a behavioral analysis of the grief process

BEHAVIOR THERAPY 15, 529--543 (1984)

REVIEW ARTICLE

A Behavioral Analysis of the Grief Process

WILLIAM S. BRASTED

EDWARD J. CALLAHAN

West Virginia University

Grieving is virtually universal in human experience but has received little at- tention from a behavioral perspective. This paper presents an overview of a behavioral analysis of grieving through integrating experimental phenomena and clinical observations. Experimental phenomena explored are examples from animal literature involving behavior changes akin to human response to loss. Clinical observations are derived from the literature on normal and pathological grieving and from the authors' work with families experiencing perinatal loss. Recom- mendations and concerns for behavior therapists working with grieving individuals are presented.

P e r h a p s the m o s t c o m m o n t r a u m a h u m a n s suffer is the d e a t h o f s o m e - one close. T h e usua l r e s p o n s e to th i s loss is gr iev ing . D e s p i t e i ts f r equen t occur rence , g r i ev ing has on ly r ecen t ly been c o n s i d e r e d in a b e h a v i o r a l m o d e l (Aver i l l & W i s o c k i , 1981; G a u t h i e r & M a r s h a l l , 1977; R a m s a y , 1979; V o l k a n , Ci l lufo , & Sarvey , 1976), w i th m o s t a t t e n t i o n p a i d to p a t h o l o g i c a l grief. T h i s p a p e r p r o v i d e s a b e h a v i o r a l c o n c e p t u a l i z a t i o n o f g r i e f as a n o r m a l even t , v i e w i n g the p s y c h o l o g i s t as a p o t e n t i a l l y effect ive c o n s u l t a n t to t hose e x p e r i e n c i n g g r i e f a n d those des ign ing e n v i r o n m e n t s to fac i l i t a te h e a l t h y gr ieving . Spec ia l effort is m a d e to in t eg ra t e exper i - m e n t a l a n d c l in ica l d a t a in the u n d e r s t a n d i n g o f grief.

G r i e f r e s p o n s e s a re n o t r e l a t ed so le ly to the d e a t h o f a s igni f icant o ther . Essen t i a l to the o c c u r r e n c e o f g r i e f is a s igni f icant loss, e i t he r l i tera l , as in d i v o r c e w h i c h i n v o l v e s the loss o f a spouse , o r s y m b o l i c , as w h e n a w o m a n has a h y s t e r e c t o m y a n d loses he r p o t e n t i a l m a t e r n a l s ta tus . O t h e r sources c o v e r a spec t s o f g r i ev ing in such losses (e.g., Ca l l ahan , Pawl ick i , N icho l a s , & H a m i l t o n , in press; Speck, 1978). T h i s p a p e r wil l focus on

The authors wish to thank Nancy M. Todd and William J. Fremouw for their comments on an earlier version of this paper. Requests for reprints should be sent to Edwara J. Callahan, Department of Psychology, West Virginia University, P.O. Box 6040, Morgantown, WV 26506-6040.

5 2 9 0005-7894/84/0529--054351.00/0 Copyright 1984 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

530 BRASTED A N D C A L L A H A N

losses due to the death of a significant other; adequate discussion of the entire range of loss is beyond its scope.

Grief Defined Bereavement is the "total response pattern, psychological and phys-

iological, displayed by an individual following the loss of a significant object, usually a loved one" (Averill, 1968, p. 721). Grief, then, is only one component of bereavement, and it must be distinguished from mourning, the culturally determined procedure for behaving after loss (see also Graves, 1978). In every culture, various mourning responses (e.g., wearing black, attending wakes) have evolved as socially appropriate. While mourning is intriguing, this paper will focus only on grief, those psychological and physiological responses which appear unrelated to cultural dictates.

