Dual process model of grief

Chapter 12 - Personal Loss

Question(s):

Compare the Adaptive grieving model (Martin & Doka, 2000) and the Dual Process model (Stroebe & Schut, 2001).

What are the similarities and differences?

Which seems to fit best to your style of counseling?

Why is that so?

Conceptual Approaches to Bereavement

There are a variety of models, ranging from psychodynamic to constructivist to cognitive- behavioral approaches, that seek to deal with loss (Bowlby, 1969, 1973, 1980; Cohen, Mannarino, & Deblinger, 2006; Gillies & Neimeyer, 2006; Neimeyer & Levitt, 2000; Osterweis, Solomon, & Green, 1984; Powers & Griffith, 1987; Raphael, 1983).

Historically, stage/phase models (Bowlby, 1969, 1973, 1980; Kübler-Ross, 1969; Kübler-Ross & Kessler, 2005) have achieved a great deal of fame and notoriety.

A Counterpoint to Traditional Models

Dutro (1994) has described how our concepts of grief and loss have become more dynamic, moving from the medical or pathology theories to more interactive models. Dutro’s comprehensive and dynamic model views grief and loss from the perspective that each individual experience loss according to psychophysiological, affective, and cognitive-behavioral factors, such as the mode of death, relationship of the deceased, prior losses experienced, and domiNant subcultural norms. These factors figure into a dynamic structural model of grief that, according to Dutro, is in sync with sociocultural life in the 21st century.

His and others’ dynamic, individualistic grief models (Dyregrov & Dyregrov, 2008; Humphrey, 2009; Konigsberg, 2011; Neimeyer, 2000; Worden, 2002) refute many ideas about grief that have been associated with older stage theories:

1. The common assumptions concerning “stages” of grief are not supported.

2. Placing time limitations on grief is inappropriate.

3. The withholding or suppression of sadness in response to bereavement is not necessarily pathological.

4. Insistence on severing ties or detaching oneself from lost objects denies lifelong bonding and use- fulness of positive memories.

5. One-size-fits-all models don’t work because each individual griever’s experience is unique. Grief is not a unitary phenomenon but rather a multidimensional, interactive, individual experience for every bereaved person, based on a complex set of interwoven variables.

6. There are no fixed beginning and ending points in grieving.

7. While grief does not end, it does change. From that standpoint two current models, the dual process model (Stroebe & Schut, 2001; Stroebe et al., 2008) and the adaptive grieving model (Martin & Doka, 2000), seem to best represent current thinking (Doughty, 2009; Humphrey, 2009) on the fluid, idiosyncratic nature of grief and grieving and how the crisis worker should consider approaching them.

The Dual Process Model.

The dual process model may be characterized as an approach-avoidance model that has two components: loss orientation and restoration orientation. Loss orientation stressors are associated with the loss itself, which may be experienced in ruminating about it and having behavioral, emotional, and cognitive reactions to it that oscillate between avoiding and confronting the disrupted bond with the object of the loss (Stroebe & Schut, 2001; Stroebe et al., 2008). Stroebe and Schut see this process as a normal and natural process of loss adaptation. For instance, a college athlete may feel sadness and anger over the loss of a girlfriend (confronting the stressors) but redouble workouts and increase his study time (avoiding the stressors) in efforts to put lost love out of his mind. As the loss recedes in time, and in line with how processing models are sup- posed to operate, a restoration orientation begins. So, both avoidance and confrontation are to be seen as a normal and natural process of loss adaptation (Humphrey, 2009, p. 47).

Restoration orientation occurs when grievers start to come to grips with the consequences of the loss and begin to form new roles and identities, develop new relationships, make life changes, and engage in new activities that distract their grief. The newly aggrieved widow we met at the gas pump at the beginning of this chapter may start to engage in

restoration orientation by alternately avoiding her confrontation with loneliness by sitting in front of the TV for hours on end and deciding to confront it by joining a church renewal group that her newly met crisis counselor and pump jockey told her about. The primary task of restoration orientation is attending to rather than avoiding life changes, doing new things, seeking distraction from grief, and dealing with new roles, identities, and relationships (Humphrey, 2009, p. 48).

One of the major advantages of this model is that it recognizes that grief is not static, but is a series of waves with crests and troughs that ebb and flow at their own pace but gradually move into more quiet, placid, and calm affective, behavioral, and cognitive waters that nourish growth. However—and this is a big “however”—these researchers propose that the griever can get into hot water and move into prolonged grief if this ebb and flow does not occur (Stroebe et al., 2008).

