Trauma and Grief Assessment and Intervention

Building on Strengths

Renée Bradford Garcia, Elizabeth C. Pomeroy

• Publisher: Routledge
• Year: 2021
• ISBN:
  9780429620751
• Edition: 1
• Topic: Psicología
• Subtopic: Trastorno de estrés postraumático (TEPT)

With clarity and eloquence, Trauma and Grief Assessment and Intervention comprehensively captures the nuance and complexity involved in counseling bereaved and traumatically bereaved persons in all stages of the life cycle.

Integrating the various models of grief with the authors' strengths-based framework of grief and loss, chapters combine the latest research in evidence-based practice with expertise derived from years of psychotherapy with grieving individuals. The book walks readers through the main theories of grief counseling, from rapport building to assessment to intervention. Each chapter concludes with lengthy case scenarios that closely resemble actual counseling sessions to help readers apply their understanding of the chapter's content. In the support material on the book's website, instructors will find a sample syllabus, PowerPoint slides, and lists of resources that can be used as student assignments or to enhance classroom learning.

Trauma and Grief Assessment and Intervention equips students with the knowledge and skills they need to work effectively with clients experiencing trauma and loss.

CHAPTER 1
Understanding Grief and Loss – An Introduction

DOI: 10.4324/9780429053634-1

Loss is a universal experience that everyone encounters at one time or another. Though an expected aspect of being human, the death of a loved one can fundamentally upend the lives of survivors and leave them casting about for a way to continue living without their beloved. The turmoil caused by a significant loss disrupts a person’s functioning both internally (physically, emotionally, cognitively, and spiritually) and externally (socially and occupationally). When loss is coupled with elements of trauma, it can give rise to additional complications in physical and emotional well-being and sometimes have lasting implications for how the bereaved survivors move through their lives and experience the world. A recent survey related to grief, loss, and spirituality reveals that helping professionals receive little in-depth education or training in grief and end of life care prior to entering the field (Pomeroy et al., 2019). Though there are numerous theories of grief and loss that have been postulated by experts, there are fewer that address trauma and grief combined, though the two are intricately linked more often than not. As interest and demand for grief and loss services increase, there is a need for an understanding of the grief process that considers individuals within the context of the environments in which they function, rather than just examining their intra-psychic experiences. This chapter will provide a brief overview of prominent theories and models of grief and loss. Readers are encouraged to explore the extensive body of literature that exists on these theoretical frameworks for more in-depth explanations. This chapter will also present the authors’ framework of grief that encompasses a person-in-environment and strengths-based perspective. Trauma, and the ways that trauma and grief intersect, will be discussed in Chapter 2.

THEORIES OF GRIEF AND LOSS

Freudian Theory of Loss

In the early 20th century, Freud provided a theory of “mourning and melancholia” that distinguished between “normal” and “pathological” mourning. He suggested that relinquishing emotional ties with the object of attachment involved obsessive remembering followed by a complete severance of emotion to the loved one and re-attaching that emotion to another person. While this other person is only a substitute for the lost loved one, the mourner eventually internalizes the reality of the loss, extinguishes the emotional energy expended on the lost loved one, and, in turn, frees it to be directed toward another. Freud also believed that the psychological identification with the lost person is internalized so that aspects of that person become part of the mourner’s psychological make-up thus making the grief process challenging yet survivable (Berzoff, 2004; Freud, 1917).

Freud also distinguished healthy mourning from pathological mourning and differentiated between “mourning and melancholia.” In both cases, the emotional experience is similar; however, with melancholia the mourner has a lack of self-esteem, is self-critical, and eventually develops pathological melancholia (depression) or grief. Freud postulated that this prolonged depression that accompanied the grief process was due to unconscious conflicts with the person who died which led to a more complicated mourning period. Threads of Freud’s theory of mourning can be found in more recent theories and frameworks that guide current practice. Clearly, Freud’s theory furthered our understanding of the grief process; however, his focus on the intrapsychic and unconscious elements of a person’s psyche failed to account for environmental influences that impact the mourner’s coping capacities.

