WORKING

BEREAVED
W1TH THE
THE SERIES IN DEATH, DYING, AND BEREAVEMENT
ROBERT NEIMEYER, CONSULTING EDITOR

Beder—Voices of Bereavement: A Casebook for Grief Counselors

Berger—Music of the Soul: Composing Life Out of Loss
Buckle & Fleming—Parenting After the Death of a Child: A Practitioner’s Guide
Davies—Shadows in the Sun: The Experiences of Sibling Bereavement in Childhood
Doka & Martin—Grieving Beyond Gender: Understanding the Ways Men and Women Mourn, Revised Edition
Harris—Counting Our Losses: Reflecting on Change, Loss, and Transition in Everyday Life
Harvey—Perspectives on Loss: A Sourcebook
Katz & Johnson —When Professionals Weep: Emotional and Countertransference Responses in End-of-Life Care
Klass—The Spiritual Lives of Bereaved Parents
Jeffreys—Helping Grieving People – When Tears Are Not Enough: A Handbook for Care Providers, Second Edition
Jordan & McInotsh—Grief After Suicide: Understanding the Consequences and Caring for the Survivors
Leenaars—Lives and Deaths: Selections from the Works of Edwin S. Shneidman
Leong & Leach—Suicide among Racial and Ethnic Minority Groups: Theory, Research, and Practice
Lester—Katie’s Diary: Unlocking the Mystery of a Suicide
Martin, Doka—Men Don’t Cry … Women Do: Transcending Gender Stereotypes of Grief
Neimeyer, Harris, Winokuer, & Thornton—Grief and Bereavement in Contemporary Society: Bridging Research and Practice
Nord—Multiple AIDS-Related Loss: A Handbook for Understanding and Surviving a Perpetual Fall
Roos—Chronic Sorrow: A Living Loss
Rogers—The Art of Grief: The Use of Expressive Arts in a Grief Support Group
Rosenblatt—Parent Grief: Narratives of Loss and Relationship
Rosenblatt & Wallace—African-American Grief
Rubin, Malkinson, & Witztum—Working With the Bereaved: Multiple Lenses on Loss and Mourning
Tedeschi & Calhoun—Helping Bereaved Parents: A Clinician’s Guide
Silverman—Widow to Widow, Second Edition
Werth—Contemporary Perspectives on Rational Suicide
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FORMERLY THE SERIES IN DEATH EDUCATION, AGING, AND HEALTH CARE

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Corless, Pittman-Lindeman—AIDS: Principles, Practices, and Politics, Abridged Edition
Corless, Pittman-Lindeman—AIDS: Principles, Practices, and Politics, Reference Edition
Curran—Adolescent Suicidal Behavior
Davidson—The Hospice: Development and Administration. Second Edition
Davidson, Linnolla—Risk Factors in Youth Suicide
Degner, Beaton—Life-Death Decisions in Health Care
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Doty—Communication and Assertion Skills for Older Persons
Epting, Neimeyer—Personal Meanings of Death: Applications for Personal Construct Theory to Clinical Practice
Haber—Health Care for an Aging Society: Cost-Conscious Community Care and Self-Care Approaches
Hughes—Bereavement and Support: Healing in a Group Environment
Irish, Lundquist, Nelsen—Ethnic Variations in Dying, Death, and Grief: Diversity in Universality
Klass, Silverman, Nickman—Continuing Bonds: New Understanding of Grief
Lair—Counseling the Terminally Ill: Sharing the Journey
Leenaars, Maltsberger, Neimeyer—Treatment of Suicidal People
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Leng—Psychological Care in Old Age
Leviton—Horrendous Death, Health, and Well-Being
Leviton—Horrendous Death and Health: Toward Action
Lindeman, Corby, Downing, Sanborn—Alzheimer’s Day Care: A Basic Guide
Lund—Older Bereaved Spouses: Research with Practical Applications
Neimeyer—Death Anxiety Handbook: Research, Instrumentation, and Application
Papadatou, Papadatos—Children and Death
Prunkl, Berry—Death Week: Exploring the Dying Process
Ricker, Myers—Retirement Counseling: A Practical Guide for Action
Samarel—Caring for Life and Death
Sherron, Lumsden—Introduction to Educational Gerontology. Third Edition
Stillion—Death and Sexes: An Examination of Differential Longevity Attitudes, Behaviors, and Coping Skills
Stillion, McDowell, May—Suicide Across the Life Span—Premature Exits
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Wass, Corr—Childhood and Death
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 ORKING
EREAVED
Multiple Lenses on Loss and Mourning

SIMON SHIMSHON RUBIN,

RUTH MALKINSON,
AND ELIEZER WITZTUM

I~ ~~~J~~n~~~up
New York London
Routledge Routledge
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Library of Congress Cataloging-in-Publication Data

Rubin, Simon Shimshon.

Working with the bereaved : multiple lenses on loss and mourning / Simon
Shimshon Rubin, Ruth Malkinson, Eliezer Witztum. -- 1st ed.
p. cm. -- (Series in death, dying, and bereavement)
Includes bibliographical references and index.
ISBN 978-0-415-88165-4 (hardcover : alk. paper) – ISBN 978-0-415-88166-1
(pbk. : alk. paper)
1. Bereavement--Psychological aspects. 2. Loss (Psychology) 3. Cognitive
therapy. I. Malkinson, Ruth, 1938- II. Witztum, Eliezer. III. Title.

BF575.G7.R83 2012
155.9’37--dc23 2011018664

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the Routledge Web site at
http://www.routledgementalhealth.com
 For my unmet siblings, Rachel and Yisroel Rubin,
and their mother, Sara Krauthammer,
killed 1943 in the Holocaust
—SSR

To the memory of my beloved parents

Nahum Bogin and Shoshana Nerfin-Bogin
—RM

For the memory of my dear parents

Shmuel (1914–2001) and Yafa (Sonia) (1922–2000) Witztum
—EW
 Contents

Series Editor’s Foreword ix

Preface xi
Acknowledgments xiii
About the Authors xv

SECTION I CHOOSING LIFE AFTER LOSS

1 Love—and Loss—and Life 3

2 Current Perspectives on Bereavement 19

SECTION II THE TWO-TRACK MODEL OF

BEREAVEMENT: CONTINUING BONDS AND
CONTINUING WITH LIFE
3 Introduction to the Theory and Clinical Applications of the
Two-Track Model of Bereavement 35