In the earliest empirical evaluation of grief, Lindeman (1944) inter- viewed survivors of victims of the Coconut Grove fire in Boston. He found five typical responses in the normal process of grief: (a) somatic distress: deep sighing, lack of strength and appetite, and intermittent loss of breath; Co) guilt: verbal statements indicating a sense of self-blame for the death; (c) anger directed toward others for mentioning cues associated with the death; (d) preoccupation with the image of the deceased: survivors frequently thought they had seen or heard the deceased; and (e) agitated, nongoal directed behavior. Each behavioral component appeared to dis- sipate over highly variable times.

Lindeman's description of grief was based upon clinical observations derived from a limited sample, although subsequent evaluations tend to support his work (Bowlby, 1980; Clayton, 1979; Parkes, 1965). Because of this apparent consistency, numerous theorists have posited stage theories of grief typically consisting of three to five stages through which the bereaved will normally progress. The following discussion of three stage theories will illustrate their commonalities.

Stage Theories Engel's theory (1961, 1974) suggests that the grief process consists of

three stages: (a) denial and shock, a phase in which the griever fails to believe the loss, (b) developing awareness, in which the bereaved discovers the significance of the loss and experiences the psychological and physiological consequences, and (c) resolution, in which the bereaved adapts to the new situation by reestablishing old behavior patterns and developing new relationships and activities. Though these stages may vary in intensity and duration, Engel asserts that they will occur in order.

A second theory (Bowlby & Parkes, 1970) suggests that grieving occurs in four stages. Similar to Engel, Bowlby and Parkes~s first stage, numbness, is marked by shock and lack of acceptance. Howe~er, Bowlby and Parkes split the stage described by Engel as developing awareness into two distinct stages: pining, which involves yearning for and attempting to regain the deceased, and disorganization, involving an acceptance of the loss, de-

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pressed affect, sleep and appetite disturbances, and reduction in goal- directed activity. Finally, the bereaved begins reorganization which is equivalent to Engel's resolution stage.

Kubler-Ross (1970) provides a third stage theory similar to these. Her five stages begin with denial which she describes in the same manner as the previous two theorists. However, she has divided Bowlby and Parkes's (1970) pining stage into two distinct components: rage and anger, and bargaining. In rage and anger, frustration from the loss can be directed at the deceased for having died, at others (such as hospital personnel) for letting the death occur, or at the griever for perceived past injustices to the deceased. Bargaining follows and involves attempts to regain the lost object, the death not being fully accepted. The fourth stage, disorganization, is described in terms similar to Parkes and Bowlby's equivalent stage. Kubler-Ross's final stage, acceptance, is similar to Engel's (1974) resolution, and Bowlby and Parkes's (1970) re-organization stages. Thus, Kubler-Ross's additions focus on cognitive contents not previously em- phasized.

Obviously there is strong similarity in behavior patterns described as the grief process. Though these theorists state that the duration and intensity of stages are highly variable, they also assert that these progressions represent a normal process, and that deviations from the pattern may be pathological. Bugen (l 977) suggests that the variability among individuals' grief responses severely diminishes the utility of stage theories: the stages may not occur in order, an individual's behavior may not change enough that recognizable stages will be discernible, and behaviors associated with certain stages may not occur at all for a given individual. To overcome these problems, component theories have been proposed.

Component Theories In lieu of stages, Bugen (1977) and others (Ramsay, 1979; Ramsay &

Happee, 1977) suggest that grief may be conceptualized as having components which vary in duration, intensity, and presence. The components cited reflect a breakdown of response patterns which other theorists have described as stages. For example, Ramsay (1979) suggests that such components as searching behavior, pining, despair, guilt, anxiety, etc., may occur as denial of the loss. These patterns are similar to the stages presented by Engel (1961), Bowlby and Parkes (1970), and Kubler-Ross (1970). However, the variability of behavioral responses is recognized in this proposal. In addition, Ramsay (1979) provides enough detail to allow operational definition of components for empirical evaluation.

