Bereavement theories and application in a group setting
Carolyn Smith, MSW for Hazel Burns Hospice
Definitions
Disambiguating concepts associated with grief is a great early exercise to do in group. It is helpful to remind people of the many levels on which we adjust to loss, and how expectations change over time and across cultures. Inquiring about participants’ family or cultural traditions is another useful way to broaden the range of “normal” or more narrowly-defined reactions to loss. A discussion of this can be a good whiteboard activity for the ‘thinking’ or ‘psych-ed’ phase of group, as opposed to the ‘feeling/sharing’ phase. Here are a few definitions from the literature to use as starting points.
Grief: The distress or emotional reaction resulting from bereavement; the reaction to loss (DeSpelder & Strickland, 2005). Grief is more widely experienced than just at a death, and is something felt after many kinds of losses.
Mourning: The process by which a bereaved person integrates the loss into his or her ongoing life (DeSpelder & Strickland, 2005). According to Émile Durkheim, this process is culturally-defined, that is, the expectations for how a person or community mourns the loss of someone of importance vary across time and culture Durkheim & Swain, 2008). Rituals of mourning have been traditionally more public-facing than grief; it is the social expression of grief (Stroebe & Schut, 1998).
Bereavement: We are bereaved when we have lost a loved one to death (Genevro, Marshall, Miller, & the Center for the Advancement of Health, 2004). Another way of thinking of it is as a period of time, after a loss, during which we experience grief and conduct our mourning.
Cultural expectations of grief
While all cultures, (and most species), experience grief, there is great cultural variation in expectations for how that grief is expressed at the individual, family and community levels. Considering how other cultures respond to grief can give us insight into our own grief processes. We can break down grief reactions into the categories of emotional/affective; behavioural, physical (somatic or physiological), and cognitive. Crying, a a physical reaction, is found universally. Non-Western cultures tend to express grief on more somatic ways, whereas in the West, depression is a more commonly expected reaction (Stroebe & Schut, 1998).
Specific examples:
Navajo, Native American Indian, historical
Grieving was limited to four days. Even during these days, the expression of grief, and discussion of the deceased, was constrained. Following the four days, the bereaved were expected to return to normal life. The underlying theory was that the deceased spirit would be harmful to survivors if the bereaved didn’t follow these rules (Stroebe & Schut, 1998).
Ilongot, Philippines, 1900s
Renato Rosaldo discovered that Ilongot men equate devastating loss, and the resulting grief, with rage. The rage of grief is universally recognized and spurs a party to assuage the grief through headhunting; that grief impels the taking of another human life. The tossing away of a human head allows the griever to throw away his anger (Rosaldo, 2004).
Japanese sosen suhaui ancestral traditions
Grief is seen as less an internal state and more as activities people undertake. Continuing attachments between the living and the dead are maintained by “...an elaborate system of collective and domestic rites and observances, through which the living facilitate the smooth passage of deceased loved ones to the afterlife and ancestorhood’ (Valentine, 2009, p. 6).
Infant death, Western cultures, pre-1920s
The death of infants in the West prior to the advent of institutionalized medicine was common. As a result, grief over the death of a baby was less pronounced than it is today (Stroebe & Schut, 1998), as we now believe our children should outlive their parents.
After discussing these widely varying cultural expectations for grief and bereavement, the group can think of more examples they’ve experienced, heard or read about, to broaden the scope of what normal grieving looks like. It is worth noting that politics and war can also profoundly shape the way we grieve our dead.
Western theories of grief
An understanding of how we came to our contemporary understandings of grief can help us gain insight into our own ideas around grief. A good place to start would be to have group members share what they have gleaned from their own lives about what grief, bereavement and mourning are supposed to look like, and help them draw the connection between personal beliefs and underlying theories. From there, a look at the various theories that have evolved since Freud kicked off the whole psychological study of grief in 1917 can offer participants the opportunity to see how their experience fits, or doesn’t fit, within the theories. If group members are enthusiastic about theory, they may even want to formulate their own theory of grief -- call it the Hazel Burns Theory of Grief.
The most important thing to note about Western theories of grief is they situate grief process within the individual and almost completely neglect the role and expression of grief within family and community systems. The advent of scientific rationalism in the 1900s kicked off the study of grief, and has run parallel to the pathologization of mental health and the development of the Diagnostic and Statistical Manual of Mental Disorders (or DSM), in its many versions. In other words, theories of grief track the evolution of psychiatry and psychology as rational, scientific disciplines, for better or worse.
Most importantly, Freud established the construct of human behaviours as being on a scale from normal to abnormal and pathological (Granek, 2010). In particular, the work of grief, Freud believed, was to detach the mourner’s libido, or emotional energy, from the dead and to sublimate that energy into other areas of their lives. Failure to do so would result in psychiatric illness resulting from pathological grieving, although Freud also felt that grief could never completely be resolved (Granek, 2010).
