How do we understand grief and bereavement? Over the past 100 years, answers to this question have changed and evolved. Christiane Manzella, PhD, Senior Psychologist at the Seleni Institute, emphasizes the importance of understanding normative grief so that mental health professionals can offer effective treatment. In this spirit, we now share 100 Years: Highlights in Conceptualizing and Understanding Grief.
1917. Freud published Mourning and Melancholia (1917/1957). Freud described and recognized that mourning is a normal yet painful process. Freud made the distinction between a healthy process of mourning and pathological mourning. Mourning is a normal response – and the person experiences sadness, loss of interest, and turning away from reality. These same experiences are present in melancholia except that in mourning the person loosens the ties to the deceased – decathects from the love object – and bit by bit returns to normal, but in melancholia this does not occur. Freud describes mourning as a conscious response to a death and melancholia as an unconscious process along with a loss of self-regard. “In mourning it is the world which has become poor and empty; in melancholia, it is the ego itself” (p. 246) – similar to the contemporary concept of depression. Considering letting go of the lost loved one while doing “grief work” as the healthy response to grief shaped clinical interventions until the 1980s and 1990s.
1944. Lindemann published Symptomatology and Management of Acute Grief. This paper is often cited and is considered a classic in the field of grief and bereavement. Lindemann’s theory resulted from his observations and work with survivors of the Cocoanut Grove Nightclub fire in 1942. 492 people died and hundreds more were injured. Following Freud’s conceptualization, Lindemann conceptualized grief as “work” and considered that a healthy and successful resolution of grief included cutting the emotional bond with the deceased: Accept. Let go. Move on.
1969. Kübler-Ross published On Death and Dying. She described experiences of terminally ill individuals – opening awareness around death and dying and that terminally ill individuals had been ignored and needed to be heard. Her views around what terminally ill individuals needed became extrapolated into the well-known five stage model of grieving: denial, anger, bargaining, depression, acceptance. This happened even though Kübler-Ross intended her observations to explicate and clarify experiences of those who were terminally ill, not to describe the grief process for those were bereaved. This five-stage model of grief further built on the views of Freud (1917/1957) and Lindemann (1944) that it is healthy for a bereaved person to work through the grief and eventually accept the loss, let go, and move on.
1960s through the 1970s. Societal shifts resulting in a reduction of natural supports following a death. For example, how many of us live within 50 miles of where we were born? In all likelihood, this societal shift played a role in an increased need for effective support for bereaved individuals and the resulting growth of mental health professionals specializing in grief and bereavement counseling and therapy.
1970s through the 2000s. The five-stage model dominated clinical applications until the mid 2000s. And, many researchers and clinicians carried out research that questioned this model. Research efforts to replicate Kübler-Ross’s views did not replicate the five-stage model of grief, which was widely presented as being representative of a normative grief process (Maciejewski, Zhang, Block, & Prigerson, 2007; Metzger, 1980).
1980s through the 2000s. Those involved in clinical applications – that is, grief counseling and therapy – seriously questioned the concept of grief as a stage-based model. As clinical applications were being developed, most clinicians working with bereaved individuals started to abandon the stage-based model because of the recognition that most of those who were bereaved did not go through grief in stages, especially not in linear stages. There was recognition that grief was clearly related to attachments (Bowlby, 1980); and, revisions in the assumptive world (Neimeyer, 1995; Parkes, 1988); that grief often involved “re-writing” the life narrative; and making meaning and moving through grief in waves or phases – not in stages (Neimeyer, 2001, 2011).
1993. Rando published Treatment of Complicated Mourning. Rando described significant problems around conceptualizing normative grief versus complicated mourning. One major difficulty she described was the lack of a diagnostic category representing complicated mourning (or complicated grief) in the third edition of the Diagnostic and Statistical Manual for Mental Disorders – the DSM-III-R (American Psychiatric Association, 1987). The only diagnostic category present was a V code (not a mental illness) reflecting uncomplicated bereavement (V62.82). Rando’s work was instrumental in opening exploration around distinctions between normative grief/mourning and complicated or pathological or prolonged mourning.
