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Section 23
The Dual Process Model of Coping with Bereavement:
Rationale and Description

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Coping with Bereavement: Evaluation of Contemporary Theories
The Grief Work Hypothesis
Following accounts to be found in the scientific literature, grief work can be defined as a "cognitive process of confronting a loss, of going over the events before and at the time of death, of focusing on memories and working toward detachment from the deceased. It requires an active, ongoing, effortful attempt to come to terms with loss. Fundamental to current conceptions is the view that one needs to bring the reality of loss into one's awareness as much as possible and that suppression is a pathological phenomenon" (Stroebe, 1992, pp. 19-20). From this definition, we can derive the "grief work hypothesis," which refers to the notion that one has to confront the experience of bereavement to come to terms with loss and avoid detrimental health consequences (Stroebe, 1992).

It is not surprising that the notion of grief work has had such an influence in both theoretical and applied fields, even to the extent that it has become a "blueprint" for coping. Intuitively, it is easy to accept that one must, for example, "give sorrow words": Grief work seems to be at the essence of grieving, and this common belief is reflected in scientific formulations. To do justice to researchers, it must be added that, while they did consider grief work to be fundamental to adaptive grieving, their writing reflects awareness of greater complexity. Grief work was a major theme, becoming a guiding principle of coping for many, but minor themes can be identified alongside (cf. Walter, 1996). For example, the writing of Lindemann (1944,1979) shows recognition of the tendency of the bereaved to pull back from grief:

One of the worst pains there is, is sorrow. Having to suffer this, one gradually masters this pain, and gradually gets away from the inclination that one has not to think about it, to be busy with getting the deceased out of one's mind--forgetting it--putting things away which belonged to him; moving into another place so that one will not be reminded of him .... On the other hand, one may suffer through his mourning, and while one does that, do the essentials of grief work, which now becomes important for all people who are faced with a loss. (1979,p. 234)

However, although there has perhaps been some oversimplification, even unfair representation of classic contributions, it is, in our view, fair to say that they considered the grief work hypothesis to be fundamental, that other processes were more implicitly than explicitly documented, and that it has consequently been the grief work hypothesis that has dominated much of our thinking in the bereavement field.

Shortcomings of the Grief Work Hypothesis
As noted above, a number of grief theorists have recognized the limitations of the grief work formulation and questioned the acceptance of it as a dominant principle. In a seminal contribution, Rosenblatt (1983) analyzed 19th-century descriptions of how people dealt with grief, to evaluate contemporary scientific research on coping, and in particular, to assess the validity of the grief work notion: Although the emotional experience was found to be similar in the two centuries, people in the 19th century did not struggle to detach themselves, their memories and hopes, from the deceased. In an influential paper, based on their analyses of some empirical work, Silver and Wortman (1980) argued the case that working through was not only not associated with recovery but even detrimental to it. In a monograph that has helped to redefine principles of grief intervention, Worden (1991) reformulated the process of grieving in terms of distinct tasks that the bereaved have to undertake.

In a review of theoretical and empirical research on grief work, following some of the leads of the earlier theorists, Stroebe (1992) summarized a number of shortcomings associated with the grief work hypothesis. The main points of criticism concerned the lack of clarity in the definition of grief work (e.g., the confounding of negative associated rumination with more positively associated aspects of working through), the poor quality of operationalizations in empirical studies (e.g., grief work operationalized as yearning and pining), the absence of sound evidence for it (some studies failed to confirm that confrontation of grief is a predictor of adaptation) and the lack of apparent application across cultures (prescriptions other than the grief work hypothesis exist: These appear to be associated too with adaptation). These criticisms still pertain today.

However, whereas the earlier conclusion argued for more empirical testing and refinement of conceptualization, there are now good reasons to argue, in addition, for a revised model of coping. In our view, there are two main reasons for this, namely, limitations in scientific representation of bereavement phenomena within the grief work framework and its lack of general application.

Inadequate Representation of Bereavement-Related Phenomena
The first concern, whether the observed phenomena of grieving are adequately represented in the grief work hypothesis, can be illustrated by looking at (a) the definition of the stressor bereavement, (b) process, and (c) outcome variables.

Bereavement as stressor: The lack of specification. Lacking in grief work formulations in general is specification of precisely what has been lost and what has changed through bereavement. There has been a lack of recognition of the range of stressors, the multiplicity of losses, integral to the bereavement experience. Not only is there the loss of the person, but adjustments have to be made with respect to many aspects of life (cf. Worden, 1991). Such secondary stressors also need to be dealt with and (re)appraised, just as the meaning associated with the death of the valued person per se needs repeatedly to be thought through, even "pained through" (Lindemann, 1979). As Neimeyer (1998) noted, adaptation to loss involves the restoration of coherence to the narrative of our lives. We return to consider the two types of stressor later on.

