* Grief and Bereavement

Working with

Dr Edith Maria Steffen, CPsychol, AFBRsS, FHEA HCPC Reg

HCPC-registered and BPS Chartered Counselling Psychologist
Senior Lecturer in Counselling Psychology, University of
Roehampton
* Learning Outcomes
ü To be able to reflect on own experience and understandings of grief
ü To gain an understanding of how grief can be defined
ü To become familiar with different theoretical perspectives on grief
ü To learn about different clinical presentations of grief, and how to distinguish
grief from depression
ü To develop a critical understanding of diagnostic issues related to grief including
awareness of what is meant by ‘complicated grief’ and ‘prolonged grief
disorder’
ü To consider the specific context of COVID-19 and its implications for grief and
bereavement
ü To become familiar with some therapeutic approaches for working with grief
 * Reflecting on
Mourning…
üHow did you first learn about
death and grief?
üHow is grief expressed in
your own culture/family?
üWhat belief systems have you
grown up with around death
and bereavement?
üWhat rituals have you
observed/been involved in?
üHave your beliefs changed?
* What is Grief?
‘This usual reaction to bereavement [i.e.
intense distress] is termed grief, defined
as a primarily emotional (affective)
reaction to the loss of a loved one
through death. It incorporates diverse
psychological (cognitive, social-
behavioral) and physical (physiological-
somatic) manifestations.’
Stroebe, M.S., Hansson, R.O., Stroebe,
W. and Schut, H. (2001), Handbook of
Bereavement Research, p. 6.
* The Grief Work Hypothesis 1
üFreud’s Mourning and Melancholia (1917):
üFunction: to achieve the goal of
relinquishing the bond with the deceased
and become free to engage in new
relationships
üProcess: painful process of hypercathexis,
‘working through’ and decathexis
ü‘Working through’: active and painful
process of confronting thoughts and
feelings associated with the loss
* The Grief Work Hypothesis 2
üLevels of grief-related distress generally decline over time.
üBUT: do bereaved people need to confront grief in order to adjust to the loss?
üThere is little evidence that disclosure of emotions to others leads to better
adjustment.
üAvoidance can be an effective way of coping.
üHowever, talking about intrusive thoughts to others is associated with better
adjustment (social support?).
üSome evidence exists for a positive impact of cognitive reframing, sense-
making and finding meaning/benefits.
üVirtually no empirical evidence exists to supports the hypothesis (Archer, 2008).
* The ‘Breaking Bonds’ Paradigm
üDisengagement from the deceased is seen as
necessary in order to adjust to the loss.
üPathologising of the bond led to techniques
such as ‘re-griefing’ psychotherapy.
üInternalisation of the deceased is seen as
serving disengagement, or else pathology.
üContinuing are bonds seen as ‘unresolved’
loss, and signs of complicated grief.
üThe theory fails to distinguish between
forgetting someone is dead and a non-static
continuing relationship with the deceased as
an ongoing resource, spiritual presence etc.
* The Breaking Bonds Paradigm as a Cultural
Construction
ü Freud’s theory, as located in modernism, i.e.
emphasis on reason, rationality and
observation, continuous progress, goal-
directedness, efficiency (in psychology:
machine metaphor of human functionality)
ü Grieving then seen as a debilitating
emotional response, troublesome
interference with daily functioning (Stroebe,
Gergen, Gergen and Stroebe, 1996)
ü Effects of two world wars on grief
expressions and stance towards deceased
(Walter, 1999)
* Grief is a Permanent Reality
‘The reality is that you will grieve forever. You will not “get over” the loss
of a loved one; you will learn to live with it. You will heal, and you will
rebuild yourself around the loss you have suffered. You will be whole
again, but you will never be the same. Nor should you be the same nor
would you want to.”

― Elisabeth Kübler-Ross and John Kessler (2005). On Grief and Grieving,

p. 230.
* Attachment Theory and Stages of Grief
üCompares grief reaction (non-adaptive) to separation reaction
(adaptive) and explains it as an inevitable cost of the formation of close
relationships, aiding survival and leading to natural selection.

