Australian and New Zealand Journal of Psychiatry http://anp.sagepub.

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An International Perspective on Bereavement Related Concepts

Warwick Middleton, Ann Moylan, Beverley Raphael, Paul Burnett and Nada Martinek Aust N Z J Psychiatry 1993 27: 457 DOI: 10.3109/00048679309075803 The online version of this article can be found at: http://anp.sagepub.com/content/27/3/457

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AN INTERNATIONAL PERSPECTIVE ON BEREAVEMENT RELATED CONCEPTS

Warwick Middleton, Ann Moylan, Beverley Raphael, Paul Burnett, Nada Martinek

This paper reports on part of a study which was aimed at assessing the views of leading researchers, theorists or clinicians working in the field of bereavement on key issues including, as reported here, concepts of different forms of grief as well as favoured theoretical orientations. Of a range of conceptual models the most favoured, by a large margin, were attachment theory and the psychodynamic model. The views of the experts were canvassed with respect to the use of seven selectedterms usedto denote some variant of the grieving process. There was, on the part of the respondents, reasonable support for the syndromes of delayed, chronic, anticipatory and absent grief. Inhibited and unresolved grief tended to be described using one of the four terms already supported, while the use of the term distorted grief attracted little support. Australian and New Zealand Journal of Psychiatry 1993; 27:457-463
The number of papers published in the area of bereavement is vast and the literature is growing exponentially. Yet there is the disconcerting observation voiced by a number of writers that even apparently basic areas lack consensus. Differing theoretical viewpoints superimposed on the literature highlight the lack of agreement on what constitutes normal grief. Consideration of abnormal forms of grief reveals a plethora of descriptive terms used to denote some variation from norma1grief. Some terms have a long history and are derived from a theoretical construct. Others lack definition and are used as little more than alternative adjectives. The fact that such terms are
Royal Brisbane Hospital, Herston, Queensland Warwick Middleton FRANZCP, Deputy Director of Psychiatry Ann Moylan RN, MCP Beverley Raphael MD, FRANZCP, Professor Paul Burnett M Ed St, Dip App Psych, PhD, MAPsS Nada Martinek RN Correspond with Dr Middleton

constantly being added to the literature may mean that workers are opting for new labels to avoid theoretical controversies or uncertainties surrounding the use of previously used terms. A modest sampling of terms used to denote some variation from normal grief includes: absent [ 11, abnormal [ 2 ] ,complicated [3], distorted [4], morbid [ 5 ] , maladaptive [6], truncated [7], atypical [8], intensified [9l, unresolved [ 101, neurotic [ 1 I], dysfunctional [ 121, chronic [ 131, inhibited 1131, and delayed [ 131. Much is written in the bereavement area without defining the theoretical basis from which it is viewed. On the other hand there is criticism of the lack of agreed definitions, or operationalised criteria for key syndromes. For example, Jacobs and Kim [ 141 point to the absence of universally accepted standardised, descriptive criteria for pathologic grief (p. 3 15). Although grief related syndromes are not singled out as distinct clinical entities in commonly used systems of psychiatric nosology, the various forms of abnormal grief and their possible associations with defined

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INTERNATIONAL PERSEPCTIVE ON BEREAVEMENT RELATED CONCEPTS

psychiatric disorders make their definition important both from a defined treatment and a medico-legal perspective. In an attempt to canvas representative opinion on a number of bereavement related themes, a questionnaire was devised to seek opinions on a wide range of issues. Open ended and closed questions eliciting responses that could be rated or categorised were included. The objectives of the questionnaire included: a) gaining a perspective on the degree of acceptance workers in the field have for commonly used terminology applied to the description of atypical forms of grief; and b) identifying the key theoretical constructs applied by such workers to the field of bereavement. This paper reports on the investigation of the key theoretical constructs used by respondents and an analysis of respondents opinions concerning selected syndromal entities of atypical forms of grief that had each achieved fairly wide usage. This investigation provides insights into the theoretical positions of those working in the bereavement field. It also highlights the issue that communication within the field is hampered by the lack of operationalised criteria for syndromes, and the lack of agreed meaning for even commonly used terms.

