Potential new treatment for Prolonged Grief Disorder?

 “The attempt to escape from pain, is what creates more pain.”
-Gabor Maté

Planting Seeds:  Ayahuasca as a Potential Intervention for Prolonged Grief Disorder

Kenneth J. Breniman

Marian University

THA615 Bereavement Theory and Practice

May 13, 2018

  

Introduction

             It is a dynamic time of growth and discovery in the field of thanatology as western research continues to refine theoretical frameworks and establish best practices for grief counselling. While Kubler-Ross is credited for jumpstarting the field of thanatology, her stage model has been criticized for its lack of empirically-based research (Stroebe, Schut, & Boerner, 2017).  In hindsight, we critique her lack of grounded evidence-based processes while maintaining some reverence for her willingness to bring new and applicable knowledge into our collective consciousness.  Within a death avoidant patriarchal civilization, may we always hold some gratitude for our thanatological grandmother.

Thanatology has evolved rapidly since Kubler-Ross (1969) presented the world with an empirically unsound yet compellingly influential stages model. Sackett et al (1996) remind us that evidence-based processes includes the essential integration of both the expertise of individual clinical practitioners, as well as the most rigorously researched clinical evidence. Ideally, meticulous researchers and progressive practitioners will eventually intersect, collaborate, and find ways to further our understanding of how humans cope with loss.

Prolonged grief disorder (PGD) is one example of how both thanatological researchers and grief counselors are attempting to build consensus on its definition and to establish effective treatment protocol. According to Jordan and Litz (2014), in contrast to a normative grieving process, persons with PGD experience bereavement difficulties which “persist or grow rather than diminish with time” (p. 181). With limited conclusive data on the efficacy of treatment modalities, current best practices focus on “psychoeducation about grief; encouraging repeated emotionally evocative processing of the reality of the loss in written or oral form; promoting social reengagement, and teaching the patient to challenge unhelpful thoughts that inhibit completion of the aforementioned tasks” (Jordan & Litz, 2014, p. 185).  As we continue to collect and synthesize data from various scientific domains including neuroscience, researchers and practitioners alike will continue to define what PGD is, and what effective treatment interventions might be implemented.  And, if no stone is to be left unturned in developing effective PGD treatment protocol, are there any interventions the field of thanatology has yet to seriously consider or evaluate?

Ayahuasca, a sacred and potent plant medicine used by South American indigenous populations for traditional holistic healing since approximately 1500 BCE (Naranjo, 1986), is now globally used both legally in some contexts (i.e. US-based UDV and Santo Diame churches) and underground in other settings (i.e. traveling shamans) (McKenna, 2007).  Contemporaneously, it is becoming increasingly more common for seekers to travel to South American countries where ayahuasca is both legally recognized and culturally sanctioned (Frescska, Bokor, & Winkelman, 2016). Just as the ayahuasca vine climbs its way to the top of the rainforest canopy, this plant medicine known appropriately as ‘grandmother,’ has branched out from Indigenous use and into the edges of western civilization.

While there is much to be understood before legal and formal therapeutic use is mainstreamed in the United States, in light of increasing use around the world, further research on ayahuasca is inevitable and imperative. Further, as more people are accessing ayahuasca as a form of biopsychospiritual healing (McKenna, 2007; Shanon, 2010), how can grief therapists become better prepared to provide integrative and holistic clinical support for those who seek out plant medicine in their grieving journey?  It is the aim of this research paper to provide a brief review of relevant literature along with a summary of considerations for ayahuasca-assisted grief therapy. The project component is a case vignette including a integrative treatment plan involving a client who utilized ayahuasca as a modality to treat her PGD-related symptoms.

Literature Review of Ayahuasca

Neuroscience research is providing invaluable data on how brain functioning may influence grief, especially complicated, prolonged and traumatic grief. Simultaneously, neuropharmacological studies are revealing how ayahuasca’s ingredients (DMT, B-carbolines) synergistically impact brain functioning (McKenna, 2007) and the various clinical outcomes in the treatment of addiction, PTSD and depression (Shanon, 2010). Ineluctably, advances in neuropsychology will continue to influence the field of thanatology and bereavement counselling practices. Both through personal experience and extensive academic research, this author is not alone in encouraging further thanatological research on the therapeutic application of ayahuasca treatment for PGD.

