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Article 30

A Metatheory of Grief

Implications for Counselors

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Catherine Beckett and Cass Dykeman

Note: The research contained in this manuscript was conducted under the approval of the Oregon State University Institutional Review Board (Study ID 5398). Parts of the manuscript were prepared as part of the first author’s dissertation.

Mental health professionals use both theory and case conceptualization to guide effective practice (Rainforth & Laurenson, 2013). As such, counselors should understand the breadth and depth of grief theories. To aid in this understanding, we review the conceptual metatheories that operate concurrently in grief work. A metatheory can be defined as a fundamental set of ideas concerning how phenomena in a particular field should be considered and explored (Bates, 2009).

There exist three metatheories in grief work. In chronological order of their creation, these metatheories focus on: (1) stage-based models, (2) task-based models, and (3) idiographic models. Each of the following three sections in this review describes a metatheory’s: (a) conceptualization of grief, (b) definition of normal versus pathological grief, (c) relevant research, (d) implications for counseling, and (e) application of the metatheory. Finally, a summary of grief metatheories and their clinical applications is presented.

Stage-Based Models

Conceptualization of Grief

The publication of Elisabeth Kübler-Ross’s On Death and Dying in 1969 filled a tremendous gap in literature, education, and practice, present since Freud’s publication of “Mourning and Melancholia” in 1917. In an historical review of grief theories, Maples (1998) noted that prior to On Death and Dying, Western culture conceptualized death as something: to be feared, too unpleasant to talk about, and even too unpleasant to think about. As a psychiatric resident, Kübler-Ross was disturbed by the lack of attention to death and dying in the medical curriculum. Her five-stage model (denial, anger, bargaining, depression, and acceptance) was an attempt to find universal patterns in the grieving process, and it emerged from her own work with a group of terminally ill patients. Despite the fact that Kübler-Ross’s theory had not been empirically tested, several researchers noted in 2011 that Kübler-Ross had been embraced at the time as a “guru” and that her stages had been generalized in both popular and professional circles to cover all kinds of grief—across individuals, cultures, and different kinds of losses (Kohler, 2011; Konigsberg, 2011).

Kübler-Ross’s five-stage model was echoed in additional stage or phase models of grieving by both Bowlby and Parkes. In his work on attachment theory, Bowlby (1963, 1977, 1980) delineated four phases, similar in many ways to Kübler-Ross’s, that occur when a person experiences the grief of separation from an attachment figure: numbness; yearning and separation anxiety; despair and disorganization; and finally reemergence into life. Bowlby also extended his model to cover losses beyond relational separation and bereavement, including losses such as functions, roles, health status, and dreams about the future.

Parkes’s grief theory (1971, 1972) described a preprogrammed set of behaviors that is cued by a loss: numbness; searching/pining; depression; and recovery. Sanders (1989) described phases of bereavement (shock, awareness of loss, withdrawal, healing, and renewal). She also focused on internal and external mediating factors that lead to individual differences in mourning, asserting that individual circumstances such as age, gender, and the circumstances surrounding the loss lead to very different experiences. She warned that the concept of fixed time limits for grief may be harmful to the griever.

Normal vs. Pathological Grief

In the stage-based models, grief consists of a uniform series of distinct phases. Most models describe progress through stages that include: (1) numbness or shock, (2) movement into and through a series of difficult emotions, and finally (3) a place of recovery. Failure to move through phases in a timely fashion is considered problematic and predictive of future difficulties. Maples (1998) noted that if grief is unresolved or becomes fixated at some stage, mental and physical health can become disrupted. Weiss (1998) was one of the earliest grief theorists to differentiate ordinary grief from pathological grief. He posited that ordinary grief shows itself through intense distress and moves toward resolution, while pathological grief does not (Weiss, 1998).

Stage-based models laid the foundation for what Stroebe (1992) later termed the grief work hypothesis (GWH). Stroebe stated that the GWH held that a griever must engage in an effortful attempt to come to terms with a loss and bring the reality of the loss into awareness as much as possible. Within the GWH, suppression of grief-related cognition and emotion, or of the expression of them, was seen as a pathological phenomenon. Also enfolded in the GWH are the notions that strong emotions are inevitable and necessary, that lack of distress equals pathology, that processing the loss externally and verbally is required, that “letting go” or breaking the bond with the lost object is a central goal, and that recovery/resolution within a relatively brief amount of time is the expected outcome (Costa, Hall, & Stewart, 2007; Wortman & Silver, 1989).

