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Article Excerpt
The primary purpose of the present article is to provide an overview of three theories of mourning--The Dual Process Model of Coping with Bereavement, Meaning Reconstruction and Loss, and Attachment Theory and Loss: Revisited. These are linked both by their emphasis on the phenomenological and by ideas such as balance and flexibility. Connections are drawn between the mourning theories and counseling theories that are commonly employed by mental health counselors.
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Death and non-death-related losses are pervasive experiences that often lead to considerable stress and may serve as catalysts for psychiatric illness (Bloom-Feshbach & Bloom-Feshbach, 1987; Harvey & Weber, 1998). Nonetheless, mental health graduate programs do not routinely include death-related training in their curricula (Duggan, 2000; Hunt & Rosenthal, 1997), even though research indicates that death-related issues present a unique challenge for beginning master's-level mental health practitioners (Kirchberg, Neimeyer, & James, 1998).
Significant and profound advances in theory have been made in the field of thanatology (i.e., study of death and dying) since the pioneering work of Kubler-Ross (1969). In this article, background information, including definitions, and a brief introduction to three current theories of grief and mourning are provided. In addition, connections are offered between these advances in thanatological theory and the theories commonly used in practice by mental health counselors. The intention is to present links that will assist mental health counselors in incorporating cutting edge conceptualizations of grief and mourning into their work with bereaved clients.
BACKGROUND INFORMATION
Definitions
Because discrepancies exist in their usage within the field of thanatology (Corr, Nabe, & Corr, 2000), the terms bereavement, grief, and mourning will be defined for this article. Bereavement is the state of having experienced a loss (Rando, 1995); this definition corresponds with the accepted practice of describing an individual as bereaved, rather than as bereaving. Grief is the generally passive and involuntary reaction to the state of bereavement. Although grief is commonly considered an emotional state (i.e., sadness), it actually extends well beyond the realm of emotions (Rando, 1993). The complex responses associated with grief span the affective, cognitive, physical behavioral, social (Rando, 1995, Worden, 2002), and spiritual domains of human functioning (Cook & Dworkin, 1992; Corr et al., 2000). Mourning involves the active processes of coping with bereavement and grief (Rando, 1995). Although there appears to be consensus that mourning involves some kind of integration of the loss experience (Corr et al.; DeSpelder & Strickland, 2002; Rando, 1995), the exact nature both of the processes involved and the optimal outcome of this integration are areas of considerable controversy (e.g., Wortman & Silver, 2001).
Theories of Grief
Because grief is the involuntary reaction to bereavement, theories of grief are those that offer descriptive pictures of how the varied responses may manifest. Kubler-Ross' (1969) five-stage theory of the dying process (i.e., denial, anger, bargaining, depression, and acceptance) is one such example. Prior to the work of Kubler-Ross, Parkes (Bowlby & Parkes, 1970; Parkes, 2001) developed a description of the phases of grief that extended Bowlby's (1969, 1973) attachment theory. These phases included "(a) numbness, (b) yearning and searching, (c) disorganization and despair, and (d) reorganization" (Parkes, pp. 29-30).
The many descriptive stage/phase theories of grief that have emerged in the literature (e.g., Kavanaugh, 1972; Miles, 1984; Sanders, 1999), including those with up to 10 discrete elements (Westberg, 1971), are potential therapeutic tools in normalizing the experience of bereaved individuals. However, mental health counselors must be cautious when applying such theories to clinical work. The ease with which these theories can be consumed has often led to literalism in application (Payne, Jarrett, Wiles, & Field, 2002; Worden, 2002). Such literalism, rather than preventing complications in the experience of grief, can and often does produce such complications. When misapplied, these descriptive theories of grief responses can serve to foster a should or must (e.g., Ellis' 2000 REBT) mentality for bereaved individuals such that their concerns about grieving correctly actually become a stressor in and of themselves. Both Kubler-Ross (1969) and Parkes (2001) stated that their identified patterns were descriptive and only rough guides. In general, (a) there is no reason to believe that there are a discreet number of responses to the state of bereavement, (b) even if there were, there is no evidence to suggest that these responses would proceed in a linear fashion, and (c) such descriptive approaches were / are not intended to serve as prescriptions for the right or correct manner in which to die or experience grief (Corr, 1993).
