Assessment And Intervention

There have been many attempts to categorise grief but little consensus beyond a general view that for most people there is a reduction and change in the nature of distress over time. What is an appropriate time interval or the nature of the distress is less easy to determine. Many studies have used general assessment measures such as the Beck Depression Inventory or the General Health Questionnaire, which were not designed to measure the changes specific to the distress of bereavement. Efforts continue to distinguish 'typical' from 'atypical' grief. The Texas Revised Inventory of Grief (Faschingbauer, 1981) is the best known but it has been criticised for a lack of sensitivity to variation in some items and retrospective judgements. For a comparison for the strengths and limitations of instruments used in the assessment of grief see Neimeyer & Hogan (2001).

Many UK hospices use simple assessment questionnaires to assess which relatives should be offered additional bereavement support. These are based on Parkes' early work yet the measures are of uncertain validity (Payne & Relf, 1994).

An assessment scale that attempts to categorise grief will reflect the model of grief and mourning practices that are dominant in that culture, for example, how often the bereaved person should visit the grave or when and at what level social activity should be resumed. These measures are unlikely to be useful in working with someone from a different culture. Visiting the grave less frequently might be seen as beneficial for one person but as avoidance by another. Rosenblatt (1997) suggests there may be an indigenous sense of normality but the definition of pathology will vary across cultures. Some cultures rewrap bodily remains over time but a request by a British twentieth-century widow to do this would be seen as morbid. Also, there can be rapid change of practice within a generation, and within a subculture; for example, it has become more acceptable for women of the Western Isles of Scotland to attend the graveside following the funeral service. What is seen as 'normal' is not constant. The validity of the concept of a universal model of grief is challenged by those who argue there is no place for this in the postmodern world (Small, 2001). However it is the hypothetical models that generate the interventions used to work with those who seek help in their bereavement. Influential models are described below.

Psychoanalytic Model

Freud (1917) acknowledged that mourning is painful but cautioned 'although mourning involves grave departures from the normal attitude to life, it never occurs to us to regard it as a pathological condition and to refer it to medical treatment. We rely on it being overcome after a certain lapse of time and we look upon any interference with it as useless or even harmful.'

He states that reality demands that all libidinal energy is withdrawn from the lost object and this process will happen gradually as all emotional investment and hopes are gradually relinquished. 'When the work of mourning is completed the ego becomes free and uninhibited again... The ego severs its attachment to the object that has been abolished.'

Freud regards melancholia as very similar to mourning but with an important exception 'the disturbance of self-regard is absent in mourning'.He makes the distinction by stating 'In mourning it is the world which has become poor and empty; in melancholia it is the ego itself.'

Small (1999) argues that Freud has been misunderstood in suggesting the relationship with the deceased is abandoned and suggests that mourning is better understood as the withdrawal of projective identification by which the reality of what is lost is acknowledged and the separate boundaries of the self are rediscovered and developed. Klein had postulated that the infant learns that it is separate from its carer and this is a terrifying realisation but with a loving carer the infant gains security through internalising the object. Vaillant (1988) asserts that it is not the loss of the loved object in itself but the failure to create an adequate internal model that causes psychological harm.

Volkan (1972) describes the way in which some bereaved people maintain their relationship with the dead person by 'linking objects'. These objects are not the comfortable mementoes that many keep or can wear with comfort such as a watch or a brooch. These linking objects are invested with great emotional significance and cause great distress rather than sadness if lost because of their significance. Linking objects are used by Ramsay (1977) working from a behavioural model of phobic avoidance of grief, which is discussed later.

The Freudian model is cathartic and postulates that by ventilating emotional distress the person can withdraw libidinal energy and reinvest it in other object relations. Freud terms this 'grief work' and this concept of 'work' has been developed by therapists such as Worden (1983, 2003). Worden's delineation of the tasks of grief has been extremely influential in bereavement counselling. He proposes four key tasks:

1. To accept the reality of the loss. There may be particular difficulties in accepting that this separation is permanent if the relationship had frequent separations because of work abroad or military duty. The reality of the death is hard to accept for different reasons if the body is absent - for example, if it has been destroyed in a major incident or is missing. This is explored further in the section on sudden/unexpected death. Religious faiths that believe in personal reunion after death or contact through a spiritualist would be viewed as denial by those who do not share their beliefs.