Relevant Research

The majority of the grief research and literature during this period (from the 1960s into the early 1990s) is focused specifically on bereavement, and nearly all of it focuses on White adults in Europe or America. It was not until the end of this period that more attention began to be paid to cultural and gender differences. Maples (1998) suggested that further study of cross-cultural grief patterns, as well as individual differences in grieving, was warranted. Fowlkes (1990) also charged that bereavement research had focused almost exclusively on the loss of nuclear family members—a very narrow conception of relationship loss.

Implications for Counseling

For both practitioners and clients, the work of Kübler-Ross was revolutionary in opening the door to talking about the grief experience; there was relief at having a template to follow and constructs and language to guide the work. However, the conceptualization of the path to recovery that the stage model presented was narrow. Konigsberg (2011) described this conundrum as having only two possible outcomes: a person either repressed the stages, thereby getting stuck in painful, unresolved emotions, or, s/he worked through the stages and came out stronger and wiser. Counselors, by implication, needed to be well trained in the stages and to convince clients to engage and work through them. As the stages of grief model made its way into popular consciousness, it was also widely incorporated into health and mental health education. It was then, and it remains to this day, the most recommended resource for grief and bereavement support (Kohler, 2011).

Critiques

Assessing validity is important because theoretical assumptions are likely to influence the field’s research agenda and also to guide clinical practice (Davis, Wortman, Lehman, & Silver, 2000). As early as the mid-1970s, researchers were noting a lack of evidence to support stage-based practices in grief counseling (Rosenblatt, Walsh, & Jackson, 1976). When the first significant body of research finally emerged in the late 1980s and the 1990s, it failed to support the assumptions of existing stage-based models (Costa et al., 2007).

The first major critique to emerge from this research challenged stage-based models’ focus on emotional and psychosocial dynamics. Corr (1992) noted that these models excluded physical and spiritual experiences of grieving and were therefore limited. The second major critique challenged the concept of “letting go” or breaking the bond with the lost object as being necessary; instead, studies indicated that the bond with a lost object continues but must change to accommodate the fact that the object is no longer present. Klass, Silverman, and Nickman (1996) stated that people were not ending but altering and then continuing their relationship to the person they had lost.

Beginning in 1989, three research teams published major empirical challenges to the GWH, which asserts that grief work, conducted in particular ways, is necessary to achieve healthy adjustment to bereavement (Bonnano & Kaltman, 1999; Stroebe, 1992; Wortman & Silver, 1989). Despite widespread endorsement of the GWH in the field, little empirical evidence existed to support it. Wortman and Silver (1989) debunked the beliefs that normal grief must include intense emotional distress, that it must be “worked through,” and that it will at some point be “resolved.” In addition, they noted that the perpetuation of unrealistic assumptions held by counselors sometimes led to client self- perception that their own responses are inappropriate or abnormal. Stroebe’s (1992) criticism of the GWH focused on the lack of clear empirical support, including the absence of clarity of research concepts, of clear evidence supporting the hypothesis, and of research and application across populations and cultures.

Additional studies leveled more particular criticisms of the GWH and its assumptions. Pennebaker, Zech, and Rime (2001) found that writing or talking about feelings does not in and of itself lead to recovery. Bonnano and Kaltman (1999) challenged the need for grief work even more strongly, reporting that in their findings, some repression or avoidance may be helpful in the short and long term. Both the GWH and stage-based models were criticized for being culturally biased. McCabe (2003) pointed out the Western values embedded in the GWH, such as linear progression, goal completion, autonomy, and detachment. Stage-based models were criticized for being too linear and having too little room for individual responses (McCabe, 2003; Worden, 2009). Corr (1992) noted that any universal stage model risks overgeneralization, which may then stereotype vulnerable individuals. These studies and many others led to a shift in metatheory, as researchers and practitioners worked to correct some of the problems presented by stage-based models.

