Grief theory: stage or process.

McCabe, Marilyn. (2003).

The Paradox of Loss: Toward a Relational Theory of Grief. Westport, Connecticut: Praeger. Hard Cover. (xiii + 219). $70.00. ISBN 0-275-97986-5.

Marilyn McCabe is a psychologist in private practice and Adjunct Faculty member for the Georgia School of Professional Psychology at Argosy University, as well as the Advanced Psychodynamic Psychotherapy Program sponsored by the St. Louis Psychoanalytic Institute and the Nashville Psychoanalytic Study Group.

Many therapists have had the experience of working with a client in bereavement who seems to almost refuse to acquiesce to the expected stage models of grief. These same therapists have probably questioned these stage models, even suggesting to their clients that there is no correct way to grieve. In The Paradox of Loss, McCabe turns classic grief theory on its ear by challenging such long held accepted wisdom as grief proceeds in expectable stages, that one should "get over" grief in a timely fashion, and that grief is itself (or may become) a kind of pathology.

McCabe uses two main strategies to critique prevailing grief theory. As the subtitle indicates, McCabe is interested in the developing field of Relational psychoanalysis and uses it and constructivist philosophy to shape her arguments. Her second strategy is an "experience near" approach in which she describes her own grief journey extracted from personal journals she kept for several years following her own mother's death (she also intersperses other first person accounts). The lining of her own experience is a beautiful example of a Relational approach, for every theoretician can most fully be understood through his/her own experience. Instead of hiding behind theory or empiricism, McCabe recognizes that in some profound way theory/science is biography.

In Chapter 1, "Grief Theory and Subjective Accounts," McCabe articulately summarizes the most prominent grief theories even as she begins to systematically critique them. Her foremost critique of the reigning models is their stage/phase component. These models posit that in grief something is lost and subsequently doing grief work means that one should "give up" what has been lost and move on. The models further suggest that "giving up" involves systematic movement through expectable and linear stages or phases. Being unable to "give up" the lost object and move through the stages in a timely fashion suggests that unresolved grief or pathology has set in. Not only does this risk placing the mourner in the role of "dysfunctional patient" but also it makes the mourner the sole focus. McCabe argues that this entirely misses the ongoing relationship between the survivor and the deceased and the way in which the self of the survivor may be changed. McCabe implies that stage/phase theories, although they give intellectual assent to the concept of internalization, really don't allow for an ongoing co-constructed relationship to continue between the living and the deceased. McCabe believes that grief is a combination of stages and processes, and most importantly, grief moves in unpredictable and idiosyncratic ways for each mourner. She consents that grief does seem to change over time but this does not mean that phases are completely discrete from one another or linear, or that they may never be re-experienced.

In chapter three, "The Biases Beneath Grief theory," McCabe uses Relational psychoanalysis and constructivist philosophy to critique a grief theory bias toward linear progression, completion, and detachment from the deceased. Below these biases is another bias toward autonomy and separateness. Constructivism and Relational theory suggest that the self is always in transition, always being co-constructed, multiplicitous, contextual, and embedded. When stage/phase theories hold to a view of the self as separate and autonomous, the self is conceptualized as on one side of grief and the deceased on the other--the best we can do is remember the lost. A Relational view of the self allows for an on-going intersubjective relationship between the deceased and the living. The living continue to search for the lost and continually find them in new and different ways. The living may imagine how the deceased might experience current events or what they might say if they were present. In searching for the lost, the living find them, re-construct them, and continue to relate with them. In this "finding" the self of the searcher is also changed and in some sense co-constructed by the deceased. Thus from McCabe's process model, "giving up" the lost one is not the goal and not "giving up" is not a form of pathology. In fact, keeping the lost one "alive" within the self is an inescapable component of being human.

Although this is not a Christian book in the traditional sense, I believe it is a deeply spiritual one and subsequently has import for psychologists and clinicians from Christian persuasions. McCabe suggests that one of the difficulties we have with death and why we inadvertently gravitate toward stage/phase models is our own anxiety related to death. She concurs with existential philosophers and psychologists in arguing that one must come to terms with death in order to truly live. Too often in our churches, and even in our therapy offices, parishioners and clients may be pushed toward relinquishing their grief in an unconscious attempt by the therapist/friend/pastor to avoid their own discomfort. Christian "helpers" may make this worse by implying subtly or overtly that one need not mourn for the loss of a loved one because they are in a "better place" (e.g., heaven, with the Lord, etc.). This sort of theology may lead many a Christian to feel guilty because they don't seem to be fitting the stage/phase theory expectations. They may even come to believe that if they can't "give up" their loved one somehow they are not exhibiting faith in God. One implication of McCabe's work is that Christians could come to think about the ongoing-ness of grief work as an actual gift from God. It is a precious gift to remain related in a real and profound way to someone who is no longer with us.

Perhaps the most poignant chapter is four in which McCabe shares her own journal entries (as well as other first person accounts) written after the death of her mother. She uses a kind of qualitative analysis to search for themes and meaning in her entries. This chapter blends seamlessly into the next two where she more thoroughly discusses the paradox of loss. In these chapters McCabe guides the reader into understanding that the paradox of loss is that the loved one is gone and not gone. Here again she relies heavily on Relational psychoanalysis and constructivist thinking to explore the self as dialogical, embodied, and constructed. She examines such concepts as object permanence, object constancy, and attachment to explore "enduring presences" and demonstrates that what was lost also remains--even if what remains does so in a different form. This facilitates the process of memory and rememory (continual construction). She even thoughtfully uses some of the latest work in neuroscience on memory and emotions to support her claims.

Paradox of Loss is not a particularly long book but its thorough theoretical argument at times can feel slightly redundant. Nevertheless, McCabe has an engaging writing style and the use of personal accounts of grief and her use of literature and poetry makes for enjoyable reading. The enduring value of this book is that it provides a systematic and highly convincing rethinking of contemporary grief models. I believe it is a must-read for clinicians who regularly work with individuals in bereavement. It could be argued that perhaps all therapy in some way is about grief. I found the implications to go beyond the actual loss of a loved one and to be applicable to other kinds of grief (e.g., loss of idealized self and other representations, etc.) as well. This is a rather expensive book, but I believe it is an invaluable resource to help clinicians know how to more accurately empathize with the real process of grieving.

Reviewed by BRAD D. STRAWN, Ph.D.