Grief and Bereavement

Thanks so much, Colette, and it's a great privilege and honour to be here. Hello, everyone, and thank you for coming. Thank you for joining. It's great to see so many of you coming here tonight and spending some time on this topic. To me, it's always topical, but at the moment it has become even more topical and we're going to cover some of this as well. I'm just going to familiarize myself here. What I'm going to cover is quite a broad introduction to grief and bereavement. There's going to be different elements to this presentation today. I'd like you, with all of the information and theory that's going to come, also always to keep in mind your own experience and your own understandings of grief. So therefore, the first learning outcome is actually to be reflective around our own grief, to then have an understanding of how grief is actually defined, what sort of different theoretical perspectives there are around different clinical presentations of grief. One question that people often ask me is how do you distinguish grief from depression? I put that in there as another point. Critical understandings of diagnostic issues around grief. What is complicated grief, what is prolonged grief disorder, these things that people often ask and get confused about, I find and then I'm going to dedicate some specific space to Covid-19 grief or pandemic related grief more generally, which is, of course, an increasingly acute issue for all of us to work with and will probably be for a long time. Also, I'm just covering some very broad, different therapeutic approaches to working with grief.

Getting started with ourselves. Before we jump and dive into the theory, I'd like you to just consider for a moment, just for yourself, how did you actually first learn about death and grief? Just recalling this. How is grief expressed in your own culture and your own family? I put there something on food, because whenever I ask people about their grief traditions, they tell me something about food. What belief systems have you grown up with around death and bereavement? What rituals may have observed or been involved in? Have your beliefs changed? Have the rituals changed? Have the customs changed and I'm just talking generally not necessarily Covid-19 related to change, but just cultural change perhaps and individual change. I'd like you just to keep that in mind as you're listening to the theory, because when we meet clients working with grief, we're working with a universal human issue that affects us all. That's very different from some presentations that people come with, where we may not have personal or immediate contact ourselves with. This is a different issue. This is something that connects and combines us all and affects us all so we as counsellors and as therapists, can't sit there with a client without actually having experienced loss and grief ourselves and that coming into it in some form. So, it's very important to be aware of it but maybe for tonight, just to hold it lightly and look after yourself during this presentation. If you are very much affected by something or triggered, please do look after yourself.

What is grief? Sometimes people think grief is just the sadness you feel and sometimes they say, 'oh, no, anger can be part of it as well' and so on. There can be some confusion around it. In the literature, one of the definitions that is used and that I can recommend using as a general definition is the one which defines it as a primarily emotional reaction to the loss of a loved one through death. This is very specific. It's not about non-death related loss, which is a different topic. It's about death related reaction and there's many different aspects to it, cognitive, social, behavioural, physical. I think the physical manifestations of grief can sometimes be underestimated. When we as counsellors, therapists, psychologists think about emotions and psychology, we sometimes forget how physical loss is and how if you are taking a more experiential approach to the practice that you might want to work out with your client, where they're feeling it in their bodies, that loss.

Going into the theory, we usually start with Freud. Yeah, because so much goes back to Freud. The whole 20th century approaches to grief work, bereavement, they often have their roots in Freud's famous paper Mourning and melancholia. Whether you like it or not, I always say to people, this paper is so coy. Everyone should read it and it's freely available on the Internet. Freud said the function of grief is that you basically get over that person that you're connected with, you relinquish the bond, you're giving them up, you let go and then move on so that you become free to engage in new relationships. This was the mantra of the 20th century that you had to work through this. There's a process of 'hyper cathexis', you're really getting in there and then you're working through and then you're free to let go which is 'decathexis'. That is painful and it requires confrontation. This was something a lot of us grew up with in the 20th century.

