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Clark - 2001 - MAPPING GRIEF AN ACTIVE APPROACH TO GRIEF RESOLUT
Clark - 2001 - MAPPING GRIEF AN ACTIVE APPROACH TO GRIEF RESOLUT
Death Studies
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MAPPING GRIEF: AN
ACTIVE APPROACH TO
GRIEF RESOLUTION
Sheila Clark
Published online: 11 Nov 2010.
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SHEILA CLARK
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This article describesa clinical tool, the Grief Map, that isdesignedto assist those who are
grieving death and non-death losses.The map provides a constructive multidimensional
framework for dealing with the phenomena of the grieving process and for rebuilding life
following major loss.The method of developing the map and its various uses as an assess-
ment, educational, and therapeutic tool are detailed with illustrative case examples.The
underlying precepts on which the map is based and its correlates with current theory and
research are discussed.The limitations of the map and issues for further research are dis-
cussed.
Grieving people want to know how to deal with grief but Silverman and
Klass (1996) noted that they tend to refer to familiar models even if they
are not appropriate.This is problematic as older models provide limited
prescriptive frameworks and lack structure for rebuilding life again.Yet
a considerable amount of interest has been generated recently in how
people reconstruct their lives following major loss. Indeed, constructs of
the grieving process have moved on from passive models, such as the val-
ley (Psalm 23), disease (Engel, 1961), and stages (Kubler-Ross, 1970;
Westberg, 1966), to active approaches involving work (Freud, 1917=1934;
Lindemann, 1944; Parkes, 1988), tasks (Worden, 1991), dosing (Stroebe
& Schut, 1999), participation (Macnab, 1989), and challenge, personal
growth, and fulfillment (Attig,1991; Frankl,1963,1969).
531
532 S. Clark
This article describes a clinical tool, the Grief Map, which is simple to
use, provides a constructive multidimensionalframework for the grief ex-
perience, and incorporates the concepts of the active models mentioned
above. The map adheres to additional recommendations for grief con-
structs (Corr, 1999; Shuchter & Zisook,1993; Stroebe & Schut,1999) by
being non-prescriptive and allowing for individual, gender and cultural
differences.Through its applicabilityto both death and non-death related
losses, it also encompasses disenfranchised grief, thereby also providinga
framework for a broad range of client issues found in clinical settings.
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Method
The map was created using a stepwise clinical and consultative process.
The initial draft was the result of a study of grief, using field methodol-
ogy (Schatzmann & Strauss, 1973) in individuals attending a support
group for persons bereaved through suicide. The author acted as lead-
er=facilitator in the group discussion at 96 support meetings.These were
attended by 97 participants (74 women and 23 men) on a mean of 4.5 oc-
casions (range 1720). The mean time of entry was 2.3 months after the
death (SD ˆ 9.5, range 0.5760) and the majority of attendances oc-
curred during the first 2 years after bereavement. Grief phenomena ex-
perienced by participants were observed and recorded by the author
immediately after each meeting. The time interval since the death at
which these phenomenawere experienced by individuals was also noted.
Phenomena were drawn as triangles to represent mountains, which were
placed under the most relevant section of a three-part timeline, repre-
senting early, middle, and late periods of grieving. At this stage, the
map included all the phenomena of ``Unreality,’’ the three top lines of
phenomena under ``Survival,’’ and all the phenomena of ``Reorganisa-
tion’’except ``New relationship with the deceased’’and``Finding meaning
from the loss’’ of the final map shown in Figure 1. During the study, the
author noted the loss of self-esteem (Sëguin, Lesager & Kiely, 1995)
and lack of recognition by participants of their accomplishments in deal-
ing with their grief and their ongoing lives. In addition there was fre-
quent use of negative euphemisms, such as ``breaking down,’’ ``falling
down a pit,’’and ``victim.’’ The map with its mountains was conceived to
reframe the participants’perceptions of their coping abilities in terms of
positive attributes and control over their situations.
