Connections between counseling theories and current theories of grief and mourning.
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.
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 is given to how each mourning theory connects to one primary counseling theory; however, brief mention is occasionally made to other counseling theories that may resonate with aspects of each mourning theory. The intention is to offer mental health counselors direction regarding the usefulness of the mourning theories presented.
Stage / Phase Approaches to Mourning
Two approaches to mourning have used a stage / phase approach and have emerged from a solely death-loss focus. Worden (1996, 2002) developed four tasks of mourning: to accept the reality of the loss, to work through the pain of grief, to adjust to an environment in which the deceased is missing, and to emotionally relocate the deceased and move on with life. As noted by Stroebe and Schut (2001), Worden's work was an important development in the understanding of the process of coping adaptively with bereavement as each task is clearly defined in an action-oriented manner. Rando (1993, 1995) similarly identified six "R" processes of mourning: (a) recognize the loss, (b) react to the separation, (c) recollect and reexperience the deceased and the relationship, (d) relinquish the old attachments to the deceased and the old assumptive world, (e) readjust to move adaptively into the new world without forgetting the old, and (f) reinvest. Rando operationalized these elements of mourning as processes rather than tasks; however, like Worden (2002), she suggested that mourners must successfully complete these elements in order to integrate their loss in a healthy manner. Although the step-like format of these approaches leaves them susceptible to the dangers of literalism, both Worden (2002) and Rando (1995) have argued for a fluid understanding of mourning, one in which these elements can and do exist simultaneously and are revisited over time.
Stage / Phase approaches to mourning and person-centered counseling. As noted earlier, a person-centered approach to counseling can, through its focus on the uniqueness of the human experience, balance the dangers of literalism in stage / phase type theories. Rogers (1980) consistently emphasized the phenomenological perspective of each client (Hazler, 2003) and the formative actualizing tendency of each organism to move toward the realization of his or her full potential (Raskin & Rogers, 2000). Difficulties arise for individuals when obstacles, including conditions of worth (e.g., prescriptions for how one must mourn), are placed in the paths of developing individuals. Such conditions lead to an external locus of evaluation in which clients are overly concerned with how others view them; as a result, a disparity emerges between clients' perceived self-concept and their genuine experience. Bereaved individuals who are exposed to rigid, "almost dogmatic" (Hagman, 2001, p. 18), conditions of worth regarding how the mourning process must look may lose touch with their true individual experience. On the other hand, person-centered counseling can provide a critical opportunity for bereaved individuals to regain a subjective sense of their personal responses and actions related to death loss events. Although theories of grief and mourning can be used to inform the person-centered mental health counselor's work, his or her primary role is to provide the therapeutic conditions of empathy, unconditional positive regard, and congruence (Raskin & Rogers). Clients can then view the conditions of worth imposed by society (e.g., dictates of how to mourn) more realistically, accept their own responses, and follow their own subjective valuing process, which leads to positive growth. Therefore, the person-centered approach is particularly useful in increasing bereaved individuals' insight and awareness into their grief and mourning experience (Barbato & Irwin, 1992). Nonetheless, mental health counselors using a Rogerian approach should be encouraged to direct their therapeutic attention beyond a sole focus on grief expression to incorporate aspects of the mourning theories. Person-centered mental health practitioners serve their clients best, however, when they remain vigilant to the phenomenological core of their theoretical approach.
Dual Process Model of Coping with Bereavement (DPM)
Stroebe and Schut (2001) described their dual process model of coping with bereavement as an integration of existing ideas rather than a completely novel framework. They acknowledged the influence of stress and trauma theories (e.g., Horowitz, 1986; Lazarus & Folkman, 1984), general theories of grief (e.g., Freud, 1917/1957; Rubin, 1981), and other models of coping with bereavement (e.g., Cook & Oltjenbruns, 1998; Nolen-Hoeksema & Larson, 1999). Although originally developed with regard to the death of a partner, DPM appears to have application to other situations of bereavement.
