psychodynamic theories in grief and bereavement
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Smith College Studies in Social Work 73(3), 2003 273
PSYCHODYNAMIC THEORIES IN GRIEF AND BEREAVEMENT*
Joan Berzoff, EdD, MSW
Abstract
This paper considers those psychodynamic theorists who contribute toour understanding of the ways in which loss, grief, and bereavement maylead to structural and internal changes. The ways in which loss maypromote or undermine psychological growth are considered.Cross-cultural and constructivist views on loss and bereavement areconsidered with recognition that grief and mourning take many forms andare not necessarily ever resolved.
Remember
Remember me when I am gone away,Gone far away into the silent land;When you can no more hold me by the hand,Nor I half turn to go, yet turning stay.Remember me when no more, day by day,You tell me of our future that you planned:Only remember me; you understandIt will be late to counsel then or pray.Yet if you should forget me for a whileAnd afterwards remember, do not grieve:For if the darkness and corruption leaveA vestige of the thoughts that once I had,Better by far you should forget and smileThan that you should remember and be sad.
—Christina Rossetti
Christina Rossetti expresses the desire to be remembered not withsadness, but with a smile. Grief and bereavement are always a complexset of emotions that include sadness, anger, and distress but may also
*This paper will appear in the forthcoming book (2004), Living with Dying: A SocialWork Textbook in End-of-Life Care (working title), by J. Berzoff and P. Silverman, fromColumbia University Press.
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include humor, joy, and laughter. According to Webster's dictionary, griefis largely negative: "an intense emotional suffering caused by loss,misfortune, injury or evils of any kind...hardship, suffering and pain"(Webster, 1979, p. 801). But psychodynamic views of grief andbereavement suggest that grief, bereavement, and mourning aremultidimensional, and depend on the nature of the loss, the way the lossis metabolized, the meaning of the loss, who the mourner was before theloss (Rosenblatt, 1993), how the loss is socially constructed (Neimayer,2001; Klass, Silverman & Nickman, 1996), and the ways in which the lossmay actually positively transform the mourner (Silverman & Klass, 1996;Silverman, 1986; Cassem, 1975; Worden, 1991). While grief may leavethe mourner with longing and regret, it may also allow the mourner tocontinue a relationship with the deceased (Klass et al., 1996) and growfrom the experience.
This paper, then, will discuss a range of psychodynamic theories aboutgrief and bereavement. I will examine the ways in which grief may beviewed as pathological, but will also discuss how people may betransformed in adaptive ways by their losses. I will look at a range oftheories that explain how the deceased may become a part of the mourn-er's psyche: through introjection, intemalization, and identification, andhow this may shape not only the mourner's ego, but also superego. I willlook at why some grief is accompanied by self-blame, self-hatred, andeven suicide, while other losses leave the mourner sadder but wiser(Loewald, 1962). I will examine a number of different trajectories forgrieving, while emphasizing that grief is always a unique phenomenonthat differs based on multiple factors: pre-existing losses, the mourner'spersonality, and the meaning to the mourner of who and what has beenlost. Throughout, I will suggest that loss and mourning are ubiquitous togrowth and development from childhood through old age. Since there isno universal experience of grief, and the "resolution" of grief is aparticularly Western concept, I will discuss why time limits for grief mayinterfere with grieving. Finally, I will also look at the ways in which grief,like any psychosocial phenomenon, is always socially constructed.
Hence the paper begins by examining those psychodynamic theoristswho best contribute to our understanding of the ways in which grief andmourning shape the mourner's self and ideals. Using concepts fromSigmund Freud, Melanie Klein, D. W. Winnicott, John Bowlby, MargaretMahler, E. M. Ainsworth, Vlamik Volkan, Gerald Kaplan, ErichLindemann, Colin Murray Parkes, Hans Loewald, John Baker, PhyllisSilverman, Robert Neimayer, and others, I also, describe a number of
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sometimes competing, sometimes complementary lenses through whichto see how losses can build on or undermine psychic structure.