Process Variables: A Non-dynamic, Intrapersonal Conceptualization
The dynamics of confrontation-avoidance. With respect to process, the grief work hypothesis conveys a sense for the need to confront the pain and work through the loss. This is understood to be an effortful process. Yet, the dynamic process that reflects the realization of loss, on the one hand, and the fight against the reality of loss, on the other hand, is neglected in this conceptualization. Denial too takes place at times, it is likewise effortful and (particularly in earlier formulations) it is claimed to be detrimental to health. Representation of the tendency, even necessity (as we will argue later) to confront combined with the tendency to avoid, deny, or suppress aspects of grieving as part of the coping process is still needed in scientific analysis. We need to examine further the extent to which confrontation and avoidance of primary and secondary stressors takes place and is efficacious.

Coping in social/interpersonal context. This dynamic process of coming to terms with a death does not take place in isolation. The bereaved are surrounded by others, some of whom are, likewise, grieving for the deceased. Implicit in the grief work model is the notion that one can work through grief with the help of others. However, the focus has been essentially intrapersonal: When the social setting of grief is considered (even this is rare) it is still the impact on individual adjustment that is the focus of analysis. Neglected so far (though of potential integration also in existing formulations) is analysis at an interpersonal level. Interactions with others can be expected to affect the grieving process and adjustment on both intra- and interpersonal levels. For example, discordance in the expression of distress between a bereaved mother and father can be interpreted in terms of more or less grieving by each partner, and affect their relationship, well-being, and the way they cope together and apart.

Outcome variables: "Medical model" focus. With respect to outcome variables, the grief work formulation leads one to focus on the potential link between a confrontational style of grieving and outcome in terms of psychological and physical symptomatology. Adherence to a grief work framework limits the focus largely to health outcome factors, even though, of course, well-being and adjustment are of central interest. Nevertheless, there has been a tendency to neglect other "products" of grieving (cf. Walter, 1996), for example, "positive growth" outcomes (Tedeschi & Calhoun, 1995), creation of a durable narrative about the deceased, reconstruction of the meaning of the deceased in ongoing life (Walter, 1997), and emergence of different roles and identities. Positive outcomes in addition to individual health indicators include relationship maintenance and restored functioning of the family as a unit (e.g., reassignment of the roles of the deceased to other members). The alternative, narrow view of functioning runs the risk that grief will be understood in terms of psychological and medical problems: Something that needs curing, needs to be overcome, is bad. There is the implicit assumption that, after the death of a close person, one must return to a positive state of mind and well-being as soon as possible. The danger, following this line of reasoning, is that human suffering, integral to grief as we know it, will be considered bad, and that the human condition should only, ideally, encompass positive states and emotions, a view that is far from universal (cf. Buddhist beliefs).

Lack of Universal Application
The grief work hypothesis has been suggested as a general explanation of functional coping. Yet, its relevance to understanding and explanation of gender and cultural patterns is questionable.

Gender specificity. First, the grief work hypothesis does not take adequate account of preferred masculine ways of going about grieving, which are typically less confrontive with respect to the emotion of grief, and less overtly expressive of distress and depression than those found among females (Stroebe, 1998; Stroebe, Stroebe, & Schut, unpublished manuscript). Although male grieving has recently received some scientific attention (e.g., Lund, in press), in the past female grief has been much more studied. As Carverhill and Chartier (1996) have described, this is "A reversal of the usual trend in psychological research to generalize from a largely male sample" (p. 1). The question arises, then, whether the grief work hypothesis that has been derived from the study of a largely female sample is, in fact, generalizable to a male sample: Is what we have at present a "female model of grieving"?

Cultural specificity. Second, we contend that the grief work hypothesis is culture-bound, at least with respect to the overt level of grief. Different conceptualizations of acceptable or "healthy" ways of coping are to be found in non-Western cultures (Stroebe & Schut, 1998; Stroebe & Stroebe, 1987). Some cultures show little or no evidence of "working through" patterns, for apparently this would be considered detrimental to the health of the bereaved and those around them (e.g., among the Muslim community of Bali, according to Wikan, 1990). In other cultures, the bereaved appear to work through normality in very different ways from western understanding of "normality," for example, mutilating the body, or tearing of the hair, as evidenced in some Aboriginal tribal peoples (see Stroebe & Stroebe, 1987).
- Stroebe, Margaret, Schut, Henk; The Dual Process Model of Coping with Bereavement: Rationale and Description; Death Studies, Apr/May 1999, Vol. 23, Issue 3.

Personal Reflection Exercise #9
The preceding section contained information about the dual process model of coping with bereavement.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 23
Why is the universal application of grief work hypothesis questionable in relation to gender?  Record the letter of the correct answer the Answer Booklet