Morgan (2000) stated that grief impacts people on many levels: emotionally, biologically, sexually, economically, socially, and spiritually. In essence, all aspects of a bereaved person’s life are affected by grief. Freud’s (1917) seminal bereavement paper, “Mourning and Melancholia,” was the first to propose the necessity of doing grief work, which he defined as a cathartic process of reviewing and then severing the psychological bonds to the deceased, in order to create room for a new attachment to a live person; “a withdrawal of the libido from this object and a displacement of it on to a new one” (p. 249).
Stroebe (1992) more recently defined grief work 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 towards detachment from the deceased” (pp. 19-20). Freud (1917) compared melancholia, which he considered pathological, to the normal process of mourning; he argued that while both share the same features of dejection, loss of interest, inhibition, and loss of capacity to love, melancholia was distinguished by its punitive and painful view of the self, during which the grieving person expects punishment (a belief which may reach delusional proportions).
“In mourning it is the world which has become poor and empty; in melancholia it is the ego itself (p. 246). The pathology becomes the conflict within the ego, as opposed to the normal struggle to reconcile the loss of the object. Freud introduced ambivalence as a necessary precursor to melancholia, implying that the quality of one’s prior relationship to the deceased was an important factor. The ambivalence toward the lost object created a maelstrom in the grieving individual, who struggles to both detach and remain attached simultaneously.
His assumption was that all people need to do the “work” of grieving, where “every single one of the memories and situations of expectancy which demonstrate the libido’s attachment to the lost object is met by the reality that the object no longer exists” (Freud 1917, p. 255). Freud believed that the ego then became “free and uninhibited” (p. 245) once the grief work was completed, and ready to form a new attachment.
While these were theoretical constructs, based on Freud’s observations of grieving persons, they were assumed to be representative of the process of grieving and had implications for the bereavement field for many decades afterward. Freud himself even stressed that further study was needed to identify those who may be predisposed to develop melancholia, and that his paper was actually not addressing grieving, per se; he was exploring dimensions of depression.
The distinction between normal and pathological grieving was further explicated by Lindemann (1944), who interviewed 101 bereaved individuals from both an inpatient and outpatient population. Lindemann described the trajectory of normal grief as a fairly comparable phenomenon across patients, characterized by “(1) somatic distress, (2) preoccupation with the image of the deceased, (3) guilt, (4) hostile reactions, and (5) loss of patterns of conduct” (p. 142).
Lindemann observed that it was not unusual for people experiencing a normal grief reaction to resolve the immediate symptoms within four to six weeks with the care of a psychiatrist. Lindemann (1944) viewed morbid grief reactions as a distortion of the normal grieving process. These pathological responses included a delay or distorted reaction to the loss (i. e. , overactivity, or no observable change in affect), somatic reactions that mimic the illness of the deceased, hostility against those perceived as responsible (i.. , the loved one’s physician), prolonged isolation from social supports, and intense self-persecution and desire to punish oneself, including suicidal ideation.
Lindemann (1944) defined grief work as “emancipation from the bondage to the deceased, readjustment to the environment in which the deceased is missing, and the formation of new relationships” (p. 143). He believed that an obstacle to the successful resolution of grief was the avoidance of expressed emotional distress.
Lindemann seemed perhaps overly optimistic by stating that a person could be assisted through a morbid grief reaction in eight to ten interview sessions, yet this may have been seen as a welcome departure from Freud’s (1917) statement that mourning is “long-drawn-out and gradual” (p. 256). Furthermore, this could have been a precursor to the studies supporting the profile of the resilient individual (discussed in greater detail below). Anderson (1949) described the symptomology of 100 hospitalised bereaved patients under his care, who exhibited anxiety, hysteria, agitated and anergic depression, and hypomania.
Anderson clearly endorsed the pathology of a delayed grief reaction, stating, “It is obvious that such states of mind will pervert, distort and prolong the natural process of grief in reference to patients who were unable to cry or who appeared elated. Anderson (1949) also believed the necessity of understanding the bereaved patient’s relationship to the deceased, and endorsed that an ambivalent attachment would produce a conflicted and prolonged bereavement process.
Anderson (1949) wrote about his own observations of morbid grief, which he defined as “so persistent and intense in its nature that those who exhibit it give the appearance of suffering from an acute, rather than a chronic, mental illness” (p. 48). Anderson was particularly interested in those patients who exhibited a “violent reaction to the various forms of cathartic treatment” (p. 49), who became demonstrably more disturbed, suicidal or began hallucinating, following an attempt at re-enactment of the traumatic event.
Given the context of when and where this article was written (post-World War II London), a sympathetic and understanding attitude toward the huge number of grieving people was certainly appropriate. Both Anderson’s (1949) and Lindemann’s (1944) articles offered the first recognition that not everyone experiences grief in the same way, as well as the recognition that some individuals will require more support than others. Anderson’s observations regarding the different trajectories of grief response possible within an in-patient population paved the way for the theories and empirical studies that followed.
Discerning an overall pattern of grieving, Bowlby (1961) originally defined the phases he believed were pathognomic to normal grief process as: (1) a person’s biological response systems focus on retrieving the deceased and are unable to terminate once activated (e. g. , weeping, expressions of anger); (2) this biological response gradually subsides into a period of disorganization, pain and despair (e. g. , restlessness, depression); and (3) reorganization (e. g. , ability to have new relationships, pursue former goals).