Jul

19

2021

Models of Grief – What Therapists Need to Know

The BTP conference on Perspectives on Bereavement and Grief  takes place via Zoom, on Saturday 9th October 2021, with catch-up available after the event. Dr Erin Hope Thompson (founder and Director of The Loss Foundation), Tony Buckley (Sensorimotor Association Psychotherapist) and Dr John Wilson (author of The Plain Guide to Grief and Supporting People through Loss and Grief) will be our three expert speakers and trainers on the day. Use this link to find out more about this amazing conference!

Ahead of this conference our guest blogger is Child and Adolescent Psychotherapist Helen Campling shares her insights into some of the many ideas that can help therapists who are working with bereaved clients. There are many different theories and models of working with grief, and as many opinions about what method might be most helpful for bereaved clients during their healing journey. In this article we cover all the basis, and if you are looking to learn more about this topic why not join us for our Perspectives on Bereavement conference in October?

Models of Grief – What Therapists Need to Know

There are a number of different models of grief that can help us to support our bereaved clients

When a client comes to therapy following the death of someone close to them, they are likely to be in a state of shock. The client’s normal everyday life is in flux, and as therapists, the priority is to enable a safe and respectful space for the client to begin to find their way through their journey of loss. As therapists, empathic response and attunement to the client are key in creating the therapeutic alliance, and an awareness of a variety of different theories and models of grief enable us to work integratively, enabling us to employ aspects of different theories which best fit the client at hand.

Freud and Mourning

In his collection of papers On Murder, Mourning and Melancholia Freud outlined his fullest account of what has come to be a standard model of mourning. He discusses the individual’s need to test reality after a loss, which is a process that demonstrates to the bereaved person that the deceased is truly gone. Freud believed that all individuals have a libido, otherwise described as the life force of a person, and he considered that in order to complete the mourning process, that individual’s life force must be fully withdrawn from its attachment to the deceased person. Freud called this process ‘decathexis’.

According to Freud, if this process is not fully completed, then the individual’s psychic balance will remain disturbed since, for Freud, a part of the bereaved person will remain attached to and invested in the deceased, which he believed resulted in co-morbidities such as guilt and anger.

Bowlby and Attachment

While Freud maintains that a full psychic detachment from the deceased person is the key aim of grief work, Bowlby sees value and importance in the restructuring and maintaining of a relationship with the deceased.

Indeed, if grief is what we feel after the loss of a loved one, then mourning is what we do with that feeling, and here, in the manner of performing grief, attachment theory can be very useful. Utilising the work of attachment theory and having an awareness of the client’s attachment style can enable the therapist to understand the client and their particular challenges more fully, as the manner of mourning can be informed by their attachment style. For example, someone with a secure attachment style, on suffering the loss of a significant other, would of course grieve deeply.

However, according to Bowlby’s attachment theory, individuals with a ‘secure attachment style’ have been able to internalise positive mental models of being loved and cared about, and since our attachment system is acutely activated when we are under threat, when faced with loss, these individuals are likely to engage in the same type of searching behaviours and emotional responses that securely attached babies did when they were separated from their mothers. Bowlby believed that securely attached individuals would go through a phase of metaphorically ‘searching’ for their lost loved one, before they managed to come to terms with their loss and move towards accepting it.

In contrast, Bowlby also identified the bereavement reactions of individuals who were classed as either anxious-ambivalent or avoidant attachment styles. In the case of these individuals, Bowlby believed that as anxious-ambivalent individuals can fear being misjudged and disparaged and often experience others as being unreliable in their support – that these individual’s levels of distress following a loss would be more heightened, and less likely to abate over time.

Bowlby takes the view that mourning ought to be a process of transformation of the bereaved person’s relationship with the deceased. An attachment therapist here might make much of the creation of a new relationship with the deceased, perhaps using ritual or at the very least, maintaining memories and allowing the person to speak freely about their lost loved one. The approach of Freud in this area, whilst well respected, has fallen out of favour in more recent years, with many psychotherapists and psychologists finding that bereaved individuals who maintain a relationship with the deceased often go on to recover from their grief more easily.

Continuing bonds…

Less well known than Freud and Bowlby is the work of Dennis Klass, Phyllis Silverman, and Steven Nickman in their 1996 study Continuing Bonds: New Understandings of Grief. Klass and colleagues put forward the fairly novel idea at the time that bereaved people should be encouraged to maintain a relationship with the deceased person, but in a new form.

