The professional literature on bereavement had its origins in Europe at the start of the twentieth century. In his 1917 classic paper, "Mourning and Melancholia", the psychoanalyst Freud wrote that grieving is a process during which emotional energy or libido is withdrawn from the deceased and redirected and the ego becomes free and uninhibited again (Freud, 1957). Grief theorists often neglect to mention, when referring to Freud, that he also viewed grief as a nonnal experience prompted by loss and that under nonnal circumstances most individuals would heal on their own without intervention. Freud (1957) defined grief as:
... the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as one's country, liberty, an ideal, and so on...It is also well worth noticing that, although mourning involves grave departures from the normal attitude of life, it never occurs to us to regard it as a pathological condition and to refer it to medical treatment. We rely on its being overcome after a certain lapse of time, and we look upon any interference with it as useless or even harmful. (pp. 243-244)
Stage Models
Itwas not until the end of the Second World War that another major work in bereavement appeared. Eric Lindemann, a psychoanalyst, published an important paper describing the reaction to bereavement, its course, as well as treatment for problems associated with bereavement. He was also the first theorist to conceptualize grief as a process involving stages. Lindemann (1944) identified three stages of grief: shock and disbelief, acute mourning, and resolution of the grief process. Shock and disbelief were characterized by an inability to accept the loss and there could be complete denial on occasion that the loss occurred. In the acute mourning stage, there was acceptance of the loss accompanied by various emotions and behaviors such as crying, feelings of loneliness, disinterest in daily life, loss of appetite, insomnia, as well as an intense preoccupation with the deceased.
Resolution of grief occurred when the individual gradually resumed the activities of daily living, was interested again in life and became less preoccupied with the deceased.
Lindemann coined the phrase "grief work" to describe the process of resolving grief. He saw a role for psychiatrists in helping patients with their grief work and predicted it could be done over 8-10 sessions.
In 1961, John Bowlby presented a theory of grief based on his comprehensive work on attachment formation between mother and child and the psychological reaction of small children to separation from their mothers. Bowlby (1980) suggested that grief was related to the attachment that the bereaved continued to feel toward the deceased.
Attachment behavior was defined as any form of behavior that resulted in the individual
striving to get close to the other individual. These behaviors would include seeking out the other individual, looking at him/her, calling out to the individual, and demanding to be closer to him/her. These behaviors were evident when an individual was grieving as well. Bowlby indicated that the grief process was divided into four successive phases:
numbness, yearning and searching, disorganization and despair, and reorganization. In the phase of numbness, the bereaved is stunned and there may be varying degrees of denial that the loss occurred. In the phase of yearning and searching, there is a strong urge to locate and be reunited with the deceased. Finally, in the phase of reorganization, the bereaved loosens their attachment with the deceased and begins to establish new ties with others. Bowlby recognized that there were variations in responses to loss and that not all the bereaved went through these phases in the same way or at the same speed (Bowlby& Parkes, 1970).
A similar model was proposed by Engel (1961) who described the normal sequence of grief as follows:
• Shock and disbelief The bereaved is stunned and may try to numb the pain by blocking out the loss and painful feelings.
• Developing awareness. Acknowledgement of the loss begins and anger, guilt, crying or self-destructive behavior may be present.
• Restitution. Mourning rituals such as funerals provide social support to the bereaved and stimulate the expression of emotions.
• Resolving the loss. The bereaved attempts to deal with the void left by the deceased, there may be preoccupation with the deceased that includes the loss experience as well as the relationship with the deceased.
• Idealization. Most negative and hostile feelings toward the deceased are repressed, yearning and sadness diminishes, there is acknowledgement that the deceased would want the bereaved to continue living, and interest in new relationships begins.
• The outcome. After a year or so, successful healing occurs and the bereaved is able to comfortably remember both the positive and disappointing aspects of the lost relationship.
Unlike his predecessors, Engel viewed grief itself as a disease because it produced various psychological and physiological symptoms, it caused a lot of mental anguish, and it impaired daily functioning. However, most bereavement scholars today believe only a minority of individuals will experience grief that can be labeled "pathological", meaning it fails to follow the course that is considered normal in Western society (Parkes, 2002).
