by Richard Gross
Review by Flavia Felletti on May 26th 2016
With Understanding Grief: An Introduction, Richard Gross aims to provide an accessible and comprehensive introduction to the major models of grief, focusing on the individual experience of bereavement just as on how bereavement is experienced in relation to the social, cultural, and religious contexts. Different kinds of bereavement and their impact on the bereaved are discussed. Among them: the loss of a spouse, a child, and the impact of traumatic loss on complicated grief. Further topics discussed include pet loss, death anxiety, and post-traumatic growth. Personal accounts of grief, reports of psychiatrists and psychologists working with bereaved parents, and a large number of empirical findings combine to provide a broad framework for understanding grief, suitable for the expert readers, such as professionals working with bereaved clients, just as for the interested laypersons.
The first chapter constitutes a brief and detailed introduction to the nature and experience of grief, and is devoted to introduce those notions that serve as a background for the following discussion. Firstly, the author distinguishes between grief, which although is commonly associated with death is also used in a broader context, and bereavement, which refers specifically to the loss of a loved one. Bereavement involves both a primary loss - i.e., the physical loss of a person - and secondary losses, which might include physical contact, sense of security, and social status. Secondly, the author distinguishes between varieties of grief. "Normal grief" is distinguished from complicated grief (CG), where this latter is regarded either as differing in intensity or in its form from normal grief, depending on the theory into account. "Legitimate grief" is distinguished from disenfranchised grief, which refers to a situation in which the bereaved is considered having no right to grieve, as in the case of a secret love affair, where social norms do not authorize a person to grieve for the loss of her lover. And intuitive grieving is distinguished from instrumental grieving, where the first focuses on the painful experience of the loss, and the latter on the restoration process. Thirdly, the author distinguishes between grief and mourning, and introduces the notion ofgrief work. Whereas 'grief' refers to an initial reaction to bereavement that can last also for several months, 'mourning' refers to a longer-term process that involves living the rest of one's life without the deceased. The process of mourning -- through which the bereaved tries to redefine the relationship to the deceased, the sense of self, and her assumptive world -- is aimed to severe the relationship with the deceased so to invest emotional energy into new relationships, a goal that is achieved by means of what is commonly referred to as 'grief work'. Finally, the authors describes the main sources of information taken into account in the later discussion of grief -- personal accounts by bereaved individuals, psychoanalytic accounts, research studies, and anthropological and ethnographic studies -- and the two main stages accounts of grief: Bowlby's (1980) four phases account of mourning, and Kübler-Ross's (1969) stages account of dying, often applied also to grief.
For a good understanding of grief, many variables, such as the relationship between the bereaved and the deceased, the personality of the bereaved, and the social and cultural context, ought to be taken into account. In the second chapter, the authors proceeds by discussing the relationship between attachment and grief. Bowlby's (1980) evolutionary theory of attachment and individual variations in attachment are discussed, followed by a discussion of the relationship between patterns of parenting and the child's attachment style. Four main types of attachment the way in which they affect an individual's way of grieving are discussed: secure, anxious-avoidant, anxious-ambivalent, and disorganized/disoriented. In addition, the discussion also covers the continuity between child's and later attachment, and the relationship between later attachment and grief.
The third chapter is devoted to an overview of the main existing theories and models of grief. The author firstly examines Freud's (1977) theory that, roughly speaking, conceives mourning as a process of detachment, and reflects both the desire to hold the lost object or person and the recognition that it is no longer available. The discussion turns then to the (questioned) helpfulness of grief work for the bereaved and proceeds onto the more recent theories of grief work and on the tasks that this process involves. Here, Worden's (1982 and forth) tasks of mourning, Rando's (1993) process of mourning and Parkes's (1993) psychosocial transition theory are discussed. After this, the author proceeds by discussing the Dual-Process Model (DPM) of grief (Stroebe and Schut 1999, 2010), intended both to provide a model for coping with the loss and for understanding individual differences in coping with it. This model distinguishes between loss-orientation and restoration-orientation stressors - both involved in grief, but in varying degrees --, and characterizes the bereaved as oscillating between them. The distinction between loss-orientation and restoration-orientation stressors proves to be very important in the later chapters, when gender and cultural differences in grieving are discussed. Another model of grief, the Two-Track Model (TTM) is also discussed. This model combines Freud-inspired grief work theories with an empirically oriented approach associated with stress, trauma, and life changes, considering both changes in the relationship to the deceased and biopsychological function alterations that the bereaved undergoes. The chapter ends then with a discussion of attachment after death, the continuing bonds that the bereaved preserve with the deceased.