1996. Klass, Silveman, and Nickman publish Ongoing bonds. New Understandings in Grief. This group of essays covered evolving views reflecting the view that there was a normative, healthy, and restorative aspect of maintaining an ongoing bond with the deceased – especially when the bond was close and nurturing. There was also a suggestion that letting go – relinquishing an ongoing or continuing bond – could be adaptive if the relationship was complicated (such as an abusive relationship or one involving deep trauma).
1990s through the 2000s. A growing concern over the “medicalization” of grief in relation to the growing field of grief and bereavement counseling and therapy. Questions included: What was being addressed in grief counseling or therapy? Normative grief (Sabin, 2012)? Is grief an illness where individuals recover (Balk, 2004, Bonanno, 2008)? How do we define complicated or prolonged grief (e.g., Corywell, 2012, Shear, 2007)? What role does resilience have in grief (e.g., Bonanno, 2008, Tedeschi & Calhoun, 2008)? What ways is complicated grief represented in negative internal representations (Shear & Shair, 2005)? There was a shift in the concept of grief as an illness with risk factors such as depression, heart failure, or social adjustment problems from which a bereaved individual needed to recover, to recognition that distress following loss is normative and expected and that most bereaved individuals adapt well following a loss. Further, clinicians observed that many bereaved parents and spouses in a healthy relationship with the deceased maintained an internal emotional tie with the deceased – maintaining an ongoing bond – and that this clearly could be adaptive (Klass, 2007; Kelly & Trinidad, 2012).
1999 through 2015. Strobe and Schut (1999) published The Dual Process of Coping with Bereavement: Rationale and Description, an article that described the dual process of coping with bereavement: oscillating between loss orientation and restoration orientation. These authors developed these principles into the Dual Process Model of coping with grief (Stroebe & Schut, 2010). This model has been widely adopted in treatment protocols and interventions, especially treatment of complicated grief (e.g., Shear, 2015).
Late 1990s through the early 2000s. Several important publications and research studies reflect ongoing questions and shifts in conceptualizing grief. Bonanno (2006) posited that contemporary understandings of grief and complicated grief do not accurately reflect the capacity of those who are bereaved to handle adversity, suggesting that while bereaved individuals experience perturbations following a death, their resilience is not usually recognized. He also rejected the idea of grief as “work.” In contrast, other researchers and clinicians focused on establishing complicated grief or prolonged grief as a valid construct – and one that is treatable – because they saw a profound need to recognize and address intense suffering in those experiencing complicated or prolonged grief (Prigerson & Maciejewski, 2005; Shear, Frank, Houck, & Reynolds, 2005; Zhang, B., El-Jawahiri & Prigerson, 2006). Bonanno’s (2002, 2006) emphasis on resilience influenced conceptualizations around grief and designing effective treatments. And, recognition that the normal grief process can sometimes become interrupted and become complicated or prolonged –and distinguishing this from normative grief – was also a major development (e.g., Shear et al. 2005; Prigerson, et al., 2009).
2000s though-2011: Controversy over the question: Does grief counseling help or harm? Doubts were voiced about the efficacy of grief counseling (e.g., Bonanno, 2004, 2006) and articles in the popular press also raised this question (e.g., Groopman, 2004). Concerned about this pessimism around the efficacy of grief counseling, Larson and Hoyt (2007) and Hoyt, Del Re, and Larson (2011) examined this question. They found that the doubt was raised, in part, from a report of findings from a doctoral dissertation suggesting that there was a treatment induced deterioration effect following grief counseling. While Larson and Hoyt (2007) and Hoyt and his colleagues (2007) examined many issues, an important question Hoyt and his colleagues (2011) addressed was the statistical method used to determine treatment induced deterioration. Hoyt and his colleagues (2011) found that this was an inadequate statistic and that this conclusion was incorrectly being presented as an established research finding that suggested grief counseling or therapy was harmful. Further compounding the pessimism Larson and Hoyt (2007) and Hoyt and his colleagues were investigating (2011), was that this faulty conclusion was widely discussed and cited by many researchers. And, these citations were represented as coming from Neimeyer (who had been the doctoral student’s chair) (Larson & Hoyt, 2011). In this same inquiry, Hoyt and his colleagues (2011) also carried out a meta-analysis of research studies investigating grief therapy outcomes. Controlling for wide differences in research methods, they found an overall medium effect size in positive therapy outcomes. This meta-analysis revealed that grief counseling/therapy was associated with a strong positive finding in therapy outcome studies (Hoyt et al., 2011).
