Waves of Grief

Research

Pioneers

 

Elisabeth Kubler-Ross has held center-stage for decades in the conversation about grieving, so I will give you this brief sketch of her ideas, but soon move to the less noticed contributions of other researchers whose ideas seem a better fit to most people’s lived experience of grieving.

 

Back in 1969 when doctors still largely refused to discuss death with their patients, a pioneering physician, Elisabeth Kubler-Ross, was recruited by four students to help with their “crisis in human life” assignment. She agreed to ask critically ill patients to describe what they were going through while students watched, and then to lead discussions after the patient returned to his room. After 200 of those interviews, Kubler-Ross settled on the five now-familiar categories: denial, anger, bargaining, depression and acceptance, and called them Stages of Grief. She shared the results with colleagues and wrote the book On Death and Dying that became a classic.  Grief became her life’s work.

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Her description spread fast and soon was being applied to grieving of all kinds, even though the study had only involved a small number of critically ill patients in one hospital. Gradually, family members, divorcing couples, fired employees, people who had lost their cat or their contact lens were told they were grappling with Five Stages of Grief.

 

This idea entered a vacuum and became so embedded that it has barely budged in fifty years. Since Kubler-Ross’s day, many other researchers have studied grief.  They describe it in very different terms, different from Kubler-Ross and different from each other, but their accounts don’t seem to make it into the popular discourse.

 

For instance, one study found that only one-third of subjects described their grief after a loved one’s death in the same way that Kubler-Ross’s had. Other research finds three distinct types of grievers, or a series of four tasks that grievers move through. Another emphasizes layers of loss that become revealed over time. They talk about primary and secondary losses, and spirals of grief, the central issue of yearning, and a wealth of other ideas. Their work reveals that grief isn’t all that simple, and that there are many shadings to consider.

Let me introduce you to several of these experts who you have likely never heard of. They are researchers and therapists who have made grief their lives’ work. They have moved far beyond the pioneering work of Elisabeth Kubler-Ross, and if their ideas have not worked their way into the public consciousness yet, it may be because they have largely written for each other in academic journals and texts. But they are not cool detached observers. Most of them disclose their own run-ins with grief that led them to this work. Let me share their voices with you in hopes that their ideas can help with your challenges.

Barbara Meyerhoff was an anthropologist who studied a community of elderly Jewish residents of Venice, California. In 1978, she described among other things loss and grief among her subjects. She viewed each person as having a club of life, made up of close associates and loved ones. When one of them dies, she observed, conventional wisdom suggests to let go of that relationship and move on. She believed that doing so creates dis-membering, or severing a vital connection. She saw her subjects doing the opposite, preserving the connection and memories while adjusting to the physical absence of their loved one. She called this process re-membering. Once a member of another’s club of life, always a member.  Her ideas have found traction in recent years among many narrative therapists who also question cutting off relationships as a solution to grief.  (Barbara Meyerhoff, Number Our Days, Simon and Schuster, 1978)

I was introduced to the ideas of Meyerhoff by teacher and hospice social worker Lorraine Hedtke.  She promotes the telling of stories to keep connections alive within families and relationships, and relates how she brought forward the memory of her own mother into the life of her daughter, even though her mother died several years before her daughter was born. Hedtke says that selecting stories that are to live on fosters effectiveness and helps create meaning. She says that the predominating ideas about grief dwell so much on pain and suffering at the expense of comfort and connection, that they magnify that pain.  (She and colleague John Winslade wrote Re-membering Lives, Baywood Publishing, 2004.)

J. William Worden began his exploration of grief in 1968, as a contemporary of Kubler-Ross.  In a summary of his work written in 1982 Grief Counseling and Grief Therapy (Springer Publishing) for grief counselors, he described a number of stage theories that posited as many as 9 to 12 stages of grief.  He noted that as people took the idea of stages literally, they were disappointed and discouraged that their grief could not conform to the stages. He proposed instead four tasks of grieving: accept the reality of the loss, experience the pain, adjust to the deceased being missing, and withdraw the emotional energy from that relationship and reinvest it elsewhere.  He seemed to know the grief experience inside out – in addition to the typical lists of disturbances that come with grief, he included a sense of presence of the deceased, absent-mindedness, dreaming of the deceased, and the searching and yearning that characterize the experience for many. His approach included an emphasis on attachment, the particular quality and nature of the connection with the deceased, these days a popular topic with brain researchers who try to understand how we learn empathy.

