A student’s question and the lecturer’s reply

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Last week I delivered a lecture on models of grief to medical students at Hull and York Medical School. As usual I invited the audience to contact me should they have any questions later.

This is the text of an email I received, followed by my response. As you would expect, I have respected the sender’s anonymity:

Mr Wilson

I was present at your recent fascinating HYMS lecture on grief, and whilst going through it, I have become slightly confused. I would be grateful if I could take a couple minutes of your time.

You mentioned several models of grief, and I am just wondering if there is interplay between these models or if they are completely independent from each other? For example, if you look at the dual-process model of grief – if somebody takes a purely loss-oriented approach, could you relate that to the ‘grief as work or task model’ and say that this loss-oriented approach would be likely to leave the person stuck in the yearning and searching phase?

Thanks for your time.

Thank you for your email

There’s no quick answer to your question, and it raises some important points. First I will give you the quickest answer I can to your question about an interplay between the various models.

Of the models I mentioned, and some that I didn’t, with the exception of the Stroebe and Schut Dual Process Model, all of the theorists base their ideas on their personal clinical experience with clients:

The Stage/phase models originated from the joint endeavours of John Bowlby (a paediatrician) and Colin Murray Parkes a psychiatrist. (Bowlby and Parkes 1970)

Colin Murray Parkes was the first to apply the concept of an individual’s assumptive world to grief theory (Parkes 1971). Ronnie Janoff-Bulman extended the idea into thinking about trauma (Janoff-Bulman 1992).

Meaning-making is the province of Bob Neimeyer, an American professor of psychology, prolific writer, poet, clinical practitioner with a caseload and all-round gentleman. (see for example, Neimeyer 2001)

Continuing bonds theory is primarily the work of Dennis Klass (Klass, Silverman et al. 1996, Klass 2006), now retired from clinical psychology, but a long-time practitioner/theorist.

Two models/theories I didn’t mention are Lois Tonkin’s Circles model (in my book) and Thomas Attig’s concept of relearning one’s world after a loss (Attig 1991, Attig 2001, Attig 2004, Attig 2011). Lois is a counsellor in New Zealand who like me, is currently pursuing a PhD. Tom Attig is frequently described as a philosopher but his ideas are firmly rooted in compassionate experience with grieving people.

Other models include ideas on resilience to stress (Bonanno, Wortman et al. 2002, Bonanno, Wortman et al. 2004, Machin 2009) and the concept of ‘grief work’ (Worden 1983).

It seems to me that the separation between the various models and theories is primarily due to the nature of Academia. Since the currency of Academia is original, peer-reviewed publication, each academic works to develop and substantiate her or his stance: sometimes from driven ambition, sometimes from passion for an idea and altruistic outcomes. It is for this reason that each model appears at first sight, to stand alone. My own position as an educator/writer is to introduce each model as a separate entity, and let those I teach who go on to use the models/theories, discover the links for themselves through clinical experience.

Margaret Stroebe, Henk Schut and other colleagues from the University of Utrecht, periodically publish a grief research handbook; selecting the best contributors in the field and then comparing ideas in their extensive editorial chapters (Stroebe, Stroebe et al. 1993, Stroebe, Hansson et al. 2001, Stroebe, Hanson et al. 2008). This is the place where theoretical interplay between theories is discussed. Hopefully there are reference copies of these handbooks in your library. If there are not I will request them.

Now let me explain how I make use of these models in practice. When I first meet a client I listen very carefully as they describe their post-bereavement world. This gives me an insight into the model or models I suspect they will find useful. Remember that these models have been generated by practitioners, through the observation of clients. Remember too what I said in the lecture: that I believe we each know how we personally need to grieve and that it is an instinctive and (largely) universal (i.e. culturally independent) process. For example, if I client tells me that the death has turned her world upside down, then I interpret this as a comment on her assumptive world. If a client is trapped deep in his grief; completely immersed in sadness and dwelling on the death of his wife, although several months have passed, I will recognize this as the loss oriented component of the Dual Process Model, and gently encourage him towards restoration, by pursuing new activities. If a client is avoiding grief by keeping busy, and there is evidence of somatic effects, (commonly, panic attacks, or stress related conditions: e.g. a medical diagnosis of irritable bowel syndrome, I will encourage him to talk about the deceased, even if this is upsetting. Research suggests that Attachment theory plays a part in a client’s grief in relation to the DPM. Anxiously attached, ‘clingy’ people dwell on the loss, whilst the avoidant attached types dwell on the restoration.

