Grief and Grief Counselling as Social Constructs

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Chapter 3 Grief and Grief Counselling as Social Constructs

And I believe that love is stronger than death.
Robert Fulghum

On Death and Dying

We live in the sure knowledge of our death, and yet most of us live as if it will never happen to us, or our loved ones. We spend our days surviving, collecting, building, and when a thought of our eventual demise comes up, most of us squash it immediately, believing that ignorance is bliss. We spend a great deal of our time focussing on our physical wellbeing. Yet, we cannot avoid this natural aspect of life. Sooner or later, we all have to deal with it, whether it is in facing our own mortality, or having to deal with the loss of a loved one.
Death is a ubiquitous yet frightening experience, one which fills most of us with dread. Death is the ever-present reality in our lives. Yet fear of change, fear of the unknown, fear of suffering, fear of end, and fear of loss of identity are all very common human emotions.
Before about 1930, most people died in their own homes, surrounded by family, and comforted by clergy, neighbours, and doctors making house calls. By the mid-20th century, half of all Americans died in a hospital (Ariès, 1974). With the advent of the 21st century, only 20 to 25% of people in developed countries died in the community. This move away from dying at home, towards dying in a professionalised medical environment, has been termed the « Invisible Death » by Nuland (1994).
Al Whitney and André Smith in Exploring Death and Dying through Discourse (2010, p. 68-69) believe that “As the process of death and dying becomes increasingly defined as a technical problem, a medical discourse prevails in which death is disguised, demeaned, and ignored.” They note that the subject of death inevitably raises existential questions, and ponder whether our society fears death itself, the process of dying, or the clinical, impersonal death so many experience in hospitals surrounded by clinicians who don’t know who we are. Kauffman (2001) distinguishes between a ‘good death’ or ‘death with dignity’ which is conceptualised in relation to personal control in dying on the one hand, versus the pain, suffering, loneliness, and lack of autonomy brought about by the use of advanced technology in the hospital setting. Taking death into hospitals has in a sense removed it from the natural part of life people saw it as, and made it perhaps even more mysterious, and frightful, for post-modern humans.
Let children walk with Nature, let them see the beautiful blendings and communions of death and life, their joyous inseparable unity, as taught in woods and meadows, plains and mountains and streams of our blessed star, and they will learn that death is stingless indeed, and as beautiful as life.
– John Muir (2013, p.13)

Grieving and Bereavement

The Old English term reave or bereafiani has become our modern word ‘bereavement’. The archaic definition included ‘to be robbed’ or ‘deprived of something valuable’ (Chambers Dictionary, 1995). In contemporary society bereavement most commonly refers to the process following the death of a significant person. Bereavement can be expressed in culturally various acts of mourning, for example; funeral ceremonies, or ritualised withdrawal from public activities. ‘Grieving’ refers to the psychological component of bereavement, the feelings evoked by a significant loss, especially the suffering entailed when a loved person dies (Madison, 2005). A loss is what happens (the event, or perceived event), grief is the emotional response, and bereavement is the process after the loss, hopefully including, or leading to, healing.
The relationship between the bereaved and the deceased loved one informs the individual grieving experience. There is an enormous difference between losing a cherished husband of many years, or dealing with the death of an abusive one. The closeness of the emotional ties, the quality of the relationship, the degree to which the person depended on the deceased both practically and emotionally, all radically influences the grieving experience. As Hedtke (2002, p. 10) in her article Reconstructing the language of death and grief so succinctly put it: “The significance of a person’s life continues even if the person is not around to remind people.”
In addition, the way that the person died, for instance whether the death was due to a prolonged illness when there was time to say goodbye and make amends, or due to a sudden, violent death dramatically alters the gamut of emotions that the bereaved person experiences. Furthermore, the personality of the bereaved person will influence whether the person will choose to rely on others for support, or make grieving a solitary affair, choose to wail and lament, or choose to mourn in quiet solitude. There is no recipe, no specified time limit, no one-size fits all.
Grief and bereavement is not an uncluttered bundle of emotions, which one works through, and then puts behind one. In fact, grief continues and it is not unusual to see an old person cry about a lost friend when she was young, or a mother cry about her child who died decades ago. One does not find neat and tidy ‘closure’. Most find that their daily lives are affected on every level, even though they continue with ordinary daily activities. The deceased loved one is at the same time absent, yet acutely present all the time. With time, the intensity of the emotions lessens, and the person gets used to a new normal. Eventually most will learn to live with the loss. They may revisit that loss at different points in their lives and experience grief again, and have times of normality, joys and the ups and downs of life in between these times. Often a person grows
through the process. The phrase ‘continuing bonds’ used in postmodern grief theories,
also in Narrative Therapy, is a contribution to a new language that reflects a more
compassionate understanding of this process.