Naranjo (1979) suggests ayahuasca to be comparable to intensive psychotherapy due to the plant’s remarkable medicinal ability to increase participants’ awareness and resolution of ego defense mechanisms through a process of “secure regression” (Frescska, Bokor, & Winkleman, 2016, p. 10). Kuypers, et al (2016) found ayahuasca to promote this process of secure regression through psychological effects including an increase in “creative divergent thinking” (p. 3395) and a reduction of “judgemental processing and inner reactivity” (p. 3395) which are common goals of mindfulness and cognitive psychotherapy. In other words, research has found ayahuasca drinkers are often able to acknowledge and address cognitive distortions as well as to shift chronic and debilitating emotional states into less intense, more manageable thoughts and feelings. For persons feeling ‘stuck’ in their grief for an extended period of time and/or have not had positive outcomes through traditional grief therapy, this treatment modality may offer some hope.

Preliminary findings (Kuypers et al, 2016) suggest potential for assisting participants in developing coping strategies while under the influence of ayahuasca, which is similar to exposure therapy processes and outcomes. “Repressed memories can surface causing emotional catharsis and opening the way to abreaction, relief, and remission” (Frescska, Bokor, & Winkleman, 2016, p. 8).  In surrendering to the intense ayahuasca-induced experience, participants report an increased ability to face their greatest fears including death and loneliness (Frescska, Bokor, & Winkleman, 2016). “A reassessment of the past provides the basis of for an experience of cleansing from the past events and the basis for new perspectives into one’s patterns of behaviour” (Frescska, Bokor, & Winkleman, 2016, p. 8). PGD is defined by an inability to complete or resolve the loss-oriented or the restoration-oriented tasks (Jordan & Litz, 2014). In reviewing the current literature on ayahuasca, further research might explore the following hypothesis: properly pre-screened and therapeutically supported ayahuasca users diagnosed with PGD will experience a decrease in grief-related symptomology compared with a control group. 

Risks and Contraindications of Ayahuasca Use

There are several significant limitations and risks with ayahuasca use in conjunction with PGD-related interventions. Insufficient pre-screening (i.e. medical and psychiatric history) and preparation (i.e. psychological), improper set and setting, and lack of supportive aftercare are known factors which have contributed to “bad trips” or longer term psychological harm (Gonzales et al, 2017).  Known medication interactions especially SSRIs, commonly prescribed to treat depression, and other prescriptions, as well as specific diet contraindications have led to adverse health outcomes including convulsions, headaches and cardiovascular problems (Gonzales et al, 2017). Other challenges in conducting further research include standardizing set and setting, dosage, frequency, and integration protocol (Frescska, Bokor, & Winkleman, 2016).  It is essential to also acknowledge the risk of spiritual bypassing, or attempting to move too quickly through one’s personal psychospiritual development process, and the importance of thorough therapeutic integrative support (Frescska, Bokor, & Winkleman, 2016) in the exploration of ayahuasca as an intervention for complicated grief.

Comparative Research of Near-Death Experiences and Ayahuasca Use

            While thanatological research on ayahuasca might be compared to a seedling, research on near-death experiences (NDE) is more akin to a small fruit-bearing tree.  Ongoing NDE research provides glimpses into how a bereaved person might be influenced by measurable non-ordinary states of consciousness. In researching grief among twenty-two near-death experiencers, Lee, Feudo, and Gibbons (2014) found that “NDEs produce positive effects on the grieving process” (p. 877) perhaps due to “reducing negative religious coping and helping them find meaning from their loss” (p. 877).  A near-death experiencer may face “a protracted, mental struggle that often spans several years” (Lee, Feudo, & Gibbons, 2014, p. 882), resulting in an enhanced ability to “perceive life and death with a greater philosophical and purpose-driven frame of reference” (p. 882) which contributes to an increased ability to cope with loss. One possible bridge between understanding ayahuasca’s potential for PGD treatment is the more extensive research with persons who have experienced near-death or NDE.