Stroebe and Schut (1999, 2001) argued the need for a stressor-specific model of coping with bereavement because death losses invariably involve multiple and diverse stressors rather than a single stressor. They classified these stressors into two types: loss oriented vs. restoration oriented. Loss-oriented stressors are those that pertain specifically to the death-loss experience itself. Examples include the disintegration of future plans with the deceased, the ending of the physical relationship with the deceased, and the lack of social support once offered by the deceased. In contrast, restoration-oriented stressors are those that are secondary (with regard to timing rather than intensity) to the death loss such as the addition of new household chores, decreases in financial resources, and altered communication patterns with friends and family members. Associated with each of these two types of stressors is a specific coping orientation. Loss-oriented coping involves focusing on and processing aspects of the loss (e.g., visiting the grave, looking at photographs, emoting related to the death), while restoration-oriented coping involves focusing on the secondary stressors that must be dealt with (e.g., financial problems) and determining how to tackle them (e.g., selling one's house). The core of DPM is the contention that the oscillation between these two types of coping processes actually is essential for adaptive coping. Through the concept of oscillation, Stroebe and Schut have managed to maintain the benefits of two of the most difficult to reconcile aspects of the mourning process: the need to move on with life and the desire to remain connected to the deceased (DeSpelder & Strickland, 2002).
Stroebe and Schut (2001) argued for the broad applicability of DPM. For example, complicated grief, either chronic or inhibited, can be explained by an absence of either restorative- or loss-oriented coping respectively (Stroebe & Schut, 1999). In addition, bereaved women may tend to cope in more loss-oriented ways, in contrast to bereaved men who may focus more on dealing with restoration-oriented stressors (Schut, Stroebe, de Keijser, & van den Bout, 1997). Stroebe and Schut (1999) have also suggested that the loss/restoration distinction may serve useful when discussing cultural differences in grief and mourning. As loss-orientation coping is broad (i.e., grief work, intrusion of grief, breaking bonds / ties, relocation of deceased), DPM could also be used to examine a variety of mourning related outcomes (e.g., tasks of mourning, meaning-making; Stroebe & Schut, 2001).
DPM and counseling theories. Although the primary emphasis, here, is placed on the intriguing parallels between DPM and Gestalt theory (Perls, 1969), mental health counselors identifying with a behavioral (Wilson, 2000), person-centered (Rogers, 1980), or Jungian (Douglas, 2000) framework may find DPM concepts useful in their work with bereaved clients. With regard to behavioral and person-center approaches, recent research (Schut et al., 1997) found that widowed males assigned to a person-centered intervention showed lower distress following treatment, as did widowed females assigned to the behavioral approach; whereas men assigned to the behavioral and women to a person-centered approach exhibited little improvement. Schut et al. suggested that women naturally tend toward loss-oriented coping while men naturally tend toward restoration-focused coping and argued that individuals may benefit more when treatment challenges them to concentrate on the type of coping processes to which they are less accustomed. Because DPM has a strong non-linear emphasis, the counseling theories that emphasize holism and balance are a natural fit. For instance, the link with Jung's analytical approach is clear as he viewed the world in terms of paired opposites engaged in active struggle (Douglas). Similarly, Gestalt counseling theory suggests that individuals are self-regulating and inclined toward growth, with health being defined as the organism's awareness, recognition, and appropriate attention to needs and desires as hierarchically required (Yontef & Jacobs, 2000). Through the process of organismic self-regulation, the most pressing need / desire emerges from the background of the mind as a figure. When this figured need is addressed and attended to, it then blends into the background as the next figure in the hierarchy emerges. For healthy individuals, this process is fluid, and figures shift quite rapidly.
