L67 W67 NLM classification: K WM 55 Online resources: Table of contents only Contents: Attachment, loss, and the experience of grief -- Understanding the mourning process -- The mourning process: mediators of mourning -- Grief counseling: facilitating uncomplicated grief -- Abnormal grief reactions: complicated mourning -- Grief therapy: resolving complicated mourning -- Grieving special types of losses -- Grief and family systems -- The counselor's own grief -- Training for grief counseling.
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How do attachment dimensions affect bereavement adjustment? A mediation model of continuing bonds. Psychiatry Research, 23, There is considerable writing in the psychological and psychiatric literature as to the nature of attachments—what they are and how they develop. He devoted much of his professional career to the area of attachment and loss and wrote several substantial volumes as well as a number of articles on the subject.
To develop his theories, Bowlby casts his net wide and includes data from ethology, control theory, cognitive psychology, neurophysiology, and developmental biology. He takes exception to those who believe that attachment bonds between individuals develop only in order to have certain biological drives met, such as the drive for food or the drive for sex. Bowlby argues that attachment behavior has survival value, citing the occurrence of this behavior in the young of almost all species of mammals.
But he sees attachment behavior as distinct from feeding and sexual behavior. Obvious pathological aberrations can develop in this pattern. Inadequate parenting can lead people either to form anxious attachments or to form very tenuous attachments, if any at all Winnicott, , Various attachment styles can be found in Chapter 3. The greater the potential for loss, the more intense and the more varied these reactions are.
If the danger is not removed, withdrawal, apathy, and despair then ensue. Animals demonstrate this behavior as well as humans. In The Expression of Emotions in Man and Animals, written during the latter part of the 19th century, Darwin described the ways in which sorrow is expressed by animals as well as by children and adult human beings. Lorenz, , quoted in Parkes, , p. Several years ago, there was an interesting account about dolphins in the Montreal zoo.
By not eating, the dolphin was exhibiting manifestations of grief and depression akin to human loss behavior. Psychiatrist George Engel, speaking at the psychiatric grand rounds at the Massachusetts General Hospital, described a case of bereavement in great detail. Later in his lecture, after reading a lengthy newspaper account of this loss, Engel revealed that he was describing the behavior of an ostrich that had lost her mate! Because of the many examples in the animal world, Bowlby concludes that there are good biological reasons for every separation to be responded to in an automatic, instinctive way with aggressive behavior.
He also suggests that irretrievable loss is not taken into account, and that in the course of evolution, instinctual equipment developed around the fact that losses are retrievable and the behavioral responses that make up part of the grieving process are geared toward reestablishing a relationship with the lost object Bowlby, The mourning responses of animals show what primitive biological processes are at work in humans.
There is evidence that all humans grieve a loss to one degree or another. George Engel raised this interesting question in a thought-provoking essay published in Psychosomatic Medicine. He argues that grief represents a departure from the state of health and well-being, and just as healing is necessary in the physiological realm in order to bring the body back into homeostatic balance, a period of time is likewise needed to return the mourner to a similar state of psychological equilibrium.
Therefore, Engel sees the process of mourning as similar to the process of healing. As with healing, full function, or nearly full function, can be restored, but there are also incidents of impaired function and inadequate healing. Just as the terms healthy and pathological apply to the various courses in the physiological healing process, Engel argues that these same terms may be applied to the courses taken by the mourning process.
He sees mourning as a course that takes time until restoration of function can take place. How much functional impairment occurs is a matter of degree Engel, Rather than using terms like restoration and recovery, I prefer to use the term adaptation: some people make a better adaptation to the loss while others make a less good adaptation.
In Chapter 5, we look at complicated mourning, where individuals are making a less than adequate adaptation to the loss. Before we look at the characteristics of normal grief, it would be useful to look at three terms that are often used interchangeably: grief, mourning, and bereavement. For purposes of common understanding, in this book I am using the term grief to indicate the experience of one who has lost a loved one to death.
It is comprised of thoughts, feelings, behaviors, and physiological changes that vary in pattern and intensity over time. The term grief can be applied to other losses, but in this book, it primarily addresses losses due to death.
Mourning is the term applied to the process that one goes through in adapting to the death of the person. In the Boston area, there are two Catholic colleges well known for their football rivalry. Back in the fall of , they met for one of their traditional Saturday encounters.