So, the crisis worker who uses this model should understand that it will make ab- solute sense when the griever bounces back and forth between a loss and a restoration orientation that operates on an approach-avoidance continuum and gets the worker’s undivided attention when it does not. If you understand this model, then, it is not upsetting but rather understandable that people are not static or stable as they grieve but move back and forth as they attempt to bring equilibrium and homeostasis back into their lives.

The Adaptive Model.

Martin and Doka (2000) identify grieving as three basic styles that operate along a continuum, with intuitive grieving on one end, instrumental grieving on the other, and an infinite number of variations between the two. Intuitive grievers respond to loss mainly in terms of emotion, while instrumental grievers think through their grief and/ or act on it. Most people, Martin and Doka believe, operate somewhere in the middle and have a blended style. The other component of the adaptive model targets the preferred affective, behavioral, cognitive, and spiritual strategies that grievers use to adapt to the loss. Martin and Doka place a heavy emphasis on spiritual components because of the model’s strong theoretical basis in Jungian psychology and the fact that many people place a great deal of emphasis on the spiritual aspects of adaptive grieving. It is important to note that adaptive strategies are a good deal more than, and different from, coping strategies. Coping implies “getting along” or “bearIng up,” while adaptation means engaging in behavior that will result in change. Interestingly, the same adaptive strategies may be used by persons at both ends of the intuitive-instrumental continuum but for entirely different reasons. For example, the common practice of going through a photo album of the de- ceased and reminiscing about happier times may be used by both intuitive and instrumental grievers. For intuitive grievers, it is a cathartic release of emotions as memoires flood conscious awareness and are re- lived. For the instrumental griever, the photo album may be a way of remembering, organizing, and planning activities. So, for the intuitive griever, pictures of riding horses on the family farm bring back memories of Sunday afternoon rides, picnics by the river, the smell of horses and harness leather, and grandfather’s wide-brimmed Stetson cowboy hat bobbing along in front on his horse Whiplash. For the instrumental griever, the same photos may remind him or her that the upcoming sale of the farm equipment needs to be inventoried and favorite items parceled out according to requests from brothers and sisters. It should be clearly understood that adaptive styles do not necessarily mean a rose-covered remembrance path down memory lane. Adaptive styles that are useful in the short term may be counterproductive in the long run. Emotional catharsis verging on hysteria may be fine at the funeral, but level-headed business sense is called for when the family farm is put on the auction block. Also, if primary grievers have different grieving styles, they may butt heads. An instrumental griever who throws herself back into her work may be confounded by a husband who continues to emote at any small remembrance of a daughter who has died in an auto accident. Likewise, he may be appalled that she is so callous and cold as to start packing their beloved daughter’s clothing to give to Goodwill 6 months after the funeral. While they are both using adaptive strategies that serve them well, the interpersonal divisiveness that may occur is some- thing else to behold.

People get into trouble with the adaptive model by employing dissonant response modes that are consistent with the opposite grieving style. This sets up a discrepancy between people’s inner experience and their outward expression of grief so that persons with intuitive grieving styles tend to act like people with a more instrumental style. When that happens the per- son has taken a large step toward complicated grief (Humphrey, 2009, p. 42). It should become readily apparent to you as the crisis worker that being able to ferret out and under- stand these styles can be critical in helping grieving individuals move through grief and, even more important, in helping significant others understand that the bereaved’s grief is not some weird, aberrant pathology but a highly functional, idiosyncratic adaptive measure that works for him or her.

Assessment Tools

The Texas Revised Inventory of Grief (TRIG). The TRIG (Faschingbauer, Zisook, & DeVaul, 1987) is probably the most widely used inventory to measure grief. It has two scales, Current Grief and Past Disruption. Because of their temporal nature, the two scales allow the worker to determine what kind of progress in grief resolution has been made.

The inventory asks respondents to rate themselves on a Likert scale (1 = completely false to 5 = completely true) in response to 8 questions about past behavior at the time the person died

(I felt a need to do things the deceased had wanted to do; I was angry at the person; I found it hard to sleep) and 13 questions about how the person presently feels about the person’s death (still cry when I think of the person who died; I cannot accept this person’s death; I hide my tears when I think of the person who died). It has few validity studies, and some of the items (“crying”) are replicated while other well-known concepts such as guilt are left out. Yet it has been used with a wide variety of groups, providing good cross comparisons and a wealth of normative data.

Grief Experience Inventory (GEI).

The GEI (Sanders, Mauger, & Strong, 1985) assesses the longitudinal course of grief. Self-descriptive items that are answered true/false compromise the inventory. Nine clinical scales cover Despair, Anger/Hostility, Guilt, Social Isolation, Loss of Control, Rumination,

Depersonalization, Somatization, and Death Anxiety; six research scales include Sleep Disturbance, Appetite, Loss of Vigor, Physical Symptoms, Optimism–Despair, and Dependency; and three validity scales cover Denial, Atypical Response, and Social Desirability.

