Techniques of Grief Therapy
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Techniques of Grief Therapy

Assessment and Intervention

Robert A. Neimeyer, Robert A. Neimeyer

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eBook - ePub

Techniques of Grief Therapy

Assessment and Intervention

Robert A. Neimeyer, Robert A. Neimeyer

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About This Book

Techniques of Grief Therapy: Assessment and Intervention continues where the acclaimed Techniques of Grief Therapy: Creative Practices for Counseling the Bereaved left off, offering a whole new set of innovative approaches to grief therapy to address the needs of the bereaved. This new volume includes a variety of specific and practical therapeutic techniques, each conveyed in concrete detail and anchored in an illustrative case study. Techniques of Grief Therapy: Assessment and Intervention also features an entire new section on assessment of various challenges in coping with loss, with inclusion of the actual scales and scoring keys to facilitate their use by practitioners and researchers. Providing both an orientation to bereavement work and an indispensable toolkit for counseling survivors of losses of many kinds, this book belongs on the shelf of both experienced clinicians and those just beginning to delve into the field of grief therapy.

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Publisher
Routledge
Year
2015
ISBN
9781317433019

Part I Framing the Work

Toward a Developmental Theory of Grief

Robert A. Neimeyer and Joanne Cacciatore
DOI: 10.4324/9781315692401-1
At least in English, “grieving” can be understood as a verb rather than a noun, a static state or condition. This implies that, at least optimally, it represents a form of psychosocial and perhaps spiritual transition from the initial onset of a life-altering loss through a period of frequently tumultuous adjustment to a point of relative stability beyond the period of acute bereavement. Viewed in this temporal perspective, adaptation to the loss of someone or something central to one’s sense of security and identity can therefore be seen as a developmental process, one that is not simply reducible to a set of psychological symptoms, a psychiatric diagnosis, or a culturally defined social role—though it may be understood by some in these terms too. Our goal in this initial chapter is to sketch the possible outlines of such a developmental model of grief, suggest the social needs implicit for the mourner negotiating this transition, and gesture toward the sorts of therapeutic responses at each point that might best facilitate the mourner’s movement through the series of challenges or crises this process entails. We will begin by framing our general orientation toward such a developmental theory before outlining the model itself, offering occasional citations of relevant research and brief clinical vignettes to illustrate the model’s connection to clinical practice.

An Epigenetic Framework

From an epigenetic systems perspective, both internal experience and external behavior emerge in development through coactions among multiple levels within an organism–environment system (Gottleib, 1992). In biology, epigenesis stands in contrast to both preformationist theories, which view an organism’s structures, behaviors, and capacities as innate and fully formed, as well as in contrast to maturationist views that regard such structures or capacities as the predictable unfolding of a genetic potential. Instead, in a psychological context, an epigenetic approach understands all development and behavior as emerging from a person–environment, or ecological, system composed of hierarchically organized levels that transact (Mascolo, Craig-Bray, & Neimeyer, 1997), as depicted in Figure 1.1.
Figure 1.1 The organism–environment system presupposed by an epigenetic model of development
As applied in the context of bereavement, this implies that the development of mourners’ grief processes will be jointly shaped by (a) bio-genetic factors such as their dispositional temperament, genetic vulnerability to fluctuating affective states, and physical resilience;(b) personal–agentic factors such as their emotional awareness, personal philosophy, and coping skills, (c) dyadic–relational factors such as social support, family convergence or divergence in grieving styles, and social connectivity, and (d) cultural–linguistic factors such as societal, gendered, or ethnic norms governing the expression of grief, cultural sanctions or disenfranchisement of particular forms of loss, and even the connotations carried by terms describing (or ignoring) the mourners’ status as widows, orphans, or bereaved parents. The plethora of transactions within these levels (e.g., considering conflicting needs at the personal–agentic level) or between them (e.g., personal preferences for emotional expression being invalidated by a family or cultural prescription of stoicism) configure highly individualized expressions of grief and its evolution over time for any given mourner.
Viewed in this epigenetic frame, grieving can be seen as a situated interpretive and communicative activity (Neimeyer, Klass, & Dennis, 2014). It is “situated” in the sense that mourning always unfolds in the context of a given familial, social, cultural, and historical context; it is “interpretive” in that it inevitably entails attempts to make sense of a compelling emotional experience; it is “communicative” as it is intrinsically embedded in spoken, written, and nonverbally performed exchanges with others; and it is an “activity” in that it is an enacted process, not merely a state to be endured. Thus, a fuller understanding of the development of bereavement entails more than a summation of symptomatology or even a phasic transition through essential stages that merely vary in their order or progression as a function of individual psychology. It is to this more nuanced and contextual understanding of the development of grief that we now turn.