Holy Cross beat Boston College, and after the game many people went to Cocoanut Grove, a local nightclub, to celebrate. Nearly people lost their lives in that tragedy. From his observations of recently bereaved patients he discovered similar patterns, which he described as the pathognomonic characteristics of normal or acute grief: 1. Lindemann also neglects to mention how many interviews he had with the patients, and how much time had passed between the interviews and the date of the loss.
Nevertheless, this remains an important and much cited study. Because the list of normal grief behaviors is so extensive and varied, I have placed them under four general categories: feelings, physical sensations, cognitions, and behaviors. Anyone counseling the bereaved needs to be familiar with the broad range of behaviors that falls under the description of normal grief.
Feelings Sadness Sadness is the most common feeling found in the bereaved and really needs little comment. This feeling is not necessarily manifested by crying behavior, but often it is. Parkes and Weiss conjecture that crying is a signal that evokes a sympathetic and protective reaction from others and establishes a social situation in which the normal laws of competitive behavior are suspended. Not allowing the sadness to be experienced, with or without tears, can frequently lead to complicated mourning see Chapter 5.
Anger Anger is frequently experienced after a loss. If the anger is not adequately acknowledged, it can lead to complicated mourning. This anger comes from two sources: from a sense of frustration that there was nothing one could do to prevent the death, and from a kind of regressive experience that occurs after the loss of someone close. You may have had this type of regressive experience when you were a very young child on a shopping trip with your mother.
You 1 Attachment, Loss, and the Experience of Grief 21 felt panic and anxiety until your mother returned, whereupon, rather than express a loving reaction, you hauled off and hit her. One of the riskiest maladaptations of anger is the posture of turning the anger inward against the self. Blame Anger is often handled in other less effective ways, one of which is displacement, or directing it toward some other person and often blaming him or her for the death Drenovsky, The line of reasoning is that if someone can be blamed, then that person is responsible and, hence, the loss could have been prevented.
People may blame the physician, the funeral director, family members, an insensitive friend, and frequently God.
God showed me something so precious and takes it away. Is this fair? Field and Bonanno observed two types of blame in their research. One involved blaming the deceased, the second blaming themselves. Those who blamed the deceased experienced more anger and other symptoms in the early months after the death and had fewer continuing bonds. Guilt and 22 Grief Counseling and Grief Therapy self-reproach—over not being kind enough, over not taking the person to the hospital sooner, and the like—are frequently seen in survivors.
Most often the guilt is irrational and mitigates through reality testing. There is, of course, the possibility of real guilt, where the person has indeed done something to cause the death. In these cases, interventions other than reality testing would be called for. Anxiety comes primarily from two sources.
Carried to extremes, this anxiety can develop into a full-blown phobia. The well-known author C. I am not afraid, but the sensation is like being afraid. Loneliness Loneliness is a feeling frequently expressed by survivors, particularly those who have lost a spouse and who were used to a close day-to-day relationship.
Even though very lonely, many widows will not go out because they feel safer in their homes. Stroebe, Stroebe, Abakoumkin, and Schut distinguish between emotional loneliness and social loneliness.
Social support can help with social loneliness but does not militate against emotional loneliness due to a broken attachment. The latter can only be remedied by the integration of another attachment M.
Sometimes the need to be touched is a correlate of loneliness. It may sometimes be experienced as apathy or listlessness. This high level of fatigue can be both surprising and distressing to the person who is usually very active. If not, it may be a clinical sign of depression. Helplessness One factor that makes the event of death so stressful is the sense of helplessness it can engender.
This close correlate of anxiety is frequently present in the early stage of a loss. Widows in particular often feel extremely helpless. I was afraid I would freak out and not be able to care for my child.
Shock Shock occurs most often in the case of a sudden death. Someone picks up the telephone and learns that a loved one or friend is dead. Yearning Yearning for the lost person is what the British call pining. Yearning is a normal response to loss. When it diminishes, it may be a sign that mourning is coming to an end. When it does not come to an end, it may be a clinical sign indicating complicated mourning W.
See Chapter 5 for a discussion of prolonged grief as one of the complications of mourning, and the place of yearning in its diagnosis Robinaugh et al. Emancipation Emancipation can be a positive feeling after a death. I worked with a young woman whose father was a real potentate, a heavy-handed, 24 Grief Counseling and Grief Therapy unbending dictator over her existence. After his sudden death from a heart attack, she went through the normal grief feelings, but she also expressed a feeling of emancipation because she no longer had to live under his tyranny.