Components may provide a more valid description of grief but may give up the notion of sequenced events unnecessarily. There appears to be a normal chain of behavioral and biological events which follow a loss. As Averill and Wisocki (1981) have stated, "grief is not a grab-bag of individual symptoms without internal coherence. Grief is a process, a procession, a way of coming to terms with a new reality" (p. 126). Neither stage nor component theories provide a functional analysis of such be-

532 B R A S T E D A N D C A L L A H A N

haviors, however. Events which function to prompt and reinforce the various grief responses have not yet been identified. However, some attempts have been made to explain why grief occurs with such a uniform topography. One early approach suggested that observers view grief as a disease process. Engel (1961) and Frederick (1976-77) suggest that pathological symptoms such as depression, apathy, withdrawal, and later illness (Clayton, 1979; Parkes, 1964; Parkes & Brown, 1972) indicate that grief should be equated with a disease process. Even though evidence now shows that grieving suppresses the immune system, calling griefa disease does little more than provide a new label. In contrast, Averill and Wisocki (1981) assert that grief is a normal process, not a pathological state. The disease concept could hamper the analysis of grief and call out medical "treatments," such as tranquilizing drugs, which appear to harm the natural process of grieving. Several aspects of grief may be more understand- able as functional sequellae of the loss if issues are described in terms of their parallel to animal studies in the laboratory. To allow such a parallel it is necessary to demonstrate that loss or separation is an aversive event.

Aversiveness of Mother-Infant Separation Averill (1968) suggests that much of the grief response pattern (e.g.,

anger, apathy, withdrawal) may be a function of the aversive characteristics of the loss and hypothesizes that the aversive properties of a death may be biologically determined and play an adaptive role in primates. Several authors (Averill, 1968; Rosenblatt, Walsh, & Jackson, 1976) suggest that grief may function to maintain a cohesive group structure in species living in social networks. In particular, the effects of grief on the caregiver-infant relationships may be important. I f separation of mother and infant is aversive, then mothers will act to maintain contact (Averill, 1968). In fact, Averill notes that primates evidence grief reactions similar to those seen in humans: "There is typically an unwillingness to relinquish the lost object: this may be followed by restlessness and/or apathy, withdrawal, aggression directed towards self and others, a loss of appetite and sexual interest, an inability to establish new relationships, and so forth" (p. 731). Averill notes other reports of these components in species such as chimpanzees (Garner, 1900; Hebb, 1949; Yerkes & Yerkes, 1929), orangutangs (Zedwitz, 1930), baboons (Zukerman, 1932), rhesus monkeys (Tinkelpaugh, 1928), dogs (Bowlby, 1961; Lorenz, 1952), and geese (Lo- renz, 1966). In each of these species, social organization and the mother- infant relationship appear to play primary roles in species survival. Given this background, grieving behavior may be considered one set of responses after an extremely aversive or traumatic event.

Learning Phenomena Relevant to ~3rief Can what is known about learning help us understand grieving be-

havior? Behavioral theorists have begun to provide answers to this ques- tion. Averill and Wisocki (1981) have indicated that extinction and pun-

GRIEF PROCESS 5 3 3

i shment appear to play a fundamenta l role in the bereaved individual ' s functional env i ronment . They state:

Following bereavement, reinforcement may be reduced for any of four different reasons: (1) customary reinforcers, e.g., those directly dependent on the presence of the deceased, may no longer be available; (2) customary reinforcers, although available, may no longer be effective, as when previously pleasurable activity becomes affectively neutral; (3) the person may no longer have the desire or ability to make the responses required to achieve reinforcement, e.g., due to apathy; or (4) the person may refrain from responding because of negative consequences, e.g., the response might serve as a painful reminder of the deceased or be the source of guilt or social criticism. (p. 133)

Thus, a reduct ion o f behaviors emi t ted should occur as responses are extinguished and other contingencies become effective. The resolution of grief occurs because the individual ei ther learns new responses to obtain reinforcers or new reinforcers reward previous behaviors . N o r m a l "gr ief work" m a y consist o f an initial ext inct ion which decreases responding followed by es tabl ishment o f new re inforcement schedules and the rees- tabl i shment o f some old re inforcement schedules.

