He later modified these phases to: (1) numbness, (2) yearning or searching, (3) disorganization and despair, and (4) reorganization (Bowlby 1980), and explained they were meant to serve as a fluid guide, not a sequential requirement. This explanation of grieving seeks to reorganize the original, reciprocal relationship with a real person into an internal, cognitive adjustment that allows the bereaved to adapt to a world without the loved one.
He believed the success of this process depended largely on one’s childhood experiences with resolving attachments with primary caregivers; pathology manifested when a person become stuck or fixated in one of these phases (Bowlby, 1961). Parkes (1970) conducted a longitudinal, qualitative study of grieving widows in London under age 65, referred from their primary physicians. Interviewing the widows at one, three, six, nine, and thirteen months post-loss, he found support for Bowlby’s phase theory, stating that “as time goes by, one after another of the features of grief becomes less frequently aroused and less intense than it was before” (p.464).
Parkes noticed a range in the widows’ report of coping during the 13-month interview, from those surprised by their own capacity to successfully adjust, to those who reported they continued to experience severe emotional disturbance. He emphasized bereavement as a psychosocial transition, and cautioned against the blanket assumption that an ambivalent attachment to the deceased was the precursor to the more severe reactions.
Later, Parkes (2001) observed, “it is clear that it takes time for people to accept the implications of change … only with time and support do we undertake the major task of relearning our assumptions about the world” (p. 41). Kubler-Ross’ (1969) book On Death and Dying, while written as only applicable to those who have terminally ill loved ones and are able to anticipate the stages of anticipatory grief that begin following the news of the illness, is an important contribution to the bereavement field.
Based on numerous in-person interviews with terminally ill hospitalised patients, her observations led to the delineation of five stages of coping mechanisms which allowed patients to work through and gradually accept their impending death: (1) denial and isolation, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. Kubler-Ross emphasized the importance of both respecting an individual’s rights and wishes, and showing compassion as a professional, regardless of what stage of the grief process a person is in.
The main critiques of the majority of the bereavement theories thus far is that they lack empirical support, have largely drawn from observations of people already seeking or receiving treatment, and have not examined participants’ mental health status prior to the loss. Revised Theories and Recent Research of Bereavement Wortman and Silver’s (1989) highly influential article (cited by nearly every bereavement researcher since it appeared) critiqued five assumptions widely regarded as truth in the field of bereavement, and through a meta-analysis of the available research, found little or no empirical support for all five.
They clearly articulated the lack of support for the assumptions that (1) distress or depression is inevitable, (2) failure to experience distress indicates pathology, (3) “working through” a loss is necessary, (4) recovery from loss should happen relatively quickly, and (5) finding meaning for the loss is also necessary. Wortman and Silver (1989) highlighted the recognition that considerable variability exists in response to loss, and that trajectories other than the one explained by traditional bereavement theorists should not be assumed as pathological or deviant.
They stressed the importance for clinicians to allow for these different reactions, identify strengths, and not force an expectation of specific reactions onto grieving individuals. The grief work hypothesis was challenged by Stroebe (1992), who also pointed out the lack of empirical evidence supporting the necessity of working through one’s grief. She also questioned the operationalisation of grief work as yearning or pining in some studies: “The definition of grief work lacks clarity because it does not differentiate between negatively associated rumination and more positively associated aspects of working through” (Stroebe & Schut 2001, p.385).
Stroebe articulated the need for future research to include the recognition of: avoidance as a coping mechanism, the interpersonal context of grief (as opposed to being solely intrapersonal), the need for suffering, gender differences in grieving, and cultural differences in grief patterns. Stroebe and Schut (1999) then proposed the Dual Process Model of bereavement, a dynamic process of moving back and forth between confrontation and avoidance: “At times, the bereaved will be confronted by their loss, at other times they will avoid memories, be distracted, or seek relief by concentration on other things” (p.221).
In this model, pathology occurs when there is a disturbance in the oscillation between confrontation and avoidance, and an individual remains stuck in one or the other. Stroebe defined two types of coping, which interact with and compliment each other: loss-orientation (internally processing the loss experience itself) and restoration-orientation (focusing on dealing with secondary sources of stress, such as financial and interpersonal).
These internal and situational methods of coping are not sufficiently represented by only one or two emotions; in fact, they can elicit a wide range of emotions, such as loss-orientation eliciting feelings of relief that an ill loved one no longer has to suffer, feelings of sadness while looking through photographs, and feelings of anger that a spouse has been left alone. Bonanno and Kaltman (1999) went further in their support of Wortman and Silver’s (1989) critique, and proposed an integrative model of bereavement, that recognizes the complex interactions of the bereavement process.
The model emphasizes four domains: (1) appreciating the context of the loss, such as a person’s previous experience with loss, his or her age and gender, available support system, suddenness of the loss, and cultural influences; (2) subjective meanings of the loss exist on a continuum, which appreciates the fluid, cyclical process that bereaved individuals experience over time, as they reappraise both the impact of the loss and how well they have adapted; (3) continued bonds with the deceased can serve an important adaptive function, and do not necessarily need to be relinquished; and (4) coping strategies and emotional regulation do not always interact with each other.
Bonanno et al. (2002) examined five core patterns of bereavement (common grief, chronic grief, chronic depression, improvement during bereavement, and resilience) on 205 widowed persons who were part of a larger study on older couples, and the subjects were interviewed twice during the 18 months following the death of their spouse. The fact that the participants had already been interviewed prior to their loss allowed the authors to examine pre-loss variables that might affect the post-loss outcome.
The authors were attempting to distinguish different reactions to loss, and the possible pre-loss factors involved (e. g. , chronic grief may be confused with chronic depression if pre-loss functioning is not assessed). In addition to the interviews, the authors used self-report scales of depression and grief symptoms, as well as information already obtained about the subject’s assessment of the quality of his/her marriage, attachment to the marriage, dependency on spouse, coping resources, importance of spiritual beliefs, one’s belief in a just world, and the perception of support available from friends and family members.
This study revealed the most common bereavement pattern was that of resilience, and was comprised of “relatively well-adjusted …individuals with adequate coping skills” (p. 1160), who did not evidence a superficial or avoidant attachment to their spouse. They also found that chronic grief reactions could be distinguished from chronic depression, and they discussed the implications for effective treatment between these two.
The authors also observed a scarcely-studied grief reaction, depressed-improved, which included those exhibiting high pre-loss depression and then improvement in their symptoms during bereavement. Lastly, they observed no significant evidence of a delayed grief reaction, and cautioned against professionals offering treatment to those who are already coping effectively.
The researchers conclude, “the wide range of grief patterns demonstrated in the present study suggests a need to re-evaluate common notions about what constitutes a normal response to a major loss” (Bonanno et al. 2002, p. 1162). In 2004, Bonanno challenged bereavement researchers to distinguish between recovery from loss and resilience to loss, the latter defined as: the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event, such as the death of as close relation or a violent or life-threatening situation, to maintain relatively stable, healthy levels of psychological and physical functioning, (p. 20).