Grief, Loss and Bereavement

Evidence and Practice for Health and Social Care Practitioners

Peter Wimpenny, John Costello, Peter Wimpenny, John Costello

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415467506
• eBook ISBN:
  9781136650291
• Topic: Social Sciences
• Subtopic: Health Care Delivery
• Index: Social Sciences

Dealing with the social experience of grief, loss and bereavement are challenging areas for everyone, including health and social care practitioners who are often well placed to offer help and support to the bereaved. This book draws together a comprehensive range of worldwide evidence for understanding and supporting the bereaved in a variety of health and social care contexts. It can be used by practitioners from a wide range of backgrounds in both health and social care to gain an appreciation of bereavement and its associated support and care. Additionally, it can be used for personal and professional development by practitioners who want to enhance their own and others' practice with the bereaved in specific contexts or organisations. The book may also be of value to those undertaking post graduate study who want to gain a wider understanding of the evidence related to bereavement and bereavement care practice in health and social care and may be seeking to add to the body of evidence in this field.

1 Background to bereavement and
bereavement care

John Costello

Key messages

• Historical and traditional perspectives on grief and bereavement influence our understanding of the experience of loss and its assessment.

• Contemporary theories of grief and bereavement are different from traditional approaches and tend to reflect changes in society.

• It is important not to become too prescriptive about grief reactions and their effect on bereavement.

• Bereavement is also influenced by social factors, such as the age of the mourner, the circumstances of the death, the social background of the bereaved and the extent to which mourning takes place.

• It is important to highlight from the evidence that bereavement is a process, affected by things such as religious and cultural beliefs.

• Most people experience bereavement as a normal healthy process and to become prescriptive about grief reactions can influence our thinking and cause us to label or pathologise bereavement as an illness.

• Both traditional and contemporary understandings of grief have a role to play in helping us provide effective quality support to those in crisis who become vulnerable as a result of experiencing bereavement.

Introduction

The purpose of this chapter is to examine traditional and cultural perspectives related to grief and bereavement, contrasting these with contemporary understandings. It provides background material for subsequent chapters and stimulates the reader to contextualise contemporary thinking and practice about bereavement based on a review of available evidence.

The chapter examines traditional perspectives from Freud (1957 [1917]) to more contemporary explanations such as continuing bonds theory (Klass et al. 1996) and Stroebe and Schut's (1999) dual process model. In reviewing some of the contemporary perspectives, the chapter examines their influence on thinking about bereavement care. The purpose is to highlight both how explanations and understandings have altered over time as a result of societal changes and fundamental understandings about individual and group behaviour. In doing so, the chapter considers more of the theoretical developments than subsequent chapters, although each chapter has its own balance between theory and practice, with the latter being prevalent throughout the book.

One of the key themes emerging from the available evidence is that the process of grief can be restorative. In this sense, as the dual process model highlights (see later in this chapter), mourners are enabled to make the necessary psychological adjustments to help them think and feel more positively, whilst also acknowledging the emotional impact of the loss and its influence on future well-being. Ultimately, the ‘key message’ of the chapter is that understanding perspectives of grief and loss is important but that we should view these as assisting our thinking about bereavement and bereavement care, rather than as restrictive models that may run the risk of labelling and pathologising grief as a condition instead of a normal process that all of us will experience at some point in our lives.

What do we mean by loss, grief and bereavement?

Loss may be defined as being deprived of something we value (Stroebe 1992). In tangible terms this includes the material loss experienced by repossession of a home, the loss of a loved one or household pet. Conversely, it could include the loss of respect, independence or even virginity! In many cases, there is an expectation that responses to loss involve varying degrees of grief. Grief consists of physical changes as well as psychological feelings and can include emotional expression, crying, loss of sleep anxiety and a wide range of symptoms, such as anorexia, restlessness, agitation and somatic disturbance. The evidence does not clearly inform us when these symptoms occur in relation to the loss. There is, however, an abundance of evidence associated with the extent to which these somatic and psychological experiences, if prolonged and sustained, may lead others to suspect abnormality.