Mapping Grief 533
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FIGURE 1
The map was then modified according to further trials. It was distrib-
uted by the researcher to participants, as a single event, at group meet-
ings for people experiencing varioustypes of loss.The groups included15
parents of children suffering chronic illness, Compassionate Friends (25
bereaved parents), 30 sufferers of motor neuron disease, and two sepa-
rate public ``healing’’ seminars of 50 and 80 attendees. The participants
were asked to rename, add to, or delete phenomena on the map and to
give feedback to the researcher in the plenary session of the meeting or to
return the map anonymously afterwards. The applicability of the exist-
ing phenomena on the map to the range of death and non-death losses
represented at these seminars was confirmed. No consistent changes
were suggested. However, a search of the literature identified additional
items,``New relationship with the deceased’’and ``Finding meaning from
the loss,’’ which were added to the map. Feedback was then obtained
through use in clinical settings by professionals from various health and
welfare disciplines who had learned about the map through professional
presentations or an earlier publication (Clark,1998). This process identi-
fied two further phenomena,``Tasks of daily living’’and ``Mental fatigue,’’
which were also incorporated.
534 S. Clark
the distress of separation and the secondary losses. The upturn of the
graph represents lessening of the distress as the loss is accommodated
and life is reorganized. The phenomena of bereavement are placed un-
der the section of the graph in which they are most prominent but are
not necessarily limited only to this area. So, for example, those phe-
nomena usually experienced early on in the grieving process are
placed toward the left and later ones toward the right. However some
phenomena may be experienced broadly over the grieving process.
An example is ``Quest for the positives,’’ which may include the early
experiences of realizing that the deceased did not suffer physically
and of others’ compassion and care, whereas recognizing a new sense
of freedom may be a later one. The diagram provides unmarked trian-
gles for additional phenomena particular to the individual. The map
is accompanied by a set of guidelines (See the Appendix), which are
explained under ``Clinical Uses.’’
The premise on which the map is based is the metaphor that the grieving
process is a journey. The grief map is the map of the possible territory
to be covered. The three-part line is the overall route. The area under
the line represents the terrain. In this, the triangles represent the com-
mon phenomena as mountains in the journey.
Grieving individuals are asked to conceptualize each phenomenon of
grief as a separate mountain and to visualize themselves climbing
upward as they progress through an issue. This provides a positive
construct for dealing with negative feelings and helps to counteract the
societal attitudes that the bereaved person is ``not coping’’ or ``breaking
Mapping Grief 535
down.’’ This positive construct assists them to identify the positive attri-
butes that facilitated their progress.
Particularly difficult issues may be reinterpreted as ascending a steep
mountain face and so making progress in a vertical dimension. Grieving
people may feel``stuck’’or ``going backward’’ in their grief. People who see
themselves as not progressing upward can be likened to clinging to a
rock face, which in itself demands strength and courage. Sometimes be-
reaved people feel discouraged when they discover that there is more to
an emotional issue than they originally thought.This is similar to reach-
ing a summit and discovering that there is still another one ahead.
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the mountain and benefit from a companion for the journey. Here a
map, counsellor, or support group may be helpful.
Just as climbers learn the skills of negotiating vertical rock faces, so
the bereaved acquire new skills. These may include expressing feelings,
using thought stoppage for intrusive thoughts and developing strategies
for sleep and self care. Similarly the bereaved will adopt new customs to
assist their survival. For example they may leave behind some of their
former friends who have difficulty accompanying them and may meet
new ones, in particular fellow travellers, who will journey with them
and with whom they can share expertise.
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More important, like any climber, bereaved people need time out to
refresh themselves. Finally, when the summit is reached, the view from
the top may open up new aspects and understanding of life and demon-
strate the individual’s personal growth.
Mountains as Phenomena
Many of the phenomena on the left and central sections of the map are
described elsewhere (Parkes, 1986; Parkes & Weiss, 1983; Raphael,
1984). Some need specific mention.``Mental fatigue’’ includes the tem-
porary loss of concentration and memory, and difficulty in problem
solving as grieving proceeds.``Daily tasks’’ refers to the everyday duties
and responsibilities, whether these are personal, such as washing and
dressing, work-related, or concerned with household duties or care of
others, including children. The term ``Mood swings’’ has been used
rather than the misnomer ``depression.’’ This better describes the labile
mood of grief and distinguishes it from the consistently low mood of
clinical depression.``Legacy of the past’’ refers to grief and traumatic is-
sues existing prior to the death as well as the recurrence of grief about
past losses.``Crisis of values’’ was a term used by Van der Wal (1989) to
imply loss of self-esteem together with a variety of changed beliefs
about self-image and existential issues, such as difficulty in decision
making, priorities and values.``Sense of loss’’ includes the void created
by the major loss and the losses secondary to it.