4 Clinical Theory and Practice at the Interface of Trauma and

Bereavement 55

5 The Relational Traumas of Bereavement 71

6 Therapeutic Work With the Relationship to the Deceased 83

vii
viii CONTENTS

SECTION III INTEGRATING VARIOUS

THERAPEUTIC APPROACHES WITH INSIGHTS
FROM THE TWO-TRACK MODEL OF
BEREAVEMENT

7 Psychodynamic Psychotherapy: Traditional and Relational Aspects

of the Encounter 103

8 A Cognitive Behavior Approach: Rational Emotive Behavior Therapy 123

9 Cognitive Therapy: Applying Imagery and Mindfulness 139

10 Strategic Integrative Interventions: Applying Letter Writing, Leave-

Taking Rituals, and Metaphor 151

11 Systemic Family Grief Therapy 171

SECTION IV EXPANDING HORIZONS: CULTURE,

CLINICAL CHALLENGES, AND FACILITATING
RESILIENCE

12 The Social–Cultural Contexts of Loss: Considerations for Culturally

Sensitive Interventions 187

13 Emergencies in Complications Following Loss 203

14 Growth and Resilience: Considerations for Clients and Therapists 213

Epilogue 225

Appendix: The Two-Track Bereavement Questionnaire (TTBQ2-70) 227

References 241

Index 259
 Series Editor’s Foreword

For the better part of the 20th century, bereavement research and practice could
be fairly described as falling principally within one of two broad trends. On the
one hand, following the pioneering work of Sigmund Freud, writers and analysts
in the psychoanalytic tradition posited elaborate and sometimes esoteric dynam-
ics of inner processes as mourners resisted coming to terms with the hard real-
ity of loss, eventually withdrawing emotional energy from the lost relationship in
order to reinvest in living relationships. On the other hand, more general medical
and psychiatric authors and practitioners concentrated on documenting the overt
symptomatology of grief, and especially with the advent of psychopharmacology,
its amelioration. By contrast to these two dominant traditions, serious attempts to
integrate the two faces of grief work were rare. As a result, generations of bereaved
people, if they consulted a professional at all, often confronted a choice between
protracted personal therapy focusing on their unconscious dynamics regarding the
loss and medical attempts to mitigate their (chiefly depressive or anxious) symp-
tomatology. Common to both approaches was a presumption of patient passivity,
insofar as little attention was paid to the active agency of the bereaved themselves in
dealing with the death and its consequences, either as individuals or as families.
Much has changed in the past few decades, however. Models of grieving as an
active process of coping with separation have grown in number and sophistica-
tion, as have the substantial empirical literatures on issues of attachment, mean-
ing making, psychological trauma, complicated grief, and a host of other topics of
direct relevance to bereavement intervention. Indeed, the authors of this book are
themselves lively participants in this burgeoning area of conceptual and clinical
work, having drawn on their own consultation with the bereaved as well as a grow-
ing research base to posit a genuinely integrative theory of grief: the Two-Track
Model of Bereavement (TTMB). Guided by this helpful heuristic frame, clinicians
are led not only to take stock of the myriad biopsychosocial consequences of loss
for clients’ daily lives (reflected, for example, by struggles in emotional, cognitive,
interpersonal, and work domains), but also to consider their ongoing relationship
to the deceased, as reflected in often complex attempts to maintain contact with
their loved ones while also buffering the painful evidence of their absence.
After briefly reviewing pioneering contributions to bereavement studies,
Rubin, Malkinson, and Witztum explore the thorough interpenetration of trauma
and bereavement, noting that the former is not limited to its impact on the emo-
tions, belief systems, and behaviors addressed under the track concerned with

ix
x SERIES EDITOR’S FOREWORD

biopsychosocial functioning, but indeed extends to various features that compli-

cate the relationship to the dead. Among these are the ways in which the traumatic
imagery that typically accompanies violent death, as well as relational traumas
like betrayal or conflict, can contaminate the very memories of the deceased that
might otherwise give solace. As the authors share with the reader case study after
case study, it becomes more and more clear how inadequate traditional models
are in capturing the nuances of post-loss adaptation and its myriad challenges.
Rather than simply deactivating one’s attachment to the deceased, the “work of
mourning” is found to consist both in regulation of the multifaceted disruption
in biological, psychological, and social functioning occasioned by the death and
in renegotiation of one’s constructive relationship to the deceased, drawing on
personal, familial, religious/philosophic, and cultural supports for reengaging life
as it now presents itself.
For me, the heart of the book is the convincing, clinically rich portrayal of psy-
chotherapy with the bereaved, going beyond facile vignettes to explore the nuances
of actual cases, in all their reality and recalcitrance. In these core chapters the
reader will step into that fruitful liminal space in which clinicians may prompt
clients through the use of imagery and metaphor, spiritual beliefs and practices,
letter writing and chair work to reestablish, renegotiate, and sometimes partly relin-
quish their bonds with the dead. Sorting through tangled legacies of past losses
and conflicted relationships in psychodynamic work, promoting adaptive interpre-
tations of grief and survivorship in cognitive behavioral/rational emotive therapies,
and realigning family relationships in systemic work all contribute to a robust depic-
tion of grief therapy, not as a stand-alone specialty, but instead as an empirically
informed refinement of general frameworks for practice. The book closes with an
advocacy for suicide and crisis intervention in the earliest phases of loss when a
subset of the bereaved show great vulnerability, and with a welcome attention to
cultural diversity in mourning rituals as displayed by different ethnic or religious
communities in the United States and Israel.
In sum, Working With the Bereaved: Multiple Lenses on Loss and Mourning
offers truth in advertising; it is a thorough and thoughtful handbook for working
with both the symptomatic and relational challenges of grieving, one written by
intelligent clinicians for intelligent clinicians. I hope that it will offer a trove of
concepts and methods that enhance your practice with grieving clients, as it will
enhance mine.

Robert A. Neimeyer, PhD

Series Editor
 Preface

This book is competing for your time and attention. The potential reader consider-
ing a book referring to loss and bereavement in its title has entered the first circle
of curiosity. What will justify the decision to read on? The authors, all seasoned
readers themselves, sought to write a book that would be interesting, informative,
and useful for a wide swath of clinicians. Those of you who proceed will be the
judge of that.
This book is written for clinicians by clinicians. It is written by people who are
not strangers to loss and bereavement for people who should not be strangers to
loss and bereavement either—even if they experience themselves as such. Many
of the things we have written will interest anyone who wishes to learn more about
bereavement. Nevertheless, despite the temptation to write a book for “Everyman,”
we have chosen to write for “Every-clinician” and to do so in a way that is designed
to be appropriate for widely varying theoretical, personal, and clinical orientations
and experience levels.
No human being is a stranger to love, attachment, and life with others. No
human remains a stranger to loss, loneliness, and death. Our personal and profes-
sional lives have allowed us to take on the challenge of helping others live more
fully in the transitional space that exists between love and loss, attachment and
loneliness, and life and death. Our intent is to produce a book that will be of inter-
est and of use to clinicians in the fields of mental health as well as other persons
interested in the area. We have made liberal use of clinical material throughout the
book. This facilitates communication, maintains interest, and is closest to much of
what we do as psychotherapists.
Having addressed the what and how questions (what we attempt to do and
how we do it), there remains the who question. Who has written this book? The
formal aspects of that question are easiest to answer. We are a clinical psychologist,
social worker, and psychiatrist who maintain active psychotherapy practices while
also serving as academic and clinical faculty. We have written independently and
together on a range of issues related to bereavement as well as to other aspects of
mental health. More detail about the formal aspects of who we are can be found
on the About the Authors page as well as on the Internet.
We invite you to continue on with us and enter additional circles of curi-
osity. The book is composed of four sections: Section I: Choosing Life After
Loss; Section II: The Two-Track Model of Bereavement: Continuing Bonds and
Continuing With Life; Section III: Integrating Various Therapeutic Approaches

xi
xii PREFACE

With Insights From the Two-Track Model of Bereavement; and Section IV:
Expanding Horizons: Culture, Clinical Challenges, and Facilitating Resilience.
In the Appendix, we include the full Two-Track Bereavement Questionnaire
(TTBQ2-70). Designed for clinical and research use, the TTBQ2-70 has value as
a screening tool, and as a measure of pre- and post-treatment effectiveness. The
measure is accompanied by a short commentary. The chapter titles further clarify
the nature of the topics we address.
 Acknowledgments