A questionnaire was devised which sought responses to a number of open-ended categorical questions. Respondents were asked to indicate the nature and duration of their involvement in the bereavement area, their qualifications and whether they had special areas of interest within the field of bereavement. Additional questions covered respondents views of normal and pathological grief, and other bereavement related phenomena, as well as eliciting views on the entities absent grief, delayed grief, chronic grief , distorted grief ,unresolved grief, inhibited grief and anticipatory grief. With respect to each of these seven entities, chosen as those appearing most frequently in the literature, respondents were asked whether or not they thought it occurred, and if it did occur what its characteristics and distinguishing features were. Subjects were asked to rate in order of importance to them conceptual models that they found useful. They had the opportunity to rank the following models: psychodynamic, attachment theory, be-

havioural, cognitive, neurophysiological, sociological and ethological, and as well could specify and rank some alternative model. The questionnaire was distributed to 155 people. They were identified from two main sources: (a) those presenting at the 2nd International Meeting of Grief and Bereavement held in London in June 1988, who indicated long term clinical andlor research involvement in the field, and (b) those identified from the scientific literature as having published in the field or having contributed a major clinical or theoretical work. Between June 1988 and July 1990,77 returned completed or partially completed questionnaires, one of which had very little information. Another 8 wrote giving their reasons for not attempting the questionnaire, the most common one being that despite being associated with publications in the field their involvement was not primarily with bereavement itself and they thus disqualified themselves. Two questionnaires were returned as the addressees had recently become deceased. Of those who responded, 89% had 5 or more years experience in the bereavement field and 63% had in excess of 10 years experience. Of the 77 responders, 38 came from U.S.A., 14 from the United Kingdom, I 1 from Australia, 3 from Israel and Canada respectively, 2 from South Africa and the rest from other countries. By profession, 26 were adult psychiatrists and 6 were child psychiatrists, 17 were psychologists, 6 were non-psychiatrist doctors, 6 were sociologists, 4 were social workers and 4 were counsellors not otherwise specified. The remainder included a psychoanalyst, an epidemiologist, a member of the funeral industry and 5 not otherwise specified. While the respondents were to some degree a self selected group there was no reason to believe that they were not a reasonably representative group of those writing about bereavement or working in the area. Of the 155 potential responders 85 made some reply and within this group there were many who have made important contributions to the literature. Most who filled in the questionnaire were positive about the project while a few expressed criticisms either in response to the wording of particular questions or to express a view consistent with the belief that the issues being questioned had long since been sorted out. Given the fact that most of the data being sought was in the nature of opinion which would be inappropriately restricted if addressed solely from a categorical

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W.MIDDLETON, AMOYLAN, B.RAPHAEL, P.BURNETT, N.MARTINEK

459

Table I . Individual syndromes. Responses to the question: Does this occur?

~~ _ _ . _ _

Absent grief n Responses Yes No

50 9 6 12

Delayed grief n
%

Inhibited grief n
41 9 11 16
%

Chronic grief n
57 5 1 14
%

Distorted grief n
28 8 18 23
%

Unresolved Anticipatory grief grief n

44 5 7 21
%

n
55 5 4 13

Dont know
Not answered
I

64.9 59 11.7 3 7.8 4 15.6 11

76.6 3.9 5.2 14.3

53.2 11.7 14.3 20.8

74.0 6.5 1.3 18.2

36.4 10.4 23.4 29.9

57.1 6.5 9.1 27.3

71.4 6.5 5.2 16.9

I

format, open-ended questions were frequently used. Individual responses, of which there might be a number in response to a question, were sorted such that a grouping system was imposed on the data.

Results
Although not the principal focus of this report, there was a general, but not universal, acceptance of the concept of normal grief on the part of the respondents. An ability to grieve openly, to resolve the loss and to move towards resuming the routine activities of daily living with regard to work, social interactions and relationships were commonly identified as part of the processes of normal grief.

psychodynamic and 19 chose attachment. Of the remainder, 4 chose behavioural, 3 chose cognitive and sociological respectively and one person nominated each of the following: family, ecological, cognitive/behavioural, social/psychological and phenomenology.

b)Bereavement related entities

With respect to the seven selected entities, which were those most frequently found in the literature, respondents were asked initially whether or not they considered such syndromes to occur. There were three possible responses to this question. Additionally there was the option of not answering. Those who answered were to either tick YES or NO or to make a comment that they did not know. Tabled below are the responses with respect to the individual syndromes. With respect to each of the seven syndromes, responses to the questions What are its characteristics? and What are its distinguishing features? were broken down into their component statements. It was recognised that some respondents gave answers that included more than one component. It was hoped to show whether or not congruent themes commonly emerged when bereavement workers were given the opportunity to respond to open ended questions regarding syndromes commonly referred to in the literature. Again a number answered by stating they did not know or felt that they were unqualified to answer. The total number of separate identifiable comments that were made in response to asking what were the characteristics and distinguishing features of the seven nominated syndromes are illustrated in Table 3. Some