Grief Reactions

Reactions to a loss can be physical and psychological. It is not uncommon to experience periods of intense distress and feeling such as (but not limited to) the following: longing crying, dreaming of your loved one, anger, denial, sadness, despair, insomnia, fatigue, guilt, loss of interest, confusion and disorganization, disbelief, inability to concentrate, preoccupation with thoughts of your loved one, fleeting hallucinatory experiences, meaninglessness, withdrawal, avoidance, over-reacting, numbness, relief, sadness, yearning, fear, shame, loneliness, helplessness, hopelessness, emptiness, loss of appetite, weight gain.
Schwiebert (2003) lists grief reactions that are common especially during the early stages of loss, including:
Physical Symptoms:
Hyperactive or under active.
Feelings of unreality.
Physical distress such as chest pains, abdominal pains, headaches, nausea.
Change in appetite.
Weight change.
Fatigue.
Sleeping problems.
Restlessness.
Crying and sighing.
Shortness of breath.
Tightness in the throat.
Loss of appetite or over-eating.
Sleeplessness.
Dry mouth and skin (possibly caused by dehydration from crying).
Extreme tiredness.
Increased sensitivity to loud noises.
Pain that may mimic the way the loved one died, such as in the chest area.
Emotional Reactions:
Shock and disbelief.
Sorrow.
Guilt (‘if only’s’ are common).
Loneliness and a sense that no one really cares about you or understands what it’s like.
Loss of a sense of meaning in life.
Relief (especially when the deceased suffered before death, or in a sudden death, where there was no suffering).
Anger.
Depression.
Numbness.
Fear.
Irritability.
Longing.
Anxiety.
Cognitive Experiences:
Frequent thoughts about the one who died.
Difficulty maintaining concentration.
Forgetfulness.
Confusion.
A sense of unreality.
Shock and numbness.
Feeling detached from others.
Lack of motivation.
Hallucinations, sensing the loved one’s presence.
Slowed thinking.
Behavioural Reactions:
Searching for the deceased.
Wandering aimlessly.
Trying not to talk about loss in order to help others feel comfortable.
Needing to retell the story of the loved one’s death.
Apathy.
Dependence.
Withdrawal.
Spiritually – Philosophically:
Why did God let him die? Why him/her? Why me?
Why is God punishing me? Life is unfair!
What did I do wrong to deserve this?
What is the meaning of life? What is the point to it all? (Schwiebert, 2003).