Hogan Grief Reaction Checklist (HGRC).

The HGRC (Hogan, Greenfield, & Schmidt, 2001) is designed to discriminate grief reactions from depression or anxiety. Its 61 items target categories of Despair, Panic, Blame/Anger, Disorganization, Detachment, and Personal Growth. It can discriminate variability in the grieving process as a function of cause of death and time elapsed since death.

Inventory of Complicated Grief (ICG).

The ICG (Priger- son et al., 1995) specifically targets symptoms of grief that are distinct from bereavement-related depression and anxiety and predicts long-term functional impairments. Its items are rated on a Likert scale from “never” to “always.” Items target long-term grief, such as not accepting the death, feeling anger or disbelief, avoidance, and auditory and visual hallucinations of the person.

Quality of Object Relations (QOR).

The QOR is a structured interview that measures the recurring pat- tern of relationships over the course of the individual’s life span. It assesses relationship patterns that range from primitive (unstable and destructive) to mature (reciprocating and mutually involved). A person operating at a primitive reacts to perceived separation and loss, or disapproval and rejection from the preferred object with intense anxiety that affects their functioning in deleterious ways as they try to grieve the relationship. They become candidates to meet a grief therapist. At the mature end of the continuum, the person has good social relationships that are marked by affection and tenderness. Individuals assessed on the mature end can effectively mourn loss relation- ships and tolerate unobtainable relationships (Piper et al., 2011).

Fitting Technique to Style of Grief

The Dual Process Model.

When workers operate with contemporary grief models, they are going to have to be nimble, fluid, and adaptable as clients oscillate back and forth between a loss orientation and a resto- ration orientation. In Stroebe and associates’ (2005) dual process model, the griever sometimes confronts and sometimes avoids the stressors of both orientations (Humphrey, 2009, p. 49).

In fact, one of the primary jobs of the worker is not only to tolerate but also to encourage such oscillation (Stroebe & Schut, 1999).

Humphrey (2009, p. 51) lists the following recommendations for using the dual process model:

1. Identify and explore both loss and restoration stressors and the specific avoidance and confrontation responses the client uses.

2Keep in mind that an initial period when the client is fixed in a loss orientation is normal. Identify evidence (or lack thereof) of oscillation as time moves forward.

3. Normalize and validate the dual process model by explaining how it works and why it applies to the client’s particular situation.

4. Address problematic avoidance such as excessive alcohol/drug use, extreme denial, suppression of emotion, or acting out.

5. Do not push clients toward restoration. Let the oscillation work.

To Humphrey’s recommendations we would add another, which we feel is critical to effective resolution of any situation where families or significant others are interwoven in the fabric of the grief. That recommendation is psychoeducation with family and other support systems as to how this model works. Otherwise, there may be some very frustrated and un- happy significant others who, on the surface, see little progress and indeed regression. In that regard, we feel it is highly important to include significant others in progress assessments and support meetings that rein- force them for “sticking in there.”

The Adaptive Grieving Model.

The same flexibility and ability to operate in a fluid manner is called for from the worker in Martin and Doka’s (2000) adaptive model. In our experience, clients seldom remain fixed at one point on the model’s intuitive–instrumental continuum. In our opinion, this model calls for a fairly high degree of ability and skill to operate in an eclectic manner across a wide array of therapeutic modalities to fit with affective, behavioral, cognitive, and spiritual reactions of clients. Note the addition of spiritual to the usual triad of intervention strategies. While we don’t necessarily believe you have to be able to quote directly from the Bible, Talmud, Koran, or any other spiritual source, we do believe you had better know something about this area and be able to work in it. To not know about spirituality and faith when working with loss, grief, and bereavement or, worse yet, discounting them is akin to not knowing or discounting any of the

affective–behavioral–cognitive triad modalities when involved in other therapeutic endeavors. Given the foregoing admonition, the following strategies from Martin and Doka (2000) can serve as starting points.

Affective Strategies.

Affective strategies should initially allow for emotional catharsis through a range of what may be construed as negative emotions from crying to angry swearing. Because emotional

dysregulation is seen as a major problem in problematic grieving, setting the stage for emotional exposure is important in regaining regulating abilities. Successive approximation to full emotional regulation through carefully graded, stepwise exposure to experiencing painful feelings is important. Likewise, carefully planning and choosing times, places, and people with whom to field-test affective interaction with others moves the grief from the counseling session into the real world. Assessment and revision of these field experiments is important in determining abilities, skills, and limits and also reinforces the idea that plans fail but people don’t.