As both emphasize the person-environment dialectic, the gestalt approach to health and adjustment blends well with the DPM distinction between the two major types of stressors associated with death loss: Those that can be addressed through internal processing, and those associated with the secondary losses in the environment that may be more amenable to external adjustments. Creative adjustment is the Gestalt term used to describe the process employed by individuals when they are faced with the changing demands of the environment, such as a death loss (Sabar, 2000). More specifically, creative adjustment involves a balance between internally adjusting to current conditions and externally working to change the environment, when such change is possible and appropriate (Youtef & Jacobs, 2000). Creative adjustment occurs when individuals are aware of their own organismic functioning such that they attend to the hierarchical needs / desires that emerge in new situations and make the appropriate internal and external adjustments. For bereaved individuals, "creative adjustment during mourning means adapting to 'what is,' changing oneself and reorganizing one's environment to fit the new reality of the deceased person no longer being physically present" (Sabar, p. 161). This description clearly parallels the DPM.
Another strong connection between DPM and Gestalt theory is the attention given by both to dualism and oscillation. According to Gestalt theory, life is marked by polarities (Yontef & Jacobs, 2000), and each figure stands against an opposite ground. For healthy functioning, both poles of each dichotomy must be allowed to become figures, and the constantly shifting balance between the poles is critical to the process of creative adjustment. As connected with the DPM, bereaved individuals have a dichotomy with regard to loss- and restoration-oriented coping, and both poles must be allowed to rise as figures and be addressed as hierarchically required by the organismic functioning of the individual. After a loss, bereaved individuals need to self-regulate both the pace and intensity of their grief, following a comfortable rhythm of avoidance of and attention to the pain so that they become neither overwhelmed nor numb (Sabar, 2000). Based on her clinical work with the bereaved, Clark (1982) took this notion of rhythm even further and defined times within the mourning process as either periods of connecting or separating. The similarity between her descriptions of these periods and the loss and restoration orientations of DPM is striking. More specifically, Clark explained that during connecting times, "people were involved in their life activities, making plans, doing everyday tasks, exploring and experimenting" (p. 59). In contrast, when in a time of separating, peoples attention centered on the impact of their loss. Thus, in a wave-like rhythm, "therapy flows back and forth during transition times between awareness of separating and awareness of connecting, between times of 'living' and times of 'dying'" (p. 61).
Just as Stroebe and Schut (1999, 2001) described complicated grief as a disturbance in the oscillation, Gestalt theory suggests that neurotic regulation occurs when some aspects of one's mental background are not allowed to become figures, that is, when the polarities are not fluid, but rather become hardened dichotomies (Yontef & Jacobs, 2000). The recommendation for mental health counselors with regard to both approaches is to foster the acknowledgement and expression of both dimensions, loss and restoration, thereby encouraging clients toward balance.
Meaning Reconstruction and Loss
Neimeyer (1998; 2001b) drew on contemporary constructivism and narrative conceptualizations to argue that meaning reconstruction is the central process faced by bereaved individuals. According to formal constructivism, reality is not objectively knowable, but rather is subjectively determined by the organizing efforts of individuals over time and within specific contexts (Lyddon, 1999). Reality and meaning change as changes occur in contexts, experiences, and individuals' active ongoing attempts to organize their perceptions of the world. One way in which human beings describe and organize their lives and their sense of reality is through the use of narrative or story (Bruner, 1990). Through this lens, "human beings are viewed as (co) authors of their life stories, struggling to compose a meaningful account of the important events in their lives and revising, editing, or even dramatically rewriting these when the presuppositions sustaining these accounts are challenged by unanticipated or incongruous events" (Neimeyer, 2001b, p. 263).