Liester (2013) summarized the nine elements of NDE initially identified by Dr. Raymond Moody as follows: a sense of being dead, peace and painless, out-of-body experience, tunnel experience, meeting people of light including friends and family, meeting a being of light that radiates love and understanding, life review, a rapid rise into the heavens, along with a “reluctance to return to life” (p. 27). Other common NDE phenomena include a shift in perceiving time and physical space (Liester, 2013). Interestingly, Shanon (2010) found eight of the aforementioned nine elements of NDE to be common in ayahuasca-induced experiences (AIE). The one major difference between NDE and AIE is unlike near death experiences, ayahuasca does not seem to contribute to one’s hesitancy to reengage in life (Liester, 2013). In other words, AIE is a voluntary occurrence which simulates all but one element of a near-death experience. AIE typically promotes a willingness to step back into one’s life with a readiness to integrate newly acquired insights.

            Building on Moody’s foundation, current research indicates the following perceptual changes are common in both NDE and AIE: “heightened sensory perception, visualizations, extraterrestrial travel, meeting teachers or guides, visions of the divine, and hearing music” (Liester, 2013, p. 38). Further, the four main emotional experiences shared by both NDE and AIE persons are fear, ecstasy, peace, and love (Liester, 2013).  In addition, Liester (2013) also identified common cognitive shifts among NDE and AIE persons such as “self-understanding” (p. 40), a sense of interconnectedness, “intuitive and expanded knowledge” (p. 40).  While Strassman (2001) once proposed DMT, one of the chemicals prominent in ayahuasca, to be a molecule that is released by the brain at the time of death, evidence-based research has yet to fully back up his hypothesis. Even though evidence-based research has yet to clarify why NDE and AIE are so similar, there is enough crossover and common phenomena to warrant future research. 

            Even though ayahuasca has been used for centuries as a treatment for various biopsychospiritual conditions, current empirical research is limited on ayahuasca’s potentiality as an intervention for prolonged grief disorder (PGD).  Gonzales et al (2017) conducted a mixed method, cross-sectional, online-based survey study to explore the use of ayahuasca in grief therapy.  In measuring grief and experiential avoidance, Gonzales et al (2017) found the ayahuasca users reported, “lower levels of grief than people who attended a peer-support group” (p. 15) due to ayahuasca-induced direct emotional confrontation of the loss, leading to “feelings of peace and acceptance of death” (p. 16). While small in scale and lacking longitudinal data, the Gonzales et al (2017) study successfully plants a seed within the field of thanatology so that further studies can examine ayahuasca’s potentiality as a form of grief therapy.

Proposed Guidelines for Ayahuasca-Assisted Grief Therapy Research

As western science gradually finds ways to comprehend the potential therapeutic value of ayahuasca, how should thanatologists proceed with future research of this ancient plant medicine? Johnson, Richards, and Griffiths (2008) recommend the following safeguards in moving forward with human hallucinogen research: “Exclusion of volunteers with personal and family history of psychotic disorders or other severe psychiatric disorders, establishing trust and rapport between session monitors and volunteers before sessions, careful volunteer preparation, a safe physical session environment and interpersonal support” (p. 603), and thorough follow up with participants, especially regarding a rare yet harmful condition, known as hallucinogen persisting perception disorder.

With the re-emergence of psychedelic research, “carefully conducted research that respects hallucinogens’ unique and often powerful psychological effects may potentially inform the treatment of various psychiatric disorders,” (Johnson, Richards, & Griffiths, 2008, p. 616) including complicated, prolonged and traumatic grief.  Further research will want to explore several facets of combining plant medicine with PGD-focused psychotherapy including set, setting, timing and frequency of ayahuasca use, best practices and protocol for preparation and integration sessions with a grief therapist, and longitudinal studies of participant outcomes.

Considerations for Grief Therapists working with Ayahuasca Users

So, how does a grief therapist work with a bereaved client who has already had an AIE or is preparing for an AIE?It is an ethical obligation for a grief therapist to acknowledge when a presenting case is beyond one’s scope of competence.  Not all grief therapists may be comfortable with treating AIE clients and seeking clinical supervision or referring to a more appropriate practitioner are also parts of providing ethical and competent grief support. For grief therapists interested in supporting bereaved persons with AIE, here are a few key points for consideration.