Relief Many people feel relief after the death of a loved one, particularly if the loved one suffered a lengthy or particularly painful illness. Sometimes relief is the reaction following a completed suicide after a long series of suicide attempts. However, a sense of guilt often accompanies this sense of relief. After a loss, they feel numb. Again, this numbness is often experienced early in the grieving process, usually right after the person learns of the death.
As you review this list, remember that each of these items listed represents normal grief feelings and there is nothing pathological about any one of them. However, feelings that exist for abnormally long periods of time and at excessive intensity may portend a complicated grief reaction.
This is discussed in Chapter 5. The following is a list of the most commonly reported sensations experienced by the people we see for grief counseling: 1. If so, physicians need to inquire about deaths and losses as part of their diagnostic evaluation.
Cognitions There are many different thought patterns that mark the experience of grief. Certain thoughts are common in the early stages of grieving and usually disappear after a short time. But sometimes thoughts persist and trigger feelings that can lead to depression or anxiety.
There must be some mistake. You are never quite ready for it. I once went out for a social evening in Boston and took a cab home. I told the driver where I wanted to go and sat back while he proceeded down the road.
I thought maybe he was a new driver and did not know the city, but he commented to me that he had a lot on his mind. A little later he asked again and then apologized and said that he was feeling very confused. Preoccupation Preoccupations can be obsessive thoughts about the deceased. These often include obsessive thoughts about how to recover the lost person.
Sometimes preoccupation takes the form of intrusive thoughts or images of the deceased suffering or dying. Rumination is another form of preoccupation. People engaging in ruminative coping think persistently and repetitively about how bad they feel and about the circumstances that precipitated their feelings Eisma et al. Sense of Presence This is the cognitive counterpart to the experience of yearning.
The grieving person may think that the deceased is somehow still in the current area of time and space. This can be especially true during the time shortly after the death. Some found this sense of presence comforting, while others did not and were scared by it Worden, Hallucinations Hallucinations of both the visual type and the auditory type are included in this list of normal behaviors because hallucinations can be a frequent experience of the bereaved.
With all the interest in mysticism and spirituality, it is interesting to speculate whether these are really hallucinations or possibly some other kind of metaphysical phenomenon Kersting, Aaron Beck and his colleagues at the University of Pennsylvania found that the experience of depression frequently is triggered by depressive thought patterns. These can range from sleep and appetite disturbances to absentmindedness and social withdrawal.
The following behaviors are commonly reported after a loss and usually correct themselves over time. Sleep Disturbances It is not unusual for people who are in the early stages of loss to experience sleep disturbances. Sleep disturbances sometimes require medical intervention, but in normal grief they usually correct themselves. This happened morning after morning and soon caused problems because he could not function well at work. After about 6 weeks, the disorder began to correct itself, and eventually it disappeared.
This is not an unusual experience. However, if sleep disorder persists, it may indicate a more serious depressive disorder, which should be explored Tanimukai et al. Sleep disorders can sometimes symbolize various fears, including the fear of dreaming, the fear of being in bed alone, and the fear of not awakening. After her husband died, one woman solved the problem posed by her fear of being alone in bed by taking her dog to bed with 28 Grief Counseling and Grief Therapy her.
Eating Disturbances Bereaved animals exhibit eating disturbances, which are also very common in human mourning situations. Although appetite disturbances can manifest themselves in terms of both overeating and undereating, undereating is the more frequently described grief behavior. One client was concerned because on three separate occasions she had driven across the city in her car and, after completing her business, had forgotten that she had driven and returned home via public transportation.
This behavior occurred following the death of a close friend and eventually corrected itself. Social Withdrawal It is not unusual for people who have sustained a loss to want to withdraw from other people. Again, this is usually a short-lived phenomenon and corrects itself.
I saw one young woman shortly after the death of her mother. This single woman was a very sociable person who loved to go to parties. This may seem obvious and appropriate to the reader, but this woman saw her withdrawal as abnormal. Some people withdraw from friends perceived as oversolicitous. Often these dreams serve a number of purposes and may give some diagnostic clues as to where the person is in the whole course of mourning Cookson, This guilt was manifested in low self-esteem and personal recrimination and was associated with considerable anxiety.
During one of her daily visits to her mother in the hospital, Esther had left the bedside for coffee and a bite of food. While she was out, her mother died. While in therapy, she had a dream about her mother. In this dream, she saw herself trying to assist her mother to walk down a slippery pathway so she would not fall. But her mother fell, and nothing Esther could do in the dream would save her.