Meaning making following death loss involves a complicated balance between redefining the self and an implicit reweaving of how one engages with the world (Neimeyer, 2001b). Viewing mourning as a process of meaning reconstruction captures the idiosyncratic nature of the experience and acknowledges that the primary task is not one of returning to pre-loss functioning, but of developing a meaningful life without the deceased loved one (Wortman & Silver, 2001). Major death losses are viewed as significant disruptions to personally and socially constructed narratives (Nadeau, 1998; Neimeyer, 1998), assumptions about the world (Janoff-Bulman, 1989; Rando, 1993), and personal identity (Neimeyer, Prigerson, & Davies, 2002). Bereaved individuals are, therefore, left with serious questions such as "What will my life look like now?," "What did the deceased's life mean?," "How can I feel safe in a world such as this?," and "Who am I now that this death has occurred?"
Eighty percent of individuals faced with difficult life events, including death losses, engage in a process of asking "Why me?" (Davis, Wortman, Lehman, & Silver, 2000). Davis et al. concluded that (a) a significant subset (20%-30%) of bereaved individuals appeared to function well without engaging in the process of meaning making; (b) less than half of the individuals who engaged in meaning making found any meaning, even a year beyond their death loss; (c) those bereaved individuals who found meaning were better adjusted than those who searched and did not find meaning, but they appeared to continue searching even after finding meaning. Neimeyer (2000) gleaned three lessons for mental health practice from Davis et al.: (a) when clients are struggling with meaning making, and the majority will, it is important to facilitate this process; (b) when clients do not spontaneously engage in a search for meaning, mental health counselors must be cautious about initiating the process; and (c) the process of meaning making is just that, a process, and not an outcome or achievement, because meanings associated with death loss are continually revised. More specifically, although an early focus may be on the why of the death loss, later attention is often given to the possible benefits of the loss experience for survivors. It is finding meaning rather than the content of that meaning that has been associated with greater adjustment.
Meaning reconstruction and loss and counseling theories. Although the primary emphasis is placed on the connections between meaning reconstruction and loss and the existential approach to counseling (May & Yalom, 2000), mental health counselors identifying with narrative (Freedman & Combs, 1995) or cognitive-behavioral (Beck & Weishaar, 2000) orientations will find the concepts of meaning reconstruction useful in their work with bereaved clients. As the narrative approach has a foundational position in Neimeyer's (1998; 2001b) approach to meaning reconstruction and loss, mental health counselors espousing this orientation will connect easily with the meaning reconstruction conceptualization of mourning. At a basic level, mental health counselors can provide a safe and validating environment in which bereaved clients can tell and retell the stories associated with their death losses. This process can be facilitated for bereaved clients through "careful listening, guided reflection, and a variety of narrative means for fostering fresh perspectives on their losses for themselves and others" (Neimeyer, 2000, p. 264). In addition, scholars have suggested connections between cognitive-behavioral therapy (CBT) and meaning reconstruction in loss (see Fleming & Robinson, 2001; Powers & Wampold, 1994). Fleming and Robinson discuss how CBT can be useful in assisting clients in challenging their "extreme, absolutistic views (e.g., 'the world is malevolent')" (p. 656) and in the processes of assimilating new experiences or accommodating existing assumptions as required. It is important to note that Neimeyer (2001b), who argued that CBT approaches actually oversimplify the process of searching for meaning, called for a broader definition of meaning reconstruction beyond the conscious and purely cognitive to "a predominantly, tacit, passionate process that unfolds in a social field." (Neimeyer, 2000, p. 552).