My personal view, arrived at through clinical work, is that there are strong links between Attig’s relearning idea and assumptive world theory. Both involve constructing new meanings of the life and death of the deceased and the life of the bereaved person. The nature of continuing bonds is under-researched. The health and usefulness of a continuing bond is, I believe, very dependent on attachment style: clingy people arguably retain an unhelpful bond based on pretence rather than symbolic presence. I also think that meaning-making plays a strong part in constructing a healthy continuing bond with the deceased.

Finally, I’ve come to your specific question. The answer is ‘yes’, a loss-oriented approach relates directly to grief work. At the end of the twentieth century, a popular view was that grief work, i.e. concentrating on the loss, was an essential part of a journey back to health. As a novice practitioner, I was taught to encourage clients to do their grief work. Tears were seen as almost a prerequisite of a successful outcome. Margaret Stroebe and colleagues have questioned that (Stroebe, Stroebe et al. 2002), and the DPM grew from this questioning (Stroebe and Schut 1999). Then you ask if dwelling on loss can lead to a person becoming stuck in the loss and yearning phase. I don’t yet know enough to give you a definitive answer, but I suspect that it can. There is also a question over whether membership of a mutual support groups can prolong grief, since new, recently bereaved members can affect the grief of others in the group.

Interesting papers by Freed & Mann (Freed and Mann 2007, Freed, Yanagihara et al. 2009) explored your question and related it to the neuroscience of grief. They made a distinction between the ‘protest’, or yearning and searching phase, and the despair phase. Sadness in the former instance is part of attachment, a belief that it exists to encourage reunion with an absent loved one, whilst sadness in the latter is part of detachment. If you believe that grief performs a biological function, despair exists to encourage a bereaved person to accept the reality and stop searching. Freed and Mann hypothesized that to work with clients in either encouraging or distracting their sadness, one should know from which of these places the sadness comes from, and suggested that an fMRI scan might provide the answers. In fact, work by Mary Frances O’Connor (Gündel, O’Connor et al. 2003, O’Connor 2005, O’Connor, Wellisch et al. 2008) has shown that the fMRI scans of grieving people, particularly those diagnosed with complicated grief, show heightened neurological activity in brain regions associated with yearning for the deceased. If we look carefully at the pattern of tears and sadness, it initially comes over a grieving person in waves, several times a day, and subsides between them. Over time the waves get further apart and shorter in duration. I believe that this would be reflected in changes in neurological activity. A more generalized ‘low’ sadness often follows. O’Connor suggest that grief sadness is probably not an either or mater between yearning and despair, but that there may be a transition between the two, both expressed tearfully (O’Connor 2013). I also believe that there is a good case for counselling very cautiously during the yearning waves of grief; holding and watchful waiting, perhaps providing a telephone helpline, but not engaging in weekly counselling. This is a frightening time, and people need to feel they are kept safe. Once these waves largely subside, gentle, client-led weekly support can follow, which hopefully leads the client to an acceptance of the reality of the loss, new meanings, restoration activities, relearning and adjustment of the assumptive world, and the establishment of healthy continuing bonds.

I hope this answers your questions. I have taken the liberty of using your question and this answer on my blog, although obviously I have protected your anonymity.

Best wishes
John

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Attig, T. (2001). Relearning the World: Making and finding meanings. Meaning Reconstruction & the Experience of Loss. R. A. Neimeyer. Washington DC, American Psychological Association: 33-53.
Attig, T. (2004). “Meanings of death seen through the lens of grieving.” Death Studies 28: 341-360.
Attig, T. (2011). How We Grieve: Relearning the World. Oxford, Oxford University Press.
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