Much grief behav io r can be unders tood i f one considers that no rmal schedules o f re inforcement have been seriously disrupted by the loss of a significant other. The degree to which the surv ivor ' s role was dependent on the deceased is a crucial de te rminan t o f the topography o f the grief response (Lindeman, 1944; Marriss, 1958). Averi l l ' s (1968) discr imina- t ion between role-loss and object-loss, with the fo rmer providing a greater disrupt ion o f behavior , has empir ical support . In a control led compar i son o f young widows and widowers, Parkes and Brown (1972) found that men evidenced fewer health p rob lems after the death o f their spouses than women. The daily routine o f the m e n was less disrupted than that o f this group o f w o m e n who funct ioned typically as housewives. Addit ionally, the death o f an infant typically results in a more profound effect on the mothe r than the father (Benfield, Leib, & Vol lman, 1978), perhaps because mothers are usually more invo lved with daily routines o f raising an infant.

Extinction appears to be a pa rs imonious explanat ion for m a n y grief- related behaviors across species. Regardless o f species, m a n y materna l behaviors are reinforced by the presence o f the infant. Dea th o f the infant produces extinction o f these behaviors . "Searching" for the dead child m a y be an extinct ion burst (the sharp increase in rate o f responding when re inforcement is initially discontinued). Previous searches for the child have been rewarded by finding the child. Following the death, m a n y stimuli which elicited searching (e.g., hearing a baby cry, seeing the clock m o v e to the t ime the baby ordinari ly awoke f rom a nap) still occur. When these behaviors are no longer rewarded by finding the child, an extinction burst occurs: The no longer-rewarded behav io r occurs more frequently at first and then gradually declines in frequency.

Extinction plays a p rominen t role in other formulat ions o f the grief process suggested by U l l m a n n and Krasner (1974) and Gauth ie r and


Marshall (1977) as well. According to these accounts, normal grief and mourning are reinforced by contingent support. Eventually, this support is withdrawn (extinction) and replaced with reinforcement for more adaptive behaviors, such as renewing social contact, resulting in reintegration into normal activity and resolution of grief.

This account suggests important implications. Since factors such as social skills, communication skills, and the strength of the support system will mediate the process of grief, social learning theory may be a crucial tool in grief analysis. Specific behavioral deficits impeding recovery from the grief process might be noted as well as assets the individual has available. Indeed, specific grief behaviors emitted by an individual could be a function of imitative learning (Bandura, 1965). This seems likely in socially evolved components of bereavement such as wearing black, ar- ranging funerals and attending wakes; however the utility of this paradigm for understanding the initial somatic distress or appetite suppression appears less convincing.

At this point, the learning principles which have been applied to grief will be briefly summarized. Reinforcement of grieving initially occurs, though these responses will be punished later by the social group. Ex- tinction may play a fundamental role: In fact, early agitated behavior may be an extinction burst. Since the agitated behavior does not result in the return of the lost object, responses wane as evidenced by the period of apathy, withdrawal, etc. Later decreases in responding (e.g., apathy, withdrawal) may result from loss-induced extinction of many behaviors for- merly reinforced by or with the significant other. Eventually, the individual learns new responses or develops new sources of reinforcement for behaviors previously in his or her repertoire and subsequently enters a period of resolution.

In addition, the deceased may not have functioned solely as a dispenser of reinforcers. His or her presence and behavior may have functioned as discriminative stimuli which cued many of the survivor's behavior. With the absence of the deceased, these discriminative stimuli are simply no longer present. Behaviors which were associated with the deceased such as eating meals, going to bed, or going to a favorite restaurant may acquire aversive properties because they may now "serve as a painful reminder of the deceased" (Averill & Wisocki, 1981, p. 132).