Although the existential approach to counseling (May & Yalom, 2000) is a dynamic theory of conflicting forces rather than a constructivist approach, there are striking parallels between this counseling theory and the meaning reconstruction conceptualization of mourning. The collaborative therapeutic attitude emphasized by Neimeyer (1999), which involves recognizing the importance of "being" above and beyond "doing," is closely linked with the notion of ontological experience central to existential therapy (May & Yalom). In addition, there is an acknowledgement of a sense of "knowing" extending beyond the conscious, intellectual, and rational that is at the heart of both approaches (Neimeyer, 2000; Rychlak, 1981). Neimeyer (1999) underscored the richness of metaphor in meaning making and argued that the use of such images can lead to the discovery of constructs and life assumptions so basic that they are below the level of conscious awareness. In parallel form, for the existential counselor, "mystery enfolds knowledge, contains knowledge ... mystery is the latent meaning always awaiting our discovery and always more than our knowing" (Bugental, 1987, p. 273). Finally both approaches emphasize assisting clients in reassessing and reorganizing the patterns of their lives and the ways in which they have answered the major questions of their lives (May & Yalom, 2000, Neimeyer, 2001a). Existential mental health counselors address this task more directly through confronting clients with questions and statements that focus on clients' personal responsibility, while underscoring the need to become engaged in life. In contrast, the narrative strategies suggested by Neimeyer (1998, 1999, 2001a) such as writing epitaphs, life imprints (i.e., imprints deceased has left on bereaved's life), and past/future-self letters attend to the issues of reassessment and reorganization in a more subtle manner. Despite this distinction, both approaches emphasize the crucial need for clients to gain new and fresh perspectives regarding the situations and events in their lives.
Both meaning reconstruction and loss and existential approaches are grounded in the notion of subjective reality in contrast to objective truth (May & Yalom, 2000; Neimeyer, 2001b). Advocates of both approaches stress the phenomenological and context-bound nature of existence. The three forms of world, as identified in existential therapy (Rychlak, 1981), clearly align with the suggested domains or contexts in which bereaved individuals reconstruct meaning. More specifically, the Umwelt, defined as the environment, is connected to the assumptions bereaved individuals must revise regarding the external world. The Mitwelt, defined as the social world, is connected with the social narratives created with fellow human beings that must be now reconstructed. Finally, the Eigenwelt, defined as the relationship with self, clearly fits with bereaved individual's need to redefine the self after a significant death loss.
Existential therapists contend that humans struggle with internal conflicts that parallel the process of meaning reconstruction and loss. Existential conflicts are the direct result of the individual's confrontation with each of the four ultimate concerns of existence including death, freedom, isolation, and meaninglessness, with death being the most obvious (Yalom, 1981). Although "existential therapy is not a comprehensive psychotherapeutic system" (May & Yalom, 2000, p. 288) with an outline of detailed techniques, a concept that drives this approach is that of responsibility. In this vein, May and Yalom quoted Sartre who equated "responsibility to authorship: to be responsible means to be the author of one's own life design" (p. 289). Through the process of existential therapy, clients are encouraged to face the ultimate concerns, including death and meaninglessness, understand that decisions are unavoidable; and identify how they make decisions. The death of someone close fosters the bereaved individual's reflection regarding his or her own mortality (May & Yalom). This event is one in which individuals must face death and the meaninglessness that it engenders. Clients must be encouraged to fully experience the anxiety appropriate to this life circumstance and to then use that anxiety to re-author their lives and creatively transcend the "past and present in order to reach the future" (May & Yalom, p. 277). As argued by Neimeyer (1999), rather than providing trite assurances, mental health professionals are charged with assisting the bereaved in integrating the multi-leveled loss-related meanings into the ongoing narratives of their lives.
Attachment Theory and Loss: Revisited
Recent discussions in thanatology have focused on reassessing the role of attachment and attachment theory (e.g., Fraley & Shaver, 1999; Noppe, 2000; Stroebe, 2002) in the process of mourning. At a basic level, attachment theory suggests that human infants are biologically predisposed to bond with primary caregivers (e.g., parents) and then as adults with other emotionally important persons (e.g., mentors, romantic partners). Even in adulthood, persons will experience distress when separated from the attachment figure unexpectedly or when stressed, fatigued, or ill (Bowlby, 1969; Shaver & Tancredy, 2001). The manner in which infants experience the relationship with their primary caregivers (e.g., dependable vs. undependable) will affect how they form, maintain, and relinquish later relationships (Bowlby, 1969; Stroebe, 2002). More specifically, each individual builds a working model of relationships between the self and others (Bowlby; Noppe; Shaver & Tancredy; Stroebe). Research with infants (Ainsworth, Blehar, Waters, & Wall, 1978) and adults (Bartholomew & Horowitz, 1991; Fraley & Shaver; Hazan & Shaver, 1987) has indicated that each person develops a relatively stable style of attachment. These styles of attachment have been termed secure, avoidant, anxious/ambivalent (Ainsworth et al.; Hazan & Shaver), and disorganized/disoriented (Main & Solomon, 1990).