However, as already emerged in the first chapter, grief cannot be fully understood outside social and cultural contexts. Indeed, with the fourth chapter the focus shifts from the individual experience to the social dimension of grief. The author firstly discusses western's society attitude toward death and the medicalization of death. Since Freud distinguished between normal and pathological grief, it became possible to talk about the "symptomatology" of grief, and of abnormal forms of grief, generally distinguished in terms of duration and intensity from normal forms of grief. Worth noticing, Durkheim and those influenced by him argued that the intensity of grief is strongly affected by social constructions and is not an innate or natural tendency, and as it will become evident in the later chapters, society plays a key role in regulating individual's way of grieving. For what concerns western societies, as Aries (1981) and Gorer (1965) argue, death can be seen as a taboo. On the one hand, the media are obsessed with death and there is a considerable interest in the topic, on the other hand, death is largely denied. Even further, death has been highly professionalized. As the author claims, death professionals (e.g., funeral directors) do now the job that once was done be the deceased's family, and this can be seen as a way in which death is hidden. However, despite the professionalization of death, the family is very much affected by the death of one of its members, event that occurs indeed within the context of existing relationships and family dynamics. A death changes the equilibrium of the family system, undermining its functioning and affecting available emotional and physical resources. Healthy family processes following bereavement are the sharing of the loss, the maintenance of open communication, and the reorganization and regain of the equilibrium often disrupted by the loss. In the absence of such processes a death might have dramatic consequences on the equilibrium of the family, as well as on individuals' way of coping with the loss. Among other factors contributing to determine how the individuals cope with the death of a family member is also the type of the loss at stake, deaths involving children, adolescents, and non-elderly adults are in fact particularly difficult. In case of children bereaved, positive parenting plays a crucial role. While the effects that the death of a child has on the family can vary consistently in their consequences on the equilibrium of the family. Some couples reported increased closeness following a loss, while others reported growing apart. This partly depends on the fact that individuals within the family experience grief in different ways and, e.g., intuitive grievers might mistake instrumental grief as a lack of grief. Turning the focus from the family to the whole society, the author proceeds at this point by discussing funerals and other rituals following death. Every society has rituals for death, and such rituals play an important role in facilitating the acceptance of the loss and the emotional healing, serve as an affirmation of faith and religious beliefs, and provide a context for receiving emotional support from family, friends, and the community. Late changes in funerals in western societies are also discussed here, together with how such changes relate to a change in the nature and place of religion and spirituality in society. Finally, the author discusses disenfranchised grief (DG), an individual's grief not validated by others that occurs when the individual is not entitled the right to grieve. Disenfranchised grief very much reflects the social context of grief, and may remove those factors that usually facilitate mourning (e.g., participating in funerals) just as make it impossible to receive social support.
In the fifth chapter, the author examines more in depth the cultural and religious aspects of death and dying. In all cultures, people grieve the loss of a loved one, in most societies people feel that the deceased continue in some way beyond death, and most societies prescribe norms concerning mourning. As emerged before, bereavement is experienced within a cultural framework; indeed, cultures influence the way people represent bereavement, as well as their feelings and actions. Furthermore, they regulate implicitly or explicitly their members' mourning, instructing the bereaved on how to think, feel, express her grief, and to manage her continuing bonds with the deceased. Societies differ on how they regulate the expression of grief's emotions, as well as in their policy about continuing bonds. And sub-cultures and different ethnicities are also important to be taken into consideration, for individuals of some ethnic group might struggle to get the adequate support in societies where the norms that regulate mourning differ significantly. Concerning religion, some important aspects are worth noticing. First, whereas in traditional societies people where exposed to a very limited number of religions, in modern societies people are increasingly exposed to a larger number of religious traditions, and old rituals lost much of their power. Second, there is an important distinction to consider relating to helping the bereaved: the distinction between the official version of the religion and the religion as it is lived or enacted by the individual and his community. However, leaving aside the differences within religion traditions, those who belong to the same religion tend to adhere at least to some common norms and prescriptions. The chapter ends, indeed, with a discussion of the major world religions' norms and prescriptions concerning death and bereavement.