As this book is an amalgam of the life experiences of the authors forged in the cru-
cible of their personal, intellectual, and therapeutic experiences, it makes sense to
acknowledge some of those experiences. Many forces have served to temper the book
and to influence the way in which we understand loss and bereavement and share
that with you the reader. We do this first in the plural, speaking as one, and then we
continue on to speak in our own individual voices as the singular beings we all are.
Professionally, we acknowledge our own teachers, our clients, our supervisors,
and our supervisees for the education they gave us. From all of them, we learned a
lot about the human face of loss and how to communicate what we know, and are
still learning, to ourselves and to others. The commonalities and the singularities
of bereavement are striking. Both poles of interpersonal loss deserve our attention,
our understanding, and our respect. Humility in the face of the pain and longing
of bereavement is something that one learns and relearns over time. Respect for
human resilience—for the ability of people to cope, grow, and develop—is some-
thing more fully appreciated in the context of the therapy relationship. The unique
conditions of psychotherapy allow for a category of interpersonal connection, and
emotional intimacy, in a framework that encourages the sharing of private thoughts
and feelings. To be a psychotherapist is to be accorded a privilege and a sacred
trust. To listen, to hear, and to help bereaved clients is to accomplish what we are
expected, and have been allowed, to attempt. Our abilities and our tools are not
unlimited, but our basic humanity should never lag behind either. This, too, has
been taught to us by our teachers, our students, and our clients.
We have been very fortunate in the realm of colleagues. First and foremost,
our ability to work together over a span approaching a quarter century has been a
source of professional creativity and personal satisfaction. It is said that the whole
is greater than the sum of its parts, and that is our subjective appraisal of our joint
work. Our circles of colleagues extend much farther and wider than the three of
us. The International Work Group on Death, Dying and Bereavement, more com-
monly known to its members as the IWG, has connected us with a fascinating array
of leaders in the field.
To our publishing team at Routledge, Senior Editor Dana Bliss, Associate
Editor Anna Moore, and Project Editor Iris Fahrer, and to series editor and friend
Robert Neimeyer, we extend our thanks and appreciation. They are a professional
and personable group. We wish to thank the Witztum families for permission to

xiii
xiv ACKNOWLEDGMENTS

use original artwork by their mother. We thank those assisting us in Israel, Meyrav
Blizovski, Mertyn Malkinson, Michal Rubin, and Galia Witztum.
At this point, the individual authors add their individual thanks and acknowl-
edgments.

I acknowledge my debt to my two parent countries and cultures, the United States
and Israel, for giving me wonderful traditions and challenges. From time to time,
I have been able to share a sliver of my own thoughts on those influences on,
and their interplay with, my professional work in both ethics and bereavement.
I have been fortunate to have the support of my colleagues and students in the
Department of Psychology and at the International Center for the Study of Loss,
Bereavement and Human Resilience at the University of Haifa. Finally, I thank
my wife Lisa, our children, and their families—Abraham; Sara, Yehuda, Naomi
and Joshua Halper; Jonah and Annabella; and Michal—for being who they are.

Simon Shimshon Rubin

Haifa

Writing the acknowledgment concludes a unique journey filled with people who
were a source of inspiration and support as the book was moving toward its final
form. In addition to being thankful for working as a threesome, a growth experi-
ence for me, I would like to thank my colleagues and students for the inspiration
and support they provided throughout the writing. I wish to express special thanks
to my husband, Mertyn, whose patience and support were invaluable all along the
way. And finally I would like to thank my dear children, Yael, Dan, and Guy, and
their families, who continue to educate me about evolving relationships.

Ruth Malkinson
Rehovot

I would like to thank my colleagues and friends for their inspiration and help over
the years. Professors Haim Dasberg and Onno Van der Hart deserve special men-
tion in that regard. Closer to home, I wish to especially thank my children, Galia,
Dan, and Uria, and my brother Menachem and his wife, Nilly, for their help and
support in difficult times.

Eliezer Witztum
Jerusalem
 About the Authors

Simon Shimshon Rubin, Ph.D., is a full professor of clinical psychology and

director of the International Center for the Study of Loss, Bereavement and Human
Resilience at the University of Haifa in Israel. He is chairman of the Postgraduate
Psychotherapy Program at the Department of Psychology based there as well.
Dr. Rubin is active as a clinician, consultant, researcher, and teacher. He has lec-
tured and published extensively on bereavement, ethics, and training in psycho-
therapy. Over the course of his career, Dr. Rubin has been a visiting professor at
the Northwestern and Harvard University medical schools; board member of the
International Work Group on Death, Dying and Bereavement (IWG); chair of the
clinical psychology program at the University of Haifa; chair of its University Ethics
Committee; director of the Israel Ministry of Health’s Haifa Child, Adolescent and
Family Clinic; and senior clinical psychologist at Michael Reese Medical Center
in Chicago, Illinois. Professor Rubin’s Web site can be viewed at http://psy.haifa.
ac.il/~rubin.

Ruth Malkinson, Ph.D., is adjunct senior lecturer at the Bob Shapell School of
Social Work, and the School of Medicine, Tel Aviv University. She is the founder
and director of the Israeli Center of REBT (Rational Emotive Behavior Therapy).
Dr. Malkinson is also a core member of the International Center for the Study of
Loss, Bereavement and Human Resilience at the University of Haifa. She is a past
president of the Israeli Association for Couple and Family Therapy. Dr. Malkinson is
a member of IWG (International Work Group for Death, Dying and Bereavement)
and consults, lectures, and conducts workshops nationally and internationally on
these subjects. She teaches and practices individual and family therapy along the
life cycle. Her most recent book is titled Cognitive Grief Therapy: Constructing a
Rational Meaning to Life Following Loss (2007).

Eliezer Witztum, M.D., is a full professor in the Division of Psychiatry, Faculty

of Health Sciences, Ben-Gurion University of the Negev. He is director of
Psychotherapy Supervision at the Mental Health Center, Beer Sheva and senior
psychiatrist at the Community Mental Health Center of Ezrat Nashim Hospital in
North Jerusalem.
Professor Witztum’s areas of expertise include cultural psychiatry, the history
of psychiatry, trauma and bereavement, strategic and short-time dynamic psycho-
therapy, and the treatment of pedophile sexual offenders.

xv
xvi ABOUT THE AUTHORS

Professor Witztum has published more than 200 scientific publications. He

coauthored (with D. Greenberg) Sanity and Sanctity (2001) and collaborated
(with Aryeh Kasher) on King Herod: A Persecuted Persecutor: A Case Study
in Psychohistory and Psychobiography (2007). His recent Hebrew language
books include Spirit, Loss and Bereavement (2004); Genius and Madness: The
Complicated Relationship Between Creativity and Psychopathology (with V.
Lerner, 2008); and To Bear a Child: Psychological Aspects of Fertility Problems
and Their Treatment (with Z. Birman, 2010).

The authors have published numerous articles together and coedited the following
books: Loss and Bereavement in Jewish Society in Israel (1993) and Traumatic
and Nontraumatic Loss and Bereavement (2000).
 Choosing Life After Loss
Section I

Figure S1.1 James Guthrie, A Funeral Service in the Highlands. © Culture & Sport
Glasgow (Museums).