Toward a Developmental Model of Grieving

The individuality of grief arising from the epigenetic systems perspective notwithstanding, some broad continuities can be discerned in adult mourners who encounter various developmental challenges in the course of their bereavement, particularly when the loss involves an intimate attachment figure (such as a child, partner, parent, or other loved one, such as a best friend or close sibling). To describe these challenges we draw upon the classical scaffolding of Erikson’s conception of development as a series of “crises,” each of which entails contending with a dialectical tension between two poles (e.g., trust vs. mistrust; autonomy vs. shame and doubt; ego integrity vs. despair) (Erikson, 1968).
Like Erikson, we propose that satisfactory resolution of these tensions at a given point in development entails grappling with both poles of each dichotomy, and doing so in a given social field and historical and cultural context, which when done successfully permits fuller and less impeded engagement with subsequent challenges. Optimally, this process leads to a synthesis of the polarities of each crisis and establishes the ground for engaging the next. However, unlike Erikson, whose concern was normative “macro” lifespan development from infancy to death, our focus is at the “micro” level of adults facing the challenge of significant loss at a given moment in the life cycle.
For convenience, we describe this process in terms of three successive crises, which meld into one another over the course of bereavement. Here we will briefly outline these crises, underscoring the developmental challenge posed by each, the implicit questions that drive the ongoing quest for meaning in the experience, associated priorities as they arise and shift over time, and the psychosocial needs or supports that promote their satisfactory resolution.1 More briefly, we suggest some illustrative therapeutic stances and strategies having special relevance to each crisis, pointing toward subsequent chapters in this volume for their further explication. Finally, we will anchor each in an actual case illustration that gives a human face to the developmental tensions that each period of grieving characteristically entails. Table 1.1 summarizes this developmental model.

