Therapy for grief resolution: accepted theories and new developments.

This article was originally published in the BACP Private Practice Journal, December 2018

In the two decades I have come to specialise in bereavement counselling, a great deal has changed. Research in the field has helped our profession develop a greater understanding of grief. This has implications for the way that we can best support our clients, something that I am keen to explore here. In order to contextualise current thinking on grief, I begin with a twentieth century review.

100 years ago, Sigmund Freud published ‘Mourning and Melancholia’ ¹. It established a pivotal believe in therapeutic practice, that bereaved individuals needed to sever the emotional connection to the deceased. The breaking of the affectional bond was achieved through what Freud called ‘grief work’. “You need to let go,” entered the lexicon of advice to the bereaved. Those that showed no cathartic distress were said to be ‘in denial’. Both of these ideas became so established that they were regarded as truisms for the twentieth century. When Helene Deutsch’s bereaved patients showed no “manifestations of mourning”, she drew on Freudian concepts to label what she saw as her patients’ pathological avoidance². Her fellow Freudian psychoanalyst, Erich Lindemann, worked with the bereaved families of the 1942 Coconut Grove Night Club fire in Boston. In 1944, based on the outcomes of his treatment, he published his work on the symptomology and management of acute grief ³. Grief work became medicalised, a position reinforced by George Engels 1961 paper, rhetorically titled, ‘Is Grief a Disease?’ ⁴.

Meanwhile in Britain, John Bowlby moved away from Freudian psychoanalytic theory and established a new understanding of grief, based on the protest behaviour of infants separated from maternal care. He was joined by Psychiatrist Colin Murray Parkes at the Tavistock Clinic, and in 1970 they jointly published a four-phase model of grief: 1 numbness, 2 yearning and searching, 3 disorganisation and despair, 4 greater or lesser degree of reorganisation⁵.

Bereavement counselling initially found a home in the British hospice movement. John William Worden’s book ‘Grief Counselling and Grief Therapy’ ⁶quickly became the go-to book for counsellors working in bereavement services. Worden’s ideas were firmly embedded in the ‘grief work’ hypothesis. Stages of grief were translated into tasks of mourning: Task 1 accepting the reality, Task 2 experiencing the pain of grief, Task 3 adjusting to the absence of the deceased, and Task 4 letting go. Armed with this guidance, together with a knowledge of Bowlby and Parkes’ phases, grateful and well-meaning practitioners took their grieving clients on a prescriptive journey. In his book, ‘Love and Loss’ ⁷, Colin Murray Parkes reflects on this observation and says that the stages of grief were never intended to be used so prescriptively. For counsellors guided by Worden’s Task Model, it was however, hardly surprising. Furthermore, the expected conclusion of grief work was that clients would let go of the deceased and move on. I vividly remember, towards the end of the twentieth century as I began to practice in this field, that clients did not ‘let go’. They held on firmly to the fond memories of the person they had lost. The myth of letting go was eventually challenged by Dennis Klass and colleagues’ book, ‘Continuing Bonds’ ⁸. This research established that once the reality of death is accepted, the bereaved person can form a new and symbolic bond with the person they have lost. Clients had been right all along in staying close to the memories and emotional legacy bequeathed to them in their bereavement.

If clients do not need to let go, do they still need to complete other aspects of their grief work? That concept too was re-evaluated. In a paper entitled ‘The Myths of Coping with Loss’ ⁹, Camille Wortman and Roxanne Silver questioned the notion that failure to do grief work was indicative of a pathological condition. Margaret Stroebe ¹⁰challenged the lack of rigorous scientific evidence that grief work is effective. Furthermore, she and her colleagues ¹¹suggested that for some bereaved people, there could be benefits in avoiding and denying the reality of the death, particularly in the early weeks following a bereavement. Stroebe has pointed to the fact that the concept of grief work was culturally biased towards Western thinking, and that there were inadequate studies of other cultures. She cites Unni Wikan’s observation of Balinese Culture, in which expressed grief is of short duration, and grief work is absent ¹². Both the myth of grief work, and the need for counselling to facilitate it, were on shaky ground.

From the bereavement counsellors’ perspective, even more uncertainty was out there. Schut and colleagues conducted a meta-analysis of research into the efficacy of bereavement counselling ¹³. Their results indicated that routine referral for bereavement counselling was ineffective and may even do harm. Counselling for moderate bereavement distress showed temporary benefits. Only clients in the most severe distress appeared to be helped by counselling.

Now feeling somewhat disillusioned in my vocation, and against this background of damning research, my practice changed. I sought evidence into what made grief counselling effective. As I read research in the field and became reflective in my practice, I began to notice a phenomenon which surprised me. Let me explain that in a former career, I taught science to young children. The philosophy of the time was one of child-centred discovery rather than the didactic delivery of facts, and was based on the work of Jean Piaget ¹⁴. The teacher listened to the child making sense of his environment and fostered the child’s natural tendency to construct schemas, or units of meaning which helped him make sense of his world. Almost a decade later, in the person-centred therapeutic space, I found myself using exactly the same skills: sensitively and empathically supporting distressed clients as they made sense of their post bereavement world through the construction of new meaning in adaptation to their loss. At the centre of this, just as it had been in the classroom, was the nurturing of a mutual curiosity shared with the client. Curiosity is infectious. It leads the intrigued child and the bereaved client towards fresh understanding.