Perhaps the most widely known and influential stage model of grief was developed by Kubler-Ross (1969) who outlined five stages an individual goes through when coping with imminent death. These stages, which have also been used to describe the grief process among the bereaved, are: denial, anger, bargaining, depression, and acceptance of the loss. The first phase consists of shock and denial which is considered a normal initial reaction. As the shock wears off, the individual may become angry over the lack of control over the loss and this may be followed by bargaining for the return of the deceased with promises of changes in behavior or lifestyle. When these bargaining thoughts yield nothing, hopelessness sets in and the individual may experience a period of depression, sadness, even despair. The final phase involves the individual fully accepting the loss and been capable of thinking about the deceased without the same emotional upheaval, as well as having positive thoughts about the future.
Rando (1984) concluded that although there were various conceptualizations of the grief process they all covered the same emotions, which she collapsed into three broad phases:
Avoidance, in which there is shock, denial, and disbelief; Confrontation, a highly emotional state wherein the grief is most intense and the psychological reactions to the loss are felt most acutely; and Reestablishrnent, in which there is a gradual decline of the grief and the beginning of an emotional and social reentry back into the everyday world. (p. 29)
A few years later, Neimeyer (1998) offered his "own distillation of prominent psychological responses to loss" (p. 18). He delineated three phases of grief:
• Avoidance - characterized by shock, numbness, and confusion initially, followed by vivid emotions as the reality sets in, and oscillating between denying the reality of the death and being overcome by grief and anguish the next moment.
• Assimilation - characterized by intense loneliness and sorrow, withdrawal from the larger social world, depression, crying spells, prolonged stress and anxiety, disturbances in sleeping and eating, physical complaints, and hopelessness about the future.
• Accommodation - characterized by resigned acceptance of the reality of the loss, lessening of physical symptoms, greater sense of control of emotions, rebuilding ties with the social world, and a continued balancing act of remembering the past and reinvesting in the future. (p. 18)
Tasks of Grief
The implication of stage models of grief is that the bereaved individual must wait because
"time heals all wounds". A number of theorists and clinicians have challenged the underlying assumption that grief is a passive process and have advocated a perspective of grief as an active process of accomplishing certain tasks that will help individuals adjust to their loss. One early model by Parkes and Weiss (1983) proposed that the bereaved need to accomplish the following three tasks in order to recover from grief:
• Intellectual recognition and explanation ofthe loss. The bereaved must recognize and be able to explain how the loss occurred to avoid further anxiety.
• Emotional acceptance of the loss. Through constant review of memories, thoughts, and feelings, the bereaved reaches a point where the reminders of the loss are not too painful.
• Assumption of a new identity. Gradually, the bereaved adjusts to an altered life situation and develops a new identity.
Worden (1991) built on the perspective that there were things that the bereaved could do to facilitate their adjustment to loss. He outlined fourtasks of grieving that need to be accomplished before grief is complete. These tasks are to: accept the reality of the loss, experience the pain of grief, adjust to an environment in which the deceased is missing,
and withdraw emotional energy and reinvest it in another relationship. Parkes (2002) remarked that this model of tasks of grieving was helpful for counselors because of its practical implications. Attig (1996) similarly endorsed the view that while bereavement (the situation of having lost a loved one) was choiceless, grief or the way an individual responds to loss was not choiceless. Attig proposed that: "grieving as coping requires that we respond actively, invest energy, and address tasks" (p. 33). However, he was not so enamoured of Worden's "tasks" and argued that they were not so much tasks but principles of coping. Attig explained that Worden's "tasks" " ... are not rigourously defined, they are not circumscribable, modest in scale, or completable" (p. 49). Attig proposed that grieving was a process of relearning the world:
Viewing grieving as relearning gives specific content to the active, task- based idea of grieving and defines the range of activities involved ... we learn how to be and act in the world that is transformed by our losses. We reshape all facets of our lives ... When we grieve, we must relearn virtually every object, place, event, relationships with others, and aspects of ourselves that the lives of those who have died have touched. Our grieving takes as long as it does because there is so much we must reiearn.