The sixth chapter is dedicated to the discussion of how an individual's grief is affected by the relationship that she held with the deceased. Firstly, the author discusses spousal bereavement, which is also the topic most research focuses on. Importantly, the author distinguishes between spousal bereavement and widowhood. The first refers to the short-term state of having lost one's spouse and has a personal meaning. The latter refers, instead, to a long-term ongoing state, which carries important social consequences. Noteworthy, an individual's reaction to the loss of a spouse is considerably influenced by the time at which this event happens in life. Whereas the loss of a spouse might be expected in later life, for younger adults it is a non-normative event, so that they are less prepared emotionally and practically then older adults. However, age is not the only matter that influences spousal bereavement, indeed, as for other kinds of bereavement, the nature of the relationship, circumstances surrounding death, and social support also play a relevant role. After spousal bereavement, the author proceeds by discussing the lost of a parent in adulthood and the loss of a sibling in children and adults. Finally, he discusses the loss of a child. The age of the child, the social contexts, and the circumstances of death have a powerful effect on the parents' bereavement. The loss of an adult child result in more intense grief than the loss of a young child, and in Third World countries, where infant deaths are more common, the death of a child is less psychologically devastating in western countries. Bereavement after spontaneous, therapeutic and induced abortion is also discussed here, followed by an important discussion of stillbirth and sudden infant death syndrome (SIDS). A stillbirth occurs when a baby born after 24 weeks' gestation fails to breathe, and the unusual type of this death is "stigmatizing" for the parents, which are marked as different. Gender differences in grieving style are likely to lead to couple conflict following stillbirth and SIDS even more than following other losses of a child. Moreover, the loss of a child also represent a challenge for parenting, indeed, despite the grief following their child's death, often parents must also cope with the challenges of parenting their surviving and bereaved children. A conclusion that can be draw from this chapter and this chapter and the ones preceding it is that many factors affect the way in which an individual grieve, among which the relationship with the deceased and her age, the circumstances of death, and the socio-cultural context. Those factors are in large part determining for whether the bereaved individual will undergo a form of complicated grief, which is the topic discussed in the next chapter.
In chapter seven, the author discusses complicated grief (CG). Characterizing processes of "normal" grief include withdrawing emotional energy from the deceased, oscillating between loss-orientation and restoration-orientation grieving, adapting to change and creating a new assumptive world, and maintaining emotional bonds with the deceased. However, although most accounts of grief discussed focus on healthy grief, complicated grief deserve an elaborate discussion on its own. Freud's account states that pathological or complicated grief involves a failure in psychologically let go of the deceased. That is to say, the bereaved remains psychologically attached to the deceased. Attachment, indeed, plays a key role in determining how an individual grieve, and in particular in how she will engage in either loss- or restoration-oriented processes. Another important factor is also the meaning reconstruction process undertaken by the bereaved following the loss. On the one hand, a painful search for meaning predicts more intense grief, especially in cases of loss through suicide, murder, or fatal accidents. On the other hand, the capacity to find significance in the loss predicts greater long-term well-being. Symptomatology and diagnosis of complicated grief are also discussed in this chapter. The author firstly introduce the reader to the debate on whether complicated grief differs quantitatively (in intensity) or qualitatively (in its form) from normal grief. He proceeds then by discussing Prolonged Grief Disorder (PGD), here characterized as one type of complicated forms of grief. Finally, the risk factors for complicated grief -- that, as we have seen, include among others kinship, gender, age, mode of death, and socio-cultural influences - are discussed more in detail. Particular attention is dedicated to bereavement following a loss through suicide, which includes both normative aspects characterizing all kinds of bereavements and non-normative aspects that characterize bereavement following traumatic deaths. A discussion of gender differences in the tendency to attempt and to complete suicide ends this chapter.