In 1988 clinical psychologist Therese Rando began her book for the general public Grieving: How to Go on Living When Someone You Love Dies (Lexington, 1988) with an account of her parents’ sudden deaths when she was a teenager. She described the phases of the grief experience as avoidance, confrontation, and re-establishment. She expanded these into six tasks necessary to move through the grief process, and stressed the importance of learning about grief in order to form realistic expectations for yourself. She later turned her six processes into assessment tools for grief therapists to use in helping clients focus. If conventional wisdom had taken in more of what she had to offer, in place of continued reliance on Kubler-Ross’s Five Stages, we would have a much better and more realistic relationship with grief today.

 

Differing Styles of Grieving, Expression

In 1989, researchers Camille B. Wortman and R.C. Silver in “The Myth of Coping with Loss,” (J. of Consulting and Clinical Psychology, 57, 349-357) challenged the idea that everyone grieves in the same way. They reported on a study of hundreds of people who had experienced a major trauma like becoming suddenly paralyzed or losing a loved one to a car accident, which they called irrevocable loss. They found four primary coping styles. Almost half the subjects did not experience intense anxiety, depression or grief, and even years later these “roll-with-the-punches” grievers were psychologically well-adjusted. Chronic grievers who experienced unrelenting distress and depression for an extended period made up 18% of their subjects. They found that 30% seemed to fit the stage model of grief, initially depressed and distressed, then returning to normal levels of well-being. Delayed grievers made up the final 2%, those who initially appeared unaffected but a year or more later became distressed.

James W. Pennebaker wrote Opening Up: The Healing Power of Expressing Emotions (Guilford Press, 1990, rev. 1997) to summarize 15 years of his research on putting upsetting experience into words. While not a grief specialist, he makes a convincing case for the health and psychological benefits of talking and/or writing about emotion and trauma.

 

Continuing Relationship & Other Taboos

Teacher and writer Thomas Attig in 1996 in How We Grieve: Relearning the World, (Oxford University, 1996) refined Worden’s task-based approach and emphasized relearning the world, the self, and the relationship with the deceased. He sees grieving as making the transition from loving a person who is present to loving them in their absence, working some of the same ground as Meyerhoff years before.

Phyllis Silverman co-edited the game-changing book Continuing Bonds (ed. Dennis Klass, Phyllis R. Silverman, Steven L Nickman, Taylor & Francis, 1996) in 1996. It reports numerous accounts of research and interventions about continuing the relationship with deceased loved ones, and focuses attention on the needs of grieving children. Instead of relying on existing theories, she and her colleagues focus on the experience of grievers. She favors helping people see themselves as problem-solvers rather than sufferers.

In 1999, Terry L. Martin and Kenneth J. Doka in Men Don’t Cry, Women Do: Transcending Gender Stereotypes of Grief (Taylor & Francis, 1999) identified a continuum of grieving styles: on one end, intuitive which is oriented around expression of intense feeling; on the other, instrumental which is based on thinking and action. In between lie the blended grievers who exhibit aspects of each.  Martin and Doka talk about the challenge for dissonant grievers who experience grief in one pattern but are limited in their freedom to express it due to gender stereotypes or cultural inhibitions. For instance, a male who is an intuitive griever but feels that the expression of raw emotion is inappropriate for a male in our society may be stymied.  These insights about grieving styles could help free families at odds with each other about how members should grieve. Each end of the spectrum needs different strategies to accomplish the tasks of accepting the loss, working through the pain, adjusting and relocating the deceased. Doka suggests that instrumental grievers especially can gain from learning about grief  ideas and approaches.

 

Grief and Relief

 

In Liberating Losses, authors Jennifer Elison and Chris McGonigle discuss such altruistic relief, where the survivors are grateful that the ordeal is over. In dual relief, survivors who have been caregivers and companions also experience relief for themselves, but find it hard to talk about. The authors also highlight relationship relief, where the deceased had been a source of criticism or worse. Being released from such ongoing hostility, abuse, or disapproval inevitably creates relief. All of these types of relief can lead to guilt in the survivors who don’t think they are allowed to admit to it. 