(p. 122)
Attig's assumption was that loss challenges us to reiearn things and places, relationships with others including the deceased and God, elements of our daily routine, and the meaning of our own life. We must relearn how to be ourselves in a world that has been changed as a result of our loss and typical tasks include deciding when to return to work, choosing to move, deciding to return to an activity that the deceased introduced into one' life, and deciding who to interact with and how often. Neimeyer (1998) subsequently reformulated these tasks as "challenges". He reiterated that these challenges were not accomplished in any particular order nor are they ever completely over. The challenges are: acknowledging the reality of the loss, opening oneselfup to the pain, revising one's assumptions about the world, reconstructing one's relationship to the deceased, and rebuilding one's identity.
Cognitive Stress and Coping Theory
The cognitive model of stress and coping of Lazarus and Folkman (1984) has been used widely in research on bereavement (Lund& Caserta, 1998; Kato& Mann, 1999; Meuser
& Marwitt, 1999; Folkman, Chesney, Collette, Boccellari, & Cooke, 1996; Goldblum &
Erickson, 1999; Stein, Folkman, Trabasso, & Richards, 1997). According to this framework, a situation (e.g. the loss of a loved one) is considered stressful when it is
"appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being" (Lazarus& Folkman, 1984, p. 19). The two key concepts in stress and coping theory are appraisal and coping. Appraisal refers to the perception that the individual is in danger as well as the perceived availability of resources for managing potential or actual harm. Coping refers to the process whereby the individual adopts certain responses to manage the demands that are appraised as stressful. In effective coping, the individual determines what form of coping is appropriate to deal with the stressful situation and then competently applies this form of coping (Goldberger, &
Breznitz, 1982). There are two main types of coping: problem-focused coping which involves managing or changing the problem causing distress, and emotion-focused coping which involves regulating one's emotional responses to the problem (Lazarus and Folkman, 1984).
Folkman et al. (1996) applied the cognitive framework of stress and coping to their study of AIDS-related bereavement among gay men in San Francisco and they hypothesized that the impact of bereavement on the person would be:
.. .influenced by the personal and social resources the person has available for coping and by the various types of emotion-focused and problem- focused coping that he uses to manage the emotional and instrumental demands of the events. (p. 3)
Data from this important study, known as the University of California, San Francisco (UCSF) Coping Project, has been published in several articles. The cognitive stress and coping model offers an alternative view of bereavement from traditional theories that assert that the death of a loved one must be confronted and worked through. The main
emphasis is on the bereaved individual's "subjective evaluations of the difficulties surrounding the loss" (Bonanno & Kaltman, 1999, p. 5). An implication of this perspective, which contrasts with the grief work assumption, is that choosing avoidant coping (i.e. not dealing directly with the problem) can sometimes be helpful to the bereaved (Bonanno, Keltner, Holen, & Horowitz, 1995).
Griefas a Dual Process
Rubin (1999) noted that two approaches underlie most of the literature relating to loss.
One approach focuses on the difficulty of working through the loss, particularly as it relates to separation from the deceased and changes or weakening in ties to the deceased.
The other approach focuses on the biological, behavioral, cognitive, and emotional effects or outcomes of bereavement. He saw a need to combine the two and so he proposed a "bifocal approach to bereavement". His two-track model of bereavement addresses both the bereavement process and its outcome. Track I focuses on the biopsychosocial reactions to loss and Track 11 focuses on how the bereaved maintain and change their relationships to the deceased.
Stroebe and Schut (1999) recognized the value of this model in identifying dual dimensions of loss - daily functioning and relationship to the deceased - but they criticized it for not focusing on the coping process itself. As a result, they proposed a dual process model of coping with bereavement (Stroebe, 1998; Stroebe& Schut, 1999).
In their view, the bereaved "oscillate" between two types of coping: loss-oriented coping and restoration-oriented coping. This means that there are times when the bereaved will be focused on thoughts of the loss (e.g., yearning for the deceased, crying, examining old photos, or imagining things that the deceased might say) - loss-oriented coping. Itis also appropriate at times to put aside one's grief, adjust to changes and make plans for the future (e.g. finances, selling one's house, or developing a new identity from husband to widower) - restoration-oriented coping. According to Stroebe (1998), "there may be different reasons why, at any particular point in time, a bereaved person will be loss- or restoration-oriented ... " (p. 11).