Early Grief: Reacting

The earliest weeks of profound loss are typically characterized by a deep narcissistic wound: the seemingly impossible has happened, and it feels as if a part of the self has been ripped away with the loved one. Early during this period, the mourner often reacts with a sense of emotional anesthesia. He or she may remain in a suspended state of disbelief, or oscillate in and out of reality, for a prolonged period of time. Once the emotional anesthesia begins to wane, and the bereaved begin to feel the full weight of the grief, the pain of the wound feels unbearable. The mourner generally understands this is an irreversible wound, one for which there is no immediate remedy. As weeks meld into months and the numbness gradually abates, mourners may experience great difficulty with self-care, cognition, emotional regulation, physical health, sleep and diet hygiene, spirituality and/or faith, social transactions, and interpersonal relationships. It may be easier in this period to withdraw in order to protect oneself from well-intentioned but unhelpful others, particularly if the mourner has not received what he or she so desperately needed in the initial wounding.
Table 1.1 A developmental model of grief
Period
Time frame
Crisis
Synthesis
Question
Priorities
Psychosocial needs
Therapeutic methods
Early grief: Reacting
Weeks after loss
Connection vs. Isolation
Self-acceptance
How and why did this happen?
Safety, Trust, Survival
Listening, Identification, Compassion
Emotion regulation, Containment
Middle grief: Reconstructing
Months after loss
Security vs. Insecurity
Continuing bond
Where do I locate my loved one?
Validation, Understanding
Audience for stories, Permission to maintain bond
Memorialization, Legacy projects, Imaginal dialogue
Later grief: Reorienting
Years after loss
Meaning vs. Meaninglessness
Posttraumatic growth
Who am I now?
Self-reinvention, Altruism
Permission to change, Signification
Directed journaling, Social action
This is a critical time for mourners. It is a time when their own wounds are fully recognizable and they also have the opportunity to notice that there are others who are wounded—sometimes by an analogous loss. Most often, mourners will seek out and find those who stories closely mirror their own. They seek similarity in others’ stories for validation of their own emotional state.
Psychosocial needs during this period include an opportunity to express difficult emotions such as anger, rage, guilt, shame, self-blame, despair, and other emotions that many others will decry. It is crucial not to have these emotions dismissed or bypassed. In essence, we bear a duty to provide a safe and nonjudgmental space for the griever to explore and express these states of deep desolation that so many others find unspeakable.
Developmentally, mourners in early grief therefore commonly struggle with issues of connection vs. isolation, as they feel that the unique anguish of their loss casts them outside the once “normal” world of relationships shared with others. At the same time, they contend with profound questions about the “event story” of the death, how it can be understood practically, existentially and spiritually, and what implications it carries for their radically changed lives (Neimeyer & Thompson, 2014). Just as they require patient tending and befriending in their grief-related emotions, mourners in this early period also need patient listeners who will join them in their quest to find meaning in the loss, without quickly resorting to their own preformulated answers.
Thus, most crucial in the period of acute wounding is promoting a sense of safety and shoring up the conditions required for mourners’ psychological survival, which may at times literally be threatened, as research on elevated risk of mortality in the early weeks of bereavement demonstrates (Stroebe, Schut, & Stroebe, 2007). For example, studies suggest that bereaved mothers who reported compassionate caregiving by providers experienced fewer negative, long-term psychological outcomes than those who felt that their needs to be upheld, heard, and treated with compassion were unmet (Radestad et al., 1996). Likewise, research documents that survivors of homicide loss fare better when their psychosocial needs for grief-specific support are met by others in their social network, whereas they struggle with greater complication as the number of negative, critical, or intrusive relations with others increases (Burke, Neimeyer, & McDevitt-Murphy, 2010). Mutual support groups of mourners suffering similar losses may be especially valuable during this period, providing a context for connection with others whose losses (e.g., of a child, or of a partner through suicide) closely correspond with the griever’s own. When the mourner meets with empathic listening and identification from the social world, the crisis of connection vs. isolation can be more easily resolved in the direction of self-acceptance, that is, a compassionate self-awareness that one’s own pain is understandable, legitimate, and mirrored in the lives of others who have suffered similar loss. Accordingly, high degrees of therapist “presence” and “containment” in the form of creating a safe “holding environment” for distressing affect is essential at this point (Neimeyer, 2012d), which may be reinforced by mindfulness as a medium for therapy as well as a prescription for client self-care (Cacciatore & Flint, 2012). Therapeutic techniques for promoting a client’s “self-capacities” (Pearlman, 2015, Chapter 31) in the context of meticulous “dramaturgical” listening (Noppe-Brandon, 2015, Chapter 35), as through searching for the felt sense of clients’ embodied emotional experience (Farber, 2015, Chapter 21; Neimeyer, 2012a), can advance this goal. Likewise, careful management of support group settings to ensure safety and toprevent re-traumatization (Neimeyer & Sands, 2015, Chapter 59; Spence & Smale, 2015, Chapter 57) can ensure the supportive interpersonal field required for participants to move toward emotion regulation and re-connection, ultimately promoting their self-acceptance of both their pain and their humanity. A case illustration of a mourner in this early period of reacting to loss follows.

Case Illustration

Anna (aged 37) is a Hopi Native American single woman who suffered the death of her 4-year-old son to cancer nine months earlier after he was diagnosed at age 2 with neuroblastoma. Anna sought counseling at the insistence of friends from work who were concerned about her significant weight loss, changes in her physical appearance, and apparent social withdrawal after her son’s death. ...

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