As I explored the research, I found myself standing on the shoulders of others. In 1971, Colin Murray Parkes had come up with a theory of psychosocial transition which he named Assumptive World Theory ¹⁵. This is our world of familiarity and established certainty: a world which, by definition, we take for granted until it is shattered by any event which evokes in us a hostile place we do not recognise. The event may a bereavement, but the distress it causes is different to separation distress. I was delighted to find that in 1992, Ronnie Janoff-Bulman had linked Parkes’ theory to Piaget’s ideas of schema formation in the process of making sense of a world shattered by loss ¹⁶.Things were beginning to look less pessimistic for bereavement counsellors. I began to construct a view of bereavement counselling that neither centred on grief work nor expected clients to let go of those that they still loved. It did not stop there, for there were more shoulders to stand on. Thomas Attig described relearning to live in a world in which the deceased was missing ¹⁷. Robert Neimeyer related meaning-making to constructivist psychotherapy ¹⁸. The stage was set to formalise my reflective practice with qualitative research to discover just how clients make sense of their post-loss world.

I wrote a research proposal for a part-time PhD ¹⁹. In the process I attended a workshop facilitated by Bill Stiles, who had developed a theory of assimilation for counselling and a scale which described the process. The Assimilation of Problematic Experiences Scale (APES) ²⁰. APES has been tested many times in many contexts. In seven stages it describes the client moving from warding off the problematic experience, becoming progressively aware of the nature of the difficulties, working through these difficulties and finding a solution. Stiles’ work was another part of the jigsaw. It linked Robert Neimeyer’s work on meaning making with the schema formation of Jean Piaget and Janoff-Bulman.

My research proposal was accepted by York St John University. I recruited ten clients and their sessions, including the assessment, were recorded and transcribed. Each client’s progress was measured using APES. The principal conclusion of the thesis was that there are six criteria which, if met, mean that the client either does not need counselling from the start, or can end counselling on attaining all six. The criteria are: 1. accepting the reality of the death, 2. making sense of the death, 3. acquiring coping strategies, 4. accepting the sadness, 5. finding meaning in life without the deceased, and 6. anticipating a positive future. During the project I met many clients who needed no more than the reassurance of an assessment session. Almost half of clients who were referred to the service fitted into this category. This fits with George Bonanno’s finding that almost 50% of bereaved clients are resilient and do not need routine referral for counselling ²¹. A second conclusion offered a tentative explanation of why counselling may do harm. Stroebe has explored the possible benefits of denying the reality of the death in the early stages ²²and this was borne out in the transcripts. It appears that for these clients, work needs to be undertaken cautiously in a person centred way, giving the client time to adjust to the reality of their loss.

Every client in the study exhibited an integration of one or more of the theoretical models into their recovery. Clients identified and articulated the changes to their assumptive world. They engaged in relearning how to cope with a new, post-loss world. They made sense of the death and found meaning in life without the deceased. All clients in the study created a continuing bond with the person they had lost. Stroebe and Schut’s Dual Process Model ²³, as a means of dipping in and out of grief whilst engaging in restorative activities, was another theme common to all participants in the study.

As my thesis developed, each successive case study produced a fresh version of APES which became increasingly specific to bereavement counselling. This I have called AGES, the Assimilation of Grief Experiences Scale. AGES uses the stage descriptors of APES, but the examples at each stage are generated by the transcripts of counselling sessions. A condensed version appears here, and I am happy to email the full version of AGES to any reader. The scale allows the counsellor to assess the client’s progress, and can be shared with the client. In my ongoing research, AGES is subject to modification in the light of evidence from further case studies.

On the evidence, both from past research and from my own, I conclude with this guidance to practitioners working with bereavement. Firstly, some potential clients will be resilient. Soon after the loss they may naturally be distressed. However, an assessment carried out therapeutically and with reassurance, may be all that resilient clients need ²⁴. There may be other issues concurrent with, or exacerbated by the loss, which could be the focus of counselling, rather than the bereavement itself. My experience shows it can help to draw your client’s attention to the Dual Process Model. Validate, from a person centred perspective, on which side of the model your client chooses to spend most of their time. As the work progresses, the client may need some gentle encouragement to spend more time oscillating between the two orientations. Respect a client who chooses to spend some time avoiding the reality of their loss, especially in the early stages. Be cautious in pushing any client into a cathartic expression of grief. Be demonstrably curious in your client’s processes. Help them to make sense of changes in their life resulting from the loss, and to construct new meanings. Support your client, in creative ways, to foster a continuing bond with the person they have lost. Most of all, follow your client closely and sensitively, rather than lead them into places they are not yet ready to go. I am very aware of how my own practice has benefitted from my research and I hope that this can be of some help to others. More detailed descriptions of models and theories of grief can be found in my book²⁵.

Assimilation of Grief Experiences Scale, AGES

Stage
0 Warded off	The client is numb with pain. Dissociation from the reality of the death. Reluctance to abandon the body.
1 Unwanted thoughts	Reminders of the death are avoided. The client is unwilling to discuss the death. Pretence that the relationship remains unchanged.
2 Vague awareness	Client exhibits a loss of identity and purpose. They become distressed when discussing the death. The client may display magical thinking when discussing events.
3 ProblemStatement/ clarification	Beginning of periods of respite from pain. The client is able to discuss the death, although this is usually upsetting. Rituals become less magical and more symbolic. Problematic situations are identified.
4 Understanding/ insight	The client is more accepting of the emotional pain and is able to ‘go with the flow’. They have a greater understanding of circumstances surrounding the death. Magical thinking diminishes. The deceased is relocated symbolically. Problematic situations and experiences are discussed.
5 Application/ working through	The client is comfortable oscillating between loss and restoration. They can clearly discuss the death with reduced negative affect. They begin to negotiate and renegotiate the relationship with deceased. Problematic situations are worked through.
6 Problem solution	The client finds new meanings in life and may begin to accept a new identity. May find meaning in the death. Fully symbolic continuing bond with the deceased is developed.
7 Mastery	The bereavement is integrated into other life experiences. Resilience equips the client for future losses. The client demonstrates an open attitude to forming new close relationships.