Dying, Death and Grief

Working with Adult Bereavement

Brenda Mallon

• Publisher: SAGE Publications Ltd
• Year: 2008
• ISBN:
  9781446242421
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

"This book?s strengths are [Brenda Mallon?s] clinical wisdom, experience and insights, and the practical, constructive, down-to-earth way in which she conveys these to her readers. This will appeal to many who are searching for guidance in the difficult task of providing support for the bereaved" - Bereavement Care, Spring 2010

?This is a well written book that makes a very useful addition to the field" - Therapy Today, February 2009

?A refreshing, down-to-earth text that examines theory and research without becoming an academic tome. It is comprehensive, focused on practice and contains important insights for developing the essential skills required to provide effective bereavement care? - Dr John Costello, Head of Primary Care, University of Manchester

?Brenda Mallon gives the term "grief counselling" definition in a way no one has done before. If you are new to counselling the bereaved, this book is the best introduction I have seen. If you are an experienced grief counsellor, this should be the next book you read? - Professor Dennis Klass, Webster University,

Dying, Death and Grief is written for anyone who provides support to adults following bereavement. Whether in a professional or voluntary capacity, bereavement care requires empathy, judgement and skill to ensure your response matches the needs of the person you are helping. Recognizing that we all experience bereavement differently, this book introduces theory and skills which can be used in any context to address a wide range of needs.

The author explains the theoretical background to attachment and loss and the core skills needed to support people who have been bereaved. Case studies and personal accounts illustrate key points and exercises help you examine your own experiences and attitudes in relation to loss. The book also takes into account topics frequently overlooked in other texts, such as sexuality, spiritual responses to loss, cultural influences and diversity, as well as the nature of chronic and disenfranchised grief.

Dying, Death and Grief is designed for use on a wide range of training and academic courses that prepare practitioners to work with the bereaved. Professionals in a range of settings including hospitals and in the community as well as volunteers and be-frienders in hospices and nursing homes will find this a useful source of guidance.

Brenda Mallon is a counsellor, trainer and author who specialises in bereavement care. She is vice chair of The Grief Centre, Manchester Area Bereavement Forum.

1

Attachment and Loss, Death and Dying. Theoretical Foundations for Bereavement Counselling

Grief is the price we pay for love.

Without attachment there would be no sense of loss.¹

This chapter explores the different theories that underpin bereavement counselling. Views on the most effective ways to support those who are bereaved have changed over many years (Parkes 2002). In looking at the variety of approaches to grief work you will discover many overlaps and see how growth from one view to another has taken place. It will show how today’s thanatologists, those who study death and the practices associated with it, think and practice. They bring sociological, anthropological and cultural perspectives to their work (Boerner and Heckhausen 2003). However, throughout this exploration we need to hold on to the idea that grief takes as many forms as there are grieving people (Alexander 2002; Benoliel 1999).

The first bonds: why love gives us hope

Why is attachment relevant to bereavement counselling?

It is important to understand attachment since it is essential for healthy emotional growth and for building resilience (Huertas 2005). Numerous theories of attachment provide a foundation for bereavement counselling (Purnell 1996). Without attachment to a significant other person, usually the parent, a child’s emotional growth will be impaired and he may experience severe difficulty in relating to others in a positive way (Bowlby 1980; Ainsworth et al 1978). When a baby cries he is looked after and so he learns to trust others in his world. From this foundation of trust grows his ability to relate to others and to empathise. Later, he will make other attachments to siblings, friends, a partner and, possibly, his own children. When a primary attachment, as these are termed, is ended through separation or death, then grieving takes place. Grief is the price we pay for love, or attachment. This is pivotal in the research by Bowlby which we will examine later in this chapter.

In her book Why Love Matters, Sue Gerhardt demonstrates how early experiences within the womb and during the first two years of life influence the child physically and emotionally. She says, ‘This is when the “social brain” is shaped and when an individual’s emotional style and emotional resources are established’ (2004: 3). This part of the brain learns how to manage feelings and how to react to other people, as well as how to react to stress, which in turn affects the immune system. This mind–body link is important when we recognise that a bereaved person will react physically, emotionally and cognitively to death: ‘It is as babies that we first feel and learn what to do with our feelings, when we start to organise our experience in a way that will affect our later behaviour and thinking capacities’ (2004: 10). A person who has had early stress, trauma and poor attachment may find grieving more difficult than someone who had secure early attachment. Those who have been bereaved as a child may find that their grief is reactivated when they experience someone’s death in adulthood. Research by Margaret Stroebe demonstrates that insecure attachment is linked to complicated grief in the adult bereaved population (Wijngaardsde-Melj et al. 2007).

