Day Two: Grief Theories

The afternoon of the second day of training, I learned about several different theories of grief. The field of counseling and psychology has several theories that I began to learn about during my undergraduate work and continue to learn about in graduate school. As a result of the type of work I will be doing at my internship, I am grateful that I am receiving additional education and training in specific grief theories. Integrating the grief education and training into my professional identity begins with understanding the foundation of each grief theory, the major themes, criticisms, and incorporating my theoretical orientation. So, here is the who's who among grief theory and then some...

Sigmund Freud

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Psychoanalytic Framework.

Conceptualized the term, "Anniversary Reaction."

Melancholia - "mourning - longing for someone that is lost"

Period of time for "normal" morning: 1-2 years

Mourning beings because one needs to detach from the lost possession, person, etc.

Gradual detachment from the loss until a person realizes that the loss no longer exists.

Mourning and Melancholia

Criticisms:

Freud contradicts himself. On one hand he says that the goal of mourning is relinquishment (Mourning and Melancholia), but he also says that a lost object is never relinquished, completely (Creative Writers and Day Dreaming).

"Normal" grief is not defined by a specific time period.

Freud's view of grief is compatible with Object Relations, Bowen, and Cognitive Behavioral theoretical orientations.

John Bowlby

John Bowlby is known for his Attachment Theory. 

Four patterns of attachment:

     Infants - secure, avoidant, anxious/ambivalent,     disorganized/disoriented.

Adults - secure, dismissing, preoccupied, unresolved.

Secure Attachment = model for "healthy" grief

Bowlby believes working through grief is important to rearrange the representations of the person and the self through four phases:

Shock (Protest). Yearning and Protest (Searching).                                      Despair (Despair/Depression). Recovery (Reorganization).

The deceased is relocated - adjustment to the physical loss of the deceased is important.

Criticism: hypothesis does not distinguish between negative rumination and working through.

Criticism: difficulty operationally defining terminology in research studies

Compatible with Experiential, Bowen, and Structural theoretical orientations.

Elisabeth Kubler-Ross

On Death and Dying
Death: The Final Stage of Growth
Living With Death and Dying
On Grief and Grieving: Finding the Meaning of Grief Through Five Stages of Loss

Known for the Five Stages of Dying (originally called the five psychological states of dying):

 Denial. Anger. Bargaining. Depression. Acceptance.

 Criticism: five stages are based on observation, not empirical data.

 Criticism: grief is not a series of steps, but a process

Cognitive Behavioral, Object Relations, and Solution Focused theoretical orientations are compatible with Kubler-Ross.

J. William Worden, PhD

Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner, Fourth Edition
Tasks of Mourning

Grief is emotional, physical, cognitive, and behavioral.

Grief counseling is focused on support groups.

Grief therapy is more complicated and is centered on individual therapy.

Grief is a journey that encompasses several tasks: accept reality of the loss, work through the pain of the grief, adjust to an environment without the deceased, move on with life, emotionally relocate the deceased and move on with life.

Mediators of Mourning: who the person was, nature of attachment, mode of death, historical antecedents, personality variables, social variables, concurrent stress.

Criticism: Stroebe and Schut state that accepting the reality of the loss is not enough because one must work toward accepting and restructuring the changed world without the deceased. In addition, experiencing the pain of the loss needs to be accompanied by grieving the loss.

Theoretical Orientations: Cognitive Behavioral, Multigenerational/Bowenian, Solution Focused, Object Relations, Structural. 

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Therese Rando, PhD

6 R's of Mourning

Founder of the Institute for the Study of Treatment of Loss

Books:  Grief, Dying, and Death: Clinical Interventions for Caregivers; Parental Loss of a Child; How to go on Living When Someone You Love Dies; Loss and Anticipatory Grief.

Major Themes of the Six "R" Processes of Mourning

1. Recognize the loss, acknowledge and understand the death
2. Experience the pain and react to the separation. Feel, identify, accept, and five some form of expression to all the psychological reactions to the loss. Identify and mourn secondary losses.
3. Recollect and reexperience the deceased and the relationship. Review and remember realistically. Revive and reexperience the feelings.
4. Relinquish the old attachments to the deceased and the old assumptive world.
5. Readjust to move adaptively into the new world without forgetting the old. Revise the assumptive world. Develop a new relationship with the deceased. Adopt new ways of being in the world. Form a new identity.
6. Reinvest

Process vs. Task

1. Process allows the caregiver to focus on the present. Caregiver is able to provide immediate feedback and intervention.
2. Using a process permits evaluation, monitoring, and change.
3. Mourning can be understood in the context of conceptual and experiental.

 Criticism:

• Focus is on where the client is in the process and may push them through the sequence of the process.
• The process is not applicable to everyone because everyone does not need to go through the process.
• Focus is on "complicated mourning" rather than the typical process.  
• Emoting does not create healing - based on research. 