Levels of grief related to stress are often quite acute, quite intense at the beginning, and then they decline over the course of time. However, do people really need to confront it to adjust to the loss? Do we have to do this now go for it and get in there? Actually, in research terms, there's little evidence that we need to do that or that we need to disclose our emotions in order to feel better. In fact, there are quite a few papers that say avoidance can sometimes be a very effective way of coping. So, we shouldn't just dismiss that and buy into this emotional expressiveness culture that arose in the second half of the 20th century in the West. However, sometimes there is also evidence that talking about intrusive thoughts can be helpful and that actually reframing and making sense is a very important aspect of it, but there isn't much empirical evidence for this grief work hypothesis.

Critics have called it the 'breaking bones' paradigm that this kind of letting go and moving on is seen to be as necessary and that pathologizes people who maintain their bond with the deceased and has led to some dubious practices and psychotherapy during the 20th century like re-grieving therapy. So, sometimes this continuing a bond with the deceased was seen as pathological or as showing there's an unresolved grief. Maybe if it's just internalized and your kind of holding that, but if you're thinking you're really still engaging with the deceased, then there's something wrong. This was something that was put against that kind of grief work hypothesis, but it fails to distinguish between forgetting someone is dead and a non-static continuing relationship. So, when it says people who are continuing their relationship with the deceased are in denial of death, most people know that their deceased loved one is dead even if they're continuing their relationship.

People have actually said that 'breaking bones' paradigm is quite a cultural construction because Freud was located in modernism in the early 20th century when people were buying into reason, rationality, progress, they wanted to leave the stuff of the 19th century behind and people needed to function. So, a grief could almost be sort of like a debilitating response that gets in the way of this functioning. Another reason that maybe there was this move towards letting go and moving on was two world wars and when there are so many deaths and people have to survive, then there is little time for staying with grief or continuing with your loved ones. You need to keep going in order to survive. That can also be a factor here why that 'letting go' and 'moving on' was so popular. We see more of those aspects perhaps returning with the Covid-19 pandemic because people may be experiencing so many deaths, especially frontline workers, that they get into the survival mode where they can't stop and grieve.

Interestingly, some people have said grief is a permanent reality and no other than Elizabeth Kubler-Ross has said this, who is famous for her stages of grief. She said "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. 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". I think that reflects what a lot of bereaved people say that they feel they should get over and that feels wrong to a lot of people and actually a lot of people say that loss will always be there, that grief will always be there. It just changes. I think it's important for us not to take it away from people. As counsellors, therapists, sometimes we want to fix things, but actually working with grief is very different. It's not about fixing anything. Here people feel much more validated if they're actually allowed to have their grief and to have their loss, but maybe take a new perspective to it.

Other theoretical perspective that has been very influential in grief and bereavement and scholarship and practice is attachment theory, of course. Attachment theory really comes from a biological evolutionary perspective and has really sort of looked at the grief and bereavement as some kind of odd side effect or the cost of relationships rather than something that's adaptive in itself. What they've said is that separation reactions, they are adaptive because if I lose my caregiver, my secure base, I need to find it again. I have to have these reactions after the loss because the connection is important to my survival, but why do we have it even when the person is dead? That, they say is just sort of an inevitable cost. It's a side effect, but it's not adaptive in itself. We need to kind of 'get over' it and that is where a stage theory comes in. There have been a lot of stage theories in the 20th century, not just in bereavement. Stage theories were simply very popular. Nowadays, I think we all realize things don't go that neatly in stages, but sometimes people find it helpful to look at it in stages. Bowlby came up with some stages, Colin Mary Parks who's not figuring in this presentation, but of course, is a very important person in bereavement scholarship and practice as a UK psychiatrist who's done a lot of work on it. Then Elizabeth Kubler-Ross, who's stages of grief are still floating around in public imagination and in the media. Every time someone talks about loss or grief, someone comes up with the stages of grief, denial, anger, bargaining, depression, acceptance and people seem to like this theory. I used to get worked up about it and I don't anymore because now I think, okay some people find it helpful and because grief is so overwhelming, you want to have something to hold on to. Sometimes people find these stages helpful. However, I can't tell you how many people I hear coming in through the door and saying 'I'm in the wrong stage' or 'I've missed out a stage. I don't think I'm grieving correctly' and that's where these stage theories have actually done some damage I think, because people think that there's a specific way they should be grieving and if they're not, then there's something wrong with them. So, a lot of time in bereavement work, I find, it's about validating people's individual reactions and responses and supporting them with their own journey. Also, from a research perspective, there's actually no evidence for these stage theories.