Erich Lindemann and Crisis Theory

Following in the footsteps of Freud’s theory of mourning, Erich Lindemann’s research following the 1944 Cocoanut Grove Night Club disaster in which over 500 people were killed advanced ideas about the grief process (Parkes, 1964, 1970, 1972). Lindemann coined the term “grief work” with his suggestion that resolution of grief required the completion of three specific tasks. First, mourners must relinquish the attachment to their loved one. Second, they must re-adapt to life without the presence of the deceased. Finally, they must establish new relationships with others. Based on interviews with survivors of the nightclub fire, Lindemann named six characteristics of “acute” grief: 1) physical distress; 2) ruminations about the deceased; 3) survival guilt; 4) angry reactions to others; 5) decline in functioning; and 6) tendency to internalize characteristics of the deceased (Parkes & Weiss, 1983). This work also contributed to crisis intervention theory and understanding how mourners respond to traumatic grief experiences.

Bowlby’s Theory of Attachment

John Bowlby’s theory of attachment developed from his early research on infants separated from their mothers and the emotional, cognitive, developmental, and biological consequences of attachment versus separation. Attachment refers to the innate tendency for humans to develop close affectionate bonds with others who are central to their lives. When the attachment bonds are threatened or broken, emotional distress ensues. According to Bowlby, life span development of attachment involves the formation of a bond (i.e. falling in love), maintenance of the attachment (i.e. loving someone), and disruption (i.e. grief and mourning) (Bowlby, 1980). He wrote extensively on his theory over the course of three volumes about how attachment behaviors maintain the affectional bond and, therefore, a state of homeostasis or balance. When loss of the attachment figure occurs and the bond is disrupted, the person experiences distress, fear, and insecurity as represented by crying, clinging, and angry behaviors in an attempt to regain the connection. When these behaviors are repeatedly unsuccessful they gradually diminish but do not stop completely.

Bowlby (1980) hypothesized that the grief process is a reflection of this basic attachment dynamic. He further described the psychological reorganization that must take place following a loss as involving four phases. The first phase entails a period during which the mourner experiences numbness and denial that serves to deflect the anguish and despair accompanying the loss. This phase can be periodically disrupted by extreme and physically exhausting emotions. The second phase is characterized by yearning and searching as the mourner begins to confront the loss. Common behaviors during this phase include interpreting events as signs from the loved one and seeking out evidence of the loved one’s presence. When these activities are unsuccessful, anger and frustration ensue. The third phase is predominated by feelings of disorganization and desolation. The realization that the attachment bond has been severed and the activities of prior phases have failed is integrated by the mourner. The person experiences a depletion of energy and a sense of being overwhelmed. This prompts a re-evaluation of the mourner’s identity and self-concept which can lead to massive psychological upheaval. The final phase, according to Bowlby, involves gradual movement toward reorganization. There is growing acceptance of the permanence of the separation and the need to construct a life despite the absence of the loved one. These phases may be experienced multiple times during the grieving process and may take days, months, or years.

In conclusion, Bowlby’s theory of attachment and loss lends itself to modern understanding and interventions currently used in practice. Bowlby’s thorough examination of attachment provides us with insight into the nature of behaviors associated with separation and loss and has been foundational to our understanding of grief and the mourning process. The advanced understanding of interpersonal neuroscience has added scientific validity to attachment theory (Cozolino, 2014; Montgomery, 2013; Siegel, 2012). The result is a growing awareness of how attachment styles that originated in childhood influence the course of bereavement later in life including the support seeking strategies that mourners use. For example, individuals with an anxious attachment style are likely to grieve in a manner that is highly emotional with lots of crying, wailing, and other outward expressions of inner pain. Individuals with an avoidant attachment style are more reserved. They are uncomfortable expressing emotions, often insisting they are all right. This knowledge may help explain why some mourners navigate significant loss more successfully than others and provides guidance on how to best help mourners with varying attachment styles (Kosminsky & Jordan, 2016). Knowledge of attachment theory adds an additional lens for viewing other models of grief and provides greater understanding of complicated grief. It allows practitioners to tailor their interventions according to the individual attachment style of the mourner. Kosminsky and Jordan (2016) provide an excellent discussion of grief from an attachment perspective in their book, Attachment-Informed Grief Therapy: The Clinician’s Guide to Foundations and Applications. Attachment theory also plays a role in understanding interpersonal trauma and will be discussed further in subsequent chapters.