Different Types of Grief

Normal or Uncomplicated grief

When it comes to a person’s emotions with the passing of a loved one, there is no typical or average. Grief is always individually experienced and is an extraordinary event in a person’s life experience. There are no timelines and grief experiences generally vary from one individual to another. While uncomplicated grief may be extremely painful, disruptive and consuming, Zissook and Shear (2009) point out that it is usually tolerable and self-limited and does not require formal treatment. ‘Normal Grief’ is marked by movement towards acceptance of the loss and a gradual alleviation of the symptoms, as well as the ability to continue to engage in basic daily activities. (Haley, 2013.) Zissook and Shear (2009) point out that “complicated grief and grief-related major depression can be persistent and gravely disabling, can dramatically interfere with function and quality of life, and may even be life threatening in the absence of treatment” (p. 67).
When Engel raised the question ‘Is grief a disease?’ in 1961 as the title of his now classic article on the subject (cited in Zissook and Shear, 2009), he argued convincingly that grief shares many characteristics of physical diseases, such as a known aetiology (in this case, death of a loved one), distress, a relatively predictable symptomatology and course and functional impairment. And while healing usually occurs, it is not always complete. In some bereaved individuals with pre-existing vulnerabilities, for example, the intense pain and distress festers, can go on interminably (as ‘complicated grief’), and the loss may provoke psychological and psychiatric complications, such as major depression.
The suffering and agony experienced after the loss of a loved one can be severe. Colin Murray Parkes (in Stroebe, Stroebe & Schut, 2001) examined the case records of 3245 adult psychiatric patients admitted to two psychiatric units in London. He found that the incidence of death of a spouse during the six months preceding the psychiatric illness was six times greater than would have been expected from the rates of bereavement obtainable from mortality figures among people of the same age.
Grief is varied and fluid and differs considerably in intensity and length among cultural groups and from person to person. It is often hard to predict how a person will cope with their loss, why they experience varying degrees and types of distress at different times, and how or when they adjust to a life without their loved one over time. The bereaved person’s personality, the relationship with the loved one, the culture they find themselves in, even their gender, will influence the grieving experience.
The terms bereavement and grief are used interchangeably in the literature to refer to either the state of having lost someone to death, or the response to such a loss. Zissook and Shear (2009) suggest that the term bereavement be used to refer to the fact of the loss; the term grief should then be used to describe the emotional, cognitive, functional and behavioural responses to the death. Also, grief is often used more broadly to refer to the response to other kinds of loss: people also grieve the loss of their youth, of opportunities, and of functional abilities. Mourning is also sometimes used interchangeably with bereavement and grief, usually referring more specifically to the behavioural manifestations of grief, which are influenced by social and cultural rituals, such as funerals, visitations, or other customs.
How long grief lasts and how intensely it is experienced are highly variable, not only in the same individual over time or after different losses, but also in different people dealing with ostensibly similar losses. The intensity and duration is determined by multiple forces, including, among others the individual’s pre-existing personality, attachment style, genetic makeup and unique vulnerabilities; age and health; spirituality and cultural identity; supports and resources; the number of losses; the nature of the relationship (e.g., interdependent vs. distant, loving vs. ambivalent); the relation (parent vs. child vs. spouse vs. sibling vs. friend, etc.); type of loss (sudden and unanticipated vs. gradual and anticipated, or natural causes vs. suicide, accident or homicide) (Bonanno & Kaltman, 2001).
Zissook and Shear (2009) point out that grief is not a state, but rather a process. They also emphasise, like Klopper (2009) that the grief process typically proceeds in fits and starts, with attention oscillating to and from the painful reality of the death. Furthermore, the spectrum of emotional, cognitive, social and behavioural disruptions of grief is broad, ranging from barely noticeable alterations to profound anguish and dysfunction. “At first, these acute feelings of anguish and despair may seem omnipresent, but soon they evolve into waves or bursts, initially unprovoked, and later brought on by specific reminders of the deceased. Healthy, generally adaptive people likely have not experienced such an emotional roller coaster, and typically find the intense, uncontrollable emotionality of acute grief disconcerting or even shameful or frightening.” (Zissook and Shear (2009, p. 69).
Shear and Mulhare (2008) distinguish between two periods of grief: the first is the acute grief that occurs in the early aftermath of a death. This can be intensely painful and is often characterised by behaviours and emotions that would be considered unusual in normal everyday life. These include intense sadness and crying, other unfamiliar dysphoric emotions, preoccupation with thoughts and memories of the deceased person, disturbed neuro-vegetative functions, difficulty concentrating, and relative disinterest in other people and in activities of daily life (apart from their role in mourning the deceased). This form of grief is distinguished from a later form of grief, integrated or abiding grief, in which the deceased is easily called to mind, often with associated sadness and longing. During the transition from acute to integrated grief, usually commencing within the first few months of the death, the wounds begin to heal and the bereaved person finds his or her way back to a fulfilling life. The reality and meaning of the death are assimilated and the bereaved are able to engage once again in pleasurable and satisfying relationships and activities. Yet, though the grief has been integrated, they do not forget the people they lost, relinquish their sadness nor do they stop missing their loved ones. The loss becomes integrated into autobiographical memory and the thoughts and memories of the deceased are no longer preoccupying or disabling. Unlike acute grief, integrated grief does not persistently preoccupy the mind or disrupt other activities. There may however be periods when the acute grief reawakens, for instance around the time of significant events, such as holidays, birthdays, anniversaries, another loss, or a particularly stressful time. It would be safe to say, based on these thoughts, that for most people grief is never fully completed and one may still find sadness and tears welling up decades after the loss of a loved one, even as one goes about life normally.
Some authors (Bonanno, Wortman & Nesse 2004; Zissook & Shear 2009) have commented that, although the predominant emotion might be pain in times of grief, in an uncomplicated grief process, painful experiences are intermingled with positive feelings, such as relief, joy, peace, and happiness that emerge after the loss of an important person. Frequently, these positive feelings elicit negative emotions of disloyalty and guilt in the bereaved. Of note, at least one investigator has found that positive feelings at 6 months following a death are a sign of resilience and associated with good long-term outcomes (Bonanno, Wortman & Nesse 2004).