Therapists should recognize AIE’s ability to “provide a psychosomatic therapeutic value that has not been described by any therapeutic models to date” (Gonzales et al, 2017, p. 16). In other words, ayahuasca may provide persons experiencing prolonged or complicated grief an opportunity to access the oscillation between loss-oriented, and restorative-oriented coping, and who are otherwise resistant to mainstream and established grief therapy techniques such as narrative writing (Gonzales et al, 2017). Additionally, and no less important is perhaps the most therapeutic effect of ayahuasca is its ability to aid in post-traumatic growth as it “promotes a new representation of the loved one and facilitates maintenance of the bond through the establishment of a new relationship” (Gonzales et al, 2017, p. 17). The hypothesis of integrating plant medicine into grief therapy becomes more interesting, especially when considering how to address the non-adaptive processes commonly seen in persons diagnosed with PGD.

It is important to recognize AIE as a voluntary and intentional intervention. The intention of attending an ayahuasca ceremony is to provide the participant an opportunity to return to life with new insights and understandings. The benefits of grief therapy for an ayahuasca user include supporting the client by properly preparing for the experience in a safe and nonjudgmental space to integrate the AIE.

            As mentioned earlier, NDE and AIE research finds significant overlap (Liester, 2013), thus becoming familiar with NDE protocol is a fair starting point for establishing therapeutic practices when working with a ayahuasca user. Unlike the vast majority of NDE, a client who uses ayahuasca has made a conscious decision to self-induce a non-ordinary mind state, has hopefully thoroughly prepared for the experience including proper medical clearance, and is seeking therapeutic support to prepare for as well as integrate the experience.

Griffith (2009) suggests therapists utilize a transcendental model allowing for the inexplicable or immeasurable components of the experience to be acknowledged and addressed. Revised from recommendations on providing therapeutic support for NDE clients (Foster, James, and Holden (2009), the following guidelines are for consideration when providing grief therapy to a client who has chosen to use ayahuasca to address PGD symptoms:

  • Avoid assuming that post-ayahuasca cognitions or behaviors are symptomatic of pathology. Likewise, remember that other mental health conditions do and can co-exist in any client. Thorough initial and ongoing assessment of the client is key.
  • “Respect the profound nature of these experiences as well as the individuality of each experiencer” (p. 40).
  • “Provide a safe, nonjudgmental environment” (p. 40) so the client “can freely discuss their experiences and the emotions surrounding” (p. 40) the ayahuasca experience.
  • Be aware of one’s own values, biases and countertransference issues. Seek consultation when needed.
  • With the framework of the dual process model as a framework, provide supportive integration of the ayahuasca experience into everyday life.
  • Reflect back the client’s intention and encourage he or she to share as a way to enhance recall of relevant details and insights as they pertain to grief therapy. Much like lucid dream details, AIE memories can fade quickly.

 

Conclusion

With an acknowledgement to the grandmother of thanatology, our current understanding of how grief works is represented by the dual process model of bereavement which identifies how the attachment style of bereaved persons influences their ability to oscillate between “loss orientation and restoration orientation” (Harris & Winouker, 2016, p. 29). One factor of PGD is an inability to move back and forth between the two orientations. Ayahuasca-assisted grief therapy also consists of a dual process where a client can oscillate between preparation grief therapy sessions, then participate in a shamanic healing ceremony to address blocked or intrusive grief work, and later return to the grief therapist’s office to tend to the integrative and restorative mode of their grieving process. Just as the ayahuasca brew consists of two sacred plants, the path towards exploring the potential use of ayahuasca in prolonged grief disorder treatment contains two invaluable parts: reverence for indigenous healing practices and respect for empirical research, which judiciously yet consistently has in many cases verified ancient knowledge.

While there remain legal restrictions and limited research available on ayahuasca-assisted grief therapy, there is persuasive data from neuroscience, psychedelic science, and thanatology that compels further study. For now, it might be sufficient to plant seeds with the scholar practitioners who seek to improve upon our current and collective understanding of prolonged grief. And as the garden is tended, the field of thanatology will continue to establish interventions that are ethical, legal and effective. The globalization of ayahuasca use and the gradual progress made in legalizing other psychedelic medicines for PTSD, addiction, and depression (MAPS, 2018) provides inspiration and impetus for progressive practitioners and researchers alike to explore this intriguing intervention for PGD. Dedicated to alleviating the psychospiritual discomfort common in PGD, this author holds much hope that someday the field of thanatology will come to include ‘grandmother’ ayahuasca as a useful treatment modality in grief therapy. 