Task-Based Models

Conceptualization of Grief

In the task model metatheory, grief responses are characterized not by progression through stages, but by behaviorally oriented tasks that must be accomplished. There is greater room for individual difference in the ways these tasks are accomplished (McCabe, 2003; Worden, 2009). Tasks are seen as nonlinear; grievers move fluidly between them, in addition to moving in and out of actively grieving. The bond with the lost object changes but continues, and like the bond, the process of grief does not end but instead changes over time (Humphrey, 2009).

Worden (1991, 2009) is credited with creating one of the best-known task-based models. This model is composed of four tasks that must be accomplished for grief to be resolved: acceptance of the reality of the loss; experiencing and working through the pain of loss; adjusting to an environment without the lost object; and establishing a changed but continuing bond. Other task-based models have been advanced by Rando, Stroebe and Schut, and Neimeyer. Each of these models will be examined in order.

Rando (1984, 1993) proposed a model based on three broad phases: avoidance, confrontation, and accommodation. Each phase contains specific processes that must be addressed for healing to occur. In avoidance, one must recognize the loss; in confrontation, one must react to separation, recollect, re-experience what has been lost, and relinquish old attachments (both to the lost object and to one’s assumptions); and in accommodation, one must readjust to the new world and reinvest energy in new ways.

The dual process model of Stroebe and Schut (1999) looked at gender, cultural, and individual differences and suggested that rather than moving through phases, people oscillate between two types of reactions: loss-oriented tasks and restoration-oriented tasks. People undertake these on different timelines, with different approaches, and in different proportions, depending on both internal factors and external pressures.

The constructivist or narrative-focused model by Neimeyer (2000) suggests that loss disrupts the deeply held assumptions on which a person’s life story and sense of identity are grounded. This model conceptualizes grief as a person’s struggle to accomplish the primary task of building a new, post-loss framework of meaning. Those in grief may therefore benefit from support around meaning reconstruction.

Normal vs. Pathological Grief

While task-based models do make more room for individual differences in the grieving process within their conceptualization of normal grief, they still have embedded within them the notion that grievers must actively work through the tasks outlined in the model. This leaves two primary ways in which a person’s grief might be viewed as pathological—if s/he appears to be stuck in one of the tasks, or if s/he is not engaged in the tasks at all.

Relevant Research

In spite of their increased flexibility, task-based models continued to be the subject of criticism in regards to cultural applicability. Wortman and Silver (2001) identified many enduring Western assumptions in grief counseling; Stroebe (1992) posited that the view of grief as a set of tasks that requires a template or “recipe” to resolve may itself be a product of industrialization. Rosenblatt (1996) noted that efforts to medicalize and routinize grief therapy may be insensitive to cultural differences and recommended a sensibility in which the diversity of realities is acknowledged. Sue and Sue (2008), who have written extensively about some of the challenges of multicultural counseling, are particularly critical of the emphasis counseling has traditionally placed on affective expression. International research further supported enormous cultural variability in the expression of and response to grief (Golden, 2009; Rosenblatt, 1993); reactions expected in one culture could be considered pathological in others.

Further studies looked more specifically at gender differences in grief (Stillion & Novello, 2001; Stroebe & Stroebe, 1983; Stroebe, Stroebe, & Schut, 2001; Zinner, 2000). One study suggested that while women struggle with prohibitions against anger, men struggle with prohibitions against sadness (Cochran, 2006). Thus, both genders may engage in processes that inhibit the successful resolution of grief. Another study showed that men and women were helped more by different interventions, with men benefitting from an emotional focus and women benefitting from a problem-solving focus (Schut, Stroebe, van den Bout, & de Keijser, 1997).

During this period, research also began to examine whether or not counseling is a useful and effective intervention for people experiencing grief. The question was first approached in 1980 by Parkes, whose research review found that counseling for the bereaved reduces the risk of poor outcomes, especially among bereaved people who perceive their families as unsupportive. Several studies showed evidence for particular risk factors associated with a higher risk for poor outcomes (Parkes, 1990; Rando, 1992), suggesting that individuals with these risk factors might have a greater need for—and benefit more from—grief counseling. A review of efficacy research by Schut, Stroebe, van den Bout, and Terheggen (2001) supported these findings, noting that the more complicated the grief process, the better the chances of interventions leading to positive results (p. 731). As a summary statement of efficacy research, Gamino and Ritter (2009) concluded that competent grief counseling can help those individuals struggling to accommodate their loss, or whose personal history and circumstances make it even more difficult than usual to cope.