a) Conceptual models
Subjects were asked, What model/models do you find most useful in conceptualising [bereavement]? Please rate in order of importance those that you find useful. Subjects were provided with seven alternative models (psychodynamic, attachment theory, behavioural, cognitive, neurophysiological, sociological and ethological), and in addition they were given the apportunity to specify other models. Of those 70 subjects (90.9% of respondents) who identified the top 3 models, the rank ordering of the frequency of models being nominated was attachment (75.7%), psychodynamic (65.7%), sociological (34.3%) cognitive (28.6%), behavioural (15.7%), ethological (14.3%) and neurophysiological (1 2.9%); 15.7% specified some other models. Of the 55 subjects who unequivocally nominated the model most useful t o t h e m , 2 1 nominated

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INTERNATIONAL PERSEPCTIVE ON BEREAVEMENT RELATED CONCEPTS

Table 2 . Percentages ofthose not nominating characteristic or distinguishing features (n=76)

-~

Absent grief n Responses Dont know/ unqualified Non responders %

Delayed grief n %

Inhibited grief n %

Chronic grief n

Distorted grief
%

Unresolved Anticipatory grief grief n % n

Y a

V a n

7 9

9.1 11.7

6 14

7.8 18.2

14 14

18.2 18.2

3 18

3.9 23.7

14 28

18.4 36.8

5
19

6.6 25.0

4 18

5.3 23.7

responses included a number of individual comments while others limited themselves to single statements. Where comments are very similar or identical they have been grouped together in order to highlight the congruity of opinion regarding these entities. The responses for each syndrome are listed in order of the frequency with which they were nominated. Only those responses made by more than 6.5% of the subjects are listed. Delayed grief emerged in this survey as being primarily defined by there being an interval of weeks, months or even years between a loss and what would otherwise be described as a typical grief reaction or in some cases a more severe grief reaction. There was support for the concept of the grief being delayed because of situations that did not allow expression at the time of the loss, and for the grief reaction being triggered by some subsequent event. Chronic grief attracted the greatest number of comments. Prominent concepts were to view it as grief that was prolonged or unending and which was either characterised by depression or which closely resembled depressive states. Depressive themes such as guilt, withdrawal or sadness were commonly mentioned and there was emphasis on the nature of the pre-existing and ongoing relationship with the deceased. Psychodynamic issues were raised by comments about such grief being unresolved and there was thought to be an ongoing preoccupation with the lost person who may have been part of what was a dependent relationship. Anticipatory grief there has been considerable debate in the literature over the appropriateness of the use of this term. Rando [ 191 makes the point that the term is a misnomer in that its use implies that one is grieving solely for anticipated as opposed to past and current losses and because use of the word grief

implies the necessity of complete decathexis from the dying person. She also points out the limited potential for acceptance and recovery until loss actually occurs. Despite such caveats, respondents saw anticipatory grief largely in the context of being a normal grief reaction in response to an expected death and which allowed emotional preparation for the loss. It was seen as embodying typical phenomena of normal grief. In defining absent grief, aside from stating the obvious, that there was little or no external sign of grief, there was a lot of comment on the intrapsychic causes of the state with denial, repression or inhibition being frequently mentioned. There were fewer comments offered regarding the remaining three entities and there was limited congruity with regard to the latter two. Inhibited grief was generally seen as being the same as either delayed or absent grief, and unresolved grief was seen as generally similar to chronic or inhibited grief. There were a limited number of responses regarding distorted grief, and no clearly defined theme other than that it was associated with excessive or extreme emotions or other phenomena.

Discussion
Approximately 50% of those contacted or approached returned questionnaires and a further 5% responded but did not return questionnaires, while approximately 45% made no response. The level of involvement in bereavement research and/or related clinical activity on the part of those who responded was judged as being similar to that of the group of non-responders. The results with respect to preferred conceptual models indicated that attachment and psychodynamic

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W. MIDDLETON, A. MOYLAN. B .RAPHAEL, P.B URNETT, N.MARTINEK

46 I

Table 3 . Total number of separate identifiable comments that were made in response to asking what were the characteristics and distinguishing features of the seven nominated syndromes