üBowlby’s stage theory (Bowlby, 1998)

ü Numbness and disbelief
ü Yearning and searching
ü Disorganisation and despair
ü Reorganisation

üElizabeth Kubler-Ross (1926–2004), Swiss-American psychiatrist, stages

of grief: Denial, Anger, Bargaining, Depression, Acceptance

üEvidence for stage theories: none

* Individual Differences from an Attachment
Perspective

ü3 attachment styles:
üSecure
üAnxious-ambivalent/preoccupied
üAnxious-avoidant (further split into two styles: fearful-
avoidant/disorganised and dismissing-avoidant)
üDismissive-avoidant and secure associated with strongest resilience
üFearful-avoidant – highest levels on all measures
* Two-Track Model of Bereavement
üOriginated by Simon Shimshon Rubin
üCombines insights of the psychodynamic and
interpersonal views of loss with the empirically
oriented stress and trauma perspective
üTrack 1: bio-psycho-social functioning
üTrack 2: relationship with the deceased
üDeveloped the Two-Track Bereavement
Questionnaire (TTBQ), useful research and clinical
measure
* Dual Process Model (DMP)
üStroebe and Schut (1999)
ü2 processes:
üLoss-oriented coping
üRestoration-oriented coping

üAvoidance and mitigation allow rebuilding

of life; confronting the loss allows
restructuring of mental representations of
the lost relationship
üOscillation between the two processes
üEvidence: empirically supported
 ü Rooted in insights from cross-cultural research and non-

* Continuing Bonds Western cultures

ü Seminal publication in 1996 by Klass, Silverman and
Nickman
ü Signalled paradigm shift in bereavement research
ü New anthology published in 2018 (Klass and Steffen)
 * Basic Assumptions of the
Continuing Bonds Model
üContinuing a relationship with the deceased is normal and can be positive for the
bereaved.
üContinuing bonds are socio-cultural, not the same as attachment relationships
between separate individuals or merely ‘internal’ connections.
üThe self is relational; part of ourselves is bound up with those we are closely
connected with, and these relationships stay part of us.
üContinuing bonds have a communal dimension, not just between individuals.
üContinuing bonds are dynamic and fluid; they are not ‘frozen in the past’.
üHow we understand and experience these bonds is shaped by cultural narratives,
(religious) belief systems and practices.
üContinuing bonds are best explored from many angles and by multiple disciplines.
 * How Do Continuing Bonds
Manifest Spontaneously?
Some examples:
üTalking to the deceased
üSharing stories about the deceased
üLeaving messages to the deceased on social media
üSense of presence experiences
üDreaming of the deceased
üKeeping significant mementos
üEngaging in rituals to honour or memorialise the deceased
üLegacy projects
üShared meanings/symbols/metaphors
* Durable Biographies
Tony Walter, British sociologist
üThe purpose of grief is to construct a ‘durable
biography’ of the deceased that allows the
bereaved to integrate the deceased into their lives
(1996).
üConstruction occurs through talk with others.
ü‘Privatisation of grief’ has led to bereavement
counselling as primary location for this.
üFacebook is a new public arena for co-construction
of ‘durable biography’ (Kasket, 2012).
* Meaning Reconstruction in Bereavement
Professor Robert A. Neimeyer, Portland Institute
of Loss and Transitions, constructivist
psychotherapist
ü‘A central process in grieving is the attempt to
reconstruct or reaffirm a world of meaning that
has been challenged by loss.’ (Neimeyer, 2016,
p. 2)
üThere is a greater need for sense-making and
reconstructing meaning (Currier, Holland and
Neimeyer, 2009).
* Disrupted Stories, Shattered Assumptions