Some evidence is there that there are individual differences in accordance to attachment style so that some people with particular attachment styles find it easier than others, they'll have a better trajectory through it. No surprise, secure fare better through grief and also dismissive avoidant. So, yeah, if I don't get very involved in relationships, then obviously the loss of them isn't going to hurt me as much. Fearful avoidant is the highest on all the sort of grief complications measures. That's an interesting one. Where anxious ambivalent/preoccupied so people are much more expressive and may come with more pain and grief and they actually do better than those who are in the fearful avoidant category. Which could be some evidence for this kind of grief expressiveness, so maybe for some people, that expressive way of working through and processing their grief is more relevant than for others.

Now, here is a different theory, and this is the two-track model of bereavement, which was developed by Simon Shimshon Rubin, and he combined a psychodynamic approach with a stress and trauma perspective. What he came up with was that actually people's grief processing is on two tracks, like a train you're fairing on, you're travelling on. One is the bio psychosocial functioning and one is the relationship with the deceased. He was actually one of the first people to bring the relationship with the deceased into the room, officially as part of his model and to say that 'actually, this relationship is important to work on and to talk about'. He also developed this questionnaire which can be quite useful not just for research, but also for clients to complete and to see what's going on for them. I've used it like that, which was quite helpful.

This model is a little similar to the two-track model, the dual process model. This model has the most empirical evidence behind it for the process of how people actually grieve. So, they came up with these two processes, the loss orientation and the restoration orientation and that people can be either in the one or the other. I actually find people can mix them more like the Gestalt figure and ground so sometimes the loss is more in the foreground, sometimes the restorations are in the foreground. They're moving like that. People in the loss orientation will be doing the grief work or having intrusive images around the grief and there are all the issues around the death itself that are going on for them and they're dealing with that or they're engaged with that. Well, that's sort of what's in their minds. Restoration orientation is where people feel 'I've got to continue living. I've got to make supper for my kids. I've got to do this, that and the other' and you're just continuing or you're making new things. You're getting engaged in life in new ways. What the dual process model says is that people oscillate between these two orientations and that that's a natural process and they usually go in their own pace and in their own ways and that's a great thing. What I find is that clients really love this model when I show them that and they find it helpful because, for example, sometimes someone may be really in this restoration orientation and they're worried if they suddenly go back to the loss, that somehow, they're going backwards. This model helps them to see that actually they're still going forwards, they just need to go back there, back and forth. Similarly, someone who's very much in loss orientation, you can show them that. If they do more on the restoration or interpretation side, it doesn't mean they can't go back because a lot of people also feel like they're betraying the deceased if they're re-orientating towards life now. So, in some ways that can be reassuring to them that it doesn't mean they're going to leave this alone.

This perspective is closest to my heart, and because I'm already far behind on my schedule, I have to be really, really brief. Just to say that this model of the continuing bonds model is based on research into cross-cultural research. So, research into non-Western culture specifically, or particularly Japanese. There was a seminal publication of this book 'containing bonds new understandings of grief' in 1996, which actually really changed bereavement scholarship and practice. It's been revolutionary and how it changed things. There's a new anthology that I've co-edited with Dennis Klaus that came out in 2018 on this and I can't go through all these assumptions, but I hope you can read them up later. What I just want to pick out is that this perspective shows that actually it's normal and natural and can be helpful to continue your relationships with the deceased. This is not just about attachment. This is a socio-cultural perspective because our relationships are embedded in systems and families, communities, groups. It's not just about me and my deceased loved one. It is about everyone around it and are they still talking about them? Are they still mentioning their name? Is there still space or a place in this society for my deceased loved one? So, this is a bigger thing, but I won't go into more detail. Just to say how continuing bonds can manifest, for example, people talking to the deceased or sharing stories about them, increasingly leaving messages on social media. You see people on Facebook saying happy birthday to their deceased loved one, a sense of presence experiences which over 50 percent of the bereaved population have. Dreams, symbols, rituals to honour people being guided by the deceased, using symbols, metaphors, legacy projects and so on. I have to rush through that sorry.