EARLY PSYCHODYNAMIC FORMULATIONS OF MOURNING
Perhaps one of Freud's most evocative papers, and certainly one of hismost significant, was written in 1917. In "Mourning and Melancholia,"Freud first distinguished between healthy and pathological mourning.From the start, he conceptualized mourning as not simply the loss of aloved object (and by this he meant person) but the loss of one's country,one's ideals, or one's home. Mourning itself, Freud thought, was not inand of itself, a pathological state, though it might often feel that way.
In Freud's view, mourning feels like dejection, exhaustion, anddepletion. In the process of grief, the mourner withdraws psychic energyfrom the outside world for a period of time. Freud described the ways inwhich the mourner is preoccupied with the loss, and using a concept fromphysics, described how the mourner decathects, or withdraws energyfrom the outside world, while hypercathecting memories of the lostperson. As the poet Rossetti (1979) suggested above, the mourner iscaught between letting go, and holding near, the object of the loss.The mourner tries to keep the person alive through telling her stories,wearing her clothes, playing her music, preparing the foods she loved, orvisiting places that were shared. Nonetheless, the language of cathexis,decathexis, and hypercathexis that Freud employed to describe thisphenomenon is off putting, objectifying, and pseudo-scientific(Bettleheim, 1980).
Perhaps Ira Gershwin (1950) better describes hypercathexis when hewrites, "The way you wear your hat...the way you sip your tea...thememory of all that...you can't take that away from me." He is demon-strating how, in mourning, each memory of the person who has died isfull of meaning. The mourner keeps the person alive through tenaciouslyholding onto as many memories as are possible. She may hold conversa-tions with the dead person, visit the grave, set a place at the table, orruminate about the events that surrounded the person's death.
No one, Freud wrote, ever abandons a libidinal position willingly, evenwhen a substitute beckons. That is why we don't fall in love after a majorloss. Grief takes energy. But with the passing of time, and with accep-tance of reality, Freud expected that the mourner would slowly decathectenergy from the person who had died, freeing up libidinal energy for newattachments. Taken literally, Freud maintained that the mourner mustde-invest love for a lost person in order to love again.
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In the same paper, however, Freud acknowledged that love may neverbe fully decathected and instead offered an alternative explanation forhow the deceased may be given up in the interest of loving again. In thefirst object relations concept to enter psychoanalytic discourse, Freudexplained that lost objects, once loved, become internalized andultimately set up inside of, and as part of, the surviving individual's egoor psychic structure. It is through identification with the lost object thataspects become part of the mourner's self. This is what makes mourningpossible, bearable, and ultimately, potentially transformative.
Unfortunately, Freud did not fully elaborate on the concept ofidentification until he wrote The Ego and the Id, in 1923. Here he wrotethat'the oedipal situation bore great similarity to the state of melancholia.For ^ e oedipal child, he wrote:
"There quite often ensues an alteration of his ego which can only bedescribed as a setting up of the object inside the ego, as it occurs inmelancholia...If one has lost an object or has been obliged to give it up,one often compensates oneself by identifying oneself with it and settingit up once more in one's ego. Since then we have come to understand thatthis kind of substitution is important in determining the form taken by theego and that it makes an essential contribution towards building up whatis called its character." (Freud, 1923, p. 19)
Freud indicated that both mourning and melancholia feel alike. Themourner and the melancholic both feel dejected; both experience a loss ofinterest in the outside world; and both feel the lack of the capacity to loveagain. But whereas the mourner feels these things intensely, themelancholic feels something else in addition. The melancholic alsoexperiences a disturbance in self-regard. The difference between themourner and the melancholic, then, is that the latter feels bad about his orher own self. In fact, the melancholic suffers from what will later becalled pathological grief. He or she feels self-critical, worthless, and mayexperience problems with appetite or sleep.
How does identification with the dead create melancholia for some?Freud thought that unconscious conflicts (particularly unconsciousaggression) toward the deceased made mourning difficult and oftenprolonged. Let me give an example:
Ginny was 35 years old when she came to outpatient treatment. She suf-fered from headaches with no organic basis, and from a chronic depres-sion. She was overweight, had unsatisfying relationships with men, andsuffered some inhibition at her job as an associate vice president in a tele-vision company. She experienced herself as not worth other'sattention but maintained excessively high standards for herself.