Anticipatory Grief

The notion of grief that begins in anticipation of loss has been coined by Erich Lindemann. He used this phrase for the first time in his 1944 paper Symptomatology and Management of Acute Grief and it has become part of the nomenclature of grief psychology. He is cited in William Worden (1991): “The term anticipatory grief was coined some years ago by Lindemann (1944) to refer to the absence of overt manifestations of grief at the actual time of death in survivors who had already experienced the phases of normal grief and who had freed themselves from their emotional ties with the deceased.” (p. 108.)
The term is more often understood as the reaction to a death you were able to anticipate such as when an individual dies from a long-term illness. As soon as you accept and understand someone you love is going to die, you begin grieving. Haley (2013) notes that grief that takes place preceding a loss can be confusing as a person may feel conflicted or guilty for experiencing grief reactions about someone who is still here. Similar emotions to uncomplicated or ‘normal’ grief may be experienced such as anger, loss of emotional control, and helplessness. A person may also feel grief over the loss of things other than the individual, such as loss of hopes and dreams for the future and the loss associated with changing roles and family structures. Many people describe an oscillation of feelings from sadness to hope, despair, and gratitude for interactions with a dying loved one that has suddenly become very precious.
Haley (2013) observes that Anticipatory Grief can allow those who love the individual to slowly and gradually prepare for and absorb the reality of the loss. Furthermore, it allows for the possibility of meaningful time spent with the individual leading to an increased sense of closure and peace.

Complicated Grief

Zisook et al. (2010, p. 1097) give a good description of what they see as the syndrome of Complicated Grief: it “is characterized by continued severe separation distress and by the dysfunctional thoughts, feelings or behaviors related to the loss that complicate the grief process. Symptoms of separation distress include intense yearning, a persistent, strong desire to be with the deceased; and by the inability or refusal to accept the death, preoccupation with thoughts or images of the person who died, and compulsive proximity seeking (e.g. keeping reminders of the person who died close by). Complicating features include ruminating about circumstances or consequences of the loss, unrelenting anger or bitterness, intense physical or emotional reactivity to reminders, avoidance of reminders, social estrangement, feeling lost and unfocused, and believing that ongoing life is now empty and meaningless and that joy is no longer possible. We draw attention to the fact that all patients with Complicated Grief should be carefully assessed for suicidality. Suicidal thoughts are very common in Complicated Grief and are of concern as suicide attempts also occur. Suicidal urges are usually related to hopes of finding or joining the deceased loved one or feeling that life without the deceased person is unbearable.”
Haley (2013) concurs that Complicated Grief describe grief reactions and feelings of loss that are debilitating, long lasting, and/or impair the bereaved person’s ability to engage in daily activities. She believes that other types of grief such as ‘Chronic Grief’, ‘Delayed Grief’, and ‘Distorted Grief’ all fall under the blanket of ‘Complicated Grief’.
Research done by Simon et al. (2007) found that Complicated Grief occurs in about 10% of bereaved individuals, and usually among individuals with a close, identity-defining relationship to the person who died. The risk may be increased among those with a history of mood or anxiety disorder, and possibly following a violent death or suicide. Because of the on-going and often severe psychological distress and risk of suicide, Zisook et al. (2010) plead for an inclusion of Complicated Grief in the DSM. Zisook et al. (2010) note that “Complicated Grief Therapy utilizes a dual focus on coming to terms with the loss and restoring the capacity for pleasure and satisfaction in on-going life” (p. 1098).

Chronic Grief / Prolonged Grief Disorder

For some bereaved persons, their strong grief reactions do not subside or lessen, but remain either the same or increase in intensity over a long period of time. This means continually experiencing extreme distress over the loss with no progress towards feeling better or improving functioning. Jordan and Litz (2014) describe on-going intense longing for the deceased, and the thwarting of loss-processing and functional restoration tasks that ordinarily lead to resolution of grief. Furthermore, the bereaved person avoids fully facing the reality of the loss and adopting new roles, even sometimes showing an aversion to seeking support. The bereaved person then spends much time contemplating the death, longing for reunion, and in general is unable to adjust to life without the individual.