Section I opens with two introductory chapters. The first chapter sets the stage and
begins the theme of the struggle to return to full life after loss. It touches upon what
makes this field so difficult to work in for many people. Case examples discussed
include the biblical story of Jacob mourning for Joseph, the son he presumed dead,
as well as more contemporary examples. The chapter closes with theoretical and
historical issues in the field centered on the work of three of the “founding fathers”
of the field, Freud, Lindemann, and Bowlby.
The second chapter presents an overview of five themes that frame much of
the discussion and thinking about loss. To cite the first, the question “Is there
2 CHOOSING LIFE AFTER LOSS

right and wrong in the bereavement response?” is addressed. The way this theme
is developed has less to do with “answers” and more to do with understanding the
context of the question and its connection to how people think about loss. The
remaining themes are also considered with attention to context as well as content.
They address the centrality of interpersonal relationships in bereavement, poten-
tial for change and growth following loss, how to facilitate adaptive grieving, and
the relevance of ethics for the field.
 Love—and Loss—and Life
1
T
he life thread of human interconnection brings with it the certainty of
loss through death. Despite the variation in circumstances and their sig-
nificance, bereavement will come to us all. The emotions accompanying
bereavement are often painful. Sadness, longing, profound unease, guilt, and feel-
ings of losing one’s mind are but a few of the emotions that may overwhelm family
members as they respond to the death of a loved one. And yet, over time, most of us
experience the loss of a loved one and continue to live a full and productive life with
acceptance of loss becoming part of it. For the clinician encountering people who
have suffered the loss of a significant other, perhaps the most basic question we ask
ourselves regarding bereavement is which responses deserve our intervention skills
and which do not? Responding to even this “relatively straightforward” question
requires us to acknowledge that the responses to such questions are embedded in a
veritable matrix of assumptions and epistemological ways of thinking about human
behavior. In the next chapter, we address some of the current assumptions and
controversies that precede questions of assessment and intervention, which take
up the major part of this book. Prior to that, however, we begin with aspects of the
therapists’ own attitudes to loss before we address the phenomenology of loss as
experienced by bereaved individuals. Ultimately, it is the therapists’ own attitudes
to loss that frame and organize the personal experience of how they approach the
encounter with the bereavement of another.

ENTERING THE FEARED REALM

WITHOUT BEING TRAPPED THERE
Separation, loss, and death are painful, frightening, and emotionally threaten-
ing. From time immemorial, the individual’s encounters with loss and death have
been met within a framework of resources and meaning structure designed to
support those experiencing the death of significant persons. The individual’s own
psychological experience of loss is strongly mediated by the meaning framework
of the familial, cultural, and religious-spiritual resources that help organize the

3
4 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

experience. The sustained attention to helping those who experience the death
of a loved one, separated physically from the deceased in the form of burial and
mourning rites, is a part of every faith tradition. The need to attend to this part of
human experience merely underscores how significant an event and process the
death of another sets in motion.
All living things die. During the time that people are alive, the impact of their
existence may be known to others or not; it may be great or small, but we believe it
is never null or absent. For those closest to the deceased, the impact of their loved
one’s death can be assessed and categorized in many ways. In many respects, that
is what this book will address. The impact of loss is so great because our connec-
tions to those closest to us are so important. Loss and bereavement are ultimately
about love and connection. One can be traumatized by being exposed to the death
of a human being whom one does not know. But one can only truly and deeply
grieve and mourn someone with whom one has a connection.
In our individual and combined experience encountering, teaching, and treat-
ing bereavement, we have noted time and again how difficult it is for some clini-
cians to acknowledge the universal significance of this topic. Most of the time, at
best, cursory attention is given to loss and bereavement during training. Rarely is
the area approached as an experience that is a central part of human existence and
so ubiquitous as to require that all clinicians have basic competence in this aspect
of the human encounter.
Clinicians’ own feelings (their “countertransference”) are operant in many
areas of experience. Some topics are avoided by many. For example, working with
victims of sexual abuse, and particularly child sexual abuse, is difficult for many
therapists, but working with perpetrators is seen as significantly more difficult and
avoidable. Whereas a therapist may avoid intentionally choosing such clients in one’s
practice, one can never know in advance whether such history will reveal itself in
what seemed to be initially a client to whom this history did not apply. At least
some familiarity with the impact and consequences of such experiences equips the
therapist with the ability to encounter the complexity of what people bring with
them unbeknownst to the therapist. Similarly, working with the terminally ill is
something that some are drawn to and others avoid (Berzoff & Silverman, 2004).
Yet no one can ever know whether one’s clients will become seriously ill and
bring that issue to bear into a therapy relationship. In the case of loss and bereave-
ment, the necessity of being familiar with the topic, even for those who are not
themselves drawn to the topic, is even more necessary, for all living persons will
both lose significant others and be the cause of a bereavement response for those
who love them. And thankfully, because people are important to each other, their
loss matters. We do not minimize how painful, upsetting, life wrenching, and
tragic the event of death can be. All of this contributes to why the field of bereave-
ment work is typically so anxiety provoking to so many. At the same time, however,
the most adaptive responses to bereavement are about finding ways to renew and
reorganize connections to oneself, to the deceased, and to the interpersonal and
greater surroundings of one’s world.
The trauma of forced separation from a loved one is the stuff of nightmares for
young and old alike. Yet the reality of human adaptation to loss and death is one of
 LOVE—AND LOSS—AND LIFE 5

survival, adaptation, and a mix of scar tissue and renewed growth. There are many
pathways in which humans respond to the physical separation from others and yet
continue to benefit from the history and essence of their connection. That fact, as
well as helping persons cope with the deleterious impact of less adaptive responses
to loss, will reverberate throughout the book.

All living things die.

One can only truly and deeply grieve someone with whom one has a
connection.

A CASE OF LOSS
Throughout this book, we focus on the therapist’s encounter with loss and
bereavement and how to assist clients. Parallel to that theme runs the idea that
the natural course of bereavement is not always salutary. We turn to the Bible’s
portrayal of one particularly painful bereavement and its “solution” for the pain
of loss depicted.
The biblical figure of Jacob stands out as a powerful case history of the
impact of child loss and bereavement for many reasons. From close attention
to research as well as intervention with bereaved parents, the details of Jacob’s
response to the purported death of Joseph convey one picture of what today we
would call complicated bereavement. The story is told in the book of Genesis
about Jacob’s favoring his son Joseph. The recipient of great love and affec-
tion from his father, Joseph is not sufficiently sensitive to the negative family
dynamic this perpetuates. Hated by his brothers, Joseph is sold by his brothers
to human traffickers who sell him off to servitude and slavery. The dynamics
of the plot relevant to us follow from Jacob being presented with the bloodied
coat of many colors that was Joseph’s and his natural assumption that Joseph has
been killed by wild beasts.

37:34 And Jacob rent his garments, and put sackcloth upon his loins, and
mourned for his son many days.
37:35 And all his sons and all his daughters rose up to comfort him; but he
refused to be comforted; and he said: “Nay, but I will go down to the grave to
my son mourning.” And his father wept for him. (Jewish Publication Society
[JPS], 1962)

The biblical story of Jacob’s grief spans a period of many years during which
he is inconsolable. Head of a clan, father to 13 children and to grandchildren, we
are told time and again that Jacob’s focus is on his “deceased son,” and his descrip-
tion of himself is a perpetual mourner destined to continue mourning until his
own death. Only one thing can change that, and that is understood by Jacob to
be impossible, and that would be a reunion with Joseph. The story continues and,
viewed from the perspective of today, seems to be some sort of unethical psycho-
logical experiment utilizing deception to make its point. The story is designed to
6 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

show us the impact of child loss for some—and its “only” cure. The impact of the
event, the loss of Joseph, and its amelioration can be seen best when a solution is
found for Jacob’s depression and grief.

Genesis 45:26 And they told him, saying: “Joseph is yet alive, and he is ruler
over all the land of Egypt.” And his heart fainted, for he believed them not.
45:27 And they told him all the words of Joseph, which he had said unto them;
and when he saw the wagons which Joseph had sent to carry him, the spirit of
Jacob their father revived.
45:28 And Israel [Jacob] said: “It is enough; Joseph my son is yet alive; I will go
and see him before I die.” (JPS, 1962)

The impact of child loss, and its ability to affect the bereaved, can be devastating,
and its effects are often lifelong. In the biblical story, we are told that Jacob is inconsol-
able and that his spirit only revives when he learns that Joseph lives. Although it is far
from clear that Jacob would meet recent DSM (Diagnostic and Statistical Manual of
Mental Disorders) proposed criteria for complicated grief, pathological grief, or pro-
longed grief disorder, there are many indications of his ongoing suffering (Prigerson,
Vanderwerker, & Maciejewski, 2008; Rubin, Malkinson, & Witztum, 2008). It is clear
from the story that despite all his ongoing familial connections, Jacob’s bereavement
exacts a great cost from him and from his extended family. In the remainder of this
book, we seek to formulate and communicate to the clinician reader, useful and fun-
damental understandings of bereavement and intervention following loss that have
conceptual, clinical, and personal meaning for therapists and clients alike.