By the 1940s, psychoanalysts referred to grief as a disease, a pattern that has continued to the present. It was a hop-skip-and-a-jump to consider grief a psychiatric condition, as psychiatry as a discipline matured in the mid 1900s. The shift toward outpatient therapy in the 1950s resulted from the after-effects of war on the psyches of former soldiers, and grief became something to be treated by mental health professionals, rather a process shepherded by religious or spiritual leaders (Granek, 2010).
Beginning in the mid 1940s, Erich Lindemann applied the methods of scientific study to grief. He developed a theory of grief with 5 distinct phases based on his observations.
Somatic disturbance (tightness in the throat, shortness of breath etc) →
Preoccupation (with the image of the dead) →
Guilt (reviewing evidence of the survivor’s negligence or failure) →
Feelings of hostility or anger →
Difficulty in carrying out everyday routines.
He also believed detachment from the dead was the ultimate goal of grief (Buglass, 2010). Because Lindemann’s work was empirically based and included an etiology and tips for prediction, management and treatment, it became very popular and elements of his theories persist today, most notably that grief is a medical disease (Granek, 2010).
While Elizabeth Kübler-Ross’s study (1969) was based on work with those who are ill coming to terms with impending death, rather than the bereaved, her staged theory of grief entered the public consciousness as a model for bereavement despite the lack of empirical evidence to support it.
Denial → Anger → Bargaining → Depression → Acceptance
John Bowlby was the grandfather of attachment theory, which illuminated how a child’s attachment to his or her parent/s could predict future relationship styles. In 1973, he also theorized that childhood attachment styles might predict how someone grieves the loss of loved ones in a series of flexible phases (Buglass, 2010).
Shock → Yearning & protest → Despair → Recovery
These kinds of theories made intuitive sense and, the writer speculates, suited the times when surveys and questionnaires to determine romantic style, fashion sense etc. dominated the popular media. Many did not hold up to research scrutiny but continue on in the popular media.
The next major advance in grief theory resulted from the work of J. William Worden. His Four tasks of grief proposed that, for grief to be resolved, the bereaved must work through all four tasks. The theoretical emphasis shifted the popular discussion of grief from passively moving through phases, to active tasks of mourning.
Worden’s Four Tasks of Mourning
Accept the reality of the loss
Work through and experience the pain of grief
Adjust to an environment without the deceased
Withdraw emotionally from the deceased and move on.
In later years, Worden updated his fourth task to include the idea that the bereaved might form an ongoing relationship with memories of the deceased in order to continue on in life.
In the late 80s and 90s, theorists became concerned that the data was not showing improved outcomes for those undergoing grief therapy (in fact, it was sometimes detrimental), and that traditional grief therapy was privileging a meaning-oriented grieving style over a more action-oriented approach (Neimeyer, 2000). They also observed the cultural specificity of traditional grief theory, and worked to address these concerns through the proposal of new models.
That was how Simon Shimshon Rubin (1999) came to publish the Two-Track Model of Bereavement, in the same year that Schutt published The Dual Process Model of Bereavement. Both models divide the tasks of mourning into two separate processes, with slightly different focusses.
Rubin’s Two-Track Model evolved from the study of parents coping with the loss of a child, before being considered as more widely applicable to different kinds of grief.
The Two-Track Model of Bereavement
Functioning: anxiety, depression, somatic, familial relationships, self-esteem, meaning, work, investment in life tasks
Relationship to the deceased: memory, emotional distance, positive/negative affect vis-a-vis the deceased, preoccupation with lost & the lost, idealization, conflict, features of loss process (shock, disorganization, re-organization), impact on self-perception, memorialization & transformation of the loss and the deceased.
(Rubin, 1999)
Rubin’s theory gave clinicians two multidimensional axes on which to assess clients and develop options for intervention, however, by citations, it has proven to be less popular than the complementary dual process model, which incorporated much of Rubin’s earlier thinking and placed a greater focus on stressors, and was developed through consideration of clients who had suffered the loss of their partners (Stroebe & Schut, 1999)
According to this theory, loss-oriented stressors are those which involve working through grief, searching for meaning etc; whereas restoration-oriented processes refer to secondary stressors that pertain to present and future concerns, such as an altered life, financial issues, household issues and shifts in identity (Zech, 2015).