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Ginny had grown up in a family that from all outward appearances wasenviable. Both parents had excellent careers and enjoyed financialsuccess. When Ginny was five, however, her sister, age seven, became illwith pneumonia. Ginny's parents, frantic with their eldest daughter's highfever, rushed her to the hospital, but not before Ginny gave her sister akiss good-bye. Her sister died overnight, and Ginny, with the magicalthinking of a five-year-old, began to experience herself as the "kiss ofdeath."
Her sister's pictures were removed from the mantle, and she was notspoken of again. Ginny felt somehow culpable, although unable toexpress her feelings, including her sorrow. She longed for a sibling toreplace her sister, and so when her mother became pregnant when Ginnywas six, she felt herself a major player in the conception. Like manysix-year-olds do in fantasy, Ginny imagined that this was her and herfather's baby. But her newborn brother was bom with Down's syndrome,and unconsciously Ginny began to associate both her loving, sexualfeelings, and her aggressive and angry feelings with loss and damage. Shespent her childhood trying to "be good" and was an excellent student, adutiful child, who, when angry would withdraw into a closet until heranger passed. At 12, she wrote a birthday song for her brother. Her moth-er, who worked in the music publishing business, showed it to acolleague, who had the song published. It was an instant hit. But Ginnywas confused. She was reluctant to take credit for this achievement, anddisavowed her success, as well as many other subsequent successes inwork and love that she did not feel entitled to enjoy. Despite enormoustalents, and a wonderful sense of humor, she experienced herself asinexplicably bad. .
"When other children appear on the scene," Freud wrote, "the Oedipuscomplex is enlarged into a family complex. This...gives ground forreceiving the new brothers or sisters with repugnance and forunhesitatingly getting rid of them by a wish." (Freud, 1916, p. 333)
For Ginny, her aggressive wishes toward her siblings were of courseunconscious. With her sister's death, however, these feelings had beenturned against herself. Her lack of awareness of her own ambivalentfeelings toward her sibling, made the grief work irresolvable. "Inmourning," Freud wrote, "the world has become poor and empty. Inmelancholia, it is the ego itself."
Jane offers a second example of complicated mourning from aclassically psychodynamic perspective. Jane, an 80-year-old ItalianCatholic woman, began to see me because she was profoundly depressed,having lost her husband of 40 years, at 73. She visited his grave and
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talked with him daily, prayed with him in the morning, and at night. Noneof this would be pathological, except for the degree to which she referredto her home as her "tomb," was unable to feed herself, shop for herself,make any new relationships, or find any meaning in her life. She had lost20 pounds and had driven her children away with a litany of complaintsabout them and about herself.
Jane had married at 40, having been the only one of seven siblings tolive with and care for her aging and often abusive parents. She took careof all of her siblings' children, cleaned their homes, and did their laundryat considerable expense to herself. She denied any anger over forgoingcollege to take care of family members, and in fact, said, throughclenched teeth, that she is never angry.
She had married a childhood friend, whom she had known, on somelevel, was homosexual. After conceiving three children, he moved intoanother bedroom and took a male lover who was 20 years his junior. Janefelt that her children blamed her for the disaffection between the couple,and did not remember, although each of her children report it, her mur-derous rage during their childhoods, in which she would hit them withbrushes, shoes, or her hands. Jane is a devout Catholic who sees herselfand her God as loving. Her husband is described as nothing less than asaint.
During the course of our work together, Jane found, folded inside adrawer of her dresser, a journal she kept during the middle part of hermarriage. In it, she confronted her loneliness, her fury at her husband, herdisappointment in her life. During his illness and his death, however,these feelings were repressed, despite the fact that her husband, on hisdeath bed, told her that he had never loved her and wished she were dead.
Why had Jane become so depressed and even suicidal? In part, Freudwould surmise, she had great difficulty acknowledging her anger towardthe husband she had lost, and this threatened her ability to hold onto hismemory. Secondly, her unconscious hatred for him had now been set upinside of and directed against her ego. The third, and perhaps most diffi-cult problem for Jane, from a dynamic perspective, was her need to main-tain in fantasy what never actually existed in reality.
