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Section 18
Theories of Grief and Mourning

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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 Kübler-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 Kübler-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 Kübler-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 (Hazier, 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.

- Servaty-Seib, Heather, Connections Between Counseling Theories and Current Theories of Grief and Mourning, Journal of Mental Health Counseling, Apr. 2004, Vol. 26, Issue 2.

Personal Reflection Exercise #4
The preceding section contained information about theories of grief and mourning.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 18
What are Rando's six "R" processes of mourning?  Record the letter of the correct answer the Answer Booklet.