The biblical story of Jacob describes prolonged grief and mourning for Joseph
and Jacob’s inability to respond appropriately to his other children.
The psychological cost to the individual and to the family following loss
can be chronic and devastating as has been known since ancient times.

CONTEMPORARY BEREAVEMENT
The effects of loss can be profound, but for the most part, these effects vary dra-
matically in duration and magnitude. Predicting the effects of bereavement has
been quite difficult and suffers from controversy regarding what those effects are
and how they are to be understood. The lifelong effects of some losses, and the
seemingly transient effects of others, have been a source of consternation as well
as inspiration for writers, clergy, physicians, and scientists. In this opening chapter,
our goal is to introduce the experience of loss and to highlight some of what has
gone into the modern psychological approach to this field. We would like to intro-
duce the reader to an understanding of the experience of loss and its aftermath
by taking things we have learned from the bereaved and constructing a composite
portrait of a bereaved young man. Although these are not the words of a specific
individual person, everything included is faithful to the themes and examples we
have encountered in our research and clinical work. The circumstances allowing
 LOVE—AND LOSS—AND LIFE 7

our speaker Joe, the youngest of three boys, to share this information are as fol-
lows: Joe enrolled in an elective course on loss and bereavement. The course
required him to narrate why he had signed up for the course and to dictate his
reasons into a digital recorder. The following are his words:

I was 14 when my mother died of cancer. No one ever told me that she was ill.
I mean we knew, but we never talked about it at home. There were days when
I ate at Gramma’s because Mom was away for “vacation.” Then she would
come back home and life went on as usual, as if nothing was wrong. Then one
day my father called us together and said: “Your mother is dead, she did not
suffer.” I started crying and went to my room where I sobbed all night, and
told myself it wasn’t true, that my dad was lying. The following morning I
woke up ready to go to school but was told that I didn’t have to and could stay
at home. My principal suggested that I see the school counselor but I turned
the idea down because I saw no point in talking about it. Mostly because it
was inconvenient. I had no one to talk with. Neither Mom nor Dad spoke
with us about her illness when she was sick. None of us did really. I do recall
that he seemed very businesslike when telling us about Mom’s death, like
he was talking about whose turn it was to take out the trash. Looking back I
guess he didn’t know what to do. He had three sons and two were teenagers.
He remarried a year after Mom died. I guess it was his thinking that it was
important to continue with life. Perhaps he even thought that my stepmom
would care for us and that would be like he was caring for us. I was very con-
fused and felt very lonely. Mom’s stuff, the furniture she liked, even the sofa
where she used to watch TV with us were taken out of the house when I was
at school. It was almost as if she never existed. It was like, like, as if that was
his way of saying that life goes on and that it didn’t pay to live in the past.
Ten years later I felt “stuck” in college. I thought maybe it was the subject,
you know, like math and business. I went for job counseling and they sent me to
the counseling center for therapy. I didn’t understand why. Therapy was about
grieving for myself, my mom, and the family. After about a month, when I kept
saying I didn’t remember much, my therapist told me to check with other fam-
ily members. My father said to put it away and move on. My brothers said they
didn’t remember much either. They said they would write me from where they
lived (out of town), but they never did. I wanted to understand all about my
mother’s death and what I went through. I connected with my aunt (my mother’s
sister), who we saw infrequently. She had helped out at our house too when
Mom was sick. She helped me recall events from when Mom was sick. Turns
out I remembered more than I thought I did, and it started coming back to me.
There was a lot. I remembered the afternoon about a month before she died,
when she was going to go on “vacation” again. We all were going to a picnic in
the park in the spring. My brothers were kicking a ball and my mother, who
broke her leg, was in a wheelchair and her sister was pushing. She looked so old
and tired. But I was ashamed of her. I didn’t want any of my friends to see her or
know that she was my mom. I wanted to disappear so I walked far behind, all by
myself. I didn’t come close so as not to be part of “them.” My dad was at work.
He was never there. Remembering it felt like it was happening again. This was
hard. I felt like crying when I remembered it. My therapist helped me see how
angry and how scared I was. I felt so bad. I felt so guilty—her own son running
away from her ’cause she looked so sick, she looked really scary. I cried (pause)
8 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

[tearing up], I hated my mom for not being like the other mothers. And I felt
like she thought it was better not to talk about it. And my dad, too. You know it
destroyed the family. Yeah. My brothers moved away as soon as they hit college
age. Before that, they were always “out” doing stuff. I was alone. My father’s
marrying again—didn’t help you know. We never took to her. She knew it too.
My stepmother is always reminding my dad what a wonderful woman she
is, taking on three kids that were not her own. Boys too. Sometimes, it felt,
and this is crazy, but it felt, like, like my mom had gotten back at us, you know,
for not caring enough that she had died. I had to work on some of this stuff. I
eventually went to her grave to ask for her forgiveness. I thought she was OK
with it too. I also had to work on forgiving myself, which is harder, and my
dad, which is even harder. I thought about how “grave”—funny word, huh—
how serious her condition had been, and how courageous she was. I mean she
knew she didn’t have much time left. She did her best to continue with routine
life in order to spare us suffering. She was of German descent, not the kind
of person to talk about feelings very much. I think talking and remembering
helped me to reach some resolution. Both with my mother and myself. My life
changed you know. I left math and decided to study social work. I stopped
being so resentful of Dad’s wife. I mean I confronted him for not talking with
us or explaining Mom’s condition. He said, that was his way, and maybe it was
wrong, but that is his way. I know he cares. But all those years, he never calls
her “my wife” or “your mother” but calls her by her first name, Paula. He still
thinks about her, I know he does. Looking back, the most unbearable part
for me was lack of communication and lack of information. I felt stuck and
dammed up for many years, like I was waiting for something to change, and
nothing did. Then finally, it did. Like everything was in black and white as in
the old movies, and now, after a year of talking about all this, like the color
was back in. Not everywhere, but in most places. Like I got my mother back.
And even my father and his wife, like she is scared of life too. Afraid that after
all she did for us, that we don’t care about her. She ain’t Mom, but she did the
best she could. And maybe that is worth keeping in mind. We all do the best
we can. And that is all that we can do. My mom used to tell us that about try-
ing our best in sports and school and not worrying about how it turns out. I
guess she knew something important. Like that tombstone in Jerusalem that
says, “We do what we gotta do and then we go,”* but it isn’t what we gotta do,
it’s what we can do.
The words of Joe convey a lot in a very short space. Condensed in this nar-
rative is a story of coping with illness and impending death. There is informa-
tion about the importance of communication and about potential risks to some
coping styles and family communication styles. The handling of impending death
and the way loss is handled afterward have the potential to affect the bereaved
for years to come. And revisiting and reconnecting with the emotions, memories,
and thoughts surrounding the death and its aftermath can have powerful and life-
changing effects as well. Making sense out of loss and its impact is a task for each
human individual and each human society.
The story of Joe presents a picture of response to loss that does not allow for
open expression of the grief or the feelings, thoughts, and questions that the death

* John Shortlidge’s (1928–1986) tombstone epitaph in the Protestant Cemetery in Jerusalem.