Freud wrote, "One feels justified in maintaining that a loss hasoccurred, but one cannot see clearly what it is that has been lost...thepatient cannot consciously perceive what he has lost either. What givesrise to his melancholia is the sense that he knows whom he has lost, butnot what has been lost in him." (Freud, 1917, p. 245) From Freud's pointof view, pathological mourning often does not end. It is debilitating to
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internalize an unresolved and conflicted relationship. Melancholia isdifficult to cure because of its unconscious and often denied roots.
In any situation of mourning, normal or pathological, Freud wrote thatthe shadow of the object falls on the ego. What a wonderful andevocative way of conveying how a mourner's psychic structure is alwaysaltered by the quality and nature of the relationship to the deceased! Butwhen the mourner denies or cannot tolerate his negative relationship tothe deceased, his or her own ego may be impoverished.
It needs to be said, however, that Freud (1960) revised his position onmourning many times, particularly with the death of his own daughter,Sophie.-By the end of his career, and as a bereaved parent, himself, herecognized the impossibility of ever decathecting from a lost object, andwrote:
"Although we know that after such a loss the acute stage of mourningwill subside, we also know that we shall remain inconsolable and willnever find a substitute, no matter what may fill the gap. And actually, thisis how it should be. It is the only way of perpetuating that love which wedo not wish to relinquish." (p. 210)
In this statement, Freud foreshadows the idea that in mourning, onealways maintains a continuing relationship with the deceased. Despite hisrecognition that the energy connected to lost objects is neverextinguished, he did not revise his theory to include this insight (Klass etal., 1996).
Loewald (1962) added a further dimension to understanding how lossand mourning may alter psychic structure in transformative ways. Helooked at the ways that identifications with the deceased shape themourner's superego. The superego is normatively comprised of identifi-cations with valued others that shape one's conscience and ideals: whoone wants to be and to become. When loss occurs, mourners inevitablyidentify with the lost person. For some, this can mean identifying withharsh, critical aspects of the other in ways that might result in a more rigid.and inflexible superego. But loss also offers opportunities to expand themourner's ego ideals.
For example, the Biehls lost their daughter, Amy, age 22, in SouthAfrica, when, as a Fullbright Scholar working to end apartheid, she wasmurdered by four Black South African men. Her parents returned toSouth Africa a year after her death to offer amnesty to her killers and pub-licly forgave their daughter's murderers. They created a legacy from herlife as well as her death, and enabled her to live on, in memory, in thecountry to which she had devoted her life. For the Biehls, their daughter'smurder altered their philosophy of how life might be lived (Biehls, 1998).
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We see commonly see superego development in those who aremourning. A mother who lost her daughter, a writer, to COPD, becomesa writer herself educating others about the illness in order to help them. Asenator's wife, widowed by her husband's plane crash, carries on hiscareer and strives to change the lives of women in the process. A womanwith breast cancer is compelled to work with other women to minimizetheir isolation and stigmatization, and this shapes how she feels aboutherself. A woman whose sister died in a bone marrow transplant unit ded-icates a part of her career to ensuring that others die with betterpsychosocial care.
OBJECT RELATIONS
KleinWhile Freud and Loewald predominately theorized about the kinds ofidentifications with the deceased that led to changes in the mourner,Melanie Klein (1940) was interested in how grief and mourning may beexperienced differently based on the mourner's developmental level. Sheidentified two kinds of anxieties that babies, early on, experience:annihilation anxiety at the most primitive level, and abandonment anxietyat a higher level. She also detailed the kinds of defenses that babiesnormatively employ to defend against these two anxieties. In her view,introjection rather than identification, helped the baby, or mourner, man-age the intense anxieties that emerge under situations of dependency, loss,or frustration. She also noted that under situations of loss, such anxietiesare simply unbearable, and that the bereaved person who experiencesthem may deny his/her need for and dependency on the person who hasdied, taking flight into manic activity.
Richard was a 50-year-old lawyer and father of four when his wifebecame ill with colon cancer. Richard had never lived alone and was high-ly dependent on her to care for their children, home, finances, bills, andto manage his daily life. As her condition worsened and during her firsthospitalization, he placed ads in the local newspapers seeking a new girl-friend to replace her. By the time she died, he had a substitute alreadyinstalled in his house.
