Models and Theories of Grief and Bereavement Listening Support Volunteers’ Training Course, St Michael’s Hospice 2015 Whistle stop tour, supply teacher principle

Why bother with theory? Helps us to understand reactions Helps us to respect difference Helps to normalise experience of grief Helps us to identify what stage the bereaved person is at. ‘Ways in’ with the bereaved person, e.g Exploring feelings Telling the story Memorialising the deceased Learning new skills Why bother with all this? What’s wrong with just being yourself, seeing where it leads you, bringing your own experience of loss and your genuine and compassionate desire to help and support. Theory helps to Normalise the experience of grief, particularly if those experiences are NOT ones you share. Lot of people want to know that they are normal and not ‘going mad’. By recognising, for example, that the Dual Process Model suggests that it’s ok to ‘take time off’ from grief, you can reassure someone that it’s not that they didn’t love the dead person, but they are oscillating between loss and restoration. Or that it’s normal to find yourself looking for the deceased, or believe that you can feel their presence. Or that if someone is reluctant to talk about feelings but would rather plant a tree in memory of the person, or make a photo album, you can reassure the family that they are an instrumental griever (Martin and Doka) and that this has value.

Some quick definitions… Bereavement is an event Grief is the emotional response to one’s loss Mourning denotes the actions and manner of expressing grief, which often reflect the mourning practices of one’s culture Stroebe et al (1993)

Freud (1917) Provided no clear model Talked of melancholia as mourning, meaning one is searching for an attachment that has been lost. The ego needs to accept the reality of the loss and to disengage and withdraw energy from the lost object of attachment. Psychoanalytical approach saw pain and confusion after a death labelled as symptoms, implication that they were pathological and a sign of illness. The idea was that if ‘correct’ mourning was observed, these ‘symptoms’ could be prevented. Depression was a sign of grief gone wrong – ambivalence towards the dead person turned inwards. Freudian theory goes people become attached to others (love objects) who are important for the satisfaction of their needs. The more important the relationship, the greater the cathexis. Grieving represents a dilemma because there’s a simultaneous need to relinquish the relationship, freeing up energy to form new bonds, and a wish to maintain the bond with the love ‘object’, the person who’s died. Characteristics of normal mourning: A profoundly painful dejection A loss of capacity to adopt new love objects Reduction in activity or withdrawal of activity not connected with thoughts of the loved one Loss of interest in the outside world because it doesn’t involve the dead person. Grief work, or decathexis: engage in repeated reality testing in order to accept that loss is permanent, gradual detachment, severing relationship bonds to allow reinvestment of emotional energy in new relationships. What’s wrong with this? Do you think we really do have to let go of a relationship in the way Freud suggests? His personal letters did not support this trajectory of grief, but nonetheless his views have been dominant in theories in early part of 20th century.

Bowlby (1961-1981) Grief triggered by loss of attachment figure Nature of grief depends on type of attachment 4 stages of grieving: numbing, yearning and searching, disorganisation and despair, reorganisation Bowlby, psychiatrist who studied children separated from families during the Blitz and from it proposed attachment theory. This goes that early in life we form affectional bonds and that these early attachments influence our relationships throughout life. The formation, disruption and maintenance of attachment bonds give rise to intense emotions, and losing the attachment figure leads to grief that has to be worked through. What he observed in young children was protest (anger, crying, contstant searching, hypervigilance), followed by despair (withdrawal, less vigorous crying) and detachment (outwardly ok, emotionally distant). The stronger the attachment the more intense is the distress when it is broken.

Worden (1991) Four ‘tasks’ of grief Task 1: to accept the reality of the loss Task 2: to work through the pain of the grief Task 3: To adjust to the environment without the deceased Task 4: to emotionally relocate the deceased and move on with life Worden: refined phases of grief, drew on Freud’s grief work, Bowlby’s attachment theory and Engel’s notion that bereavement was like a wound that had to be healed through mourning. Task 1: to accept the reality of the loss Task 2: to work through the pain of the grief Task 3: To adjust to the environment without the deceased Task 4: to emotionally relocate the deceased and move on with life

Relf, Machin and Archer (2008) ‘Responses to Loss’ approach controlled overwhelmed Resilience Identifies two core dimensions of grief: overwhelmed (focus on feelings) and controlled (focus on thinking and action). Resilience is ‘a comfortable capacity to oscillate between overwhelmed and controlled responses, whereas vulnerability is an uncomfortable tension between the feelings of overwhelming distress and the desire for control. What might indicate that a person is overwhelmed? (what might you see? What might they say? Answers: tears, anxiety, agitation, fear, pessismism, lack of trust in self, confusion “Life’s not worth living … I can’t stop thinking) And controlled: lack of trust in others, little emotional response, not seeking help, major focus on practical concerns, ‘you just have to get on with life, have to be brave’ Resilient: Can face the issues, coping strategies, self acceptance, can show emotion, can talk, accepts help, takes time out. “It’s natural … things will eventually improve … Vulnerable: angry, depressed, stuck, can’t help self or accept help, avoids the issues, doesn’t acknowledge emotional impact controlled overwhelmed Vulnerability

A Dual Process Model of Coping with Bereavement Restoration –oriented Strobe & Schut (1999) Loss Orientated Grief work Intrusion of grief Breaking bonds/ties Denial/avoidance of restoration changes Restoration –oriented Attending to life changes Doing new things Distraction from grief Denial avoidance of grief New roles/identity/ relationships

You cannot stop the birds of sorrow But you can stop them from From flying overhead But you can stop them from Nesting in your hair

References Bowlby J (1980) Attachment and Loss, Vol 3: Loss – Sadness and Depression, London: Hogarth Press Freud S (1917) Mourning and Melancholia, Collected Papers, 4, New York: Basic Books Klass D, Sliverman P R Nickman S L (1996) Continuing Bonds. Philadelphia: Taylor and Francis Kubler-Ross E (1969) On Death and Dying, New York:Macmillan Lindemann E (1944) Symptomatology and Management of Acute Grief, American Journal of Psychiatry 101: 141-149 Marris P (1986) Loss and Change, 2nd Edition, London:Routledge Martin T L and Doka K J (2000) Men Don’t Cry … Women Do, Philadelphia: Taylor and Francis Parker J (Ed) (2005), Aspects of Social Work and Palliative Care, London: Quay Books Parkes C M (1972, 1986, 1996) Bereavement: Studies of Grief in Adult Life, London: Routledge Relf M, Machin L and Archer N (2008) Guidance for bereavement needs assessment in palliative care, London: Help the Hospices Silverman P.R. (2000) “Never too young to know; death in childrens lives.” Oxford University Press. Stroebe M and Schut H (1999) The dual process model of coping with bereavement: rationale and description, Death Studies 23 (3): 197-213 Walter T (1996) A new model of grief: bereavement and biography, Mortality 2 (3): 263-6 Worden J W (1991) Grief Counselling and Grief Therapy, 2nd Edition, New York: Springer