After all, as Mitch Albom expressed so beautifully in Tuesdays with Morrie, his account of time spent with his dying teacher:

 “The death of a loved one ends a life, but not a relationship”.

It is increasingly accepted that the process of integrating loss into an individual’s life as a new part of their story is perhaps a healthier method of mourning. Indeed, in the case of child loss, the experience for a bereaved parent is probably more accurately described as a series of losses; the original loss, followed by further losses as the parent grieves for birthdays the child ought to have celebrated, the wedding they should have had, and their entire ideas about who that child might have turned out to be. In this case, it is clear to see that full decathexis is just not possible or reasonable to accept.

William Worden and the Four Tasks of Grieving

No discussion about grief and loss would be complete without mention of the huge body of work created on the subject by William Worden who wrote his classic text Grief Counselling & Grief Therapy in 1982.

Worden proposed that there are four tasks of grieving. His model is flexible and the tasks do not need to be completed in order, and can be repeated and returned to if necessary.

The pain of bereavement can be an intense and lonely experience

The first task, Worden suggests, is to accept the reality of the loss. This can often be the stage where the bereaved person can wonder about the reality of their experience, did it really happen? (Joan Didion wrote succinctly about this experience in her 2005 book The Year of Magical Thinking). Acceptance, for Worden, is more about the point at which the bereaved person is able to begin their journey of healing; perhaps after the funeral has taken place and reality is setting in.

Worden’s second task is to process or work through the grief and pain – the key word here is ‘work’ -this is not an easy task, but it is essential in order that a new chapter of life can be possible. In order to begin to heal, the griever must move towards the pain and not try and deny or avoid it – that will only serve to prolong the pain.  This is the stage where self-care needs to be paramount, as the raw and real sense of loss is faced.

The third task is that of learning to adjust to a life without the deceased in it. After whatever bereavement leave the bereaved person has been able to take ends, it will be necessary for most people to return to their pre-loss life, whether that is work, study or simply to continue with their social life from before their loss. This stage involves beginning to resume ‘normal life’ and with that, uncovering a whole host of potential little ways the deceased figured in the bereaved person’s life.

This stage can be vastly different for people according to the role the deceased played for them; for example, if the deceased had been their partner, there may be new parenting and domestic challenges and perhaps new skills to learn; things that the deceased might have taken care of before.

The fourth task is “to find and enduring connection with the deceased while moving forward with life”. This is where the bereaved person begins to forge a new path in life. Having acknowledged their loss, and begun to accept it, they find themselves able to find the glimmer of a new direction forward. For Worden, this necessitates a shift in the person’s relationship with the deceased since, as Albom said, the relationship does not end, but the life has.

This stage can bring new friendships and new dreams, as, all the while, the mourner continues negotiating the onslaught of memories and waves of grief which likely continue still. This stage is where the real healing begins. Indeed, this stage can be the longest of the four, as much shifting and insecurity may be apparent, as the bereaved person navigates the unfamiliar terrain of life post loss.

The ’Stages’ Model of Grief: Five stages…Or Four?

As stages and tasks of grief go, Elisabeth Kübler-Ross’ Five Stages of Grief is probably the best known ‘model of grief’. Yet Kübler-Ross herself was clear that her work on these stages was most relevant to those who were coming to terms with their own approaching death.

She wrote so succinctly and openly about grief in her book, On Death and Dying, about her time spent working in palliative care, that the Kübler-Ross model was taken and applied to many different types of loss.  Her work really helped to further understanding of the bereaved, but a more clinically helpful model of coping with bereavement can be found with John Bowlby.

Bowlby’s work on grief (later continued by Colin Murray Parkes) demonstrates correlations between a child’s separation from its primary caregiver and bereavement. It held mourning to be a normal, not pathological process. In his book The Making and Breaking of Affectional Bonds, Bowlby described the grief process as being centred on the idea that there are four key stages which need to be worked through before the process is healthily complete. These four stages are:

  1. An initial stage of numbness, often with outbursts of anger and intense distress, lasting approximately a few days to a week.
  2. A stage where the bereaved person yearns for and symbolically searches for their lost person
  3. A stage of despair and disorganisation
  4. A stage of organisation.

There is no set pattern in the grief journey, it is an entirely individual process, and as such these stages are not considered to be linear. It is generally accepted that all of the stages might be required to be repeated and might also be performed out of sequence.