Klein would understand Richard's flight into manic activity as afunction of his primitive level of psychological development. By denyinghis dependency on his wife and the meaning her loss had for him, hemaintained an illusory independence from the person whom he sodesperately needed. By seeking a new partner before his old one left him,he tried to manage his helplessness by convincing himself that his wife
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and his attachment to her were easily replaceable.In Richard's early history, he had experienced a series of losses: his
father died when he was eight, and his mother subsequently left him inthe care of a sibling who was rejecting, while she moved to anothercountry to be with her second husband. He saw dependency as a threat tohis own psychological integrity inducing in him a kind of mania thatrepresented some triumph over the dead, and over his earlier losses.
Klein described two normal positions in which babies (and sometimesmourners) predominately live when they are wholly dependent on othersfor their survival. The first is the paranoid-schizoid position and thesecond is the depressive position. While it may sound crazy to think ofbabies or mourners as paranoid or depressed, Klein was trying to describethe inner world of a child who cannot yet see the world or others aswhole. For the helpless baby, or for the mourner threatened byannihilation anxiety, others exist simply as need gratifiers who are goodwhen they gratify and bad when they don't. In the world of an infant, themother is the primary object and the source of all that is good whensatisfying and of all that is dangerous when she is frustrating. In infancy,a mother's milk, and symbolically her love, are incorporated orintrojected, and become a part of the child's inner world, enabling him tofeel good and worthwhile. Too much frustration, deprivation, or neglect,however, is experienced by the baby as bad and destructive, and in turnthe baby feels him or herself to also be bad. According to Klein, thebaby's inner world is populated with good objects and persecutoryobjects. Good experiences with the mother restore the baby's sense ofwell-being and worth. Bad experiences with the mother that persist overtime often contribute to an inner world that is both scary and dangerous.Many mourners whose personalities have been undermined by excessiveloss or deprivation, live in this shadowy and persecutory world where,when a new loss occurs, representations of the self and of the other areexperienced as all bad. Where there has been a sufficient balance,however, between frustration and responsiveness, a baby, and later anadult, can begin to come to grips with the fact that the person she needsand loves, is the same person who is frustrating and sometimes depriving.Klein refers to this as the depressive position, and it is a developmentalachievement because it is sad to experience oneself and others as neitherall good nor all bad. It is also depressing to give up the belief in anotherperson's omnipotence or destructiveness.
How then does loss threaten the adult's inner world? Klein suggests thatwhen someone dies, the mourner not only regresses and loses theexternal relationship, but internally, may feel as if he has lost his good
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objects. If the mourner experiences annihilation anxiety, as Richard did,he is unable to restore a sense of internal goodness or well-being. Whena mourner remains in the world of the paranoid/schizoid position, he mayexperience the death of another as his being robbed and punished. That isto say, feelings of persecution may dominate the mourner's inner world.The mourner's views of others as comforting and helpful are then thwart-ed by an inner world that is largely populated by bad and persecutoryobjects. But when a mourner has achieved the depressive position inwhich he or she sees others as both good and bad, grief can then beexperienced without the fear of destruction to the self.
Klein (1940) writes that under the best of circumstances:
The loss of a loved person leads to an impulse in the mourner toreinstate the lost object in the ego...In my view he not only takesinto himself (reincorporates) the person he has just lost but alsoreinstates his internalized good objects (ultimately his loved par-ents) who became part of his inner world from the earliest stagesof development. The early depressive position is reinstated.Among all these emotions (however), the fears of being robbedand punished by both parents are revived. That is to say (for thosein the paranoid schizoid position), feelings of persecution havealso been revived in deep layers of the mind. (p. 353)
Klein's understanding of mourning is important in a number of ways.In working with people who are grieving, it is important to understand themourner's internal world and assess the mourner's capacity to see othersas part objects or whole objects. Also mourners who have achieved thecapacity for depression may be able to experience the loss withoutexperiencing a simultaneous loss of self.