 

 

 

 

References

Frescska, E., Bokor, P., & Winkelman, M. (2016). The therapeutic potentials of ayahuasca: Possible effects against various diseases of civilization. Frontiers in pharmacology. 7(35), 1-17. doi: 10.3389/phar.2016.00035

Foster, R. D., James, D., Holden, J. M. (2009). Practical applications of research on near-death experiences. In Holden, J. M., Greyson, B., James, D. (Eds.). The Handbook of Near-Death Experiences(pp. 235-258) Santa Barbara, CA: Praeger Publishers.

Gonzalex, D., Carvalho, M., Cantillo, J., Aixala, M., & Farre, M. (2017). Potential use of ayahuasca in grief therapy.  Journal of death and dying.  0(0), 1-26.  doi: 10.1177/0030222817710879

Griffith, L. J. (2009). Near-Death Experiences and Psychotherapy. Psychiatry (Edgmont)6(10), 35–42.

Harris, D. L., & Winokuer, H. R. (2016).Principles and practice of grief counseling(2nded.). New York, NY: Springer Publishing Company.

Johnson, M. W., Richards, W. A., & Griffiths, R. R. (2008).  Human hallucinogen research: Guidelines for safety. Journal of Psychopharmacology. 22(6); 603-620.  doi:  10.1177/0269881108093587

Jordan, A. H., & Litz, B. T. (2014). Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice, 45(3), 180-187. doi:10.1037/a0036836

Kuypers, K.C., Riba, J., de la Fuente Revenga, M., Barker, S., Theunissen, E.L. & Ramaekers, J.G. (2016).  Ayahuasca enhances creative divergent thinking while decreasing conventional convergent thinking.  Psychopharmacology,233(18), 3395-3403.  doi: 10.1007/s00213-016-4377-8

Lee, S.A., Faudo, A. & Gibbons, J.  (2014).  Grief among near-death experiencers: Pathways through religion and meaning.  Mental Health, Religion & Culture.17(9);  877-885.  doi: 10.1080/13674676.2014.936846

Liester, M.B. (2013). Near-death experiences and ayahuasca-induced experiences: Two unique pathways to a phenomenologically similar state of consciousness. Journal of Transpersonal Psychology, 45(1), 24-48.  

Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., van Ommeren, M., Jones, L. M., . . . Reed, G. M. (2013). Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry, 12, 198–206. doi:10.1002/wps.20057

MAPS. (2018). Multidisciplinary Association for Psychedelic Studies research.Retrieved from https://www.maps.org/research

McKenna, D.J. (2007). The healing vine: Ayahuasca as medicine in the 21stcentury. In M.J. Winkleman & T.B. Roberts (Eds.). Psychedlic Medicine,Vol. 1: New evidence for hallucinogenic substances as treatments (pp. 21-44). Westport, CT: Praeger.

Naranjo, P. (1986). El ayahuasca en la arqueologia. America Indigena, 46, 117-127.

Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn’t. Frontiers in Pharmacology, 127.71-72. doi: 10.1136/bmj.312.7023.71

Shanon, B. (2010). The antipodes of the mind: Charting the phenomenology of the ayahuasca experience. New York, NY: Oxford Press University.

Strassman, R. (2001). DMT: The spirit molecule. Rochester, VT: Park Street Press.

Stroebe, M. Schut, H., & Boerner, K. (2017). Cautioning health-care professionals: Bereaved persons are misguided through the stages of grief. Omega: Journal of Death and Dying, 74(4), 455-473.

Walsh, K. (2012). Grief and loss: Theories and skills for the helping professions (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Wilde, D. J. & Murray, C. D. (2009). The evolving self: Finding meaning in near-death experiences using interpretative phenomenological analysis. Mental Health, Religion & Culture.12(3); 223-239. doi: 10.1080/13674670802334910

 

 

Appendix:  Case Vignette and Treatment Plan

Demographics: Sue is a 39-year-old married heterosexual female who works as a veterinarian’s assistant for the past ten years. She has been in a stable relationship with her boyfriend Tony for four years with no children. Sue’s mother lives nearby and she reports they are close. Once a Unitarian church member until her mid-20s, Sue currently identifies as “non-church going Christian.”