The key difference between the earlier models of grief (Freud’s decathexis, for example) and the later understanding of Bowlby and Colin Murray Parkes is this idea of ‘completion’. Freud’s process of decathexis will necessarily take a long time to reach its goal, because healing will not be seen as having occurred until a complete decathexis has taken place. Bowlby’s model, however, enables the individual to oscillate between experiencing periods of deep grief yet also have periods of time where they are future focused. This idea is explored further by Stroebe and Schut who talk about the Dual Process Model of Bereavement.

The Dual Process Model of Bereavement

This model maintains that a bereaved person can experience episodes of deep grief while also maintaining intervals of ‘normal’ behaviour with a level of focus towards the future, all the while also coming to terms with their bereavement and its associated emotions.

Some clients will experience a more restoration-oriented approach to their grief, finding new things to focus on and perhaps taking the opportunity to do things that the deceased person might not have approved of, while others will attend more to the loss orientation, meaning that they will focus on more of how their life has changed due to the loss and perhaps be more resistant to integration of the loss.

As in Kubler Ross’ and Bowlby’s stages, the journey to recovery, involves oscillating between different stages until the loss becomes assimilated.

The Dual Process Model of Coping with Bereavement (copyright, Stroebe and Schut, 1999).

Reframing Death

If death is the end of the cycle of human experience, then birth is the beginning. Early patterns of attachment leave their mark on our ability to neurologically process information throughout life. Attachment informed grief therapy attempts to learn directly from those patterns in infancy, and either makes use of them as they exist, or uses them to inform a process, which will enable the client to move forward and become emotionally and mentally stronger through working with their past issues.

Traditionally, it has always been assumed that death is a completely negative event which is to be dreaded and feared and that there is nothing constructive to be found where it occurs. However, if death can be reappraised as a release from suffering, or perhaps as the reunion with a beloved dead partner, then it can be seen that there could be somewhat positive aspects of death.

Ultimately, we all die, and perhaps a healthier way of treating bereavement can be found. Indeed, in Mexican culture there is the Mexican Holiday of ‘Dia de los Muertos’ – closely connected with our Halloween and All Souls Day, but where British culture seems to focus on ghosts, the Mexican festival focuses on remembering lost loved ones, lighting candles for them, playing music and even taking food to the graves of ancestors.

The idea of honouring the dead, and retaining a connection through the generations, is also found in Japan, in the Buddhist festival of Obon. This festival lasts for three days, and focuses on the idea of guiding the dead back home. People light up their gardens and homes with lanterns, to help guide their lost ancestors. It is also a time when families re-connect and relatives of the deceased make trips to cemeteries to tidy and plant graves of their lost loved ones. The short video above explains how ancestors are celebrated in Japan.

If, as a culture, we can move away from the age-old fear and terror of death as a taboo concept, the stuff of nightmares and Halloween, then perhaps it will be easier for us to accept death for what it is, and to take this acceptance into work as therapists. Surely that has to be a good thing for bereavement therapy and clients?

Want to find out more? The BTP Conference on Perspectives on Bereavement and Grief takes place on Saturday 9th October via Zoom with Dr Erin Hope Thompson, Tony Buckley, and Dr John Wilson. Click here to find out more about the day!

If you found this blogpost helpful please share it with your peers. You can also say something in the comments section below.

Our Guest Blogger:

Helen Campling works at ‘The Therapeutic Consultants’ in Burgess Hill, West Sussex. She is currently in the final stages of her Child & Adolescent Psychotherapy training and loves her work. She has particular interests in grief and loss, trauma and chronic illness. When she isn’t working, she can usually be found with a book in her hands and one of her beloved cats in her lap.

* there are affiliate links in this post, if you buy a book using one of these affiliate links we will get a very small fee. It all helps! Thank you!

 

 

 

 

 

 

 

 

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4 Comments

  1. Vinata Sriram on 20 July 2021 at 2:11 pm

    An in-depth analysis of grief. Well researched.

  2. Roger on 22 July 2021 at 7:37 am

    This is great, thank you. Really informative.

  3. Irene M on 25 July 2021 at 7:50 am

    Well done Helen! Really good reading. Well researched and so detailed with all relevant material!

  4. K M Bainbridge on 29 July 2021 at 5:01 pm

    You have presented this complex material with crystal clarity without over-simplifying which is both a gift and the result of hard work. I love the idea that for some people our beloved dead and our ancestors live among us: it’s simply that we don’t see them.

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