Theoretical Orientations:

Experiential- nature of problem is suppression of feelings; use of affective confrontation

Bowen- nature of problem is undifferential self and inability to handle anxiety; increase differentiation to create a new identity without loved one.

Narrative- nature of problem is the stories people have about themselves; change to narrative to a preferred one as they review and relinquish old one.

E.K. Rynearson, MD 

"Remember the way the person lived before remembering the way the person died."

Psychiatrist

Violent Death

Trauma

Major Theme: 

• violent death includes trauma, grief, horror, helplessness, and attachment
  
• disbelief, rage, and feeling helpless is the initial response
• imaginary and public illustration of the death
• reinforce resilence - inhibits terror and facilitates the sense of self-sufficiency
• Goals: decrease distress, enhance self-mastery, delay the replay of the trauma, connect with the person and their strengths, create meaning by restorative story re-telling. The primary goal is maintaining a sense of safety, separateness and autonomy from the dying experience. Clarify an explanatory scheme, focus on an active procedure of restoring living imagery-commemoration, reconstructive exposure-retelling the death imagery with a rational scheme that explains the symptoms and restores health and meaningful medication, and meaningful reengagement with living in a preparation for termination.

Criticism

Studies that compare trauma and grief therapies indicate improvement regardless of the type of intervention used.

Data shows grief therapies as less effect unless the client is highly distressed. 

 

 Theoretical Orientations:

Narrative-recreating a story of trauma that reinforces resilence.

Cognitive Behavioral - challenge the unhealthy schemas and reactions to death.

Solution-focused - strength based.  

Alan D. Wolfelt, PhD

Center for Loss and Life Transition 

Reconciliation Needs of Children

Author, Educator, and Grief Counselor

Major Themes: Focus is on how to meet the mourning needs of a child

• Need 1: acknowledge the reality of the death. 
• Need 2: move toward the pain of the loss while being nurtured physically, emotionally, and spiritually.
• Need 3: change the relationship with the person who has died from one of presence to one of memory.
• Need 4: develop a new self-identity based on a life without the person who died.
• Need 5: relate the experience of the death to a context of meaning.
• Need 6: experience a continued supportive adult presence in future years.

Criticism

Adults may have a need to work through the "needs" faster than the child may be ready.

 

Compatible Theories:
Experiential
Non-directive Play Therapy
Narrative
Cognitive Behavioral

                                                              Bowen 

Robert A. Neimeyer, PhD

"Grief is an active process"
"Making sense of everything"
Making Meaning

Major Themes:

• personal, familial, and cultural factors shape the adaptation to the loss.
• meaning construction is the central process
• Six Principles: validating beliefs, personal nature of grief, grieving is something we do, reconstructing the personal world of meaning, function of grief feelings as signals of meaning-making efforts, griever in the social context.
• Adaptation includes confronting and exploring concerns
• Lack of adaptation occurs when bereaved is unable to explore and articulate the construction of the relationship with the deceased.
• Constructivist shift - organize our experiences in a narrative form, "making sense" of the transitions.

Theoretical Orientations:

Post-Modernist Theories - Narrative and Constructionist

Cognitive Behavioral Theory

Experiential Theory

Bonanno and Kaltman

The Four Component Model

There are FOUR components to bereavement:

1. Context of the loss-risk factors
2. Continuum of subjective meanings associated with loss-everyday matters to meaning of life and death.
3. Changing representations of the lost relationship over time-moving to a supportive ongoing bond with the deceased.
4. Role of coping and emotion-regulation processes - emotion theory: manifests experientially, expressively, and physiologically; regulation of emotion may be deliberate or spontaneous; adjustment enhanced with the regulation or even dissociation of negative emotions and enhancement of positive emotions. 

Focus on emotion theory and the identification of spontaneous or automatic processes is the aspect of this model that makes it unique.

Belief is the positive emotions faster adjustment.

They suggested that bereavement is not about working through grief but more like one's own way of living post-loss. 

Task of the therapist is to support the client by sharing with them or modeling for them the search for a meaningful and worthwhile post-loss existence.

Criticism

Does not address complicated grief

Does not state how to use the four components

Does not explore ways of how to work with negative emotions

Theoretical Orientations:

Narrative

Experiential

Bowen

Cognitive Behavioral

Solution Focused  

Stroebe and Schut 

Dual Process of Coping

Major Themes:

• Attachment research is extremely important in understanding grief
• Most bereaved individuals shift back and forth between painful thoughts about the loss and the future
• Increased social support as bereaved has increased age because of secondary losses
• Defines two types of Stressor: Loss orientation is the bereaved person's concentration on the loss experience itself and Restoration-orientation is the focus on secondary stressors that are the consequences of bereavement.
• Specific dynamic coping process
• Culturally applicable

Criticism

Does not include inhibited or complicated grief

 

Theoretical Orientations

Attachment Theory

Cognitive Behavioral Theory