Who Died/Relationship:Sue’s 62-year-old biological father died three years ago from pancreatic cancer.  Sue reports a strained and somewhat estranged relationship with her father as an adult due to his “lack of caring and cold parenting.”

Presenting Problem:Sue presents with increasing longing for her father to be alive so they could resolve their relational issues.  Sue also presents with diminished sense of self, anger related to the loss, difficulty accepting the loss, emotional numbness since the loss, feeling that life is unfulfilling and empty, feeling shocked by the loss.  Sue reports sleep disturbance, increased food intake, increased social isolation, difficulty concentrating especially at work, increased irritability especially with partner. Depression, generalized anxiety disorder and PTSD have been ruled out. Recent medical examination ruled out any physical condition.

Goal: Suewould like support to prepare for an ayahuasca-induced experience (AIE) and support in integrating her shamanic journey. Sue’s goal is to find ways to mitigate the aforementioned  grief symptoms which she reports are intensifying. 

Legal/ethical: Sue has arranged to travel to a country where ayahuasca is legal and has thoroughly researched her options.  Therapist is a Master’s level licensed grief therapist with extensive training/experience in spiritual emergence counseling.  Ethically, it is within the therapist’s scope of competency to provide the services sought by Sue.

Crisis/Safety: Sue denies any history or current suicidal or homicidal ideation. Sue has a loving family and social support system intact.

Assessment: Sue is seeking grief therapy in conjunction with a planned ayahuasca healing session. Sue identifies early adolescent emotional neglect from her father resulting in an adult strained relationship until the time of his death three years ago. Sue complains of increased grief symptoms including longing for her dad and accompanied with significant sleep disturbances and difficulty concentration at work. She is oriented to person, place and time. Thinking is linear and her memory appears good. Affect matches content. She denies any suicidal or homicidal ideations or actions in the past or present. She states a social use of alcohol. She apparently has a strong support system including her mother and partner. She became aware of ayahuasca and has done extensive research and self-reflection in preparation for her upcoming ceremony.

Provisional Diagnosis: Sue meets the criteria of the proposed ICD-11 PDG with a score of 26 on Inventory of Complicated Grief (ICG) screening tool.

Treatment Plan: Establish therapeutic alliance with therapist and attend four grief therapy sessions prior to ayahuasca ceremony.  Upon returning from a week-long overseas trip to participate in three ayahuasca sessions, Sue will resume grief therapy and AIE integration work with therapist for approximately twelve weeks.

Highlights of Grief Therapy Treatment: Initial four weekly sessions focused on co-creating a trusting therapeutic alliance, ongoing assessment of mediators of mourning, and discussion of treatment goals.  Therapist noted client’s self-awareness of difficulty in expressing emotions around her father’s death in sessions (“numbness yet aware of anger and yearning”). Sue self-reported increased tension in familial relations and difficulty in concentrating at work.  During the week away, therapist was available via email and video conferencing for any urgent matters.  Sue emailed updates but did not request additional support while participating in the ayahuasca sessions.  Of clinical significance regarding Sue’s AIE included “witnessing without reliving the intense emotional pain” of not having a close relationship with her father along with a sense of mutual forgiveness and reconciliation.  The AIE included a review of times when her father had not been emotionally available during her childhood.  Sue reported watching the scenes “like watching a movie” where she could feel the emotions of both persons without feeling overwhelmed by them. Sue used a healing Polynesian chant (“I love you. I forgive you. Please forgive me. Thank you.”) during AIE to access feelings of sadness and acceptance which replaced the previous “numbness” she had identified.  During the integration grief therapy sessions, therapist noted a shift in Sue’s ability to express her emotions more fully, including several sessions in which she cried openly. Sue self-reported less irritability and increased ability to focus at work. Sue stated that up until now she was unable to do so but that she planned on visiting her father’s grave for the first time since his death.  Grief therapy sessions continued for an additional four weeks as Sue did experience some challenges in integrating the AIE into her daily life. One such complication included a shift in how she began to interpret her mother’s role in her estranged relationship with her father.  By the 16th session, Sue self-reported and presented with clinically significant reduction in PGD symptoms and termination was discussed. Sue was open to an additional two sessions and also to additional grief related resources. The therapist informed Sue that she could return if additional support regarding her grief was needed.

 

 

 

 

 

 

 

 

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