Implications for Counseling

While task-based models do still provide counselors with a template of sorts, they also provide more room for individual variance in how these tasks might be approached and accomplished by individual clients. This metatheory marked the beginning of a shift away from a prescription of how clients should grieve, based on an increased awareness of individual, contextual, and cultural influences on the experience and expression of grief.

This shift presents both opportunities and challenges for counselors. On the one hand, practitioners making room for difference may increase the success of counseling with a wider range of clients (Barrett, 1998; Sue & Sue, 2008) and present a smaller risk of alienating clients who are seeking support. On the other hand, a less prescriptive and more open grief concept presents more challenges for the practitioner, requiring more flexible assessment and intervention skills and an increased awareness of personal assumptions and biases. This more variable concept of grief has implications for increased challenges in counselor training as well; to wit, it is easier to teach someone a single recipe than it is to teach that person how to cook.

Critiques

Bonnano and Kaltman (1999) observed that the empirical challenges to stage- based models and the GWH created a theoretical vacuum. Despite the clear and growing research evidence against them, the shift away from this metatheory was not penetrating popular understanding or practice. McCabe (2003) noted that as a result, individuals may view themselves as flawed or “crazy” for not following the “proper” maps of grief. In 1989, Doka created the term disenfranchised grief to describe grief that is outside of the expected cultural window of acceptability, and which is therefore not acknowledged, validated, or supported. Disenfranchisement can result from unrecognized relationships, losses perceived as insignificant, or grieving styles or timelines outside the norm. The impact of disenfranchisement can be social, intrapsychic, or both (Doka, 1989, 2002). Gilbert (1996) recognized what she termed differential grief in families: the common phenomenon of family members experiencing and coping with their grief in very different ways, leading to increased stress and pain. These works and others called attention to the idea that both stage- and task-based models contribute to the maintenance of grieving norms, which may help some clients but exclude or alienate others.

Idiographic Models

Conceptualization of Grief

In this current metatheory, individual differences—both internal and external— and the unique experience of grief are emphasized. The idiographic metatheory does not replace the task model, but instead augments and broadens it; it suggests that grievers may still need to accomplish tasks but will do so in different ways and require different kinds of support (Humphrey, 2009).

Normal vs. Pathological Grief

The models of this metaframework emphasize that grief occurs within a specific individual context and within multiple and fluid contexts. Martin and Doka’s (2000) adaptive grieving style model was promulgated to address and mitigate the disenfranchisement that results from the application of nomothetic models, without regard for the individual or context. In their early work, they identified feminine and masculine grieving styles; however, upon finding that grief style is gender influenced but not gender determined, they created a continuum of styles, with intuitive on one end, instrumental on the other, and a blended style in between. Grief style influences a person’s experience and expression of grief, as well as his/her preferred adaptive strategies. Intuitive grievers experience intense, sometimes overwhelming emotions and have a need to express these feelings, effectively mirroring their internal distress. Instrumental grievers experience grief in more cognitive and/or behavioral ways; they are more modulated and private in their feelings. They tend to put their energy into directed activity (such as problem solving, organizing, or analyzing), attempting to master themselves and their environments. Grievers with a blended style show some characteristics of both of the previous styles and may be able to shift more easily from one to the other as situations demand.

Though research focused on grief style is still very limited, a grief style measurement tool was successfully piloted in 2006 (Martin & Wang, 2006), and an Internet tool designed to educate grievers about grief style, assist them in self-assessment, and provide further resources had a measurable positive short-term impact on bereaved individuals (Dominick et al., 2009).

Gamino, Sewell, and Easterling’s (2000) adaptive model of grief moved away from a pathology orientation and toward positive coping and adaptation, focusing on what factors help grievers adapt well. They identified four behavioral patterns of adaptive grieving: ability to see some good resulting from the death, having a chance to say goodbye, intrinsic spirituality, and spontaneous positive memories of the decedent (p. 633). Indeed, more researchers in this new paradigm are now calling attention to the fact that, where grief is concerned, resiliency is the norm (Bonnano, 2009) and that in the wake of grief, a variety of benefits and positive outcomes may appear (Frantz, Farrell, & Trolley, 2001).