The extinction and punishment paradigms appear to explain much of the grief response. Variations in an individual's grieving may be a function of learning histories and the social responses triggered (Gauthier & Mar- shall, 1977). However, there are some interesting empirical data which pose difficulties for this type of analysis. First, women who experience spontaneous abortions evidence significant grief reactions without having developed any observable behavior patterns associated with the lost child (Peppers & Knapp, 1980; Rowe et al., 1978; StaLk, 1980). Second, re- searchers find that elderly people exhibit a less dramatic response to the death of their spouses than do younger people (Heyman & Gianturco, 1973; Parkes, 1964; Skelskie, 1975). Since elderly people generally have

GRIEF PROCESS 5 3 5

longer standing response patterns involving their spouse, one would as- sume that their reaction would be more intense, yet this is not the case. The basic operant formulations provide only partial explanations for the grieving process; we will now turn to other experimental literature which might help integrate such findings.

Respondent Conditioning in Grief Punishment paradigms show clearly that aversive stimuli suppress be-

havior when made contingent upon those responses (Estes, 1944). How- ever, the presentation of previously neutral stimuli after association with aversive events can result in conditioned suppression or a conditioned emotional response (CER) (Estes & Skinner, 1941). This phenomenon involves initial training of an operant response using food reinforcement. During training, a neutral stimulus (e.g., tone or light) is presented inter- mittently to the organism. After the operant response is well established, an aversive stimulus (e.g., shock) is presented at the termination of the previously neutral stimulus, regardless of the organism's behavior. Ulti- mately, presentation of the CS produces suppression of behavior even in the absence of the aversive event. The neutral stimulus appears to acquire conditioned aversive properties. This paradigm may help explain some grieving responses.

One obvious application is to the understanding of response suppression comparing initial rates of operant behaviors (such as lever presses) with the response rate following the aversive stimulus presentation (Estes, 1944; Estes & Skinner, 1941; Hunt & Brady, 1955). In grieving, the loss is the aversive event and other ongoing activity is suppressed. This parallel is obvious.

In the context of grief, it may be useful to examine behavior following an aversive event more closely. In an early study, Muenzinger and Mize (1933) determined that rats exhibited abrupt flinching to shock presentation. Later studies found that flinching is only an initial response. Brush, Mook, and Davis (1960) found that momentary flinching in rats was typically followed by a freezing response, a pattern replicated with rats using other noxious stimuli such as intense light (Jerome, Moody, Conner, & Fernandez, 1957; Keller, 1941) and intense noise (Bolles & Seelbach, 1964). The initial flinching and freezing responses are often followed by vigorous attempts to escape the aversive stimulation (Bronson, 1968). However, when escape proves impossible, a generalized suppression of behavior typically occurs (Brady & Hunt, 1955; Overmier and Seligman, 1967). These typical patterns of response to a noxious stimulus may well be species specific defense reactions (SSDR) (Bolles, 1971). When SSDRs fail to terminate or avoid the aversive stimulus, they cease. Such response patterns are consistent with the grief process.

When the death of a significant other occurs it is generally described as an extremely painful event. Additionally, the death (except in the case of murder or some accidents) is not contingent on the responses of the bereaved. Many deaths are incorrectly perceived by the bereaved as re-


sponse dependent, such as deaths due to car accidents in which the bereaved was driving, or even fetal deaths when the mother believes that the death was caused by something she did during the pregnancy (e.g., smoking cigarettes, making love) (Callahan, Brasted, & Granados, 1983). The major effects of perceived response dependence may be an increase in guilt-related statements and perhaps the development of subsequent superstitious behaviors (Skinner, 1948) related to the perceived cause of death. However, women who feel they are to blame for their own rape appear to adjust better than those who feel they did all they could to avoid the rape; possibly those who feel they were to blame feel they can change their behavior and avoid future rapes. In the normative situation, the cause of death is perceived as external to the bereaved, a noncontingent aversive event. The response to this event typically involves somatic distress including deep sighing, lack of strength, breathlessness, and chok- ing sensations (Lindeman, 1944). Concomitant with the somatic distress there is generally an initial period of shock in which the bereaved is described as being "numb" (Averill & Wisocki, 1981; Ramsay, 1979). Perhaps these responses are species specific defense reactions (Bolles, 1971) analogous to the flinching and freezing responses seen in infrahuman organisms.