Behavioral Strategies.

Behavior strategies involve a variety of actions that may include substituting a range of positive addicting behaviors, such as running, quilting, fishing, gardening, singing, biking, or building something, for static behaviors such as sit- ting trancelike, watching television for hours on end, and ruminating about the loss. Making plans that deal with current problems and tasks, such as disposing of the deceased’s belongings, locating a retirement center, starting a job search, and reviewing financial plans, are all examples of concrete, forward-looking behavioral strategies. Confronting and motivating new adaptive behaviors that deal with negative ad- dictions such as alcohol and drug abuse, overeating, anorexic tendencies, or gambling are also part of the behavioral game plan for the crisis worker.

Cognitive Strategies.

Cognitive strategies deal with changing maladaptive thinking. Workers help clients create positive counter injunctions and positive mental billboards in place of negative self-defeating thoughts. Workers aid clients in reframing and re- structuring hot, all-or-none, intolerable, catastrophic thinking into cooler, less absolutistic, more preferable and tolerable thoughts. They also caringly confront clients on cognitive avoidance, denial, and minimizing or discounting the impact of the loss.

Spiritual Strategies.

Spiritual strategies are about transcending the loss through faith-based activities. This is a sensitive and tricky area to operate in be- cause of each person’s idiosyncratic interpretation of the part that spirituality and faith play in both the loss and its resolution. This is so because a secondary loss may indeed be a loss of faith over the perceived injustice or the uncaring of God in the primary loss. The worker needs to be extremely sensitive in regard to what will help the client deepen, renew, or discover new or old spiritual wellsprings. So whether through prayer, meditation, reading scripture with a group or on one’s own, burning incense at an altar, hugging a large Douglas fir tree, or spending time stargazing, the idea is to activate spiritual resources. The worker does not have to be an ordained minister to do this. Perhaps the best prototype for this area is the work of the Christian Stephen ministry, which trains laypeople to administer spiritual psychological first aid to persons who are experiencing all kinds of trouble. Named after Saint Stephen, the first Christian martyr who cared for the poor, they provide a complete system of training and equipping laypeople to provide quality Christian care to hurting people (Stephen Ministries, 2011). We think the analogy of them being the spiritual equivalent of community emergency response workers (CERTs; see Chapter 17, Disaster Response) is an apt one, and crisis workers who do not have in-depth spiritual training might do well to go through the Stephen Ministry’s workshop or its equivalent with other religions. Barring that, we heavily endorse forming a relationship with a trusted cleric with whom the worker can coordinate this facet of grief recovery.

Cognitive-Behavioral Approaches

Cognitive-behavioral therapies, which focus on changing maladaptive thinking, are the most commonly used therapies for those who suffer from complicated/prolonged grief (Cohen, Mannarino, & Deblinger, 2006; Humphrey, 2009; Shear & Frank, 2006). Cognitive-behavioral strategies are used in dealing with both loss and restoration orientations (Shear & Frank, 2006). A variety of cognitive- behavioral techniques, including relaxation training, desensitization, thought stopping, cognitive restructuring, DE propagandizing and disputing irrational beliefs, guided imagery, and in vivo imagery, are used to deal with the emotional dysregulation, behavioral dysfunction, maladaptive cognitions, and avoidance issues that are characteristic of complicated/prolonged grief.

Added to basic cognitive-behavioral therapy are the postmodernist constructivist therapies (Neimeyer, 2001, 2010b; Neimeyer et al., 2007) that focus on one of the major tasks of complicated/prolonged grief counseling—meaning making (Slattery & Park, 2015). Meaning making has to do with one’s interpretation of reality and truth as the central process of one’s life (Humphrey, 2009, p. 62). Certainly one of the core is- sues of loss is making sense of it in such a way as to reformulate one’s life, develop a new sense of purpose, and move from the past to the future.

Narrative Therapy

Narrative therapy is a postmodern social constructivist approach that emphasizes the stories or narratives of people’s lives (Humphrey, 2009; Monk et al., 1997; White, 1989). Narrative therapy is particularly important in grief work because it involves the telling and retelling of stories that thematically represent the meaning of the loss in the person’s life. It brings to light and helps clients challenge the underlying beliefs and assumptions of dominant, maladaptive narratives that they have created in an attempt to make sense and meaning of the loss and challenges negative descriptions of themselves as guilty, weak, ruined, wasted, broken, guilty, shamed, cowardly and so on, that are often a complicating factor in loss adaption (Humphrey, 2009, p. 175). Narrative therapy also helps reconstruct, rather than relinquish, the relationship of the deceased and gives voice to the unspeakable thoughts and feelings of dog grievers’ attempts to reclaim their lives and make meaning of them (Neimeyer, 2010a).