Winnicott (1951, 1958, 1960, 1965, 1971) offers a somewhat differentbut related understanding of how mourning is facilitated. Winnicott(1965) writes of the absolute and essential need, in infancy, for a motherto create a holding environment for her child: a place free from intrusionor impingement in which a child may begin to explore and develop histrue sense of self (1960). A holding environment (1958) requires both themother's presence and her absence in order to help a child to develop thecapacity for solitude and aloneness. It is through a child's connectednessto the mother, and intermittent and incremental separations from her, thata child develops a sense of self (Winnicott, 1960).
Loss is an inevitable part of any person's development and is managedthrough the infant's creation of an inner representation of the mother, inher absence. Through illusion and through fantasy, the infant develops a
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sense of the mother, despite her lack of physical availability. The infantcreates a space of imagination and of play that is neither the infant, northe mother (Winnicott, 1971). This is a transitional space in which thebaby may, for example, use a song, a blanket, or a teddy bear as a sym-bolic representation of the ministrations of his mother. Any one of theseobjects may symbolize the union of the two. When the mother is physi-cally absent, then the use of a transitional object may symbolize the unionof two now separate things, baby and mother, at the point in time andspace of the initiation of their separateness (Winnicott, 1971).
Children, and by extension mourners, create transitional objects to dealwith loss and separation. Transitional objects can thus be loved, but alsomutilated. They serve a bridging function as symbolic representations ofthe person's experiences with the loved one's soothing and comfort.Under normal circumstances, babies eventually give up their blankets orteddy bears, the outside representations of the soothing and caringmother, because her functions become internalized. Henceseparateness inevitably requires loss, but loss builds psychic structurethrough internalization. This process builds the capacity for mentalrepresentations of the lost object. When the mother has been too absent ortoo depriving, the transitional object becomes meaningless.Winnicott writes:
"If the mother is away over a period of time that is beyond a certain limitmeasured in minutes, hours, or days, then the memory of the internalrepresentation fades. As this takes effect, the transitional phenomenabecome gradually meaningless and the infant is unable to experiencethem. We may watch the object becoming decathected. Just before a losswe can sometimes see the exaggeration of the use of the transitionalobject as part of denial that there is a threat of its becoming meaningless."(Winnicott, 1953, p. 15)
Hence when a loss occurs for an adult, it is important that the clinicianassess the mourner's capacity to maintain an inner representation of theperson who has died. If an inner representation cannot be maintained,the person loses the capacity to soothe herself.
Normatively, we see mourners making use of transitionalphenomena after a death. When the World Trade Center collapsed or afterthe Oklahoma City bombing, mourners could be seen holding teddybears, or posters, or photographs of the dead. Transitional phenomenalink the mourner to the dead by helping the mourner to maintain asymbolic tie to the person who was lost. This is why so much grief workrequires the use of transitional phenomena: photographs, diaries, and realobjects that represent memories of the dead that are suffused with mean-ing. These objects need to be recognized as ways of providing a soothing
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function for the mourner, which, ultimately, can be given up when inter-nalized.
The capacity to maintain symbolic ties to the dead often reflects thenature of the mourner's inner representational world. There may be aconnection between personality disordered individuals and pathologicalgrief, since people whose self and object world are marked by insecurityand inadequacy are usually unable to see others or the self as whole andare less able to grieve (Sanders, 1988).
Mahler and VolkanMahler (1975) notes the ways in which a child's inevitable separation(read loss) from her primary love object, her mother, facilitates psycho-logical development. Every mother-child unity must encounterdisruption, loss, and repair. Internalization of the mother becomes theway in which a child can separate while maintaining a mental image ofthe mother. In the course of normal development, a toddler begins tomove away from her primary object. At the same time, the mother nolonger holds or restrains the child and actively fosters more separateness.Through minute and incremental losses of the mother's presence, thetoddler comes to internalize the mother's functions. Psychic structurethen develops through intemalizations (that continue to occur throughoutthe life cycle). Graduations, promotions, and weddings all evoke sadnessand often mourning. That is because they symbolize both loss and mov-ing on (Carr, 1975). Since loss in adulthood is inevitable, internalizationcan be seen as a lifelong process that builds character and psychicstructure (Behrends & Blatt, 1985).