 LOVE—AND LOSS—AND LIFE 9

of a parent or family member triggers. The importance of resuming life following

loss is something that all cultures address in their culture-specific ways, as we see
later in the book (Grisaru, Malkinson, & Witztum, 2008; Rubin & Yasien-Esmael,
2004). There are times, however, when the rush to return to life exacts a toll and
interferes with the very goal that is aimed for. In the case of Joe, the situation is one
that reflects what Bowlby (1980) describes as the response to loss for an adolescent
and his family when conditions are not optimal. The attempt by all the family mem-
bers of Joe’s nuclear family to avoid the impeding loss and its impact upon their
lives results here in a constriction of life, love, and familial bonds. Returning to the
story of the loss of his mother and engaging with the memories and experiences of
the loss and its impact allow Joe to grieve for his mother and open up Joe to being
able to accept himself, his mother, father, and stepmother. Actual stories and case
reports in the literature embodying the features in Joe’s narrative are by no means
rare in the field of bereavement and loss. Finding the right balance of engagement
and distance from the experience of loss is a daunting task. Nonetheless, avoiding
dealing with the experience altogether is, as many in the field would assert, a par-
ticularly perilous route to take in the attempt to continue with life.
In recent years, the importance of recognizing “resilience” and resilient
responses following loss has reentered the discussion on the impact of bereave-
ment (Bonanno, 2009). Depending on one’s perspective, it would be quite possible
to think about and classify Joe (especially in the eyes of other family members) as
the one person in his family who eventually is unable to adequately deal with the
death of his mother. At the same time, all the other family members might be clas-
sified as responding adequately and without difficulty to life after the loss—as one
might expect from “resilient persons.” Many clinical as well as research paradigms
following outcome to loss for as long as 5 years after a death would also miss Joe,
unless some areas of his academic, social, emotional, or biological behavior sug-
gested difficulty and dysfunction. And that would be unfortunate.
As we shall demonstrate repeatedly throughout this volume, addressing
bereavement response and aftermath without particular attention to the nature of
the organization of thoughts, memories, and feelings associated with the deceased
is to risk missing one of the most fundamental features of interpersonal loss.
Bereavement from a psychological point of view is not only how we live and func-
tion after loss from the view of the individual survivor’s ability to navigate and
function in the world; bereavement is equally about how we reorganize the rela-
tionship to someone important to us who is no longer living. Because that person’s
existence was important to our psychological well-being (in the present as well
as in the past), there is a need to strike a balance between letting go of what can
no longer occur, for example, the physical interaction involved in spouses’ sexual
intimacy, and the maintenance of the sense of significance and value that spouses
communicate to each other and which is not dependent on live interaction.
To better understand some of the ferment in the field of bereavement research
and intervention today, we believe it necessary to thread one’s way through a jungle
of ideas, data, and perspectives to come through the experience safely. To do so,
we shall attempt to balance the wisdom and passion of the clinician perspective
with the rigor and skepticism of the research scientist so as to integrate the thick
10 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

and rich narrative of the consulting room with the cool objectivity of the research
center. To do so, we continue with a discussion of loss and grief in the situation
where the bereaved allow themselves a painful but less defended journey through
the experience than that described by Joe.
When confronted with the loss of a loved one, one’s shock and a sense of disbe-
lief may delay the earliest awareness of the event. When the shock wears off, how-
ever, the more prominent emotions experienced may be a powerful mix of anxiety,
depression, anger, helplessness, and guilt (Siggins, 1966). There are alternative
theories as to what these emotions express (Bowlby, 1980; Furst, 1967). Perhaps at
a minimum, it may be said that they all reflect the response to the inability of the
bereaved to protect either the self or one’s close relations from the realities of death
and that, following death, it is not even possible to maintain the pre-loss bond to
those we love. Our inability to control fate, together with the permanent severance
of contact with a loved one, attacks simultaneously two foundations of human striv-
ings: the wish to be with one’s significant relations and the wish to be able to affect
and influence one’s surroundings (Bibring, 1953). Deprived of those we love, and
deprived of the ability to affect the world we live in, it is no wonder that the loss
of a loved one is so devastating in its impact (Janoff-Bulman, 1992; Parkes, 1975;
Parkes & Prigerson 2010; Raphael, 1983).
As a result of the dislocation produced by loss, the bereaved is immersed in
emotional crises. The routine of life has been dislocated. At the most basic physi-
ological level, somatic homeostasis has been upset. Sleep difficulties, eating dis-
turbances, and difficulties with concentration and thinking often emerge. These
responses may be so pronounced so as to lead to excessive use of medications—
physician prescribed or other wise—to allay the pain and anxiety that sweep over
the bereaved. While somatic routine is so disrupted, the social network is being
disrupted as well. In spousal loss, for example, the partners may fill functions for
each other and connect each other to different social circles and support networks.
As a result of loss, however, these networks and relationships may be disrupted and
the comforting elements of the relationships involved may be lost or withdrawn.
Even when the relationships remain in place, the bereaved may limit their ben-
eficial and comforting impact by pushing those relationships away. Interpersonal
ties may seem virtually meaningless for the bereaved. The prism through which
a bereaved views him- or herself and the world is characterized by a fundamental
bias: that there is no value to a life without the deceased who was so loved.
How deeply, for how long, and in what ways the response to loss should mani-
fest itself are indeed the fundamental questions of the bereavement literature.
Taking a broader view of bereavement outcome, the observation of change and
continuity following loss involves much. For it is also the manner in which the
bereaved remembers, internalizes, and maintains continued psychological involve-
ment with the deceased that is central to bereavement outcome. People remember,
imagine, accompany, and separate from their loved ones in their internal psycho-
logical world in ways that mirror the nature of how ongoing relationships to liv-
ing people are represented and maintained in the psychological world. At levels
of conscious and unconscious psychological organization, every individual has a
complete set of mental representations associated with significant people (Orbach,
 LOVE—AND LOSS—AND LIFE 11

1995). The loss of a relative destabilizes the memories and feelings regarding
the deceased and their meaning for the bereaved. As time passes, there will be
changes in what is remembered and experienced, but these features will remain at
the core of bereavement. We shall return to the importance of the relationship to
the deceased, involving the memories, thoughts, and feelings associated with him
or her, throughout this volume (Bowlby, 1980; Klass, Silverman, & Nickman, 1996;
Malkinson, Rubin, & Witztum, 2000).

The case of Joe illustrates coping styles of avoidance of emotion in a family

and contrasts it with a more open dialogue.
Resilience is not equivalent to an absence of difficulties. It also implies a
way of retaining an emotional relationship to the deceased.
How deeply, for how long, and in what ways should one respond to loss
are the fundamental questions of the bereavement literature.

THE CONTRIBUTIONS OF FREUD,

LINDEMANN, AND BOWLBY
The theoretical and clinical insights of three psychiatrists have been seminal and
continue to influence our current thinking regarding loss and bereavement. The
work of Sigmund Freud, Eric Lindemann, and John Bowlby stimulated much of
what later was to evolve in this field.