Reactive attachment disorder (RAD) is caused by the disruption of the normal cycle of loving care that a baby receives from her parents. Instead of care she may be neglected, abused or have inconsistent care which may impair the ability to make bonds with others (Bowlby 1980; Frayley and Shaver 1999). In later life the child may be unable to trust others or to allow others to have control. Accessing bereavement counselling can be problematic for someone with RAD since building therapeutic rapport may be difficult.

What you need to know about attachment – the basics

The first thorough study of grief and loss was by the father of psychoanalysis, Sigmund Freud. His early paper ‘Mourning and Melancholia’ published in 1917, is regarded as a classic text on bereavement. He argued that the psychological purpose of grief is to withdraw emotional energy from the deceased (cathexis) and then to become detached from the loved one (decathexis). He believed the bereaved person has to work through his grief by reviewing thoughts and memories of the deceased (hypercathexis). By this process, painful as it is, the bereaved can achieve detachment from the loved one and the bereaved’s bonds with the deceased become looser. This ‘attachment’ became a major factor in understanding grief for many later theorists. However, this theoretical position is not echoed in a letter Freud sent to his friend Ludwig Binswanger in 1929.

Binswanger’s son had died and Freud wrote: ‘Although we know after such a loss the acute state of mourning will subside, we also know we shall remain inconsolable and will never find a substitute. No matter what may fill the gap, even if it be filled completely, it nevertheless remains something else. And, actually this is how it should be, it is the only way of perpetuating that love which we do not want to relinquish’ (Freud 1960: 386). His words indicate the need for continuing connection with the loved one which is central to the theoretical position of Attig (2000), Silverman, Klass and others who write of the importance of continuing bonds (Klass et al. 1996).

Freud’s concept of grief as a job of work which we neglect at our peril is very useful when we consider grief to be part of a reconstruction process which Colin Murray Parkes (1971, 1996) calls ‘psychosocial transition’. Parkes (1988) introduced the concept of the ‘assumptive world’ which is changed in bereavement. All that we assumed was securely in place, our expectations about the world, our relationships and our place in it are thrown into disarray when death appears: the familiar world has become unfamiliar. Each day most of assume we will come back home. We assume we will see our friend at the usual time. We assume we will shop on Thursday after work. Then something awful happens, like a sudden critical illness, and our assumptive world is undermined.

Where the event is a traumatic bereavement then the assumptive world may be utterly shattered (Trickey 2005). Where the loss has been traumatic the rebuilding of the bereaved’s world may be more difficult because trauma impedes grief. Making sense of the event, talking about it, remembering the deceased and thinking about it may cause hyper-arousal, which the bereaved seeks to avoid. Thus, bereavement counselling or bereavement support may be much more problematic and in-depth psychological or psychiatric intervention may be needed. Parkes says that in mourning we make readjustments to our assumptive world and this constitutes a psychological shift and psychosocial change. People may need help to rebuild their assumptive world following bereavement because loss has shaken the foundations of their world (Neimeyer 2005).

For the bereaved their sense of identity may have to be redefined. Who am I now that I am no longer a father? Where do I fit in now that I am no longer a part of a couple? (Caserta and Lund 1992) Some people will retreat from social interaction perhaps because of an unconscious fear of further losses, feeling it is better not to invest emotionally in case others are taken away. Others re-evaluate their social relationships and take greater care in maintaining those relationships; may pay more attention by prioritising relationships above work, for example. The experience may lead to greater maturity and a deeper sense of understanding of the emotional life of others.

Psychoanalyst John Bowlby established attachment theory in the 1960s. In his research with babies and young children and their mothers he studied the impact of separation and the situations that cause us to feel fear and anxiety. He concluded that fear is initially brought about by elemental situations: that is, darkness, sudden movement or separation. Though these situations may be harmless in themselves, they indicate an increased risk of danger. Bowlby examined the way young children respond to the temporary or permanent loss of a mother figure and noted the expressions of sadness, anxiety, protest, grief and mourning that accompany such loss. From his observations he developed a new paradigm of understanding attachment and the impact of the breaking attachment bonds (Bowlby 1980).