Very similarly and in parallel to the continuing bonds model, when that developed Tony Walter in Britain and University of Bath, the British sociologist wrote something about the durable biography of the deceased as that this is the goal that people have or the purpose in grief. He was saying we are constructing each other through talk all the time. So, it's a very social perspective that who we are is often determined by how we're speaking, how we're talking to others, what they're seeing in us, what they're bringing out in us and the same goes for the deceased. So, after someone has died, we're actually still constructing and writing their biography. The last chapter hasn't been written. It's often things that emerge after they died, people sharing stories, this kind of thing. That was very difficult towards the end of the 20th century, where people were more and more pushed into a privatization of grief, where you could only talk about this maybe in counselling, but not elsewhere. Facebook and social media have actually changed all this. There's now a new public arena for this co-construction of the durable biography.

This is another model that is very close to my heart, which is the meaning reconstruction model. Now this is a much more existentialist, more therapy orientated model developed by Professor Robert Niemeyer in the USA. He was actually saying that a central process in grieving is the attempt to reconstruct or reaffirm a world of meaning that has been challenged by the loss. He was saying that in grief it's not just the loss of the person, but actually it's a bigger thing that's happening here. This goes back to theories by Janoff Bulman on shattered assumptions that when we are experiencing something very traumatic in our life, it disrupts our whole understanding of the world, our whole understanding of ourselves, especially when it's traumatic, when it's unexpected, when things are connected with this that are not what we expected or what we thought should happen and that can really throw ourselves into this turmoil where we have to make new sense. This whole narrative of our life is becoming challenged by this and needs to be rewritten.

This meaning making, this sense-making has been shown to be a strong predictor of grief reactions, and I'm not going through these, these are about different findings from research where it's shown that meaning and sense-making has a very important role in how people cope with their grief.

So, what's normal grief? There are actually many different assumptions, we don't know what's normal, so it can be so varied. However, generally what has been observed universally is that there's a period of distress followed by recovery. How that happens, is so variable individually, historically, culturally. It's really important that we're not imposing some kind of idea about how people should grieve or what is a normal pattern on our clients.

One concept that people find really helpful is disenfranchised grief. Now, this is when you've experienced a loss and you are not allowed to mourn this publicly. An example could be that your secret lover has died. Yeah, you can't go to the funeral. You're not recognized as a mourner. There's no right to grieve. This is an extreme example, but people experience this in all sorts of situations and sometimes to a small extent in various different types of loss. For example, someone died who was a drug user. There's something about the grief where people feel that there's a stigma there, that the person was not completely beyond reproach and so it's almost like that then is impacting on their right to mourn or how much society allows them that. There are different examples and not being able to mourn publicly, I think is also an issue in the pandemic.

There are some trajectories of grief. I'm not going much into them where you could see how people tend to fare better. Some people do better than others. Maybe you can look at that in your own time and maybe just to pick out that people who were very depressed before the death and also very dependent maybe or negative about the relationship, they have the hardest time after that. Especially where there is some sort of unfinished business in the relationship.

