A new understanding of grieving

Feb 10, 11 A new understanding of grieving

(This article by Leslie Ellis appeared in a recent issue of Insights into Clinical Counselling)

Although the classic stages of grieving delineated by Elisabeth Kubler-Ross over 40 years ago are well known and widely accepted, more current research shows that grieving does not follow such a tidy, linear formula but comes more in waves or in a spiral pattern unique to each person, and to the particular loss they are grieving. To heal from grief is now seen as less about letting go and moving on, and more about finding constructive ways to hold on to what was meaningful about the person or thing they have lost.



The classic stages of grief, from Death and Dying, the 1969 ground-breaking book by Kubler Ross are: denial, anger, bargaining, depression, acceptance. All of these may be present in the grief process, but then again, may not. And if they are present, they do not necessarily appear in that order. More often, people experience waves of grief that diminish in intensity over time, but do not go away altogether.

According to John Jordan (2006), a psychotherapist and teacher who specializes in grief counselling says, “Grief is much more heterogeneous than we thought. There are no universal five stages. We all grieve differently.”

A surprising study that looked at the mood states of older people whose spouse had died found that almost half of the respondents did not feel worse immediately after the death or at any time within five years of losing their spouse. Only 11 percent displayed the classic pattern one might expect: of becoming depressed after the death, and in time, recovering back to normal. Almost as many people (10 percent) actually had improved mood after their spouse died.

The findings were based on analyses of data from the Changing Lives of Older Couples (CLOC) study, a rare prospective survey of a random community-based sample of 1,532 married men and women age 65 and older conducted by the U-M Institute for Social Research (ISR), the world’s largest academic survey and research institution. The results have been published in the book Spousal Bereavement in Late Life (2005). While they focus on a specific population, one can still look at these results and draw the general conclusion that not everyone goes through a long, involved grief process, and some appear not to grieve at all.

Jordan describes grief as “a whole-person response to the actual or threatened loss of anything to which they are psychologically attached.” He says grief is felt in our bodies, and somatic responses are common in those who are grieving. Grief is expected when a person loses a loved one, but there are many other losses that can bring grief: loss of a pet, a role or identity, a spiritual belief, the end of a relationship, physical decline — basically the loss of anything that a person truly valued has the potential to plunge them into mourning.

There are many factors that influence how a person will respond to a major loss. As counsellors, it’s important to understand the risk factors for difficult or ‘complicated grief’, a new category in the DSM-V, which is still a work in progress. Jordan says that, “All grief is normal grief.” He sees the role of grief counsellors as similar to that of a midwife facilitating a natural process, and like a midwife, “we may need to intervene more actively if the process gets stuck.”

According to research by Selby Jacobs one of the team members working on the new DSM-V criteria, there are four types of complicated mourning:

avoidant or inhibited, where there is no apparent grief response;

masked mourning, where the grief goes underground, yet affects functioning (somaticized grief, addiction) and the person does not make the connection;

distorted mourning, where one aspect of grief looms large, but the others are absent (for example intense yearning at the suicide of a loved one, but no anger, a classic response to death by suicide); and

chronic mourning, where the bereaved person is still emotionally raw about the loss after years have passed.

As clinicians, it’s important to understand that while most people can manage their own grief process instinctively and well, there are risk factors that predispose people for a more complicated grief process where support of a counsellor would be truly helpful. These factors include: previous history of depression or anxiety; experience of a loss that is sudden or violent; loss of a child (at any age), especially for mothers; multiple losses; and losses that are seen by the bereaved as preventable or ambiguous.

Factors that may make the grief process easier include prior exposure to loss (as long as it wasn’t too much loss too early in life); high self esteem; secure attachments; a spiritual orientation; and a leave-taking that allowed the bereaved to say good-bye in a way that felt right to them. Contrary to popular belief, it does not appear in current research that a conflicted relationship with the deceased makes mourning more protracted — in fact, the opposite can often be the case.

While there are guidelines, there is simply no standard formula for grieving, and we, as counsellors must allow our clients to be the guides and experts in this process, which can be lifelong. According to Jordan, we North Americans generally have a ‘flu model’ of grief, where you get sick, go downhill to the bottom fairly quickly and then gradually get better and resume functioning. “Grief is generally understood as a temporary disruption, like an illness. But, when you lose someone to death, your world permanently changes.”

Kauffman (2002) has developed a useful way of thinking about the grief process. We all have what he calls “assumptive worlds,” our basic understanding of how the world works based on our upbringing and life experience — things like, ‘The world is a safe place; people can be trusted; kids outlive their parents; bad things don’t happen to good people.” A sudden loss can shatter a person’s assumptive world view, and grief work can be seen as the process of rebuilding it, or adjusting to the new world where nothing is as it was. It can be very disorienting.