With psychologist Mary Ainsworth, Bowlby recognized that in order to understand a person’s behaviour you had to understand their environment. The child and parent, the patient and doctor and the bereaved and bereavement counsellor are in a mutual field of activity, a system in which each influences the other (Bowlby 1975; Wiener 1989). This systemic approach takes into account the fact that we are influenced by other people, the food we eat and the air we breathe. Bowlby saw grief as an adaptive response which included both the present loss as well as past losses. He said it was affected by environmental factors in the bereaved person’s life as well as by the psychological make-up of the bereaved person.

Bowlby and Parkes (1970) presented four main stages in the grief process:

1. Numbness, shock and denial with a sense of unreality;
2. Yearning and protest. It involves waves of grief, sobbing, sighing, anxiety, tension, loss of appetite, irritability and lack of concentration. The bereaved may sense the presence of the dead person, may have a sense of guilt that they did not do enough to keep the deceased alive and may blame others for the death;
3. Despair, disorganisation, hopelessness, low mood;
4. Re-organisation, involving letting go of the attachment and investing in the future.

At the time the theory did not make reference to wider cultural differences which are highly relevant in the grieving process. In Japan, for example, the bereaved are encouraged to maintain emotional bonds with the deceased, and letting go of the attachment, stage 4 above, would be counter to their cultural mores (Deeken 2004; Yamamoto 1970). In other cultures yearning for the dead person would be regarded with disapproval since the dead person is on his designated karmic journey (Laungani 1997). However, Parkes, Laungani and Young (1997) redressed the balance in Death and Bereavement across Cultures which covers variations in grief responses in different cultures in great depth and is an excellent addition to the body of knowledge in bereavement care in the twenty-first century.

In the 1960s Elisabeth Kubler-Ross, a Swiss-born physician and psychiatrist, pioneered death studies. Her seminal book On Death and Dying (1970) was based on her work with dying patients. She adopted Parkes’ stages of grief to describe the five stages of dying experienced by those who were diagnosed with terminal illness:

1. Denial – the patient does not believe he has a terminal illness.
2. Anger – Why me? Anger towards family or doctors because they have not done enough.
3. Bargaining – The patient may bargain with God or some unseen force, to give him extra time.
4. Depression – The patient realises he is about to die and feels very low.
5. Acceptance – Given the opportunity to grieve, the patient may accept his fate, which may lead to a period of quiet reflection, silence and contemplation.

Kubler-Ross emphasised that these stages are not linear and some may be missed out altogether. Some people may never reach the point of acceptance and may die still filled with anger or other strong emotion. For others, denial fortifies them: when they have to live for a long time with a terminal illness, their hope sustains them. However, the views of Kubler-Ross have been challenged because a number of researchers have not found evidence to support them and dying people show a range of conflicting reactions (Spiegel and Yalom 1978; Stroebe and Schut 1999).

Rachel Naomi Remen has worked with people with life-threatening illness for many years. She believes that the Kubler-Ross stages are useful but she disagrees that the final stage is acceptance. She says:

I have counselled people with life-threatening illness who have lost valuable parts of their bodies, relationships and capacities. And in my experience of watching people heal from loss, the final step is gratitude. And wisdom. That’s the final step of healing from loss. It doesn’t make cognitive sense, but it makes deep emotional and spiritual sense.

(Redwood 2002: 6)

Reactions to dying are very much influenced by cultural views and religious beliefs. The response of someone who believes in reincarnation will be quite different from someone who believes in heaven and hell and who fears eternal damnation. Negative reactions to death and dying are not universal and personal philosophies will influence individual reactions.

J. William Worden, an Associate Professor of Psychology at Harvard University and grief specialist, introduced the concept of ‘grief work’ in the 1980s. Continuing Freud’s concept of grief as a job of work he described four ‘tasks’ of mourning that the bereaved person must accomplish (Worden 1991):

1. The individual needs to accept the reality of the loss and that reunion is not possible.
2. The individual has to experience the pain of grief. The extreme hurt and sadness felt may also physically affect the ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• Acknowledgements
• Introduction
• 1 Attachment and Loss, Death and Dying. Theoretical Foundations for Bereavement Counselling
• 2 When Death Happens
• 3 Core Skills in Working with Those Who Grieve
• 4 When the Worst You Can Possibly Imagine Happens: Murder, Manslaughter and Suicide
• 5 ‘She should be over it by now’: Complicated Grief
• 6 Spirituality, Religion, Culture and Rituals
• 7 Creative Approaches to Expressing Grief
• 8 Dreams in Dying, Death and Grief
• Resources
• Glossary
• Appendix: Assessments and Scales
• References
• Index