During the second grieving phase, described as "protest and yearning," the bereaved evidences agitation and heightened physiological arousal (Averill & Wisocki, 1981). Behaviors in this phase may represent attempts to regain the lost object (Bowlby & Parkes, 1970; Ramsay, 1979) and as such may be construed as attempted escape responses. This appears analogous to that stage in the CER paradigm in which the organism engages in a variety of possible escape or avoidance responses. Myers (1971) describes the behavior of rats at this point as "vigorous withdrawal, strug- gling, and locomotion" (p. 481). If the organism fails to avoid or escape the aversive event, response suppression occurs (Church, 1969). In grieving literature, the third stage, described as "disorganization and despair," is characterized by apathy, withdrawal, sleep disturbance and loss of appetite and sexual interest (Averill & Wisocki, 1981).

With the passage of time, the pain associated with the death abates. The individual develops new response patterns and the previous symptoms are relieved. The emotional component may eventually extinguish, allowing the individual to develop new response patterns to obtain reinforcers. This is similar to the conditioned emotional response in that further presentations of the conditioned aversive stimulus eventually lose suppressive power (i.e., response rates are no longer suppressed) if the unconditioned stimulus is no longer presented (Church, 1969).

Ordinarily the unconditioned aversive stimulus is presented only a limited number of times contiguous with a previously neutral stimulus, and it is typically the effect of presenting the conditioned stimulus alone which is of interest. How does this parallel the effects of the death of a significant other? Perhaps the initial discovery of the death can be considered the unconditioned aversive stimulus. Subsequently, any cues pre-

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viously associated with the deceased serve as conditioned aversive stimuli, or as Averill and Wisocki (1981) suggested, "painful reminders of the deceased." This would explain the importance of role vs. object loss in determining the the topography of grief. If the deceased played an important role in the life of the bereaved, more cues associated with the deceased would be present in the survivor's environment, and greater disruption of behavior would occur.

While the CER paradigm adds to an understanding of the grief process, other learning paradigms can help present grieving more clearly. Among these are adaptation and sensitization.

Adaptation and Sensitization The history of the individual with respect to grief appears to be critical

to his/her response to grief. For example, elderly people exhibit a flatter, less dramatic response to loss of spouses than do younger people (Parkes, 1964; Skelskie, 1975). Several animal studies have demonstrated that gradual exposure to an aversive stimulus results in a decrease in aversiveness of the event (i.e., adaptation) (Karsh, 1963; Miller, 1960). In the human life span most young people have little exposure to death, but as they age, deaths become more frequent. First, most individuals experience the death of grandparents, later parents and friends, and eventually, the death of a spouse. Thus, people are exposed gradually to more significant deaths. Perhaps, the milder response of the elderly to death is a function of this gradual exposure and adaptation. Early exposure to loss appears to have an opposite effect, perhaps sensitization.

Sensitization is a phenomenon in which an aversive event becomes greatly more effective in suppressing behavior after brief, intensive and uncontrollable presentation. After the intense preshock, an organism evidences greater disruption of response rates following subsequent lower intensity shocks and is thus considered sensitized to the effect of shock (Keltner & Marshall, 1975; Overmeir & Seligman, 1967). Individuals who experience the death of a significant other (e.g., child or spouse) early in the life span should evidence more intense grief responses to subsequent significant deaths than those who experience the more normative pro- gression of deaths. In fact, many sudden infant death syndrome (SIDS) mothers refuse to have children later for fear of another loss (Davis, 1975). Thus, the history of the individual could lead to greater or lesser effects of losses over time. Knowing an individual's grief history is critical to recognizing appropriate grieving.

