Loss Grief and Bereavement

Much of what has been written about how people grieve has focused on individual survivors. The Victorian belief that grief was a sign of a "broken heart" resulting from the loss of a love was replaced by the psychodynamic view that grief was painful because it involved letting go of attachment to the deceased. This "letting go" was viewed as essential for "moving on" with one's life, eventual recovery from depression, and a return to "normal" (Neimeyer 2001). Theories of grieving later included an emphasis on differences between pathological (complicated) and normal (uncomplicated) grief reactions (e.g., Lindemann 1944), and an emphasis on phases, stages, or trajectories of the grieving process. The best-known stage model was presented in Elisabeth Kubler-Ross's (1969) book On Death and Dying. In discussing anticipatory grief of terminally ill persons she outlines five stages: shock and denial, anger, bargaining, depression, and acceptance. These stages were viewed by many lay people and professionals as "the" way successful grief is experienced. Many still gravitate to this model for its simple linear approach, using it as a prescription to measure how grief is progressing. Since its publication, this stage model has been applied to other losses including divorce, chronic illness, and infertility.

Although these models have been prominent in the popular media, many scholars have been critical of them (Attig 1991). Studies have failed to find any discernible sequence of emotional phases of adaptation to loss, or any clear endpoint to grieving. Rather than a passive climb up a linear staircase, characteristics of grieving may more closely resemble unsteady twisting and turning paths requiring adaptation and change, but with no specific end. In addition, there is no evidence that someone who deviates from those stages is experiencing pathological grief, so authors have called for a de-emphasis on universal grief syndromes and a recognition of varied practices of subcultural groups.

There also have been many challenges to the concept of grief work that underlies these theories— an assumption that one must do cognitive work to confront the loss and that failure to undergo or complete grief work results in pathological grief. The idea that one must "work" at dealing with grief is not a universal concept, and probably is reflective of the broader emphasis in the United States that anything worth having requires hard work.

Newer models of grief tend to focus on context and circumstances of a loss, variability in individuals' grief experiences, meaning of the loss to individual survivors and their families, recognition that rather than a withdrawal of attachment from the deceased (or lost object) there is a continued symbolic bond, and adjusting to the new world that exists after the loss (including new interpretations one has of the environment, and new elements in one's identity). The emphasis appears to have shifted from identifying symptoms to the process of grieving. For example, the Dual Process Model of Coping developed by Margaret Stroebe and Henk Schut (1999), suggests that active confrontation with loss may not be necessary for a positive outcome. There may be times when denial and avoidance of reminders are essential. Most individuals can expect to experience ongoing oscillation between a loss orientation (coping with loss through grief work, dealing with denial, and avoiding changes) and a restoration orientation (adjusting to the many changes triggered by loss, changing routines, and taking time off from grief). This reflects a movement between coping with loss and moving forward, but the extent to which one needs either of these dimensions differs for each individual.

Theories about families have been slower to develop elements that address loss and grief. Family systems theory (with its emphasis on viewing reactions to loss by the family group as a disruption in the family system's equilibrium and structure requiring reorganization of roles and functions; and the impact of reactions of one family member on another) appears well suited for examining loss. However, its emphasis on the present and current interactions appears to have slowed development along this line. There are a few notable exceptions, including Monica McGoldrick's (1991) elaboration of Murray Bowen's work on the legacy of loss. Bowen (1976) suggested that a family's history and experiences with loss influences how the family adapts to subsequent losses as well as the legacy of viewing themselves as either "survivors" or "cursed" (i.e., unable to rise above the losses) that they pass on to future generations.

Another notable work is that of Ester Shapiro (1994), who integrated individual and family life-cycle development with systems theory to discuss loss as a crisis of identity and attachment, in which grief disrupts the family's equilibrium but makes possible development of new "growth-enhancing stability" (p. 17). In addressing losses related to chronic illness, John Rolland (1994) developed the Family Systems-Illness Model to examine the interface of the individual, family, illness, and health-care team. Rather than focusing on the individual, Rolland views the family or caregiving system as the central resource affected by and influencing the course of the illness.