“The reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again, but you will never be the same. Nor should you be the same, nor would you want to.”

Elisabeth Kübler-Ross

Traditional Counselling Perspectives on Grief

The ‘Grief Work’ Hypothesis

There is a long-standing tradition in the popular and scientific literature that envisages the process of grief as one of doing ‘grief work’, as a means of coping with the distress occasioned by loss, and as a means of moderating both physical and mental detriments. Freud was the first to consider grief as a coping mechanism, by proposing that a bereaved person needed to ‘work through’ his/her grief as a means of ‘detaching’ from a loss¹. He argued that the purpose of grief was to:

• Withdraw emotional energy from the deceased (cathexis), and
• Become detached from the loved one (decathexis).

By engaging in an active, though painful, process of reviewing memories and thoughts of the lost love object, a person can achieve detachment from the ‘loved’, and attain a loosening of bonds with the past connection.

Stroebe & Schut define ‘grief work’ as a “cognitive process of confronting a loss, of going over the events before and at the time of (loss), of focusing on memories and working toward detachment” (p. 199). They further describe grief work as an “active, on-going, effortful attempt to come to terms with loss”, while emphasising how this idea of loosening ‘attachment’ has become a dominant paradigm in counselling and therapy programmes during much of the 20^th century².

Grief Links to Attachment

The most impactful theorising to build upon the Freudian ‘grief work’ approach was that of John Bowlby, who argued that secure attachment is essential for healthy emotional growth³. Bowlby regarded grief as an adaptive response, which is an inevitable consequence of our predilection to attachment and it can be experienced at physical, emotional and cognitive levels. We learn emotional resources in childhood and as we progress through life we develop a wide range of attachments in our social encounters and develop ways of managing feelings towards others. When such attachments are breached or ended, grieving is a consequence.

Mallon points out that those who have had poor attachment experiences as children may find grieving problematic, whereas those who experience bereavement in childhood may find that their grief is reactivated by loss in adulthood. Insecure childhood attachment can also be linked to complicated grief, in which painful emotions are so long lasting and severe that a person may lose the capacity for accepting an intense loss and be unable to resume normal life⁴.

Colin Murray Parkes further introduced the concept of an “assumptive world”, in which we consider the world as a secure domain with regard to relationships, expectations and future beliefs⁵. When we experience a traumatic loss, we are forced to make changes to our assumptive world as we attempt to make sense of the new landscape. This can involve dealing with matters of personal identity, meaning, and social relationships, all of which can result in psychological upheaval, or what Parkes terms “psychosocial transition”⁶.

Structured Models of Grief

Building upon Bowlby’s idea of grief as an adaptive response, Bowlby and Parkes developed a structured model of the grieving process⁷. They proposed the following stages:

1. Numbness – involving shock, denial and a sense of reality
2. Yearning & Protest – which can be associated with bouts of grief, anxiety, lack of focus. It can also involve denial of the death as well as guilt or blame and a process of frequent ‘searching’ for the person we have lost
3. Despair & Disorganisation – associated with feelings of hopelessness, anger, low mood and even depression
4. Re-organisation and recovery – which involves letting go of the attachment, and in which the loss recedes, trust in life is gradually restored, and new goals and patterns of daily life are evolved.

Elisabeth Kübler-Ross adapted this four-stage model when describing the stages she observed in those dying of terminal illness⁸. Her model proposes five psychological stages of dying:

1. Denial – an expression of disbelief at the seriousness of their situation
2. Anger – involving hostility at the “unfairness” of dying, often projected/transferred onto others
3. Bargaining – involving attempts at “deal-making” to prolong life
4. Depression – associated with (often) overwhelming feelings of grief, loss, abandonment, shame, guilt and helplessness
5. Acceptance – accompanied by an emerging, often reluctant, perhaps even stoic, sense of readiness to meet death

She argued that these are not necessarily linear and that some people may never reach the point of acceptance.

An alternative approach to the ‘trajectory’ models is the ‘task model’ that was proposed by Worden⁹. Building on Freud’s ideas, he proposed that there is a group of four tasks that persons working through grief need to engage with as they disengage with their loss.