Limitations There are some limitations in using data from animal studies to un-

derstand grief behavior. One of these is the temporal factor involved in the grief response. While the effects of aversive stimulation have been assessed across only limited periods of time in infrahuman organisms, the effect of grief can last years. It is impossible to define the relationship between time in the human life span and time in the life spans of other

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organisms. The conditioned suppression of behavior does persist over considerable time even in animal studies, however.

There is also a considerable leap made by comparing noxious stimuli presented to infrahuman species and the aversive characteristics of a significant other's death, but the responses elicited appear similar in topography and function. In fact, species specific defense reactions are related to the type of aversive stimulus presented. Thus an animal may exhibit a running response in some situations, a freezing response in others, while the death of a significant other may yield another. It is not clear what, if any, grieving SSDRs exist in different species.

In addition, the CER paradigm is typically considered an analogue to anxiety (Church, 1969), whereas grieving is more commonly associated with depression. However, grief may be conceptualized as both anxiety and depression. In fact, Gauthier and Marshall (1977) have hypothesized that prolonged grief reactions may be likened to the Napalkov phenomenon, which may be seen as a form of sensitization (Napalkov, 1963). Napalkov found that presenting a single pairing of intense shock and a conditioned stimulus led to unusual results. Repeated presentations of the CS alone led to increasingly greater rises in blood pressure in dogs, while repeated presentations of the UCS (shock) led to adaptation. This phenomenon was later replicated with humans (Keltner & Marshall, 1975; Stone & Borkovec, 1975). The parallel to grief can be seen if there is avoidance of any immediate evidence of the loss (not seeing the body, avoiding the funeral, etc.) which then leads to pathological grief. Eysenck (1967) later proposed a theory of cognitive incubation of stress reactions based on Napalkov's work. Gauthier and Marshall (1977) extended Eysencks's work to grief stating:

The conditions described by our pathological grievers of intrusive thoughts about the deceased and their immediate suppression of such thoughts matches the conditions described by Eysenck as ideal for the incubation of distressed responses. (p. 47)

Furthermore, most forms of psychotherapy for pathological grief involve procedures for treating phobic behavior and obsessive-compulsive behavior, such as flooding (Gauthier & Marshall, 1977) and repeated and prolonged exposure (Ramsay, 1979). It appears that both depression and anxiety models are applicable.

Implications of Learning Models Each of the laboratory models presented makes a unique contribution

to conceptualization of the grief process. It is clear that grief may be viewed in terms of both depression and anxiety. If grieving is viewed as depression from Lewinsohn's (1974) model, then a significant other's death should result in behaviors symptomatic of depression due to the elimination of a salient source of reinforcers. Unless these behaviors come under the control of new reinforcers they should not reappear in the individual's repertoire and would thus be considered extinguished. In fact, many behaviors do not recur (Davis, 1975), although other behaviors

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increase to preloss frequency. There may be important implications for the behavior therapist in considering all possible explanations.

In the assessment of grief, pathological grieving appears to be a function of the individual's successful or partially successful avoidance of normal grief stimuli. Gauthier and Marshall (1977) suggest that some individuals develop effective methods of rapidly suppressing or avoiding the painful knowledge of the death. This may sustain short-term decreases in pain but also foster an inability to cope with an environment replete with cues of the deceased. The therapist must consider contingencies which maintain troublesome behavior. Pathological grief in our clients has often followed punishment of appropriate attempts to grieve by often well- meaning members of the support system. The therapist may need to train skills to enhance coping with a support system that suppresses appropriate grief (i.e., teaching clients to prompt appropriate behavior from friends and relatives). The potential for establishing new behaviors must also be assessed. For example, new skills in developing and achieving career goals may be needed by the individual who had been supported by his/her spouse.

