the rap y of b ere avem ent reac tio ns. A rch G en P sy ch i-atry 19 84; 41 :438 -4 48

37 . V ach on M IS , L yal l W AL , R oge rsJ , e t a l: A con tro lle dstu dy o f se lf-h elp in te rven tio n for w idow s. A m J Psy-ch iatry 1 980; 1 37 :13 80-1384

38 . L ieberm an M A , V id eka -Sh erm an L : Th e im p act o fself -he lp gro ups on the m ental he alth of w idow s an dw idow ers. A m J O rth opsych iatry 1986; 5 6 :4 35-449

39 . L ieberm an M ,Y alom I: B riefg rou ppsych oth erapy forthe sp ousally b ere aved : a co n tro lled s tud y . m t JG roup Psy cho the r 1 992 ; 42:117-132

40 . M arm ar C R . H o row itz M J , W eiss D S , e t a l: A con -tro lled tria l o f br ief psy ch oth erapy and m utu al-helpg rou p treatm en t o f con jug al be reavem en t. Am J P sy -ch ia try 1 988 ; 1 45:203 -20 9

41 . Y alom ID , V ino grado v 5: B e reavem en t group s: tech -n iqu es and them es 1988 ; 38 :41 9-4 46

42 . L ieb erm an M A G roup p rop ert ies and ou tcom es: as tud y of g rou p norm s in self -he lp g rou ps fo r w idow sand w idow ers . In tJ G rou p P sycho ther 198 9; 3 9 :1 91-20 8

applying interpersonal phycoteraphy

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