Relevant Research

In 2002, Lindstrom published a challenge to what she called mainstream thinking about bereavement; she attempted to bring together two opposing strategies—those that call for expressing the pain, and those that claim avoidance and distraction may result in better outcomes. Instead of rigidly adhering to either extreme, she promoted principles of mindfulness in grief counseling: recognizing whatever comes into the mind, without judging or fighting it, and then letting it go. She termed this a “middle perspective,” and suggested that this perspective acknowledges both the bereaved’s need for reacting and reflecting and the need for stopping sadness and pain when grief becomes overwhelming.

Rosenblatt (2008) has continued his culturally focused grief research and noted that culture creates, shapes, limits, and defines grieving. He wrote that the fit between an individual’s grief and the expectations of his or her culture is crucial and determines how well or poorly his/her grief is supported. He also reiterated the need for ongoing research that is as free from ethnocentrism as possible, in order to keep the field from being limited and controlled by researchers with culturally based biases.

Research on gender and grief has also continued. Wolfelt (1990) wrote that men in our culture still do not have permission to openly mourn in affective ways, noting the discomfort that occurs when a man openly admits to painful emotions of hurt and loss. Golden (1997) realized after years of grief counseling practice that since the majority of therapy clients are female, therapy is shaped to fit and be effective with women, and that this may need to change to effectively serve the needs of male clients.

Finally, the question of whether counseling is a useful and effective intervention for people experiencing grief has received increased research attention over the last decade. More recent studies have followed work done by Parkes (1980, 1990) and Rando (1992), which initially suggested that grief counseling is particularly helpful for individuals who have more risk factors or less social support. In 2000, a period of professional contention began when Neimeyer published a research summary that included the results of an unpublished meta-analysis by a doctoral student named Fortner (1999), whose analysis showed a treatment-induced deterioration effect (TIDE) in 38% of his sample, suggesting that counseling for grief may sometimes be harmful. Neimeyer’s summary, including the TIDE statistic, was then cited by additional researchers and was picked up by the popular media, leading to headlines such as this one in the New Yorker in 2004: The Grief Industry: How Much Does Counseling Help— or Hurt? (Groopman, 2004). In 2007, Larson and Hoyt published a strongly-worded critique of Fortner’s work, claiming that their review showed “no empirical basis” for claims about deterioration effects in grief counseling and criticizing the citation of the work, which had never been subjected to peer review, as “poor scholarship.”

More contemporary meta-analyses and reviews of research seem to have found several principles on which they can generally agree. First, the majority of people experiencing grief will recover without counseling, making grief therapy for normal bereavement difficult to support (Neimeyer, 2000). Second, there is good evidence to support the efficacy of grief therapy for a subset of grievers who are assessed as having substantial clinical distress to begin with (Neimeyer & Currier, 2009). Allumbaugh and Hoyt’s (1999) meta-analysis found that, additionally, clients who self-selected for grief counseling made greater improvements than those who were recruited for intervention; another by Wittouck, Van Autreve, De Jaegere, Portzkey, and van Heeringen (2011) found that while treatment interventions were effective for complicated grief, preventative interventions were not. In summary, when grief counseling is focused appropriately on those who need and seek it, evidence supports positive treatment effects (Bonnano & Lilienfeld, 2008; Larson & Hoyt, 2007).

Implications for Counseling

Multicultural counseling has taught us that it is important to recognize the power inherent in the practitioner position; counselors’ expectations of clients have an impact. An individual whose grief response does not conform to what is viewed as normal may be negatively judged or denied support, while more flexible expectations may lead to more supportive interactions (Costa et al., 2007).

One challenge presented by flexibility, however, is that the further we get from a clear picture of what is normal, the more difficult it is to determine what should cause concern. As important as it is to make room for individual differences, it is hard to look at a client who is severely distressed and unable to function years after a loss and think, “Well, perhaps that’s just this individual’s own process.” Setting aside recent debates about whether future editions of the DSM should include a diagnosis for pathological grief, most practitioners of grief counseling would agree that the symptomatology described by Prigerson et al. (2009) for prolonged grief disorder (grief which is chronic, unremitting, and which significantly interferes with a person’s functioning) should evoke concern. Humphrey (2009) suggested that, rather than normal versus pathological, we think in terms of uncomplicated versus complicated grief. In uncomplicated grief, symptoms diminish in intensity over time and generally move toward resolution. Complicated grief is prolonged, and symptoms intensify rather than abate; the griever does not appear to be making any progress on integrating the loss.