Loss-oriented processes:
grief work, intrusion of grief → denial/avoidance of restoration changes → breaking bonds/ties
Restoration-oriented processes:
attending to life changes → distraction from grief → doing new things → establishing new roles/identities/relationships (Burglass, 2010)
In both of these dual model/two track theories, we begin to see attention re-focussed on what is now known as continuing bonds theory (Silverman, Klass & Nickman, 1996). Developed into the mid-1990s, this theory was a reaction to the pathologization of those who refused to sever bonds with their dead loved ones. Within a few years of the publication of this theory, most researchers came to agree that continuing bonds play an important part in healing from grief (Klass, 2018).
The theory of continuing bonds brings our discussion full-circle as it brings together beliefs underlying grief practices from other cultures and an extension of attachment theory, namely, that while a loved one may die, our relationship with them continues. In its’ simplest form, Dennis Klass (2018) asks us to consider bonds as love, and that love is something that exists between two entities, even when one dies.
Narrative therapy, from Michael White’s “Saying Hullo Again” (1998), to Lorraine Hedtke’s Remembering Lives: Conversations with the Dying and Deceased (2004), demonstrate that the best way to initiate continuing bonds in an individual or group setting is to ask clients to “introduce” their loved ones.
Prompts to flesh out an introduction include, “What did you call him/her?”, and “Tell us a little bit more about him/her, what kind of life s/he had.” From there one can begin highlighting the meaning of the bond, through questions like, “What did it mean to your [loved one] to be around you?” “How did you relationship change over the years?” “How do you think your [loved one] would want you to be paying attention to, now that s/he is gone?”
To continue to cultivate the voice of a loved one, questions like, “Do you have any similarities or characteristics in common with [your loved one]?” “What would your [loved one] want to talk up, or particularly appreciate, about you?” As conversations move toward the future, we can call upon the wisdom of those who have died by using the “fly on the wall” approach, i.e., “If your [loved one] was a fly on the wall, what would s/he be hoping to see you do in this situation.” Or, “what kind of advice would s/he want to give you?” (adapted from Hedtke in Klass & Steffen, 2018).
Many people are concerned that common habits, such as continuing to talk to loved ones after they’ve died, is a sign they are “crazy.” It would be an interesting exercise to ask group participants to review a list of common habits to see which ones they are willing to admit they do, and to try to describe why they do it.
A continuing bonds checklist
Talk to the loved one
Write letters or a journal to them
Keep photos of them around
Incorporate them into special events
Imagine their advice in tough situations
Tell their stories
Tell new people about them
Ask those who knew them for more stories of them
Live life in a way they’d be proud of
Carry on their values, projects or interests
Enjoy foods they loved
~ adapted from What’s Your Grief, https://whatsyourgrief.com/16-practical-tips-continuing-bonds/
References
Buglass, E. (2010). Grief and bereavement theories. Nursing Standard (through 2013), 24(41), 44.
DeSpelder, L. A., & Strickland, A. L. (2005). Health care systems: Patients, staff, and institutions. The last dance: Encountering death and dying, 125-151.
Durkheim, E., & Swain, J. W. (2008). The elementary forms of the religious life. Courier Corporation.
Freud, S. (1957). Mourning and melancholia. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works (pp. 237-258).
Genevro, J. L., Marshall, T., & Miller, T. (2004). Report on bereavement and grief research.
Granek, L. (2010). Grief as pathology: The evolution of grief theory in psychology from Freud to the present. History of Psychology, 13(1), 46.
Hedtke, L., & Winslade, J. (2016). Remembering lives: Conversations with the dying and the bereaved. Routledge.
Klass, D., & Steffan, E. (2018). Continuing bonds in bereavement. New York: Routledge.
Neimeyer, R. A. (2000). Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death studies, 24(6), 541-558.
Rosaldo, R. (2004). Grief and a headhunter’s rage. Death, mourning, and burial: A cross-cultural reader, 167-178.
Rubin, S. S. (1999). The two-track model of bereavement: Overview, retrospect, and prospect. Death studies, 23(8), 681-714.
Silverman, P. R., Klass, D., & Nickman, S. L. (Eds.). (1996). Continuing bonds: New understandings of grief. Taylor & Francis.
Stroebe, M & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death studies, 23(3), 197-224.
Stroebe, M., & Schut, H. (1998). Culture and grief. Bereavement Care, 17(1), 7-11.
Valentine, C. (2009). Continuing bonds after bereavement: a cross-cultural perspective. Bereavement Care, 28(2), 6-11.
Whatsyourgrief. (n.d.) 16 Tips for Continuing Bonds with People We’ve Lost. Retrieved from https://whatsyourgrief.com/16-practical-tips-continuing-bonds/.
White, M. (1988). Saying hullo again: The incorporation of the lost relationship in the resolution of grief. Dulwich Centre Newsletter, 3, 29-36.
Zech, E. (2015). The dual process model in grief therapy. Techniques of grief therapy (pp. 43-48). Routledge.