Sigmund Freud (1856–1939)

Surprisingly much of clinical literature has involved a connection to the impact of
loss. This often did not occur in a premeditated fashion but reflected the realities of
clinical practice. The fascinating story of Bertha Pappenheim, known as Anna O.,
stimulated some of the earliest understandings of unconscious processes. This case
revolved around Josef Breuer’s treatment of a woman who suffered from symp-
toms of “hysterical neurosis” in response to the progressive illness and death of her
father (Breuer & Freud, 1895/1955). Much has been learned since then, and much
of what was accepted as true, even for psychoanalysis, has changed in the ensu-
ing decades (Mitchell & Black, 1995). Nonetheless, the validity of the idea that
how people respond to the emotions and experiences surrounding loss has signifi-
cant and powerful implications for their health and psychological functioning has
remained axiomatic and empirically validated. Furthermore, today, as in the past,
the bereaved’s narration of her or his experience of the events and accompanying
emotions surrounding traumatic events is deemed important. For many clinicians,
irrespective of theoretical orientation, the telling of the trauma story to others
and to oneself is understood as being one of the most critical therapeutic axes to
recovery and integration (Herman, 1992). This narration is a cornerstone of much
of psychological diagnosis and treatment in general, and more so of the treatment
of the bereaved in particular (Langs, 1976; Schafer, 1992; Spence, 1982).
12 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

In “Mourning and Melancholia” (1917/1957), Freud reported on the essence

of the bereavement process and compared it to clinical depressions (major affec-
tive disorder). A penetrating observer of the human condition, Freud focused
on the emotions felt by bereaved persons. The emotions of loss included pain-
ful depression; a dramatic drop in interest in matters associated with others
and the outside world; loss of the ability to love; and a lack of interest in things
that do not relate to the deceased. The bereaved is virtually totally absorbed in
mourning the loss. Freud stressed that this process had a clearly defined goal.
Going beyond the description of the clinical condition, Freud postulated that
the aim of the response to bereavement was one that would free the bereaved
from his or her previous commitment to the relationship with the person who
had died. Thus he presented the psychological processes of grief and mourning
as part of an adjustment and healing process following loss. When the goal of
relinquishing the commitment to the deceased was accomplished, the bereaved
would have completed the mourning process and would be free to invest anew
in relationships with others.
In the “work of mourning” (in recent years, this has been referred to as the
grief work hypothesis), Freud describes how the bereaved vividly recalls and
relives memories and associations regarding the deceased during the psycho-
logical mourning for that person. Part of the overwhelming focus on the person
who is dead, a “working through” of the implications of the loss is understood
as a process taking time. The bereaved remi nisces and emotionally connects
to memories and experiences involving the one who has died as a milestone on
the path to dismantling involvement with him or her. The bereaved gradually
absorbs the finality of the death. This awareness combines with recognition that
the deceased can no longer supply basic life needs in the real world. Successful
completion of the mourning or grief process allows the living person freedom
from bonds to the deceased and heralds a letting go of the connection. At its
terminus, the bereaved will have reclaimed the necessary emotional energy
(libidinal energy) that will allow for investment of this emotional capital in new
relationships.
Tracing the history of the bereavement field, we can appreciate that a num-
ber of Freud’s ideas were accepted by the majority of those working in the area.
Among the ideas receiving wide acceptance are the following:

1. Bereavement is a form of emotional absorption or working through of loss

characterized by components of an intrapersonal (intrapsychic) process
occurring within the persona of the bereaved.
2. The recognition and acceptance of the finality of loss is one goal of the
loss process.
3. Accepting the unrelenting permanence of loss generally follows an emo-
tionally painful process, which requires time for its impact to be fully
appreciated.
4. There are both conscious and unconscious aspects to the mourning
process.
 LOVE—AND LOSS—AND LIFE 13

5. Appreciation of the way in which the deceased is represented and orga-

nized in human experience involves a complex combination of memories,
emotions, and experience, which deserves our attention in any consider-
ation of the process and outcome of loss.

Freud’s contribution to the study of loss was an important one. Yet the extent
of Freud’s influence was such that the understanding of his work also had negative
implications for theory and practice. Freud’s stature served to hamper the empirical
investigation of his clinical insights and too often resulted in undue veneration of
his texts within the psychoanalytic tradition. Some have asserted that his work was
interpreted at variance with his intent (Siggins, 1966). For example, the view that
successful adjustment to loss resulted in a total emancipation from the deceased and
a full acceptance of the irreversibility of the loss held sway for quite some time. This
view led some to exclude children from the ability to accept loss and led others to see
any continuing emotional involvement with the bereaved as a maladaptive response
to loss (Wolfenstein, 1969). We have irrefutable proof that Freud himself understood
an ongoing involvement with memories of the deceased as a natural and even desir-
able feature that existed alongside and after the mourning process. This attitude is
powerfully addressed in his letter to his colleague, Ludwig Binswanger, who had
recently lost his child which prompted the following response from Freud:
April 12, 1929
My daughter who died would have been thirty-six years old today … Although
we know that after such a loss the acute state of mourning will subside, we
also know we shall remain inconsolable and will never find a substitute. No
matter what may fill the gap, even if it be filled completely, it nevertheless
remains something else. And actually this is how it should be. It is the only way
of perpetuating that love which we do not want to relinquish. (E. L. Freud,
1961, p. 386)

Although the psychoanalytic paradigm was predominant well into the 1960s,
the specific attention to bereavement within that conceptual framework received
relatively little attention. Too often, the psychodynamic literature addressed loss
in the context of discussions on depression, its contribution to psychopathology,
and the significance of child development for later coping with loss (Bibring, 1953;
Fenichel, 1945; Klein, 1940). The importance of attention to the impact of bereave-
ment in its own right, as a significant branch of clinical and theoretical interest,
continued to suffer from neglect.

Freud’s 1917 description of the psychological mourning process emphasized

the decathexis, or withdrawal of libidinal energy, from the deceased so it
could be invested in a new relationship.
This formulation has unduly influenced the professional mental health
field and has stressed a severance of connection to the deceased.
Freud correctly emphasized the significance of the relationship between
the bereaved and the deceased.
14 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

ERIC LINDEMANN (1900–1974)

At the same time that psychodynamic and psychoanalytic psychiatry focused on
the internal psychological struggles occurring deep within the psyche, clinical
psychiatry was beginning the investigation of bereavement from an empirical
point of view. Particularly influential was Eric Lindemann’s article on the symp-
toms accompanying acute grief and how to focus clinical intervention in response
(Lindemann, 1944). Lindemann was born in Germany and studied medicine,
neurology, and psychology there before immigrating to the United States in 1927
(Caplan, 1975). While a psychiatrist at Massachusetts General Hospital and at
Harvard Medical School, he translated his experience as a practicing psychia-
trist to the observation and understanding of the impact of various bereavements.
Responding to the horrible aftermath of the Boston nightclub fire at the Coconut
Grove establishment, he was exposed to a group of individuals who had been
suddenly and traumatically bereaved. Thus he based much of his work with this
population on clinical experience and was assisted, but not restricted, by theory.
His paper, “Symptomology and Management of Acute Grief,” described a group
of 101 bereaved individuals to assemble a descriptive ordering of responses to loss.
Working with observation, diagnosis, and clinical acumen, he reported on a syn-
drome of responses that accompany the initial reactions to sudden loss. Having
worked with a relatively large group of bereaved people, and because the work
was closely tied to empirical phenomena, his writing was utilized by a range of
disciplines and theoretical approaches.
Lindemann’s description of the acute response to the loss included atten-
tion to the following: the sense of unreality; the focus on the imagery of the
deceased; difficulties in interpersonal relationships; somatic difficult ies (such as
appetite change), tension, and restlessness; emotional responses, including guilt,
aggression, and impatience with others; and a general loss of functioning in areas
where previously the bereaved had functioned. Among some of the bereaved in
his sample, a number of these responses were extreme and overwhelming.
As others who came before and who were to come after him, Lindemann
returned to stress the concept of the “work” in grief. This included the importance
of freeing oneself from an overly strong link to the deceased, renegotiating adapta-
tion to the life environment, and the formation of new interpersonal relationships.
Lindemann described difficulties in post-loss adjustment, and proposed that short-
term interventions of 8 to 10 sessions could be sufficient during the initial acute
grief period. The grief period was defined as lasting in the range of 4 to 6 weeks.
Over the years, Lindemann’s focal attention to this period within the response to
loss, along with a paradigm for intervention, proved central to what became known
as crisis theory (Parad, 1966).