As noted by Stroebe (2002), connecting the concepts of attachment style, internal working model, and mourning following death loss has vast implications in how the constructs of grief and mourning are to be understood. Attachment styles can be viewed as parallel to the grief reactions described in the thanatological literature (Fraley & Shaver, 1999; Parkes, 2001; Shaver & Tancredy, 2001), such that persons with particular attachment patterns may be more vulnerable to particular grief-related difficulties. More specifically, individuals with an anxious-ambivalent attachment style, who have a preoccupied, clingy, and anxious orientation to relationships, may be more likely to experience chronic or extended grief. In direct contrast, those with an avoidant style, who tend to guard against investing in relationships, may be more likely to experience inhibited or absent grief. Persons with a disorganized style who lack trust in themselves and others, often exhibit signs of learned helplessness in the face of death loss (Parkes). As noted by Shaver and Tancredy, one would expect securely attached individuals to respond emotionally to the death of an important person, without becoming overwhelmed by the experience.
Although the connection between attachment style and grief response is intriguing, of particular interest to the present discussion is how the attachment styles may or may not relate to the active process of mourning. Prior to Bowlby's (1980) attachment work, Freud (1917/1957) suggested that in order to mourn effectively, bereaved individuals needed to de-invest libidinal energy from the deceased and the relationship in order to invest in new relationships. In direct reaction to Freud's idea of disengagement, recent work suggests that it is normative and adaptive for bereaved individuals to accommodate to loss through maintaining a dynamic connection to the deceased through a "continuing bond" (Klass, Silverman, & Nickman, 1996, p. xvii). According to Fraley and Shaver (1999), Bowlby (1980) allowed for both dimensions of this dichotomy (i.e., disconnection vs. maintained connection) in coping with loss, though he cautioned that difficulties can arise with either pole (i.e., disconnection leading to denial of the impact of the loss; maintaining a connection leading to the internalization of a frightening attachment if the relationship had been a negative one). Fraley and Shaver also concluded that (a) people cope with death losses much as they cope with other relationship-related losses with living persons, and (b) the process of reorganization after loss is comparable to other developmental transitions such as individuals being able to remain connected to living primary caregivers and yet establish new connections through adult relationships. Some individuals can maintain such connections while establishing new relationships, while others have more difficulty with this transition.
Healthy recovery in the face of mourning, in the attachment perspective (Bowlby, 1980), "entails finding a way to maintain a secure bond with the attachment figure while simultaneously acknowledging that the person is not physically available to provide comfort and care" (Fraley & Shaver, 1999, p. 754). The question becomes, however, does or should this recovery or outcome of the mourning / reorganization process be the same for individuals with different styles of attachment. It may be that what constitutes healthy mourning is different for individuals with different styles of attachment. Is it possible that individuals with an avoidant style, for example, who exhibit little grief, have little need to reorganize or mourn and, therefore, little conscious need to maintain a bond? Fraley and Shaver also questioned whether the lack of grief and mourning exhibited by those with an avoidant style is a defense, or whether they are responding and reacting as should be expected based on an actual lack of connection / bond. If individuals with an avoidant style actually avoid establishing intimate connections with others, they may be unlikely and unable to remain connected after an attachment figure has died. In contrast, individuals with an anxious / ambivalent style may need to mourn by actually finding a means by which to diminish an overly invested bond, post-death, rather than working to maintain the bond (cf., Fraley & Shaver).