Life events that

disrupt our self- Our assumptions about
narratives – the world as
predictable, about the
incompatible benevolence of the
with the plot universe, that people
structure are trustworthy and
that life is fair can get
shattered (Janoff-
Bulman, 1992)
* Meaning/Sense-Making as Strong Predictor
of Grief Reactions
ü In parental loss (Keesee, Currier and Neimeyer, 2008), sense-making
predicts grief reactions more than time since loss, the gender of the
parent, or even cause of death.
ü Bereaved adults have less grief-related symptomatology when able
to make sense of the loss.
ü There is greater wellbeing among older widows and widowers as
much as four years after the loss.
ü Meaning is a mediator (Milman, Neimeyer, Fitzpatrick, MacKinnon,
Muis and Cohen, 2017).
 * What is ‘Normal’ Grief?
üMany assumptions but not enough empirical evidence
üMismatch between clinicians’ views and empirical evidence
üGeneral assumption: a period of distress followed by recovery
(evidence: less than half show ‘normal’ grief pattern)
üGreat variability in responses to loss, individual, historical and cultural
variations (Rosenblatt, 2013)
üNo empirical support for absent grief as pathology; no evidence for
‘delayed grief’
(Bonnano, Boerner and Wortman, 2008)
 When a person experiences a significant loss and
the resultant grief is not openly acknowledged,
socially validated or publicly mourned

‘No right to grieve’, ‘no claim for social sympathy or

support’

* Disenfranchised Grief is legitimated only when the lives of the

Grief
victims are considered beyond reproach.

Examples: unrecognised relationship,

unacknowledged loss, exclusion of griever,
stigmatised death, mourners whose grief expression
deviates from cultural norm

Doka, K. (2008). ‘Disenfranchised grief in historical

and cultural perspective’. In: M.S. Stroebe, R.O.,
Hansson, H. Schut, and W. Stroebe, Handbook of
Bereavement Research and Practice, pp. 223–240.
* Trajectories of Grief from Prospective
Longitudinal Studies
üResilient trajectory: no mental health problems or dysfunction pre-loss, good
adjustment post-loss
üImproved trajectory: depressed pre-loss, improved post-loss (spousal illness
and prolonged caregiving); 18 months on, like resilient group
üChronic grief trajectory: pre-loss dependency and positive about relationship;
loss-related; improved by 48 months
üChronic depression trajectory: pre-loss dependency and negative about
relationship; enduring problems exacerbated by loss; poorest adjustment
(Boerner, Mancini and Bonanno, 2013)
 Grief
üHigh level of distress
üStruggle with loss; distress due
to loss-related thoughts
üPangs of grief, positive emotions
and humour may be present
üPreoccupation with thoughts
and memories of deceased
üSelf-esteem preserved (except
perceived failings vis-à-vis the
deceased)
üSuicidal thoughts about ‘joining’
the deceased
Clinical depression
üHigh level of distress
üEnduring emotional difficulties
exacerbated by loss
üPersistent depressed mood,
pervasive unhappiness
üSelf-critical/pessimistic
ruminations, feelings of
worthlessness
üSuicidal thoughts due to feeling
worthless, undeserving, unable
to cope
* Complicated Grief/Prolonged Grief
Disorder
üControversial construct giving rise to much debate – lack of consensus
üSymptoms described as ‘profound separation distress, emotionally disconcerting
and invasive memories of the deceased, emptiness and meaninglessness, inability
to accept the loss, difficulty continuing to live life in the absence of the loved one’
(Burke and Neimeyer, 2013)
üYears of debate and research around inclusion into DSM of prolonged grief
disorder/complicated grief disorder
üNew DSM-5 category of ‘Other Specified Trauma- and Stressor-Related Disorder’
due to ‘Persistent Complex Bereavement Disorder’ (a ‘condition for further study’)
lacks empirical grounding in a number of respects.
 * Risk Factors for Complicated
Grief
üBeing female
üBeing a spouse or parent (esp. mother)
üViolent death
üLow levels of social support
üAge of deceased (both younger and older)
üAge of bereaved (younger)
üSuddenness/unexpectedness of death
üBeing of non-White ethnicity
ü Anxious, avoidant or insecure attachment
style
ü Discovering or identifying the body (violent
death)
ü High pre-death marital dependence
ü High levels of neuroticism
ü Less education
ü Lower income
ü Problematic relationship with the deceased
ü Recency of the death
ü Lack of family cohesion
(Burke and Neimeyer, 2013)
 * Grief in the Time of Coronavirus