Although there is valuable information to be gleaned from the observed patterns in grief responses, these patterns should not obscure the remarkable uniqueness of the experience of grief (e.g., Aiken, 2001; DeSpelder & Strickland, 2002; Fleming & Robinson, 2001; Silverman, 2000). Factors contributing to the idiosyncratic reactions to bereavement include personality traits, cultural background, and developmental level of the bereaved as well as the nature of the relationship with the deceased, mode of death, availability of social support, and previous and concurrent stressors (DeSpelder & Strickland; Corr et al., 2000; Worden, 2002). Because of its emphasis on the individual's phenomenological experience, a person-centered framework has often been suggested as appropriate with bereaved clients (Barbato & Irwin, 1992; McLaren, 1998). However, criticisms of Rogers' (1980) work have been similar to those offered in connection with a clinical emphasis solely on grief expression, without an accompanying focus on mourning and coping. More specifically, the person-centered approach has been criticized for the contention that the therapeutic conditions are both necessary and sufficient for encouraging awareness and, therefore, growth (Corey, 2001). In fact, Gilliland and James (1998) argued that the perception of the lack of technique to move clients beyond the expression and acceptance of negative emotions is a common criticism of Rogers' approach. In quite parallel fashion, Rando (1993) has suggested that the expression of grief (i.e., the involuntary and passive reaction to bereavement) is not sufficient "to come to successful accommodation of a loss" (p. 219). Encouraging a client to articulate his or her grief reactions might be beneficial, but is likely not enough to facilitate movement and coping. Rather, assisting the bereaved in their expressions of grief is just the beginning of the journey, and clinicians are charged with the more complex enterprise of guiding clients through the active process of mourning.
Grief and Mourning
Rando (1993) stressed the need to distinguish between grief and mourning when issues of treatment are discussed. As noted earlier, grief involves the multiple responses to the state of bereavement. However, theories that have here been classified as grief theories contain elements that could be better categorized as aspects of mourning. For example, consider Kubler-Ross' (1969) stage of acceptance in which the dying individual has found a sense of peace and contemplates impending death with calm expectation. Finding a sense of peace is not merely passive; it implies action by the dying individual. In a similar vein, Parkes' (1987) last phase is reorganization, that is, bereaved individuals attempt to put the pieces of their lives back together and find a new way of living in the world. Reorganization represents a marked shift from the previous phase of disorganization. Although disorganization is an involuntary experience, reorganization implies action and is more consistent with mourning, the active process of coping with bereavement and grief. The point is that, although the definitions of grief and mourning are rather clearly differentiated, some overlap exists in some of the theories. Despite this overlap, however, theories of grief are largely descriptive.
THEORIES OF MOURNING--CONNECTIONS WITH COUNSELING THEORY
For mental health counselors unacquainted with the field of thanatology, it is useful to examine how mourning theories resonate with more traditional counseling theories. In working with bereaved clients in counseling, the question becomes: What suggestions for treatment do current theories of mourning provide beyond a narrow focus on the manifestations of grief? One way to address this question is to examine how mourning theories can be tied to more traditional counseling theories. Links between phase / stage approaches to mourning are examined first, followed by an emphasis on three current mourning theories: Dual Process Model of Coping with Bereavement (Stroebe & Schut, 1999), Meaning Reconstruction and the Experience of Loss (Neimeyer, 2001b), and Attachment Theory and Loss: Revisited (Fraley & Shaver, 1999). In contrast to phase / stage frameworks, these three latter approaches more fully capture the dynamic and non-linear process that is mourning. Within each section, primary emphasis...
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