2000s through 2013. Anticipating a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, many researchers carried out studies focused on clarifying criteria for complicated or prolonged grief (e.g., Prigerson, et al, 2001; Prigerson, et al., 2008; Prigerson, et al., 2009, Shear, et al., 2005; Shear et al., 2011; Zisook & Shear, 2009). These attempts were intended to further distinguish between normative grief (not a mental illness) and complicated or prolonged grief (a mental illness). These researchers and clinicians believed that having this clarity – and a diagnostic designation – would benefit those suffering from complicated or prolonged grief so that the right level of care could be provided as well as facilitating reimbursement for this needed care.
2013. The fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) was published (American Psychiatric Association, 2013). Problematic or pathological grief was classified in the section “conditions for further study” and was designated as “Persistent Complex Bereavement Disorder” (American Psychiatric Association, 2013, p. 789). Those in the grief work group decided that while findings of research studies yielded important findings, complicated or pathological grief warranted further study before being included in the DSM. Because Persistent Complex Bereavement Disorder is a condition for further study, insurance reimbursement cannot result.
2013. The Bereavement Exclusion: Another important development was that the mood disorders work group for the DSM-5 recommended eliminating the bereavement exclusion criteria from major depressive episode(s) (Corywell, 2012) and the bereavement exclusion was removed (American Psychiatric Association, 2013). The eight-week wait in the bereavement exclusion had been in place in prior editions of the DSM to highlight the fact that acute grief can look like a depressive episode and that waiting for eight weeks gave more time and clarity to establish if the bereaved person was experiencing normative grief or a major depressive episode (e.g., American Psychiatric Association, 1987, 2000). However, the rationale those in the mood disorders work group had for eliminating the bereavement exclusion was that the symptom pattern in bereavement was not significantly different from a major depressive episode (Corywell, 2012). Sabin (2012) and Kendlar and colleagues (2008) point out that good clinical practice involves watchful waiting and to proceed with caution before giving a diagnosis of a major depressive episode to a bereaved individual. Thus, the symptom patterns are similar yet making distinctions between grief as a normative process in response to loss (the world is empty) and depression (the self is empty) is now essentially in the hands of clinicians.
2000s through to the present. Highlights of themes: Ongoing attention to effective interventions that empower those experiencing grief using a task-based approach to coping with grief (Worden, 2009). Accurately assessing the need for maintaining a continuing bond or relinquishing that bond (Klass, 2007, Stroebe & Schut, 2010, Shear, 2015). Renewed attention to attachment styles and the ways internal representations are formed suggesting normative grief or potential complications (Shear & Shair, 2005). Renewed attention to attachment styles of the bereaved and of the clinician (Fraley & Shaver, 2016, Kosminsky & Jordan, 2016). Another important development was the recognition that there are silent losses and that the bereaved are often denied the right to grieve, which is disenfranchised grief (Doka, 2001, 2002), as is often the case in perinatal loss (Kelly & Trinidad, 2012; Kersting & Wagner, 2012). Also, importantly, there is a deep recognition that families are affected by loss (Walsh & McGoldrick, 2013) and that perinatal loss is a significant and important loss – one that is possibly one of the most poignant and challenging to grieve (Kersting & Wagner 2012; Wenzel, 2014). Doka and Martin (2010) opened exploration around the different ways that men and women grieve. There is also ongoing exploration around neurobiological influences of grief and trauma and the ways these neurobiological processes influence therapeutic outcomes. Specifically, researchers and clinicians are exploring ways that neurobiological processes influence the grief therapist’s attuned presence and ensuing therapeutic alliance – right brain to right brain communication between therapist and the bereaved – which is part of what facilitates change when working with those who are bereaved (Fraley & Schaver, 2016, Kosminsky & Jordan, 2016, O’Connor et al., 2007; O’Conner et al., 2008, Schore, 2012).