Internal object relationships are always complex. They include theperson's image of the object, the feelings related to the object, andthe feelings related to the self without the object. In mourning, it ispossible to maintain a tie to the inner representation of the love object thatalso leaves room for investing in new loves, and new activities. Internalobject relationships perform many functions: they soothe, they help inproblem solving, and they help the mourner sort out her own identity inrelation to the deceased (Baker, 2001).
Volkan (1981) discussed the ways in which transitional objects, whichhe called linking objects (actual material objects of the dead), function tomaintain a bridge with the lost person. For adults, linking objects providea way to maintain contact with the dead, in which the physical objects(clothes of the dead, jewelry, photographs) allow the mourner toexternalize elements of the self and internalize elements of the other.
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Linking objects are used to maintain the illusion of the lost person'saliveness. The mourner also uses the possessions of the dead to restoreand to resolve some of the ambivalence that characterized the relationshipwith the deceased in life.
For example, Ann, a 47-year-old internist, lost her 49-year-old brotherto a lymphoma. He had been a highly successful lawyer, and theirrelationship, while loving, was not without rivalry. She remembers think-ing in the manic way that Klein describes, "At least, when he's dead, I'llget his music collection." For about five years thereafter, Ann played herbrother's music often: in her house, in her office, and on any drive shetook. Using the music as a linking object, she essentially carried him withher, but not without a note of triumph that she finally possessed a part ofhim that she had always envied. At around the five-year anniversary, Annnoted that she no longer needed his music, and in fact, made tapes ofsome of his favorite songs, for his children. She began to change her tastein music as well.
While Volkan described linking objects as pathological, others(Satorsky, 2000) have noted the ways in which linking objects maintainties to the dead and build psychic structure. It is important to rememberwhen we speak of-introjection, internalization, or identification, that theseconstitute a person's inner representations of others, not the actual personwho has died.
BowlbyBowlby (1963,1969-1980) understood mourning as directly related to achild's tie to the mother. He observed the ways in which children whowere deprived of their essential ties to their mothers reacted to loss: Usingchildren who had been institutionalized and abandoned as his subjects, hedocumented the ego disintegration that takes place among young childrenwho were placed long term in institutional settings and without aprimary caretaker. Bowlby (1963) first focused on the pathologicalconsequences to the child of early loss, and demonstrated that the tie tothe mother, or a primary caretaker, serves as the major organizer for thechild's psyche. With the loss of that tie, a child experiences levels ofseparation anxiety that may undermine the ego. Bowlby noted a sequenceof increasingly ego disorganizing behaviors when children are separatedfrom their mothers. First, children expressed their anxiety throughprotest: a loud, angry crying and expression of pain, designed to bring thelost object back. In this view, the child's painful affects act as signals, andunder the best of circumstances, mothers or substitute caregivers respond
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to those signals with affection and love. A baby's protest cry is an activesearch to restore a lost object. But when the lost object or her functionswere not restored in the course of separation, the hospitalized childrenbecame increasingly despairing: weeping, pining, searching, andyearning for the lost object. The final and perhaps most anguished statethat he observed in infants was their detachment, a denial of the need foremotional ties altogether. A similar sequence has been noted in concen-tration camps, among prisoners of war, and among those who have beenpsychically overwhelmed by loss. Like the walking dead, such peoplemay fall into a marasmus in which hope is extinguished.
Bowlby (1969-1980) saw pathological mourning as akin to the firststage of healthy mourning: that of protest. Like the raging infant, an adultmourner for whom loss is permanent, may protest the loss and experience"anger and complaints that fester while love lies dormant" (Bowlby, 1961,p. 539). Unlike Freud, however, who viewed pathological mourning as aconsequence of unacknowledged hate toward the lost object, Bowlby sawpathological grief as involving hostility and hate toward the self.
Bowlby (1969-1980) described four kinds of pathological responses togrief. These include a persistent and unconscious yearning to recover thelost object, persistent and unconscious anger directed inappropriatelytoward others and the self, absorption in caring for someone else who isbereaved (projective identification), and denying that the object hasbeen lost.