Grief is often reported as a response to loss, which is then followed by a period of bereavement. The latter is influenced by the extent to which mourning, the social/cultural behaviour associated with death, occurs (Parkes 1993). Bereavement may be seen as the social fact of loss, which obliges the observer to offer condolences and expressions of sympathy to the mourner. This may however, be considered culture bound and varies according to the rules and norms adopted by the cultural context in which grief takes place. We can argue therefore that an understanding of the behaviour associated with loss can help us focus on what the mourner is feeling, although how they express their emotions depends on the cultural context as well as the perspective taken by the person listening to them. Because of this, health and social care practitioners supporting the bereaved need to be aware not only of the cultural significance of grief, but also about the theoretical concepts which seek to explain it. By doing this, practice is informed and the decisions that are made are more likely to be in the best interests of the bereaved.

Traditional perspectives on grief and bereavement

Grief and bereavement have been experienced since the beginning of time, although as a reference point, this chapter traces their origins from the early twentieth century by looking at the seminal work of Sigmund Freud (1957 [1917]), Mourning and melancholy, as a starting point. Evidence on bereavement is based on Freud's seminal work on the talking therapies. By examining the historical developments up until modern times, the chapter contrasts traditional approaches with what Klass and colleagues (1996) call ‘newer understandings of grief’ that emphasise mourners taking a more active role in their bereavement. Culturally, I begin by addressing some assumptions about important areas of life such as the universal nature of loss and grief and why bereavement is often seen as a process experienced in stages or phases. The chapter also considers bereavement in terms of a continuing spiritual experience with the deceased. Initially, the question I ask is Are grief and bereavement universal?’

To grieve over the loss of a loved person or object appears to be a natural phenomenon, or what sociologists called a ‘truism’, at the same time acknowledging its cultural diversity. Historically, the experience of grief is arguably something that will be encountered by people from all cultures, although the way grief is expressed is shaped by the religion, traditions, values and social norms of that particular cultural group. Firth (2000) points out that it is important for health and social care workers to understand the religious beliefs and cultural traditions of different ethnic communities. For example, in some Eastern cultures there is a tradition of expressing grief in a very demonstrable way using self-flagellation, and adhering to explicit periods of grief, such as 40 days and nights for some cultural groups (Firth 2000). In contrast, in the UK, Queen Victoria dressed in black for the entire 6-year period of mourning after the death of her husband, Prince Albert, in the nineteenth century. The wearing of black is a legacy that continues today, although to a lesser extent, and highlights how rituals may also be shaped by events and may change over time.

Working through grief

Historically and traditionally, approaches to bereavement were expressed through a range of ideas, attitudes and values that can be traced to the early work of Freud (1957 [1917]). These ideas, based on psychoanalytical outcomes from therapy, have been supported by further work from psychiatrists such as Lindemann (1944), Bowlby (1963), Kübler-Ross (1969) and Parkes (1972). Collectively, their views have laid the foundations for what many refer to as the grieving process and represent a dominant part of what may be regarded as a culture of grief and bereavement, with more people becoming interested in the values and traditions associated with death and dying (Walter 1999).

The historical literature on grief highlights an abundance of evidence to suggest that talking about loss is a helpful way to resolve grief. In Western society, Freud's (1957 [1917]) work spawned the notion of the talking therapy, which essentially argues that talking about loss is beneficial to bereavement resolution (Walter 1994). Freud argued that those who experienced loss needed to work through this and eventually emotionally detach themselves from the deceased in order to achieve successful grief resolution. This involved a process known as cathecting the expression of emotions such as love for the deceased and releasing emotional energy in the form of varied grief reactions – and then decathecting – emotionally detaching from the deceased. This view dominated understandings of bereavement, especially in psychoanalytical terms, for many decades and became known as the grief work hypothesis (Stroebe and Stroebe 1991).