Jordan says much of grief work is about adjusting of our ‘assumptive world view’ to the new reality. We need more, repeated data to let go of the old view of the world. Even though we know in our mind that a loved one has died, it takes time and exposure to contradictory data for our unconscious to accept the new reality. As Freud said, “The unconscious does not believe in death.”

Instructive in this process is how children cognitively understand death. They tend to learn and understand about death, in this order: first they need to understand fatality, the fact that people (and animals) do die; second, that once they’re dead, people can’t come back to life; and third, that death is universal and will happen to everyone, even themselves.

Children cognitively master all three ideas at about age 6, but getting it emotionally takes a lot longer. “I’m still working on universality. It’s a lifelong developmental task to make our own mortality more psychologically real,” says Jordan. “We all have the child-like mind-set in us that says, ‘Death happens to other people, but it’s not going to happen to me.’”

Grief work travels along these same developmental steps — at first the bereaved can’t believe the person is really dead. Then they work on accepting that the dead are not coming back. And finally they begin to look at their own and universal mortality. These steps are more intense and marked in sudden and unexpected death. A long illness prepares one more gradually for death and grief work takes place along the way.

Neimeyer (2001) offers some concrete steps on how to reconstruct life meaning after a major loss. He sees grief work as happening in stages. The first stage may be similar to trauma work in that you don’t want to expose someone to too much too soon. But as they’re ready, ask the questions that no one else wants to ask: where they were when they got the diagnosis, when they realized it was terminal, and when the person died. Ask about the funeral, and about what they might have done differently if that were possible.

Once the initial processing of the death is winding down, it’s a good time to ask about the deceased, explore the history of the relationship, bring stories and photos. This moves the client from a reactive to a more reflective stance, and brings up the core question of grief therapy: what have I lost? What is it I have to let go of, and equally important, what do I have to hold on to? This is where grief rituals can be the most helpful, enacting meaningful, concrete steps that bring the mourner into relationship with the dead in some way. This can mean visiting the grave, creating a shrine or altar, or coming up with something completely unique that feels right for the bereaved person.

In the later stages of grief therapy, you can start to challenge avoidance of issues where this is present and address ways the person is still stuck. For some people, this may involve taking on practical new tasks and skills that were previously handled by a spouse. At this stage, it’s not uncommon for people to re-order priorities, make major life changes and develop a new identity. The good news is that the grieving process generally makes people stronger. Processing a major loss helps people grow, deepens them emotionally and spiritually, and can be a source of awakening and transformation.

References

Carr, Deborah, Nesse, Randolph, and Wortman, Camille B. (Eds.) (2006) Spousal Bereavement in Late Life. New York: Springer Publishing Company.

Jacobs, Selby (1999) Traumatic Grief: Diagnosis, Treatment and Prevention. Philadelphia, PA: Brunner/Mazel.

Jordan, John. R. (2006) American Academy of Bereavement presentation: Grief Counselling and Clinical Practice.

Kauffman, Jeffrey (2002). Loss of the Assumptive World: A Theory of Traumatic Loss. New York, NY: Brunner/Routledge.

Neimeyer, Robert A. (2001) Meaning Reconstruction and the Experience of Loss. Washington, DC: American Psychological Association.

2 Comments

  1. Jennifer Bell, M.D. /

    Your photos are stunning!

    I also enjoyed your piece on grieving. I am trying to write a website for Boundary Stone Ministry–A Christian Alliance for Bereaved Children. I came across your site while searching for….hmmm…for what? For a way to debunk myths about childhood grieving by presenting the Truth about grief—especially as it pertains to kids who have lost a parent to death.

    I was an E.R. doctor for 10 years before I had my three kids (in 20 months while pushing 40!) That was 10ish years ago. It is strange to revisit “scientific” studies about grief after my Christian faith has deepened so much over these years and my worldview has changed. Not enough is done to study grief in kids and what is done is too often poor science. When it is good science, it is ususally still devoid of any serious consideration of God in the child’s life.

    I love the title of your website! Whether we are inward bound or outward bound, God is there. Your photos AND your writing show it! Nice work and beautiful subjects!

  2. Dear Leslie,

    Your gentle presentations depicting “inward bound” and “outward bound” are a lovely invitation to Focusing. I teach Inner Relationship Focusing in Vancouver with an emphasis on how we learn to learn.

    In your article “A new understanding of grieving” I appreciate that healthy grieving is”less about letting go and moving on, and more about finding constructive ways to hold on to what was meaningful about the person or thing they have lost.”

    Looking forward to reading and pondering more of your web-site, thank you,

    Katarina

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