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Researchers have been squabbling over the relationship between grief and relief for decades. John Bowlby, the father of family therapy, declared early on that relief in grief was “aberrant.” Another early proponent of family therapy Colin Murray Parkes predicted that initial relief would morph into self-doubt, guilt and remorse. Both Bowlby and Parkes reportedly reversed their positions late in their careers.

 

The Art of Grieving

 

Leaving the science of grief and turning to the art, in 2003, writer and psychotherapist Miriam Greenspan wrote in Healing Through the Dark Emotions: The Wisdom of Grief, Fear, and Despair (Shambala, 2003) of emotional alchemy that can change our pain into wisdom. She views grief transforming into gratitude, despair into faith, and fear into joy, if we can work to overcome our natural avoidance of those emotions.

In a lyrical consideration of Unattended Sorrow:Recovering from Loss and Reviving the Heart (Rodale, 2005), author and grief  worker Stephen Levine compared unresolved grief to a “low grade fever” that saps strength and energy. His book began as a pamphlet to put in the hands of survivors of firefighters killed in the September 11, 2001 attack and grew to be a wide-ranging riff on the costs of unexpressed grief. A friend of Kubler-Ross, he cites the numbing effect of grief that is not dealt with. He offers encouragement to follow your grief where it leads you.

These are samples of hundreds of other resources, some of them memoirs, other research accounts, still others heartfelt accounts of therapists’ encounters with grieving clients. All of them offer hard-won wisdom, and any of them might give you an insight or thought that would be just what you need on a given day.

 

Grieving in Secret:

Disenfranchised Grief and Resilience

Grief is bad enough when it is lived out in the open with encouragement and comfort from support people who wish you well. It is at its worst when it goes underground as disenfranchised grief that cannot be openly acknowledged.

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Kenneth Doka described 3 types in Disenfranchised Grief: Recognizing Hidden Sorrow, (Lexington, 1989): 1) the relationship is not recognized, for example an ex-spouse or an unacknowledged gay partner, 2) the loss itself is not recognized, as in early miscarriage or infertility, or pet loss, or 3) the grieving person is not recognized (a young child, for example). Even the circumstances of the death can elicit negative judgment and marginalize the griever – death from AIDS or drug overdose are examples, or catastrophic loss like suicide or murder that overwhelm potential support people, or the birth of a child with severe disabilities.

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The result is heightened misery. The invisibility and absence of acknowledgement can intensify feelings of anger and powerlessness; the exclusion from customary rituals increases isolation. The ultimate effect may be long-delayed grief that turns into intractable chronic grief.

 

To intervene, the first step is becoming able to recognize the impact of these complications. The next is to find a venue where the grief can be acknowledged, often a support group or joining with another co-griever.

 

A Loss That Goes On and On​

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Ambiguous loss is often included under the umbrella of disenfranchised grief. It is a big topic that is relatively unknown and deserves special attention. It offers a whole new lens to view grief. Professor Pauline Boss is the primary theorist of ambiguous loss (Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss, Norton, 2006) and describes 2 kinds: 1) a loved one is physically present but psychologically absent, as in Alzheimers, brain injuries or chronic illness, depression, severe autism, even workaholism, or 2) physically absent but psychologically present, as a distant noncustodial parent after a divorce, or a biological parent in a closed adoption, or the longing for home and family felt by an immigrant. As there is often little likelihood of the outside forces of illness or legal status or distance changing, the individual is left to search for ways to adapt, to develop resilience.

 

Boss defines resilience as “the ability to stretch (like elastic) or flex (like a suspension bridge) in response to the pressures and strains of life.” She explains that the basis for such resilience is the ability to live with ambiguity, which fills our minds when we grieve. To connect grief with resilience is empowering and points to resources that the griever may already have.

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Therese Rando, cited above, identified the factors that make up resilience: Insight, using relationships and support, optimism, initiative, creativity, and sense of humor. Those words are not usually part of the conversation about grief, but should be.