Attachment theory and loss revisited and counseling theories. Connections have been made between attachment theory and many prominent theories of counseling (Biringen, 1994). It has also been argued that attachment theory provides a framework for both conceptualizing clients' concerns and intervening within the therapeutic relationship (Bowlby, 1988; Brisch, 1999; Pistole, 1999; Pistole & Watkins, 1995). While integrating points made in the attachment literature throughout the discussion, the emphasis in this section is on exploring parallels between attachment theory and loss revisited and the interpersonal process approach to counseling.
The interpersonal process approach to counseling (Teyber, 2000) presents an interesting complement to attachment theory (Bowlby, 1969). In attachment theory, the style that individuals use in emotionally important relationships is stressed; in the interpersonal process approach, the relational level of the therapeutic process is emphasized and considered the primary tool of intervention. The interpersonal process approach includes an adaptation of Horney's (1970) work and is built upon a base of three traditions: interpersonal theory (Sullivan, 1968), object relations (Kernberg, 1968), and family systems (Goldenberg & Goldenberg, 1996).
The element of the interpersonal process approach most connected with attachment theory and most salient when working with bereaved individuals pertains to inflexible interpersonal coping strategies. During childhood, all individuals experience environmental blocks that lead to unmet developmental needs (e.g., attachment-related needs; Teyber, 2000). Teyber noted that one strategy used by clients to "rise above" or "overcome" (p. 185) their unmet needs is the development of fixed and often inflexible interpersonal strategies that tend to decrease anxiety and may indirectly satisfy the unmet needs. In addition, individuals will attempt to block the unmet needs by turning against themselves through either rejecting the self, rejecting others, or eliciting rejection from others. According to Teyber, "clients' problematic interactions with caregivers often give rise to pathogenic beliefs about themselves and others, and to faulty relational templates that shape their views of themselves, their expectations of others, and what will occur in close relationships" (p. 179).
There are striking similarities between Teyber's (2000) descriptions of the interpersonal strategies used by clients to rise above unmet needs and the anxious/ambivalent, avoidant, and secure styles of attachment. According to Teyber and Horney (1970), individuals adapt a moving toward, moving away, or moving against style in relationships because in childhood they learned which interpersonal style led to decreased anxiety and partial fulfillment of their unmet needs. Clients, who are moving toward, sacrifice the self and attempt to please others in virtually all situations. Those who are moving against try to control others. Individuals with a moving-away strategy defend against their unmet needs through extreme independence and emotional withdrawal. The moving-away strategy parallels the avoidant style of attachment; whereas the moving toward and moving against interpersonal approaches parallel the anxious / ambivalent style. Persons with an anxious / ambivalent working model desire reciprocation and union and tend to be clingy, needy, and obsessive in attachment relationships (Hazan & Shaver, 1987); separation from the loved one tends to elicit heightened anxiety coupled with anger and hostility. Individuals with an anxious / ambivalent attachment style may oscillate between moving toward and moving against in an attempt to get their need for proximity to the loved one met. Teyber suggests that the goal of interpersonal process psychotherapy is to encourage clients to use the interpersonal process relationship strategies in a flexible and reality-based rather than inflexible manner. Therefore, the primary tasks of the mental health counselor is determining what type of interpersonal strategies clients use inflexibly and then providing an environment in therapy that fosters greater interpersonal flexibility. Mental health counselors are challenged to use the therapeutic relationship as their most powerful tool in that issues are not just discussed with regard to content, but are approached at the process level of the interpersonal interaction between the mental health counselor and client.
