Bereavement and Grief: Counsellling and Therapy
Bereavement and grief impacts people on many levels: emotionally, biologically, sexually, economically, socially, and spiritually. In essence, all aspects of a bereaved person’s life are affected by grief. The lack of emphasis on the personal toll of therapy may lead to unprepared therapists; conversely, having a personal preparedness for dealing with death issues, rather than simply being trained in tactics, seems to predict more effective work with grieving persons and improved self-efficacy on the part of therapists.
This paper provides extensive research on the bereavement and grief therapies. First, it examines various definitions of grief and bereavement and differences between them. Then a variety of theories related to these processes are scrutinised and presented. Then different therapeutical approaches coping with bereavement and grief are explored. After that subject of this study is examined through lenses of two classical psychotherapy theories: Person-Centred and Cognitive Therapy. Finally, an integrated approach based on previous ones is presented.
Some conclusive remarks are also added. Definition of Bereavement and Grief Morgan (2000) and traced the words bereavement and grief back to the French word ravir and even further, to its root, the old Frisian word reva, which means to steal or to rob. Thus, in experiencing loss, one feels an acute sense of deprivation of a significant person in one’s life. Morgan (2000) stated that grief is the price we pay for love; it is the price we pay for security; it is the price we pay for a sense of warmth and for a sense that our lives have meaning (p.
1). Simply expressed, “grief is the little kid inside of us protesting. Grief is that little kid inside of us thinking that if I yell loudly enough, if I scream loudly enough maybe my loved one will come back” (p. 1). While the terms grief and bereavement may be viewed as synonymous, some authors make a distinction between them, generally defining bereavement as “the objective situation of having lost someone significant” (Stroebe, Hansson, Stroebe, & Schut 2001, p. 6).
Grief is defined as the reaction to bereavement, the “severe and prolonged distress that is a response to the loss of an emotionally important figure” (Weiss 2001, p. 47). Parkes (1970) offers a more detailed definition: Grief, it seems, is a complex and time-consuming process in which a person gradually changes his view of the world and the places and habits by means of which he orientates and relates to it. It is a process of realization, of making psychologically real an external event which is not desired and for which coping plans do not exist (p.
465). While grief is the internal experience of thoughts and feelings in response to the loss, bereavement can be described as the loss itself, and the process that expresses the internal experience of grief (Worden 2002). Thus, a person may be bereaved in having experienced a loss, but not directly experiencing grief, as in the stage of denial (Worden 2002). Bereavement is characterized most often by emotions of sadness, anger, guilt, loneliness and insecurity (Kubler-Ross 1969). Becker (1973) asserted his belief in three possible responses to death.
The first response is to deny the reality of death, to act as though it will not happen or is not important. The second response is to become mentally ill, to engage with death in a way that disregards societal and legal boundaries. The third response is to be heroic, to live life fully and to leave a legacy that upholds life and that honours one’s existence (Becker, 1973). Original Theories of Bereavement Morgan (2000) stated that grief impacts people on many levels: emotionally, biologically, sexually, economically, socially, and spiritually. In essence, all aspects of a bereaved person’s life are affected by grief.
Freud’s (1917) seminal bereavement paper, “Mourning and Melancholia,” was the first to propose the necessity of doing grief work, which he defined as a cathartic process of reviewing and then severing the psychological bonds to the deceased, in order to create room for a new attachment to a live person; “a withdrawal of the libido from this object and a displacement of it on to a new one” (p. 249). Stroebe (1992) more recently defined grief work as “a cognitive process of confronting a loss, of going over the events before and at the time of death, of focusing on memories and working towards detachment from the deceased” (pp. 19-20).
Freud (1917) compared melancholia, which he considered pathological, to the normal process of mourning; he argued that while both share the same features of dejection, loss of interest, inhibition, and loss of capacity to love, melancholia was distinguished by its punitive and painful view of the self, during which the grieving person expects punishment (a belief which may reach delusional proportions). “In mourning it is the world which has become poor and empty; in melancholia it is the ego itself (p. 246). The pathology becomes the conflict within the ego, as opposed to the normal struggle to reconcile the loss of the object.
Freud introduced ambivalence as a necessary precursor to melancholia, implying that the quality of one’s prior relationship to the deceased was an important factor. The ambivalence toward the lost object created a maelstrom in the grieving individual, who struggles to both detach and remain attached simultaneously. His assumption was that all people need to do the “work” of grieving, where “every single one of the memories and situations of expectancy which demonstrate the libido’s attachment to the lost object is met by the reality that the object no longer exists” (Freud 1917, p. 255).
Freud believed that the ego then became “free and uninhibited” (p. 245) once the grief work was completed, and ready to form a new attachment. While these were theoretical constructs, based on Freud’s observations of grieving persons, they were assumed to be representative of the process of grieving and had implications for the bereavement field for many decades afterward. Freud himself even stressed that further study was needed to identify those who may be predisposed to develop melancholia, and that his paper was actually not addressing grieving, per se; he was exploring dimensions of depression.
The distinction between normal and pathological grieving was further explicated by Lindemann (1944), who interviewed 101 bereaved individuals from both an inpatient and outpatient population. Lindemann described the trajectory of normal grief as a fairly comparable phenomenon across patients, characterized by “(1) somatic distress, (2) preoccupation with the image of the deceased, (3) guilt, (4) hostile reactions, and (5) loss of patterns of conduct” (p. 142).
Lindemann observed that it was not unusual for people experiencing a normal grief reaction to resolve the immediate symptoms within four to six weeks with the care of a psychiatrist. Lindemann (1944) viewed morbid grief reactions as a distortion of the normal grieving process. These pathological responses included a delay or distorted reaction to the loss (i. e. , overactivity, or no observable change in affect), somatic reactions that mimic the illness of the deceased, hostility against those perceived as responsible (i.
e. , the loved one’s physician), prolonged isolation from social supports, and intense self-persecution and desire to punish oneself, including suicidal ideation. Lindemann (1944) defined grief work as “emancipation from the bondage to the deceased, readjustment to the environment in which the deceased is missing, and the formation of new relationships” (p. 143). He believed that an obstacle to the successful resolution of grief was the avoidance of expressed emotional distress.
Lindemann seemed perhaps overly optimistic by stating that a person could be assisted through a morbid grief reaction in eight to ten interview sessions, yet this may have been seen as a welcome departure from Freud’s (1917) statement that mourning is “long-drawn-out and gradual” (p. 256). Furthermore, this could have been a precursor to the studies supporting the profile of the resilient individual (discussed in greater detail below). Anderson (1949) described the symptomology of 100 hospitalised bereaved patients under his care, who exhibited anxiety, hysteria, agitated and anergic depression, and hypomania.
Anderson clearly endorsed the pathology of a delayed grief reaction, stating, “It is obvious that such states of mind will pervert, distort and prolong the natural process of grief in reference to patients who were unable to cry or who appeared elated. Anderson (1949) also believed the necessity of understanding the bereaved patient’s relationship to the deceased, and endorsed that an ambivalent attachment would produce a conflicted and prolonged bereavement process.