TABLE OF CONTENTS
Declaration
Abstract
Acknowledgements
Chapter 1 Introduction
1.1 Research Problem
1.2 Objective of the Research
1.3 Motivation for the Study
1.4 Design of the Study
1.5 Chapter Review
1.6 A Personal Perspective
Chapter 2 Epistemological Framework and Research Design
2.1 Epistemological Framework
2.2 Research Design
2.3 Data Collection
2.4 Data Analysis
2.5 Trustworthiness
2.6 Reliability and Dependability
2.7 Ethical Considerations
Chapter 3 Grief and Grief Counselling as Social Constructs
3.1 On Death and Dying
3.2 Grieving and Bereavement
3.3 Grief and Mourning as Social Constructs
3.4 From Breaking Bonds to Continuing Bonds: how Views of Grief in the 20th Century Evolved
3.5 Narrative Therapy as Postmodern Bereavement Model
3.6 Identity Growth and Meaning-Making in the Process of Bereavement
Chapter 4 Narrative Therapy
4.1 Narrative Therapy
4.2 The Stance and Role of the Narrative Therapist
4.3 Therapeutic Tenets of Narrative Therapy
4.4 Enabling Identity Growth
4.5 Some Notes on the Changes in Psychology, and where Narrative Therapy fits
4.6 Narrative Therapy: A Postmodern Therapeutic Model
4.7 A Few Tenets of Postmodernism that has Particular Reference to this Study
4.8 Narrative Therapy in the Context of Social Constructivism
Chapter 5 John’s Story: A Crushing Suicide
5.1 Personal Data
5.2 Introduction
5.3 Mapping Influences
5.4 Thickening the Narratives
5.5 Saying ‘Hello’ again to a New Son by a New Father
5.6 Re-Authoring the Grief Experience within an Emerging New Identity
5.7 Identity Growth as John Gives Back
Chapter 6 Mia’s Story: Dis-covering an Emerging Identity following a Life Changing Tragedy
6.1 Personal Data
6.2 Introduction
6.3 Mapping Influences
6.4 The Loss
6.5 Re-Authoring the Grief-Experience and Externalising the Problem
6.6 Grappling with a Most Unnatural Death
6.7 Thickening the Narratives
6.8 Saying ‘Hello’ again as Marko and Mia continue their Relationship Differently
6.9 Re-Authoring her Experiences in Alignment with a New Emerging Identity
6.10 Resolution
Chapter 7 Cara’s Story: Losing a father and friend
7.1 Personal Data
7.2 Deconstructing the Problem and Mapping Influences
7.3 Thickening the Narratives
7.4 The Loss
7.5 Facing the Physicality of her Father’s Illness
7.6 Re-Authoring the Grief-Experience
7.7 Searching for an Alternative Story – Identity Growth as New Ideas about Death develop
7.8 Saying ‘Hello’ Again
7.9 An Alternative Story Found
7.10 Re-Authoring the Grief Experience in Alignment with an Emerging Identity
7.11 Resolution
Chapter 8 Linda’s Story: Dis-covering resilience through the loss of three mothers
8.1 Personal Data
8.2 Introduction: Lasting First Impressions
8.3 Mapping Influences
8.4 Thickening the Narratives of the Loss
8.5 Thickening the Narratives of her Beloved Grandmother’s Complex Character
8.6 Grief is Socially and Culturally Constructed
8.7 Deconstructing ‘the Problem’ of Feelings
8.8 Re-Authoring the Grief Experience
8.9 Searching for an Alternative Story – Identity Growth as New Ideas Develop
8.10 Saying ‘Hello’ Again
8.11 Resolution
Chapter 9 Nancy’s Story: Losing her Other Half
9.1 Personal Data
9.2 Introduction
9.3 Socially Constructed Grieving
9.4 Mapping Influences
9.5 Thickening the Narratives
9.6 The Loss
9.7 Many Unexpected Losses
9.8 An Emerging New Identity
9.9 Re-Authoring the Grief Experience
9.10 Saying ‘Hello’ Again
9.11 Re-membering Tom
9.12 Identity Growth
Chapter 10 Narrative Analysis & Emergence of Common Themes
10.1 Introduction
10.2 Narrative Therapy as a Bereavement Model
10.3 Emerging Themes
10.4 Conclusion
Chapter 11 Conclusion
11.1 Introduction
11.2 Strengths of the Study
11.3 Limits of the Study and Suggestions for Further Research
11.4 A Personal Reflection
References
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