On the right side of the map ``New relationship with the deceased’’
corresponds to Walter’s (1996) biographical model, Worden’s (1991)
fourth task of emotionally relocating the deceased, and Rubin’s (1999)
``Relationship with the deceased’’ track of his two-track model of be-
reavement. A common fear of bereaved people, namely that the de-
Mapping Grief 537
from the integration of the influence of the deceased person and from
changed priorities and values coming from the loss experience (Nei-
meyer,1998). For example, some people recognize their increased empa-
thy and sensitivity toward others and consequently take up a helping
role. Creating purpose refers to attitudes and actions adopted as a result
of the new meanings, new self, and new life.
Clinical Uses
ceived difficulty (Step 5), the relative heights of the mountains can assist
in differentiating the most difficult issues. Finally, by asking clients to fill
in the mountains to the height they perceive they have dealt with them
(Step 6), the therapist can obtain a quick assessment of the client’s
achievements as well as issues that may need to be addressed.
An example of a map completed by a young widow in the early
months after the death of her husband is given in Figure 2. In this, the
filled triangles indicate she feels she has dealt with the shock and disbe-
lief, the partially filled triangles demonstrate she feels she has made some
FIGURE 2
Mapping Grief 539
progress with these issues, and the underlined but empty triangles indi-
cate she is experiencing these issues but feels she has not made any
headway with them. The most difficult issues for her at that time were
isolation, loss of trust in others, anger and the daily tasks of caring for
the family alone as shown by the heights of these triangles.
Taking the client through this process can help to open discussion
about grief, particularly for clients who find it difficult to talk about their
feelings. Children, young people, males, those who have difficulty with
verbal expression, and those with low IQ respond well. The map can be
particularly useful for people who conceive things visually. Comments
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from clients include ``It was good to see it all in front of me.’’A client
may identify his or her emotions and sort out the confusion resulting
from being ``lost in his or her own grief’’ (Parkes,1988). At the same time
the map can help clients understand that their feelings are normal. For
example, a grieving mother commented that the map``showed me I was
normal.’’A 14-year-old girl whose mother had died, felt relieved at seeing
``Anger’’on the map, exclaiming:``So I’m not a bad girl because I’m angry
at my mother!’’
For therapists who may themselves feel lost in the story of distress, the
map can present a quick picture of the issues faced and clarify where to
start. For example, if ``Suicidal thoughts’’ or ``Mood swings’’ are under-
lined, the therapist can proceed to assess the severity of these.
Another approach, which can be used after leading clients through
this process, is to ask them to draw their own map. By inviting the client
to put personal labels on phenomena, to group related phenomena to-
gether, and to draw the height of the mountains to the scale of their in-
tensity, the map becomes a personalized record of the client’s grief on
that day.
The map also can be used as an educational tool by helping people
understand their grief. For example, explanation of ``Mental fatigue’’
may assist them in making sense of their difficulties in concentration,
decision making, and short-term memory. This will reassure them they
are not becoming demented and help them plan strategies for dealing
with these difficulties. It can also inform them that, in addition to deal-
ing with their emotions, there are the practical, social, behavioral, and
spiritual issues to deal with on the right side of the map.
The map can therefore be used to identify priority areas for the client,
alert the therapist to which new constructs the grieving person may ben-
efit from, and to form a plan of counselling and support.
540 S. Clark
Finally, the map has also been used as a self-help tool for grieving peo-
ple. By using the map with its guidelines (Clark,1998), they can normal-
ize their feelings, assess their progress, recognize their achievements and
prioritize their future actions.