Percentage of the 76 subjects a) Absent grief (total responses = 122) Inhibition of/absence of the typical expression of grief Continue to act as if nothing has happened Denial of loss or feelings related to the loss Show no external signs of grieving Absent grief is not a nosological entity Flat/shallow/overly restrained emotion Absence of appropriate emotion b) Delayed grief (total responses = 121) Typical grief - just delayed Grief delayed months or years Grief subsequently triggered by some event May be severe Grief delayed weeks The interval between loss and the beginning of grief c) Inhibited grief (total responses = 107) Cannot fully talk about, acknowledge or express the loss Inability to cry Same as delayed Same as absent Social/cultural/learnt restraint on expression of grief d) Chronic grief (total responses = 191) Depression/like chronic depression Prolonged/unending/unchanging/stuck unending distress or Guiltiself reproach Sadness, marked sadness Withdrawn, socially inhibited Preoccupation with lost person who is irreplaceable Dependency Continued manifestations of acute grief GriefAoss remains unresolved/unreconciled e) Distorted grief (total responses = 70) Excessive anger
f) Unresolved grief (total responses = 85) Is the same as chronic grief Lack of resolving major grief symptoms

18.4 13.2 13.2 11.7 10.4 9.2 6.6

18.4 14.5 13.2 9.2 9.2 7.9 11.8 9.2 7.9 7.9 6.6

25.0 21.1 9.2 9.2 7.9 7.9 7.9 6.6 6.6

6.6
15.8 7.9

g) Anticipatory grief (total responses = 140) A normal grief reaction which occurs prior to the actual loss Constitutes thoughtdfeelings about a death which might occur Sadnessfsorrow Anger Crying Emotional preparation for a death

15.8 13.2 11.8

6.6 6.6 6.6

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INTERNATIONAL PERSEPCTIVE ON BEREAVEMENT RELATED CONCEPTS

models are by far the most influential, and of the two, attachment theory was rated in the top three by just over 75% of respondents, with the psychodynamic model nominated by over 65%. Such a result is in accord with a literature in which key tenets of attachment theory have been blended with the dominant psychoanalytic theoretical framework of the earlier literature (e.g. Freud [ 151, Lindemann [51). Key psychodynamic concepts frequently referred to in the wider literature include: 1) the work of mourning, by which the mourner over time repeatedly examines aspects of the relationship with the lost person in such a way as to allow for the gradual relinquishment of libidinal bonds to that person; 2) the concept of loss occurring where the pre-existingrelationship had been characterised by ambivalence as being likely to occasion particularly severe grief reactions; and 3) the concept that healthy grief and depression can be distinguished by the absence of guilt, self-reproach and lowered self-esteem in the former, and by their presence in pathological forms of grief. Key concepts such as decathexis, object loss, ambivalently loved objects, pathologicalgrief and the work of mourning etc. are all derived from the psychoanalytictradition. It was an analyst, John Bowlby [16,17,18], who introduced a new dimension to views of bereavement by integrating analytical and ethological theories. Attachment was identified as a behavioural system,common to many species, the function of which was to ensure personal and species preservation. Bowlby demonstrated that bereavement was but one form of separation event from an attachment object. Thus Bowlby saw separation phenomena, particularly anxiety and anger, as part of the reaction to loss, and that when hope was given up for the return of the lost object, sadness, depression and despair would supervene. Attachment theory linked the manifestations of pathological grief to childhood experiences and the pattern of parental attachment behaviour. The seven syndromes selected for comment were linked to long established theory or terminology used in the bereavement literature. For example, the concept of absent grief dates back to Deutsch [l]. Lindemann [ 5 ] discussed delayed grief, and defined morbid grief reactions as distortions of normal grief. Lindemann defined the hitherto unappreciated syndrome of anticipatorygrief in which the patient is so concerned with her adjustment after the potential