Because attachment style appears connected to subsequent grief and mourning, the interpersonal process approach, informed by the tenets of attachment theory, could be an effective approach for addressing death and dying issues in counseling. If bereaved individuals tend to use either an inflexible approach to interpersonal relationships (Teyber, 2000) or a rigid style of attachment (Bowlby, 1988), they may develop difficulties as they attempt to cope and mourn. In reality, there exist relationships that are helpful and healthy and those that are unhelpful and damaging. Just as individuals need to determine whether it is advantageous to move toward, move against, or move away from individuals with whom they have living relationships, they must do the same with regard to the relationships with the deceased. It is quite likely that securely attached individuals would have relatively little difficulty with this process as they view relationships realistically and tend to use a variety of interpersonal approaches in a flexible manner. However, persons with avoidant and anxious / ambivalent attachments, paralleling those with inflexible interpersonal approaches, face difficulties because of treating all relationships, including those with the deceased, in the same rigid manner. Therefore, the interpersonal process approach to counseling, with its goal of providing clients with a relationship different than others they have experienced, would encourage flexibility in living relationships and also in those with the deceased.
CASE APPLICATION AND INTEGRATION
Following the death loss of his younger sister, a single, 35 year-old male client, John, was referred to counseling by his employer. The client described his employer's concerns regarding his low mood and recent drop in productivity. Although not self-referred, John appeared open to the counseling process but expressed difficulty understanding his change in functioning because he did not consider his relationship with his sister to have been a close one. Informed by the tenants of meaning reconstruction to loss and the existential approach to counseling, John's mental health counselor, Sally, delved more deeply into the meaning John attached to his relationship with his sister, including his conceptualization of the term close. In addition, attention was paid to how this death loss affected his personal identity and personal mortality. Sally encouraged John to write a loss characterization (i.e., description of himself following the death loss) and an epitaph for his sister. It became clear that John had been focusing a great deal of psychological energy on comparing his relationship with his sister to other people's sibling relationships. He eventually also shared that he was having difficulty with now viewing himself as an only child.
Sally used the concepts connected with the DPM and gestalt counseling to educate John regarding the dual nature of the stressors involved in death-loss situations. She encouraged him to balance his coping efforts between those that were loss and restoration oriented. In session, Sally emphasized the need for John to be present in the moment and to allow his moment-to-moment needs to rise and be discussed. Both John and Sally learned that he had been so consumed with thoughts about his sister's death that he had had difficulty in addressing the appropriate and necessary external changes needed in his daily life.
Although counseling moved along smoothly for 2 months, John then missed four sessions in a row, repeatedly calling to apologize and reschedule. When he returned, Sally, informed by attachment theory and loss and the interpersonal approach to counseling, processed the missed sessions with John and wondered out loud about his perceptions of their therapeutic relationship. The client shared his concern of becoming overly dependent on the counselor. It became clear that, as a child, John had learned from his actual interactions with his parents that his needs were not likely to be met through attempting to connect with them. He developed an adaptive approach of depending on himself rather than seeking support through relationships. Sally thanked John for voicing his concerns, and they discussed factors that would need to be present for John to feel safe and less vulnerable in the counseling relationship. Through this process, John was able to move toward the counselor and to recall incidents from childhood where his sister had been a confidant and support in the midst of parental discord. Informed by the tenants of the mourning and counseling theories noted above, Sally was able to assist John in discovering new perspectives of his loss and novel means by which to cope.
As illustrated in the case application, just as mental health professionals tend to use an eclectic approach in counseling (Norcross, Hedges, & Prochaska, 2002; Watkins & Watts, 1995), many of the concepts from these mourning theories can be integrated and used in combination. The dual process model offers direction with regard to the process of mourning; meaning reconstruction and loss provides the most direction regarding desirable content and possible outcomes of counseling; and attachment theory and loss revisited informs particularly with regard to the nature of the optimal therapeutic relationship. In contrast to the more traditional stage / phase-based approaches to mourning, the three mourning frameworks presented are marked by a recognition of the idiosyncratic nature of mourning. In addition, all theories direct both bereaved individuals and mental health counselors toward a mourning process characterized by acceptance, balance, and flexibility.
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Heather L. Servaty-Seib, Ph.D., is an assistant professor, Counseling and Development, Purdue University, West Lafayette, IN. E-mail: email@example.com