2. To experience the pain associated with it. Some would argue that grief work cannot be avoided: 'it is also likely that grief work cannot be put off indefinitely, that an avoidance of certain reminders of a loss makes it likely that one will grieve later on... as one encounters still other reminders that set off the process of dealing with emotionally charged memories and hopes' (Rosenblatt, 1996). A high level of manifest grief is not necessarily an indication of a cathartic process that will inevitably resolve with time. People who obtain high scores on posttraumatic stress disorder (PTSD) scales after a major incident are often those individuals whose scores remain elevated a year later. A chronic sense of personal distress, which is exacerbated by bereavement, may be mistaken for expressed grief precipitated by bereavement. Alarcon (1984) suggests that an individual with a personality disorder will have difficulties that reflect ongoing problems in establishing interpersonal relationships rather than grief for a lost relationship. Rosenblatt (1997) cautions that talking about the loss is seen as healthy expression of grief in Euro-American counselling now but may not be seen as appropriate bereavement behaviour in another culture. There is some evidence that those who avoided intense feelings of grief did not have a worse outcome at 14 months than those who experienced emotional distress Bonnano et al. (1995). A study of 253 bereaved adults found that those who engaged in ruminative thinking were more depressed at six months even after controlling for initial levels of depression, social support, gender and other factors (Nolen-Hoeksema, Parker & Larson, 1994).

3. Adjust to an environment in which the deceased is missing. The sense of the presence of the dead person is common and usually felt as comforting rather than unpleasant. One widow recounted the strong sense of her husband lying close to her in bed but on being questioned said she had never stretched out her arm to touch him because she knew he could not be there and did not want to confront the emptiness. Most of the widows interviewed by Conant (1996) had sensed their husband's presence vividly and unexpectedly at times. During sleep there may be dreams in which the fact of the death is acknowledged openly between the bereaved and the deceased (Cathcart, 1984).

4. Emotionally relocate the deceased and move on with life. Sometimes the final task has been described as 'resolution' but this term is problematic for the reasons described earlier. Originally Worden (1983) listed the need to withdraw emotional energy and reinvest it in another relationship but he later modified this to an understanding that the bereaved will maintain a different kind of relationship with the deceased and acknowledged the work of Klass, Silverman & Nickman (1996).

Attachment Model

Bowlby was influenced by the research of animal ethologists, which described the critical period during which the offspring attach to the parent. This attachment provides security as well as food and warmth. Ethology and other animal research indicated the importance of early social relationships on the development of later relationships and maturation.

Disruption of the bond was observed to cause pining and searching to recover the lost object. The Robertson's recordings of young children separated by hospitalisation supported his argument that this research was relevant for human behaviour. Bowlby (1980) developed his theories of attachment and loss over decades and influenced the early work of Parkes, which described a phase model of grief with initial protest and disbelief followed by disorganisation manifest by searching and pining then resignation.

The formation of secure attachments in early life enables one to face future challenges and losses. On hearing the news of her elderly husband's death Ursula Bowlby (1991) wrote:

Instead of being shattered I felt suddenly comforted. He seemed secure in my heart and I knew I would carry him about with me for the rest of my life. I have this sense of continuous companionship ...I didn't expect it, I recognise it...the same thing happened... (when my mother died). I had spent my life dreading losing her, yet when she died I felt her safe in my heart, and free, free from the disabilities of old age.

Behavioural Model

The similarities between phobias and the avoidance of grief by some bereaved people led Ramsay (1977) to suggest that those who avoid their grief yet remain distressed could be helped by confrontation with the feared cues that trigger painful emotions. Systematic desensitisation to stimuli such as favourite music, photos and 'linking objects' without the possibility of distraction or escape should facilitate anxiety reduction. He argued that avoidance maintained the person in a state of grief and also learned helplessness develops at the loss of social reinforcement (Seligman, 1975). The grieving person no longer engages with the world and therefore does not find alternative sources of gratification. Ramsay asserts that linking objects can be used effectively as cues in the desensitisation hierarchy without psychodynamic interpretation or awareness of unconscious psychological processes and disagrees strongly with Volkan on this point. He states that a 'limited number' of people were helped by prolonged exposure and flooding but no more information is given about the sample.