Lindemann’s landmark studies and empirical work helped bring the field of
loss and bereavement into the modern era.
He focused on traumatic grief and on short-term interventions.
 LOVE—AND LOSS—AND LIFE 15

John Bowlby (1907–1990)

Undoubtedly, the individual whose body of work significantly and systemati-
cally transformed the field of loss was John Bowlby. The British-born psycho-
analyst Bowlby developed attachment theory as a developmental and emotional
structure for understanding the developing individual and the individual’s
management of interpersonal relationships across the life cycle. Relationships
and relationship styles were understood to reflect aspects of behavior in inter-
personal relationships as well as tendencies to psychological organization of
experience within the individual. With a matrix for thinking about the nature
of relationships within the individual, the theoretical framework for under-
standing the individual’s response to the death of another was given a solid
footing and rooted firmly in the tapestry of the individual’s interpersonal
relationships.
Succinctly stated, some highlights of this perspective are useful. Starting from
the crucial importance of the mother–child bond for the individual child’s devel-
opment, Bowlby went on to a comprehensive theory emphasizing both intrapsychic
and interpersonal relationships (Bowlby, 1969, 1973, 1980). In this theory, Bowlby
postulated that people have a need, most apparent in times of danger or stress, to
be close to the important attachment figure. As the maturation process unfolds,
however, the same proximity function is achieved by connecting to the inner men-
tal representation of significant others who serve as attachment supports. These
characteristics are central and integral to the development and function of the
individual throughout life.
For the same reasons that the psychological experience and organization of
relationships are central to the individual’s physical and psychological well-being,
the threat to these relationships take on cardinal importance. A threat to close-
ness in childhood, such as an actual separation of some duration, triggers what
is commonly referred to as separation anxiety. The individual will try to reduce
this harbinger of danger by attempting to rejoin the significant other. As people
mature, much of this tendency to regain closeness escapes awareness and func-
tions from within the psyche as an unconscious dynamic. Only a small part of this
generally emerges as interpersonal behavior and interaction, although psychologi-
cal experiments have been devised to demonstrate this very process in adulthood
(Mikulincer & Shaver, 2007, p. 20). Across the life cycle, a portion of the need to
seek safety by proximity to secure attachment figures will remain as the wish to
regain closeness to the significant figures of childhood and their later counterparts
in some mixture of symbolic and literal fashion (Cassidy & Shaver, 1999; J. Sandler
& Sandler, 1978; Stierlin, 1970).
Bowlby, Ainsworth, and virtually all of the developmentalists and clini-
cians working with attachment theory have identified and characterized a vari-
ety of attachment styles that characterize persons (Mikulincer & Shaver, 2007;
Oppenheim & Goldsmith, 2007). While all persons form attachments and those
attachments are central to people’s physical and psychological well-being, the
organization of those styles varies. In addition to the adaptive “secure” attach-
ment style, there are insecure attachment forms, namely, anxious-ambivalent and
16 WORKING WITH THE BEREAVED: MULTIPLE LENSES ON LOSS AND MOURNING

avoidant attachment styles, which function to deny, dismiss, or otherwise minimize

the free-flowing attachment to significant others.
In situations of loss and death, there is a convergence of the wish to be close to
the person in the flesh and the wish to become close to the mental representations
associated with him or her. When death occurs, a set of responses is set in motion
that seems well designed to bring about a physical reunion with that significant
other in many of the normal situations where that significant person had been alive
and accessible. When it becomes clearer to the bereaved that there is no avenue
by which to change the situation and connect to the deceased, the import of loss
is apprehended. A collapse of the defenses against this sad reality, and an inability
to resist the disorganization that often follows, results in depression. The sense of
helplessness is also tied up with the realization that one is powerless to return the
deceased. Arising from the ashes of this powerlessness is a reorganization of how
one will live after loss. With the recognition and a degree of acceptance that death
has irreversibly claimed the significant other, the change demanded by that reality
can be undertaken.
The humanity, rigor, scope, and firm connection to human experience were cen-
tral to Bowlby’s written work. Bowlby succeeded in translating and transforming the
rich complexity of psychoanalysis into a new and understandable framework with
many opportunities for empirical study. By avoiding many of the pitfalls of metapsy-
chology (J. Sandler, Dare, & Holder, 1972), Bowlby combined empirical, ethological,
intrapsychic, and interpersonal approaches to emphasize the following: (a) the impor-
tance of actual as well as psychologically accessible relationships within the person
for the development and functioning of the individual across the life cycle, and (b)
threats to the connection with significant others of the inner and outer worlds of the
individual, which are triggered by significant separations in general and by death in
particular. In the case of death, the threat triggers the loss response.
Together with Colin Murray Parkes, a major figure in his own right, Bowlby
(1980) conceptualized the loss process as traversing a set of four recognizable
stages: (1) shock and numbing when the individual is struggling to make sense of
the fact of the loss; (2) the search for reunion with the deceased and being attuned
to reminders of him or her; (3) disorganization expressed in the erosion or collapse
of previous ways of being with the self and the other; and (4) a reorganization of
one’s inner and outer life, to some extent, which allows the bereaved a way to live
adaptively with the changed realities of life. These stages are not meant to be taken
as a linear series of stations or a universal blueprint for the successful management
of the bereavement response. The move away from stage theory is strong but by
no means complete (Holland & Neimeyer, 2010; Maciejewski, Zhang, Block, &
Prigerson, 2007).
We suggest using the “stages” of bereavement as representative heuristic con-
structions that highlight individual aspects of the response to loss. Ultimately, there
is a great deal of overlap and fluctuation in how the bereaved responds to loss. The
stages set forth here structure and assist in the narration of the distribution of
various elements in the response to loss. The relative proportions and weighting of
the features of each of the stages generally shift over time. The value of attention
to them, however, is constant. Recognizing the wide variation among individuals
 LOVE—AND LOSS—AND LIFE 17

in their responses to loss while also recognizing the limitations of stage theories of
human behavior is important for theoreticians and clinicians alike.
Freud, Lindemann, and Bowlby are three clinicians whose writings related
to loss and bereavement remain relevant and seminal to much of what modern
clinicians and researchers are working on today. This is not to say that their con-
tributions are universally accepted as valid and supported by current research.
Sometimes the exact opposite is true. Current research and thinking may stand
in opposition to the work of Freud, Lindemann, and Bowlby. At the very least,
we can recognize the gaps between the tools and information available to experts
today and that which was available to them in their respective generations. Yet
even when these gaps are evident, the writings of these pioneers provide stimula-
tion and a focus for our evolving understanding of the field in ways that continue to
benefit from their place in the intellectual and clinical history of our field.

Bowlby’s work on attachment and loss continued the significance of the rela-
tionship to the deceased for normal development and for bereavement.
Bowlby and Parkes’s stage theory of bereavement was influential and
described stages of shock and numbing, searching, disorganization, and
reorganization.
Contemporary theory is assisted by the phenomena described in stage
theories but has moved sharply away from the implication that people prog-
ress through stages in bereavement.

CONCLUDING REMARKS
In this opening chapter, we have invited the reader to look to the human experien-
tial encounter with loss and bereavement as well as history relevant to the evolu-
tion of the field. The interpersonal interconnectedness of the human encounter
underlies the significance of bereavement and is central to its full appreciation.
This will emerge in greater detail and with clinical relevance as we proceed. We
now turn to a number of important issues that preoccupy many working in the field
from both clinical and research perspectives.
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