Attachment Theory and Therapy

Attachment theory is one of the oldest theories to deal with grief. While it has origins as a phase theory, it still has a great deal of utility and is a basic premise of grief and loss. Attachment creates bonds that are rooted in the core of our existence, and when those attachments are broken, severe fractures and breaks can occur in the personality. Attachment theory emphasizes separation anxiety arising from the griever’s attachment to the deceased, the breaking of bonds of affection, and the need to emotionally detach from the lost object. Attachment theory proposes that hu- man beings form close affiliation bonds (emotional attachments) from birth because close attachment between parent and child is an evolutionary adaption that keeps infants secure and safe, and the resulting close physical contact with the parent enhances physical, emotional, and cognitive development (Bowlby, 1969, 1980, 1988).

The key component in understanding attachment theory comes from Main’s (1996, 2000) research on “coherent narrative,” which is the way parents told the stories of their lives. It was the most potent predictor of whether their own children would be securely attached to them. In other words, it wasn’t what actually happened to them as children, but how they made sense of what happened to them. Thus, making meaning of one’s childhood, regardless of the actual event, corresponded positively with emotional integration and better parenting (Schuurman & De Cristofaro, 2007). When Bowlby’s and Main’s research is translated to loss and grief, it is thus not how one actually lived with the deceased, but how one thought about how one had lived with the deceased that really matters. As such, how the narrative of that thought process unfolds has a great deal to do with whether one moves through the loss and grief well or not. If the narrative is maladaptive, then it follows that the griever will be maladaptive as well. At that point, narrative therapy’s ability to change the story comes into the therapeutic picture. Thus, attachment theory can blend well with narrative therapy (Dallos & Vetere, 2009).

SUMMARY

The stage models of death, dying, grief, and bereavement have become outdated due to a lack of research to prove their viability. Newer models of loss picture grief as highly individualist and not progressing neatly through linear stages. The adaptive model pro- poses that grieving over loss occurs along a continuum of styles and that no particular style is the one, right, true path to resolution. The dual process model promotes grieving as oscillating back and forth be- tween a loss orientation and a restoration orientation over an extended period of time. Several different types of loss typify the kinds of human events or tragedies that might bring crisis workers into contact with persons experiencing grief. All of these losses are the same in that they may strike individuals with grief and all that grief entails.

Examples of such losses are:

(1) the death of a spouse

(2) the death of a child

(3) bereavement in childhood

(4) job loss,

(5) separation and divorce

(6) the death of a pet,

(7) bereavement in elderly people

(8) the trauma associated with HIV and AIDS.

However, loss is also different in that persons may suffer from a primary loss, secondary loss, multiple loss, ambiguous loss, and stigmatized loss. Every human being will, at one time or another, suffer personal loss. During our lives most of us will encounter numerous people who are experiencing bereavement or grief as a result of some personal loss. What may be clearly perceived as a personal loss ranges from a devastating occurrence, such as the death of a spouse or a child, to what many people might view as a minor loss, such as that of a pet or a family heirloom. In any event, it is an important loss if the individual perceives it as such, and workers must treat each client’s loss with empathy, caring, and sensitivity. Although the bereaved can never for- get the loss and return to a state of complete precrisis equilibrium, he or she can be helped to reformulate the loss within a context of growth and hope. Most loss is resolved by grieving and mourning that help the person place the loss in memory and move forward with living. Complicated/prolonged grief is a manifestation of loss that has not been re- solved, grief that has gone unreconciled, mourning that hadn’t been completed, and as a result is now pathologic. Complicated/prolonged grief may occur after an extended period of time in regard to a non- traumatic loss and have coexisting disorders such as depression and anxiety. It may also result from a traumatic loss and be classified as traumatic grief with the possible coexistence of PTSD. Complicated/pro- longed grief is transcrisis in nature and, if not dealt with, can cause serious to lethal physical and psycho- logical problems for the individual suffering from it. Intervention strategies, techniques, and skills that crisis workers need for helping people in these categories of grief are focused on cognitive-behavioral and constructivist approaches but may be highly eclectic when interventions are tailor-made to fit the idiosyncratic needs of the individual’s grief process. Crisis workers who work with grieving clients, and particularly clients with complicated/prolonged grief who do not take care of themselves emotion- ally, physically, and spiritually, become vulnerable to vicarious traumatization and compassion fatigue, particularly if they have not resolved their own losses.