These comprise:

1. Accepting the reality of the loss
2. Working through the pain of the grief
3. Adjusting to the new reality, from which the loved one is missing
4. Emotionally re-locating the deceased and moving on with life

Worden describes reactions to grief across four dimensions:

Emotional	Sadness, Anger, Guilt, Anxiety, Loneliness, Fatigue, Helplessness, Shock, Yearning, Emancipation, Relief, Numbness, Depression
Physical	Hollowness in stomach, Tightness in chest/throat, Breathlessness, Weakness in muscles, Dry mouth, Lack of energy, Intolerance of noise, Sense of unreality
Cognitive	Disbelief, Confusion, Preoccupation, Hallucinations, Sense of presence
Behavioural	Crying, Sighing, Social withdrawal, Absent-mindedness, Dreams of deceased, Calling out & searching, Avoiding reminders of deceased, Sleep or appetite disturbance, Restless over activity, Carrying/treasuring objects of deceased, Visiting reminder places

Critique of ‘Grief Work’ Approaches

While both the stage and task model approaches have gained credence in popular culture relating to loss, grief and dying, recent theorising has begun to question the dominance of the grief work approach. Doka, for example, has questioned the methodological soundness of the methods Kübler-Ross used to collect her data, while also pointing out that subsequent research has not supported the concept of linear stages¹⁰.

Furthermore, Silver and Wortman have argued that working through grief according to the principles laid out in the structured adaptive models may even be detrimental to recovery¹¹. In addition, Kastenbaum has argued that to accept the stage model approach as being universal, leads to a minimisation of the complexity of how individuals respond to loss, and does not take into account environmental circumstances in which the grieving person is situated¹². As a result, of these challenges, a growing questioning of the ubiquity of responses to loss has begun to emerge and this has led to the advent of new perspectives relating to the experience of grief.

In our next (and final) post in this series, we will consider more recent, and less structured, ‘personalised’ approaches to the grief experience

© Pat Lyons & Margaret Lenihan, 2016

References:

1. Freud, S. (1917). Mourning and melancholia. Reprinted in Strachey (ed. and trans.), The standard edition of the complete psychological works of Sigmund Freud. (Vol. 14), pp. 237-259). London: Hogarth Press (1957).

2. Stroebe, M. & Schut, H. (1999). The dual process model of coping with     bereavement: Rationale and description. Death Studies, 23, 197-224.

3. Bowlby, J. (1980). Attachment and Loss, Vol. 3 Loss: Sadness and depression.  London: Hogarth Press.

4. Mallon, B. (2008). Dying, Death and Grief: Working with adult bereavement.  London: Sage Publications.

5. Parkes, C.M. (1988). Bereavement as a psychosocial transition: process of            adaptation to change. Journal of Social Studies, 44, 3, 53-65.

6. Parkes, C.M. (1996). Bereavement: Studies of grief in adult life. (3^rd ed.). London: Routledge.

7. Bowlby, J. & Parkes, C.M. (1970). ‘Separation and loss within the family’. In C.J. Anthoney and C.J. Koupernik (eds.), The Child in his family. New York/Chichester: Wiley.

8. Kübler-Ross, E. (1969). On Death and Dying. New York: Macmillan.

9. Worden, J.W. (1991). Grief counselling and grief therapy: A handbook for the mental  health practitioner. New York: Springer.

10. Doka, K.J., (2103). Historical and Contemporary Perspectives on Dying, in            Meagher, D.K., & Balk, D.E. (2103). Handbook of Thanatology. New              York: Routledge.

11. Silver, R., & Wortman, C. (1980). Coping with undesirable life events. In Garber, & Seligman, M.E.P. (Eds.). Human helplessness: Theory and applications, (pp. 279-340). New York: Academic Press.

12. Kastenbaum, R. (1998). Death, Society, and Human Experience, 6th edition.  Boston: Allyn & Bacon, 1998. See also, Kastenbaum, R. (2000). The Psychology of Death. New York: Springer.