Critiques

Research focused on differences, styles, and adaptation in the grieving process is in its infancy; very little yet exists. The primary issue with this metatheory seems to lie in the ongoing question of whether these new understandings have penetrated professional thinking and led to any changes in our expectations, judgments, and practice (Costa et al., 2007; Middleton, Moylan, Raphael, Burnett, & Martinek, 1993). Doughty’s 2009 Delphi study found some of this new understanding among a panel of grief counseling and research experts, but Doughty expressed great uncertainty about non-specialist practitioners, calling for studies to look at how counseling professionals are aware of the latest research.

Summary

This review of the literature provided a history of three grief metatheories: stage- based models, task-based models, and idiographic models. Each section has examined the metatheory’s (a) conceptualization of grief, including definitions of normal versus pathological grief, (b) relevant research contributions during that period, (c) research on cultural and gender influences, as well as research on the efficacy of grief counseling, (d) implications for counseling practice, and (e) finally, critiques of each metatheory’s models.

Stage-Based Models

The first stage model, published in 1969 by Kübler-Ross, filled an enormous gap in literature, education, and practice; though it was based in Kübler-Ross’s work with terminally ill patients, it was quickly generalized and became known as the stages of grief model. It provided a language for professionals and laypeople to talk about death and grief, as well as a template for understanding the experience. This model was followed by additional stage or phase models of grief, which collectively formed the foundation of what was later termed the grief work hypothesis (GWH): the belief that successful resolution of grief can only come through actively experiencing and processing, rather than avoiding or suppressing, the emotional distress of a loss.

Task-Based Models

Beginning in the 1980s and 1990s, many of the assumptions embedded in the GWH were challenged on the basis of lack of empirical support. In fact, this first wave of significant grief research also failed to support existing stage-based models (Costa et al., 2007). This led to the rise of task-based models, such as Worden’s (2009), in which the griever must accomplish tasks of healing. Task-based models were seen as less narrow, less linear, and better able to accommodate differences in individuals’ approaches to grief—based on age, gender, culture, loss history, and many other factors (Jeffreys, 2011)—and were therefore seen as less likely to inappropriately pathologize. Culture and gender research from this period identified and cautioned against what Sue and Sue (2008) termed affective bias—the tendency of counselors to emphasize and privilege affective expression, thereby alienating clients whose value systems may be different. Research on the efficacy of grief counseling also proliferated during this period, generally concluding that for clients in high distress, whose grief was not self-resolving, counseling interventions were often helpful.

Idiographic Models

The space created by the empirical challenges to the GWH served as both gap and opportunity. Researchers noted the need for an integrative conceptualization of grief, leading to the third metatheory. The concepts of disenfranchised grief (Doka, 1989) and adaptive grieving styles (Martin & Doka, 2000) emerged during this period, but neither concept yet has a substantial body of research to support and illuminate it. In this most recent metatheory, researchers and practitioners alike struggle to balance making room for differences with agreement about what should cause concern.

Finally, there seems to be a growing disconnect between research and practice, in that while our empirical understanding has moved beyond stage-based models and the GWH, most practice, education, and popular understanding has not. In the journal Death Studies, an editorial asserted that the field is at a “critical juncture” in terms of actively working to align research and practice. This editorial emphasized the need to make explicit provisions for practice and research to reciprocally influence each another (Balk et al., 2004). Indeed, an increasing number of researchers and practitioners have noted this current lack of alignment between research and practice—most notably, the lack of incorporation of newer and more empirically supported models of treatment into practice work. There is real concern that this disconnect will lead to ineffective practices, and potentially to some clients experiencing disenfranchisement in the counseling process. Costa et al. (2007) noted that grief-related beliefs held by both a bereaved individual and a potential support provider may impact how an individual’s grief process is understood and supported. Part of the work to be done in this new metatheory lies in examining how outdated beliefs may be impacting the effectiveness of grief support, and what is needed to update and improve the support being given to those in need.