So, to compare grief and clinical depression, because people often want to know, 'well, how do I distinguish that?' There are some pointers, if you really need to distinguish it. In depression, you also have the distress and you also experience the emotional difficulties, but they're more enduring and they're exacerbated by loss rather than caused by the loss. The other thing is that people who are grieving, they may be sad one minute, but they may have a joke and make a joke the other minute so they can go up and down. Whereas in depression, you're often just down. The other big difference is that in grief you're preoccupied with the deceased, whereas in depression, it's yourself, your self-worth is so low that you're so self-critical. Also, when you're thinking about suicide, is that in depression it may be because you're feeling so worthless or undeserving or unable to cope, but in grief, your suicide wishes may be about joining the deceased. So that's important and there is a higher suicide rate in grief. It's something to be aware of maybe when you're working with people. This doesn't mean you can't have both. You can be grieving and depressed. If you want to label people in that way or label their experiences in that way. The diagnostic systems allow you now to do this, whereas in the past they didn't.

There is an issue around this complicated grief thing and prolonged grief disorder, what is it? It's a controversial construct, as so many are, and there's a lot of debate around it. Usually they're talking about very profound separation distress, very emotionally difficult challenging memories of the deceased, emptiness, meaninglessness, difficult to cope, difficult to move on with your life. There's a lot of debate around that whether it should go in the DSM or not, it's still not in the DSM, but it's now in the ICD11 as prolonged grief disorder and it will be entered into DSM soon as prolonged grief disorder as well.

There are certain risk factors for complicated grief that have been found like being female, interesting. There's actually some critique on that, namely that female ways of grieving are being pathologist. There are other things like witnessing the death, especially a violent death, sadness, unexpectedness. Yeah, all sorts of issues. Again, Covid-19 is believed to have many of those characteristics that may increase the prevalence of prolonged grief disorder and complicated grief. That's where we're moving to now.

Now we're in the time of coronavirus. We are approaching a million deaths worldwide. For every death we're sort of thinking that there are five people who are very closely affected by it, that's five million people grieving and if you think about complicated grief, prolonged grief disorder, that is in best circumstances 10 percent but it's been predicted for this pandemic, for coronavirus to go up to possibly 50 percent. So, 50 percent of five million people worldwide might be suffering prolonged grief disorder in the future just if we stop now dying from it.

So, what contributes to this? There are all these different stressors to bear in mind. First of all, the context of the death, like people are saying they can't say goodbye. That leaves people with this unfinished business and a lot of regrets and remorse and unfinished business generally. All of these things you really wanted to tell them before they die. Unexpected death, premature death, preventable death. All these are features and criteria that increase people's grief complications. Rupture in the bond, death in an ICU or hospital is also a factor. That leads to greater grief complications or intrusive treatments, or when there's a discordance between the wishes of the people and the treatment they're getting, when there's less communication with medical staff, not being able to comfort them. One woman was saying all she could do was look through this glass pane and just waving. These are extreme stressors around the context of the death that make that death very traumatic and it can lead to PTSD as well. I didn't even cover that.

Stressor two: Restrictions on burial funeral rites. There is this huge importance for us to actually do these rites, to do the right thing by our deceased loved ones, there is a cultural need for us. Not able to view the body or come near the coffin can be extremely distressing, not able to clothe the dead. These are things I picked up sometimes on social media where people were writing how difficult it is for them in the course of the last few months, funeral planning by telephone only. It's interesting that in the U.K. we've just heard that funerals are now allowed to have 30 people. I think weddings, it was 15. I can't remember, but it's interesting that there's actually now recognition how important it is to attend a funeral of a loved one. Even those funerals will still probably be restricted in how they're conducted. The social distancing, you can't hug, that physical closeness of being there for each other. Sometimes that is the most important thing and not the words you say, but just that physical presence and all of this is denied people.