Lieberman (1978) selected 19 bereaved patients whom he identified as having morbid grief and intervened using what he termed 'a forced mourning' procedure using behavioural principles of systematic desensitisation and implosion and involving family members where possible to facilitate generalisation. Sixteen were reported to have benefited, one was unchanged and two deteriorated. Closer examination of those who had improved led him to suggest that this strategy is most helpful to those with family support and, in addition, different grief patterns may require different emphasis. Some individuals may be helped by an initial opportunity to ventilate displaced anger and then receive forced mourning and others required a combination of behavioural strategy and interpretative psychotherapy with attention directed to their nightmares.

A small controlled study of guided mourning by Mawson etal. (1981) randomly allocated 12 people to either a guided mourning treatment in which they were encouraged to confront painful or avoided stimuli in the manner described by Ramsay or to a control treatment in which they were advised to avoid any distressing thoughts and to conceal painful reminders such as photos and possessions. Those who received guided mourning demonstrated greater improvement than the control group on a number of measures, which was maintained at 10- and 28-week follow-up. The authors acknowledge that the intervention had not been as effective as earlier studies had hoped and quote Parkes' comment that this type of intervention may not be useful for people who can readily express themselves but in a self-punitive way or if grief is used as a reason to avoid new challenges.

Cognitive-behavioural Intervention

Further criticism of the limits of a narrow behavioural model is made by Kavanagh (1990) who agrees that 'searching' to recover the lost object is more prominent than avoidance of reminders and chronic preoccupation with grief is more common than phobic avoidance of the distress. He notes that this approach can help alleviate anxiety but he concurs with Parkes that there are more effective ways of managing depressive symptoms such as a goal-oriented approach. This is supported by an earlier paper by Sireling et al. (1988), which used a guided mourning intervention. One group was told to focus on bereavement cues and the second group to avoid them but both groups were encouraged to engage in enjoyable activities and advised about resuming social relationships. Both groups experienced similar levels of improvement in depressive mood.

Kavanagh argues that the Lazarus & Folkman (1984) model of stress and coping skills offers a constructive way forward for people experiencing problems in their bereavement. A situation is perceived to be stressful if the repertoire of coping strategies is judged to be inadequate to the challenge. If support is given to develop and extend coping skills, depending on individual need, then the situation will be perceived as less stressful. Learning cognitive strategies to detect and challenge negative cognitions is part of this. He summarises that a balance between exploring the loss and managing the depressive symptoms will be the most effective intervention.

The Dual-process Model

The two processes described in this model are that of loss orientation and restoration orientation. Stroebe & Schut (2001) suggest that effective mourning requires a balance of both and people oscillate between the two processes. They suggest that these processes are similar but not identical to emotion-focused and problem-focused coping. An activity that is restoration oriented could involve both confronting emotion and managing a practical task.

There is some indication that gender differences are relevant. In Western culture women express emotional distress more readily and men tend to focus on the practical tasks. A small study by Schut etal. (1997) compared two interventions and found that each gender benefited most by being directed towards its less familiar strategy. There is some support for this in an unpublished study (Duran, 1987) cited by Kato & Mann (1999). When interventions were analysed by gender it was revealed that a social support intervention, which was unhelpful to the women, was beneficial to the male participants. A social activities group had no effect for the women but was harmful to the male participants. Parkes (2000) comments that if given choice, people may choose the intervention that is easier for them but this might not be the most effective for them.

Existential Model

Existential philosophy states that existence precedes essence. The perspective that grief is an active process of construction is closer to the existential writers such as Neimeyer et al. (2002) who consider bereavement a challenge to our sense of identity and meaning.

Bereaved people need to develop a changed sense of self and the world around them, a process that is variously described as revising the assumptive world or a need to 'incorporate the experience into their ongoing life-narrative' (Neimeyer, Prigerson & Davies, 2002). This may be particularly difficult for some people because of their maladaptive inner models of the world but it is difficulty in assimilating change that causes grief to become complicated.

Klatt (1991) states 'It is not illness or death which are a challenge but the failure to find meaning in life.' Bereavement may provoke an existential crisis only if it challenges the sense of meaning and a new sense of meaning is not developed. Some become more aware of life's transience and can identify positive change (Landsman and Spear, 1995). This perspective reminds us that a crisis is also an opportunity for growth. One young woman bereaved traumatically by the death of a partner for the second time acknowledged this had changed and deepened her personal philosophy of life but was able to smile and remark ruefully 'If this is being wise, I'd rather be foolish.' A study of 30 caregivers whose partners had died of AIDS reported that those who found meaning in their caring were less depressed and were more likely to demonstrate positive wellbeing at bereavement and better recovery at 12 months (Stein etal., 1997).

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