death of father or son that she goes through all the phases of grief (p. 147-148). Parkes in 1965 described three principal forms of what had by then become known as pathological grief. These were: chronic grief, denoting an indefinite prolongation of grief with exaggeration of symptoms; inhibited grief in which most symptoms of normal grief were absent; and delayed grief in which the painful emotions were avoided for a time at least. The use of the term unresolved in connection with grief has tended to be descriptive and atheoretical (e.g. Zisook and De Vaul [ 101 defined unresolved grief in an outpatient group who had lost a first degree relative in terms of whether the subjects reported having difficulty dealing with the loss). While lacking the historical pedigree of the other terms, distorted grief was included as a fairly widely used term, in that regard not unlike a number of others found in the literature. Aside from the seven syndromes selected for examination in this survey, some of which might well be expected to overlap to a greater or lesser degree, there have been alternative terms, but their use is less common and they were not assessed in this study. By concentrating on what seemed to be the most prevalent terminology, it was hoped to demonstrate the utility or otherwise of these seven terms. With respect to the question of whether the nominated syndrome occurred, there was marked variation from syndrometo syndrome,both in terms of the percentage who indicated that they did not know or the percentages of those who failed to attempt a written response. The rank ordering of the syndromes in terms of the percentage of responders who thought they occurred is largely supported by the other three possible responses. For example, distortedgrief attracted the lowest percentage nominating it as occumng, as well as the highest percentage who either did not know or who failed to answer. The rank ordering of the degree of support for the syndromes was along the following lines, with the syndromes ranked in order of most support to least support: Delayed, Chronic, Anticipatory, Absent, Unresolved, Inhibited, Distorted. It would appear that the first four syndromes, where the deviation from normal grief was fairly clearly characterised in the term itself, attracted considerably more support than terms which relied on some theoretical explanation in response to the question: What is it about this form of grief that is unresolved/ inhibiteddistorted?

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W.MIDDLETON, A.MOYLAN, B.RAPHAEL, P.BURNEIT, N.MARTINEK

463

With respect to the request to define characteristic and distinguishing features, similar trends emerge. There were more responses offered regarding the first four syndromes and more congruity regarding what was suggested.

References
1. Deutsch H. Absence of grief. Psycho-Analytic Quarterly 1937; 6: 12-22. 2. Pasnau RO, Fawney FI,Fawney N. Role of the physician in bereavement. Psychiatric Clinics of North America 1987; 1 0 109120. 3. Sanders C M. Grief: The mourning after.New York: John Wiley, 1989. 4. Brown J T, Stoudemire G A. Normal and pathological grief. Journal of the American Medical Association 1983; 250:378-382. 5 . Lindemann E. Symptomatology and management of acute grief. American Journal of Psychiatry 1944; 101:141-148. 6. Reeves N C, Boersma F J. The therapeutic use of ritual in maladaptive grieving. Omega 1990; 20:28 1-29 1. 7. Widdison H A, Salisbury H G. The delayed stress syndrome : A pathological delayed grief reaction. Omega 1990; 24:293-306. 8. Jacobs S C, Douglas L. Grief a mediating process between a loss and illness. Comprehensive Psychiatry 1979;. 20: 165-175. . 9. Lieberman P B, Jacobs S C. Bereavement and its compliation in medical patients: A guide for consultation-liaison psychiatrists. International Journal of Psychiatry in Medicine 1987; 17:23-39. 10. Zismk S, De Vaul R A. Unresolved grief. American Journal of Psychoanalysis 1985; 45:370-379. I I. Wahl C W. The differential diagnosis of normal and neurotic grief following bereavement. Archives of the Foundation of Thanatology 1970 1:137-141. 12. Rynearson E K. Pathologic grief: The queens croquet gown. Psychiatric Annals 1990 20295-303. 13. Parkes C M.Bereavement and mental illness. British Medical Journal 1965; 38: 1-26. 14. Jacobs S C, Kim K. Psychiatric complications of bereavement. Psychiatric Annals 1990 20:314-317. 15. Freud S. (19 17) Mourning and melancholia. In: Sigmund Freud: Collected Papers, vol4. London: Hogarth Press, 1957. 16. Bowlby J. Attachment and loss: 1. Attachment. Harmondsworth: Pelican, 1971. 17. Bowlby J. Attachment and Ioss:~.Loss. Harmondsworth: Pelican, 1975. 18. Bowlby J. Attachment and 10x3. Sadness and depression. Harmondsworth: Pelican, 1981. 19. Rando TA. Anticipatory grief the term is a misnomer but the phenomenon exists. Journal of Palliative Care 1988; 4:70-73.

Conclusions
The results suggest that a good deal of the confusion or lack of definition in the literature is reflected in the responses of those involved in the field. The terms examined here have meaning both in the descriptive, adjectival sense as well as implying an underlying theoretical construct. Respondents seemed more comfortable with the descriptive orientation, while the overlap in even widely used terms points to there being considerablepotential redundancy in the bereavement nomenclature and the need to be more rigorous about the way in which terminology is used in research settings. Despite this, there appears to be general support for and agreement about the terms delayed, chronic,anticipatory and absent grief. It is suggested that the commonly accepted criteria identified by these experts be accepted until diagnostic criteria are developed, and that other descriptive terms are avoided because of the significant ambiguity of their meaning - even among experts.

Acknowledgement
This study was funded by a NH&MRC project grant.

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