Bereavement may set the the occasion for the individual to experience repeated exposure to conditioned aversive stimuli (e.g., cues associated with the deceased). If the individual experiences such cues, extinction will occur with a gradual loss of the aversive qualities of the stimuli. Extinction probably reflects the course of normal grief; if successful avoidance strategies are developed, extinction cannot occur and a pathological grief reaction will occur. There are interesting empirical data to support this. Numerous studies (Benfield et al., 1978; Kennell, Slyter, & Klaus, 1970; Rowe et al., 1978) have demonstrated that when a perinatal death occurs, there is a greater probability of mothers exhibiting pathological grief reactions if they do not: (a) see the dead infant, (b) name the baby, or (c) attend the funeral service. Perhaps since few cues associated with the deceased infant appear in the mother's environment, there will be less likelihood of the mother being exposed to the conditioned stimuli. How- ever, if the mother sees the infant, names him/her, and attends his/her funeral, more tangible cues are provided to enable repeated exposure and extinction of the emotional response.

Interestingly, Leitenberg, Rawson, and Bath (1970) have found that unrewarded responses must occur for a response to extinguish. In their animal study, they found that rewarding an animal for making an alter- native response (thus preventing the occurrence of the unrewarded response) only delayed the occurrence of an unaltered extinction curve. Thus, people who distract themselves from experiencing the frustration of contact with stimuli associated with the deceased probably only delay their inevitable grief process. Evidence of early avoidance of grieving may be a flag for the clinician to warn medical staff or family to note. On the other hand it is important for the observer to note that if people have a history of early and intense losses, their grieving may be more intense than that of others yet not be pathological.

Treatment and prevention of pathological grief may involve skill train-

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ing to enable effective coping with the new set of contingencies affected by the death. Grievers may need to learn effective strategies to maintain their appropriate grieving with little support from others. There are clear guidelines implied here: It is critical to face the stimuli of grieving while knowing that the process will be individual and varied, yet healthy.

Concluding Remarks Averill and Wisocki (1981) stated that grief is a coherent process. The

consistency of responses to bereavement across higher primates supports this contention. Perhaps this consistency reflects the fact that the survivor emits a pattern of responses as a function of the death just as animals emit a pattern of parallel responses to stressors in various laboratory paradigms. Though the specific topography of grief may be variable across individuals, essentially the same process occurs, usually a normal process which does not suggest pathology. This is a crucial ethical consideration for the behavior therapist. Before proceeding to therapeutic goals and the choice of procedures, the therapist must consider whether the client's behavior is indeed pathological or simply a normal response to grief. "Therapy" for normal grieving is inappropriate; brief guidance and re- assurance may be all that is required. The natural support system and perhaps time will be the most effective "therapy." In this situation clients may benefit from permission to feel what they feel and from information on the process of grief.

This paper has suggested some implications for the therapist despite the lack of controlled studies on grief. Perhaps this dearth of hard data reflects the numerous difficulties involved in attempting to research an issue as sensitive as grief. To begin, the researcher must consider the ethical issues involved in collecting data during an emotionally laden event: Is it justifiable to ask a bereaved parent for behavior samples following the death of his or her child? Second, the researcher must con- front someone else's intense emotional responses. Third, there are few models available to provide guidelines for this type of research. As a result of these difficulties the majority of studies evaluating grief have used retrospective interview formats (Benfield et al., 1978; Rowe et al., 1978; Stack, 1980). Prospective studies are needed.

The first step in grief research is to determine a valid and reliable methodology to assess grief. Some initial steps have been taken by Kennell et al. (1970) in the development of a quantifiable grief questionnaire. With such methods it would be useful to test current assumptions about grief. Longitudinal studies using repeated measures would be optimal if the researcher could find willing subjects. Regardless of the specific topic, there is a great need for empirical research to enhance our understanding of grief.

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