Stressor three: social isolation and grief. This is the huge impact, it has huge impact on people to then be sent home on their own, possibly not being able to see anyone. They're shielding, they're being socially isolated, their self-isolating or they're in quarantine, whatever it is. They are lacking social support and the significance of social support and bereavement is huge because loneliness, people feel they are under house arrest, not able to use technology perhaps some older people sometimes don't have that technology, there's lack of distraction because not much is happening. All these activities maybe that you used to go to, they're not happening, maybe no spiritual support. So, an enormous stressor. Then there's additional stressors with financial precarity, as we know with what's happening all around us other health concerns, worries about other family members, maybe other deaths, maybe anxiety about one's own mortality. There's a lot of research on coronavirus anxiety that could come into this and other complicating factors, female gender or being an ethnic minority, which has been shown is a factor as well. So, there's more implications of how difficult it is to grieve about death and coronavirus death needs a lot of those criteria. There's a lot of helplessness around. Anxiety, anger, guilt, we’re expecting huge increases in depression, anxiety, prolonged grief disorder and PTSD. There's some learning from other pandemics how this increases people's mental health problems and that there's like a crisis of meaning, a violation of the assumptive world and how we're seeing a disproportionate loss in minority communities as well.

That was a quick run-through of the coronavirus. I'm aware of time, and I hope I can just whizz through my final few slides, which are just more like pointers to say. For the clinical assessment of the response to bereavement, I've just put together here based on another chapter somewhere or in a whole section of the book, really what to look for and what to cover when you're meeting someone for the first time who's been bereaved. It doesn't mean you need to sit there with a tick box with all these issues, but it's something to keep in mind. All the things that might be relevant, like how they're telling you the story of the death. What does it mean to them? What the relationship of the deceased means to them, how they view their own loss, any cultural factors that are affecting that. Is there social support available? Maybe their history of mental health problems, current life situation, quality of past relationships, coping skills, their expectations about how counselling might help. So, there's quite a lot that can be useful to bear in mind, not necessarily asking everything. I just wanted to highlight key approaches and what they might be focused on. Psychodynamic psychotherapy would look a lot at not just the conscious, but also unconscious features and factors in the response to the loss and look at how past relationships are significant now for this, how past experiences of loss might be impacting, how the self is experienced as different to before the loss. Through countertransference and therapist’s awareness of themselves is, of course, very important in psychodynamic therapy. I think it's important, maybe not under the name of countertransference that we talk often about use of self. It's about that awareness also of the self that comes in. There may be a link between the loss and current problems, but it may not, it's not necessarily the case so some kind of openness is important.

CBT approach are quite different to grief. I haven't actually worked in a straightforward CBT way with bereavement, although I do CBT, but it just hasn't felt right for me to do rational emotive therapy using ABC, but I wouldn't rule it out. It may be that with some clients it can be very helpful. There's also complicated grief therapy by Kathy Shear, which includes a very strong exposure element to the event of the death, which can be very helpful to people who have a traumatic experience around that death. I have used EMDR for bereavement and grief and especially for the traumatic elements of the death rather than for the relationship or itself or act for accepting that reality gap that there is a gap that cannot be filled and how can you live meaningfully with that. Different ways which I won't go into now bit by bit.

I just wanted to finish with meaning reconstruction therapy, which is also meaning oriented therapy, which I use or have also been involved with, with Robert Niemeyer together in some pilot research that we've done. This is a narrative- constructivist approach. It's much more existential in a way, as we've already spoken about when I said this whole assumptive world that is shattered or challenged by the loss and that the person needs to reconstruct. This is not a very cognitive, intellectual, abstract method. It is very experiential. It's really about engaging with that process, maybe through letter writing and getting in touch with those emotions, feeling it in the body, using symbolization, maybe even focusing, chair work is used in this as well, like the empty chair to deal with unfinished business, narrative techniques. We use like letter writing and so on. Then there's that reflective element, of course, as well. It's very much grounded in humanistic values so it's more like linking with person-centred and experiential therapies generally. The focus is on processing the event story of the loss, accessing the back story of the relationship, the continuing bond, and then finding new meaning in life. Meaning is central here in two ways. One in terms of sense-making and one in its significance finding. What really matters to me, that's the existential element of it. That meaning in terms of what do I value? What gives me meaning and how can I find a meaningful way of living with this loss, with this grief going forward?