FIGURE 3a
Mapping Grief 541
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FIGURE 3b
the map to facilitate family discussions about grief with her husband and
the remaining four children. The husband discussed his feelings about
the ``Isolation’’ mountain, which led to both husband and wife recogniz-
ing the seriousness of the breakdown of their relationship since the death
of their daughter. In particular, the husband was able to identify from
the map a number of issues he was dealing with, such as guilt and blame,
and was able to explain to his wife how these issues made it difficult for
him to communicate with her. This also led the children, who ranged in
age from 13 to 22, to identify their feelings of aloneness. The family were
then able to put in place some strategies to draw them together.
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The map has also been used by an art therapist for assessing young
people in the aftermath of a peer’s suicide. It was found easy to use in
therapeutic group work with teens as part of a program of activities
and discussion about their experiences with death and grief. Teens
warmed to the idea of a map and found it easy to check off and color in
the triangles that fitted self. The process helped to bring into the open
hallucinations, nightmares and other frightening thoughts and feelings
that individuals were reluctant to speak about. It became a reference
point to discuss shared experiences and open the way to specific topics,
such as beliefs, cultural norms and the extrasensory dimension.
Case Examples
Case 1
Mrs. X is a 59-year-old divorced woman who somatized her emotions.
She regularly frequented her general practitioner’s surgery with physical
complaints as a ticket-of-entry to talk about emotional issues. After a
new diagnosis of non-insulin-dependent diabetes was made she con-
sulted her general practitioner with grief due to her apparent loss of her
health.
She was introduced to the map at this point. The map was a catalyst
toward her identifying her feelings and enabled the emotional issues that
had previously been bottled up inside her to be brought to light. For
homework she drew each mountain on a separate sheet in proportion
to the size of her feelings and listed the causes and associated feelings
alongside. She returned with several pages of ``mountains’’on which she
had obviously spent considerable time and which led to some important
Mapping Grief 543
by those she had previously had faith in, and consequently perceived
herself to be isolated and unsupported. She identified anger because the
diabetes was yet another loss in her life, at her family past and present, at
her husband, and at the church leaders.
The map was useful in giving her a framework for legitimizing and
working through the grief that had built up over her life from the many
losses. The pictorial and written representation of these losses and asso-
ciated emotions not only assisted her catharsis but also helped the coun-
sellor to understand her perspective. For example, the issue of her
integrity relating to the diabetes could be addressed in relation to the
physical and sexual abuse and with education about the causes of dia-
betes. The various losses, many of which she had never previously
discussed with anyone, were addressed in turn.
The counsellor also challenged her to look at the mountains of reor-
ganization. As a result she found that learning to manage her diabetes
would equip her better to live a healthy life style for the rest of her life.
She also perceived she would have a better understanding of how to help
others through her own understanding of dealing with diabetes and this
also gave meaning to her experience of diabetes. After some months she
completed another map and, from the increased number of filled-in tri-
angles, recognized the progress she had made. Following this she was
able to list several pages of personal attributes that helped her see herself
as a whole person. Her somatized symptoms reduced with a program of
ongoing counselling and support.
Case 2
Mrs. Y was a 35-year-old widow with 10-year-old twins. She presented
for counselling following the suicide of her husband 8 months previously.
544 S. Clark
She appreciated she made progress and could identify her personal
strengths. Consultationson a monthly basis helped her work through the
various mountains and provided support and recommended strategies
for dealing with the mountains of reorganization. In a second map com-
pleted10 months later, she hadtotally filled in``dailytasks’’aswellas partly
accomplished some of the mountains of reorganization. At this point she
recognized she was``turning a corner,’’ talked proudly about her achieve-
ments and terminated her counselling. For her, the map was helpful in
helping her identify her strengths and in assisting her to move on.
Discussion
the journey also provides the notion of resting from the journey, which
corresponds with the dual-process concept of ``time off from either cop-
ing orientation.’’
Central to the success of completing the journey are the concepts of
challenge, choice, and control, which Frankl (1963) and Attig (1991) de-
scribed. The map also accommodates both the psychological as well as
the social transitions (``Daily tasks’’; ``Creating a new life’’) of Parkes’
(1988) model and of Averill and Nunley’s ``Levels of Organization’’
(1993). Like Rubin’s (1999) model, the map provides for both tracks of
grieving:``Functioning’’and ``Relationship to the deceased.’’
Conclusion
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Appendix