Kübler-Ross and Stages of Grief

Although Lindemann was a pioneer in crisis intervention, death and dying were still taboo subjects when the United States was forced to confront the mass destruction of the Vietnam War. It was the 1960s and 70s, and America was a “society bent on ignoring or avoiding death” (Kübler-Ross, 1969, p. 25) despite the fact that death and trauma were occurring on a monumental scale due to the Vietnam War, the Kennedy assassinations, the assassination of Martin Luther King, Jr., and the Kent State student protest and shootings. Elisabeth Kübler-Ross’s work was revolutionary in that it opened the doors to discussion about death and dying as well as grief and loss – subjects that were stigmatized in American culture during the middle of the 20th century. Originating from her experiences as a physician of terminally ill persons, her first book, On Death and Dying (1969), included a stage model of the psychological coping process experienced by those who were terminally ill. Later, this model was applied to the grief experience and was the accepted paradigm for many years. Kübler-Ross’s model included five stages of grief: 1) denial and isolation, 2) anger, 3) bargaining, 4) depression, and 5) acceptance.

During the stage of denial and isolation, the person has difficulty comprehending the loss and the reality that death is imminent. The person could be considered to be in a state of shock – numb to the emotional ramifications of loss. Isolation or withdrawal was noted as a common behavioral component of this initial reaction to a terminal diagnosis (Kübler-Ross, 1969).

In the second stage, denial fades as anger and rage over the terminal prognosis take over. Often the person feels as if the terminal diagnosis is unfair or a cruel turn of fate. At times, this experience may take on irrational proportions and be difficult for others to comprehend. The anger then yields to the third stage called “bargaining” (Kübler-Ross, 1969).

During the bargaining phase, the person attempts to “strike a deal” with a higher being for a postponement of the inevitable death. For example, the person may secretly promise to be “good” in exchange for more time on Earth. Bargaining eventually leads to the fourth stage, “depression” (Kübler-Ross, 1969).

Kübler-Ross (1969) says depression is experienced as “a sense of great loss” (p. 97) and suggests that there are two types of depression: reactive and preparatory. In reactive depression, the person experiences the multiple losses resulting from the terminal illness (e.g. financial, employment, family roles, physical deterioration). In preparatory depression, the person grieves the impending losses associated with the knowledge that death is imminent. Loss of significant others, loss of physical self, loss of the material world, and the final separation from others are all components of preparatory depression. In this sense, Kübler-Ross links depression and grief as similar emotional experiences.

The final stage of this model is “acceptance,” during which the person resolves their feelings of anger and sadness. While not necessarily content, they await their death with “quiet expectation” (Kübler-Ross, 1969, p. 124). She suggests that during this stage, the person may experience an absence of emotion and be “void of feelings” (Kübler-Ross, 1969, p. 124).

Though introduced as a model to assist health professionals in understanding their dying patients, Kübler-Ross’s work has been applied to the experience of bereaved persons after the death of a loved one. Her framework has been considered the hallmark for understanding death and dying and many elements of her conceptualization are still used by professionals today. The primary criticism of this model was the fixed and sequential aspect of the stages.

David Kessler, a renowned expert on grief and collaborator with Kübler-Ross, added a sixth stage to the model: finding meaning (2019). This can take many forms such as advocating for a cause connected to the loved one, recalling memories of them, doing things they enjoyed, or helping others in honor of the deceased. Kessler explains that this process involves “finding a way to sustain your love for the perso...