Globally, as of 1:08pm CEST, 20 September 2020, there have

been 30,675,675 confirmed cases of COVID-19, including 954,417 deaths, reported to
the WHO.
 * Stressor 1: Context of Death
üLack of opportunity to ‘say good-bye’
üLack of opportunity to resolve ‘unfinished business’
üUnexpected, premature or ‘preventable’ death
üRupture in caregiving bond
üDeath in an ICU/hospital
üIntrusive treatments
üTreatments discordant with patient’s or family’s wishes
üRestricted communication with medical staff (depersonalised/PPE)
üDistress at seeing loved one suffer and not being able to comfort them
 * Stressor 2: Restrictions on
Burial/Funeral Rites
üUnable to observe cultural/religious rituals
üNot able to view the body or come near the coffin; not able to clothe
the dead
üFuneral planning by telephone only
üFuneral restrictions to six or ten grievers, brevity of ceremony, no
singing, no post-funeral meal, no exchanging of condolences/hugs
 * Stressor 3: Social Isolation in Grief
üLack of social support
üLoneliness
üSense of being under ‘house arrest’
üNot able to use technology to ‘connect’ with family
üLack of distraction/restoration opportunities
üLoss of spiritual/religious community support
* Additional Stressors
üFinancial precarity
üHealth concerns
üWorries about other family members
üDeaths of other friends and family
üAnxiety about one’s own mortality (coronavirus anxiety)
üOther complicated grief factors: female gender, ethnic minority
* Implications for Grief during COVID-19

üThe difficulty of grieving a ‘bad death’ (Carr et al., 2020)

üHelplessness, anxiety, anger, guilt
üExpected increases in depression, anxiety, prolonged grief disorder and post-
traumatic stress disorder (Eisma et al., 2020)
üLearning from previous pandemics: multiplicity of loss, uncertainty, disruption of
connectiveness and autonomy
üCrisis of meaning, violation of assumptive world
üDisproportionate loss in minority communities
* Clinical Assessment of Response to
Bereavement – based on Neimeyer and Jordan (2013)

1. Clients’ narratives of the death and their 6. The psychiatric history of the mourner
reactions to it 7. The stability of the mourner’s life situation
2. Exploration of the meaning of the loss for the 8. The quality of the client’s past relationships
mourner and the relationship with the deceased 9. The coping skills possessed by the mourner
3. Clients’ own evaluations of their responses to 10. The mourner’s expectations about counselling and
loss how it might help
4. An assessment of the ethnic, cultural,
religious, gender-based and social-class factors
that affect the mourner’s experience of the loss
5. The quality of perceived social support from
family and intimate others
* Psychodynamic Psychotherapy
üAppreciation that conscious and unconscious features of the response to loss are
operant
üPast and present features of the relationship to the deceased are significant.
üPost-loss experience of self
üPrevious experiences of loss
üTherapist’s own attitudes and history re loss and bereavement play a role.
üLink between loss and current difficulties can be neither assumed nor ruled out.

Simon Shimshon Rubin, Ruth Malkinson and Eliezer Witztum (2012). Working with the
Bereaved: Multiple lenses on loss and mourning. New York: Routledge.
* CBT and Bereavement
üREBT, using ABC model to identify and correct maladaptive
beliefs
üComplicated grief therapy, including exposure treatment/CBT
for PTSD/EMDR
üACT to help clients accept the reality of the loss
üSchema therapy for the relationship with the deceased
üBehavioural activation, especially where grief is accompanied
by depression
üCognitive restructuring
üUse of behavioural experiments
 * Meaning Reconstruction Therapy
üNarrative-constructivist
üExperiential and reflective
üGrounded in humanistic values
•
üFocus on:
üProcessing the event story of the loss
üAccessing the back-story of the
relationship (continuing bond)
üFinding new meaning in life

(Neimeyer, 2012)
* Upcoming Lectures
4th October - Self-Concept
Emma Chapman, counsellor and trainer

11th October - Suicide Risk

Dr Andrew Reeves, Associate Professor in the Counselling Professions
and Mental Health, Counsellor/Psychotherapist and Social Worker

25th October - ACES (Early Childhood Experiences)

Dr. Suzanne Zeedyk, research scientist, speaker, trainer,
researcher on early years development
* Thank you!
Don’t forget to claim your CPD certificate.