It was impossible. This dream was a significant turning point in her therapy because she allowed herself to see that nothing she could have done would have kept her mother from dying. This important insight gave her permission to shed the guilt that she had been carrying for several years. Some ways to utilize dreams in grief counseling and grief therapy are presented in Chapter 6.
Avoiding Reminders of the Deceased Some people will avoid places or things that trigger painful feelings of grief. They might avoid the place where the deceased died, the cemetery, or objects that remind them of their lost loved one.
One middle-aged woman came for grief counseling when her husband died after a series of coronary attacks, leaving her with two children. For a period of time she put all pictures of her husband away in the closet, along with other things that reminded her of him. This obviously was only a short-term solution, and as she moved toward a better adaptation of her grief, she was able to bring out the items that she wanted to live with and display his picture on the piano.
Quickly getting rid of all the things associated with the deceased— giving them away or disposing of them in any way possible even to the point of having a quick disposal of the body—can lead to a complicated grief reaction. This is usually not healthy behavior and is often indicative of a highly ambivalent relationship with the deceased. Ambivalent relationships are one of the mediators of mourning described in Chapter 3. Searching and Calling Out Both Bowlby and Parkes have written much in their work about searching behavior.
Calling out is related to this searching behavior. Please come back to me! It is a close correlate of the physical sensation of breathlessness. Restless Hyperactivity A number of widows in our Harvard studies of bereavement entered into restless hyperactivity following the deaths of their husbands.
The woman mentioned previously whose husband left her with two teenage children could not stand to stay at home. Crying There has been interesting speculation that tears may have potential healing value.
Stress causes chemical imbalances in the body, and some researchers believe that tears remove toxic substances and help reestablish homeostasis. They hypothesize that the chemical content of tears caused by emotional stress is different from that of tears secreted as a function of eye irritation.
Tests are being done to see what type of catecholamine mood-altering chemicals produced by the brain is present in tears of emotion Frey, Tears do relieve emotional stress, but how they do this is still a question. Further research is needed on the deleterious effects, if any, of suppressed crying.
Visiting Places or Carrying Objects That Remind the Survivor of the Deceased This is the opposite of the behavior that people engage in to avoid reminders of the lost person. Often underlying this behavior is the fear of losing memories of the deceased. They wore the same size, and although this might seem like an example of someone being thrifty, the fact was that the daughter did not feel comfortable unless she was wearing something that had belonged to her mother.
She wore these clothes for several months. As her mourning progressed, she found it less and less necessary to wear clothing that had belonged to her mother. Finally, she gave most of it away to charity. The reason for outlining these characteristics of normal grief in such detail is to show the wide variety of behaviors and experiences associated with loss.
Obviously, not all these behaviors will be experienced by one person. However, it is important for bereavement counselors to understand the wide range of behaviors covered under normal grief, so they do not pathologize behavior that should be recognized as normal. He tried to point out that depression, or melancholia, as he called it, is a pathological form of grief and is very much like mourning normal grief except that it has a certain characteristic feature of its own—namely, angry impulses toward the ambivalently loved person turned inward.
It is true that grief looks very much like depression, and it is also true that grieving may develop into a full-blown depression. Depression may also serve as a defense against mourning. That is, the people who have lost someone do not have less regard for themselves as a result of such a loss, or if they do, it tends to be for only a brief time.
Even though grief and depression share similar objective and subjective features, they do seem to be different conditions. Freud believed that in grief, the world looks poor and empty, while in depression, the person feels poor and empty. Although such negative evaluations can exist in the bereaved, they tend to be more transient. The recent Diagnostic and Statistical Manual 5th ed. They have used antidepressant medication to treat patients whose depression persisted late into the course of bereavement and did not resolve spontaneously or respond to interpersonal interventions.
These were usually people who had a history of depression or some other mental health disorder. They found improvement in sleep disorders and appetite disturbance as well as an improvement in mood and cognition. This response suggests a biological dimension to the depression.
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Topics from this paper. Grief reaction Cessation of life grief counseling. Grief Therapy mental health Loss, Grief, and Bereavement. Wounds and Injuries Handbooks. Citation Type. Has PDF. Publication Type. More Filters. Bereavement theory: recent developments in our understanding of grief and bereavement.
This … Expand. View 2 excerpts, cites background. View 1 excerpt, cites background. Journal of Creativity in Mental Health. Death and bereavement remain a cultural taboo that continues to impact helping professionals.
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