Working through grief is seen as an ultimate goal by many bereavement counsellors who subscribe to the view that mourners should acknowledge the permanent absence of the deceased by initial expression of emotion, focusing on past memories and by being encouraged not to suppress feelings. This rather formulaic approach to explaining emotional expression after loss almost prescribes grief through recognition of the reality of the loss, working through feelings and ‘moving on’, or, as Worden (1991) points out, ‘emotionally relocating’. The latter is an important part of grief work and involves severing the emotional bond with the deceased (or decathecting). This is often a painful process and involves letting go emotionally, moving on and relinquishing any future hopes of a relationship. Freud believed that to continue to have any on-going emotional connection with the deceased was pathological (Rando 1995; Davies 2004).

Closely aligned to, and following, a similar psychodynamic approach, the work of the American psychiatrist Lindemann (1944) supported Freud's grief work hypothesis, expressing the view that grief may be seen as an acute illness episode with clear symptoms and a pathological focus. Lindemann's study, which focused on a clinic for survivors and others from a nightclub fire in Boston, began to categorise grief into ‘normal’ and ‘abnormal’. Lindemann identified that grief could be seen in terms of its symptomatology and management. His study was notable for, amongst other things, suggesting a medicalisation of grief.

Developments in the 1960s and 1970s

In the 1960s, Bowlby (1963) outlined his early work on childhood attachment, which underpinned much of what Freud and others had been arguing for in terms of grief reactions. In 1969, following the assassinations of JF Kennedy and Martin Luther King, Elizabeth Kübler-Ross (1969) published findings from her work in a New York hospital with 250 patients diagnosed with cancer. Her notion of grief being experienced as a series of stages, published as a book, On death and dying, was a best seller and sold a million copies in the first year. However, unlike her predecessors, Kübler-Ross worked not with mourners after death but with those facing impending death from cancer. In this sense she was working clinically with the living, and drawing conclusions about their reaction to their cancer diagnosis.

Building on the work of Freud, Bowlby and Kübler-Ross, Parkes's (1972) seminal work Bereavement: studies of grief in adult life was largely based on retrospective analysis of case studies of patients who presented with depression. This work is regarded as a classic and, together with Kübler-Ross's study, led to what has become known as stage-based theories or approaches to grief and bereavement.

The idea of experiencing grief and bereavement in stages or phases was developed by Parkes (1972, 1991) in the UK and by an American psychoanalyst, William Worden, in the USA. Parkes's work indicated that grief was experienced as a series of phases, beginning with shock and anger, and leading to pining and yearning behaviour. He also stressed the importance of it being seen as a process and that counsellors could identify aspects of grief as normal or abnormal. His early writings held that retained emotional links with the deceased could be seen as pathological, although subsequent reprints modified this view. Parkes argued that many of the emotions experienced by the bereaved varied in intensity, were not constant and were likely to be felt as ‘pangs of grief’ (1991: 60), depending on a number of factors, such as the relationship of attachment between the mourner and the deceased. Worden (2001), somewhat later, identified grief as occurring in stages, with the bereaved behaving as an active participant in their grief, undertaking four emotional tasks and not becoming a passive recipient of grief as an illness. Worden identified that, in order to successfully resolve grief, mourners are required to accept the reality of the loss, experience the pain of grief, adjust to an environment where the deceased is missing and, finally, emotionally relocate.

Developments from the 1990s onwards

In the 1990s growing disillusionment with stage theories and the grief work hypothesis, and the lack of clarity about what constitutes healthy bereavement, led Stroebe and Schut (1999) to construct a model of bereavement based on research, which examined the ways that spouses coped with the loss after the death of their partner. Their dual process model has become applicable in describing coping in more diverse groups of mourners. Unlike other models, the dual process model identifies and includes stressors associated with bereavement, as well as how people cope with loss using a variety of cognitive strategies. The key feature of the model, however, is its focus on explaining the process by which mourners oscillate between activity oriented to the loss and restorative behaviour (Figure 1.1).

The central argument of the model is that mourners can be observed demonstrating various behaviours (dependent on individual and cultural idiosyncrasies), that can be considered as either restorative or loss-focused...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures
• List of tables
• List of boxes
• List of contributors
• Acknowledgements
• Introduction
• 1 Background to bereavement and bereavement care
• Part I Bereavement across the lifespan
• Part II Contexts of bereavement
• Part III Education, interventions and organisation of bereavement care
• Index