In the eighth chapter, the author discusses the wide context of grief, including topics as pet loss, fear of death and death anxiety, meaning reconstruction in bereavement, and post-traumatic growth. The loss of a pet might induce responses that are as severe as those associated with the loss of another human being, including sleep loss, social and psychological difficulties. As it happens in the case of a human loss through death, the bereaved of a pet loss tends to maintain an attachment with the pet, holding its belongings and recalling fond memories. Noteworthy, pet loss might be given as an example of disenfranchised grief. Indeed, those grieving the loss of a pet often feel unsupported and reluctant to talk about the intensity of their grief. For what concerns fear of death, instead, the awareness of our mortality that is seen as a part of our human condition that inevitably produces in us fear and a sense of powerlessness, and that can be regarded as a form of anticipatory grief. Freud interpreted fear of death as a cover story used to mask true underlying problems, such as unresolved and unconscious conflicts. Indeed, he claims, our death is unimaginable and when we try to imagine it, we perceive ourselves surviving as spectators. By contrast, Kastenbaum (2000) claimed that fear of that should not be explained away as a disguised representation of a deeper conflict, and that rather all our anxiety is rooted in the awareness of our mortality. This seems to be in line with the fact that death has been medicalized and removed from family and community involvement, as well as with the fact that we try to keep distance from the living that have been touched by death, such as recently bereaved. The discussion moves at this point on gender and age differences in death-anxiety. Studies reported contrasting results concerning whether there are gender differences in death-anxiety. Instead, concerning age differences, Kastenbaum (2000) after reviewing a number of studies reached the following conclusion. First, that older people generally do not report higher level of death-anxiety. Second, that high school students are more apprehensive about the loss of a loved one and the finality of death. Third, that employed adults fear premature and painful death, and are the less concerned with the impact of their own death on others. Fourth, that retirees fear to become helpless and dependent on others, and are the most concerned with the impact of their death on their loved ones. Finally, that individual personality seems, in any case, to be more important than age as long as life approaches its end. The next topic treated is meaning reconstruction in bereavement. As human beings, we seek an order, plan, and significance in human existence, but there are occurrences that might threaten and destroy our too vulnerable assumptive world. Such occurrences are, e.g., the diagnosis of a serious illness, or the news of a loved one's sudden death. Neyemer and Sands (2011) describe such occurrences as crises of meaning. Struggling with finding a meaning for the loss may lead to reactions such as prolonged grief disorder and it is particularly acute in the case of traumatic losses. Again, particular attention is devoted to the case of suicide, which -- according to Sands et al. (2010) -- violates our assumptions about the predictability of the world and the constant presence of a loved one, and challenges our beliefs regarding the inherent value of life. The focus turns then on post-traumatic growth (PTG). PTG refers to a process in which a trauma serves as a catalyst for positive changes. A number of factors that influence the likelihood of PTG, among which the expression or disclosure of concerns surrounding traumatic events, the reaction of others to self-disclosure, and the sociocultural context. Joseph (2012) individuates people's psychological functioning increases following a traumatic event: enhancement of the relationships, changes in the own view about the self (e.g., personal strength), and changes in the philosophy of life (e.g., core values). This is also in line with the fact that trauma survivors, which are somewhat forced to build anew their assumptive world, often report that their previous views of life seems now shallow to them. In Joseph (2012: 817) words, 'When adversity strikes, people often feel that at least some part of them… has been smashed. Those who try to put their lives back together exactly as they were remain fractured and vulnerable. But those who accept the breakage and build themselves anew become resilient and open to new ways of living.'
The book ends then with a comprehensive list of recommended readings and website, including academic texts, personal accounts of grief, anthologies and poetry, useful website and helping lines for the loss of a child, for children and teenagers and for those coping with sudden, violent and traumatic bereavement. In addition, it includes also websites of faith and minority groups and of funerals organizing associations.
Overall, the author certainly succeeds in his aim of providing a comprehensive introduction to the major models of grief. Furthermore, he does an excellent job in emphasizing the importance of contextualizing the loss in order to better understanding individuals' grief following bereavement and helping the bereaved. Indeed, when interested in investigating individual's emotional experiences and responses we might be very likely to commit the error of forgetting that individuals exist within the context of a family, of a community, and of social, cultural, and religious traditions. The author also does a great job in examining the many topics surrounding the experience of grief while generally maintaining a smooth and very clear writing style. The quantity of information and the number of theories discussed might sometimes make the reading process a bit difficult, especially to the reader not yet familiar with the topic. However, the brief summaries provided at the end of every chapter can be of good help to such reader for singling out the most relevant information. Given the introductory character of the book, many of the theories named are not discussed in depth. This is offset, however, by the presence of the very useful list of readings and websites provided at the end of the book.
© 2016 Flavia Felletti
Flavia Felletti, MA student at the University of Barcelona