For more than a decade, Bowlby (1969-1980) was particularlyinterested in the internal working models that children develop throughtheir real relationships to their primary caretakers. For infants in settingswhere there was both maternal rejection and neglect, and no substituteobjects for maternal caretaking emerged, permanent and irreversible egodamage could be the consequence. However, he may have confounded theeffects of institutionalization with the effects of loss, so that where sub-stitute care was offered consistently, the long-term consequences of per-sonality disturbances were less likely (Eisenberg, 1975).
Bowlby (1969-1980) further thought that children experiencepathological or chronic mourning that can look like depression. Theopposite side of pathological mourning may be total detachmentfrom loved objects that can look like the absence of grieving.Bowlby described four stages of grief:
1. Numbing. Initially the griever is numb and unable to feel theimpact of the death.
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2. Yearning and Searching. There is pronounced separation anxi-ety that prompts the mourner to try to find and recover the lost
. object. Repeated failures to restore the lost object may lead tothe next stage.
3. Disorganization and Despair.
4. Reorganization.
In reality, people do not grieve in such linear ways. Furthermore, many(Bonnana, 2001; Schucter & Zisook, 1993; Stroebe & Schut, 1987) havequestioned Bowlby's emphasis on protest, anger, and the expression ofnegative affects as important and normative aspects of the mourningprocess. In fact, minimal expression of negative emotion directed at thebereaved may reflect a healthy form of dissociation, in which the mourn-er moves in and out of awareness of the loss. In contrast to Bowlby andFreud then, a number of the more contemporary researchers (Bonnana,2001) have found that a minimizing of emotion is linked to reduced griefover time. This finding calls into question the degree to which theabreaction of emotion is necessary or desirable in grief and mourning.
Bowlby's work has been further elaborated through research onattachment (Ainsworth et al., 1978). Not all losses are the same; ratherloss is always mediated by the internal working models that constituteany individual's attachment style. Ainsworth described a range of attach-ment styles that characterize children and adults as mourners. Those whohave secure attachment styles are able to maintain clear and coherentmemories of others. Those with less secure attachment styles fall intothree groups. The first are those who are avoidant of attachment, or inadulthood are dismissive. They tend to suppress the need for others. Thesecond are those with anxious or preoccupied attachment styles. Theymay be highly expressive but unable to cope with and maintain coherentmemories in the absence of the other. The last group is referred to as"disorganized attachment" and includes those who cannot create an orga-nized narrative of the other in her absence. The latter two attachmentstyles are often found in people who have been traumatized and are veryimportant to assess in trying to understand the range of capacities formourning. Death is the loss of an attachment, and grief and loss will lookdifferent, depending on the mourner's attachment style.
Grief requires the capacity to maintain an inner representation of thedeceased, but there are ways in which the deceased continue to change,inside the mourner, while the mourner's relationship to the deceased alsochanges (Baker, 2001).
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ADAPTATION TO LOSS
In the 1940s in Boston, the Coconut Grove Fire broke out and hundredsin the nightclub were killed. Erich Lindemann (1944), a psychiatrist andpioneer in grief and mourning research, worked with the survivors of thistrauma and the family members of those killed in the fire. He was the firstto describe acute grief as a psychological syndrome and also enumeratedthe symptoms of normal grief, as distinguished from pathological orcomplicated grief. Drawing on previous concepts from drive, egopsychology, and object relations, Lindemann (1944) included in hisdescription of normal grief the expression of physiological symptoms,preoccupation with the image of the deceased, guilt feelings related to nothaving done enough for the deceased, hostility for other professionalswho had not rescued the deceased, and changes in patterns among thebereaved, for example, restlessness and irritability, as well as difficulty inorganizing activities and conducting social relationships. What he con-sidered to be pathological, or complicated grief reactions included thedevelopment of symptoms that represented an incorporation of the lostperson, overactivity or manic behavior, marked hostility without sadnessor apathy, or self-destructiveness. Lindemann (1944; 1979) also introducedthe concept of anticipatory grief, suggesting that those facing a loss ordeath may go through all the phases of grief, which may protect themourner or undermine the mourner's capacity to grieve. Lindemann'sviews on complicated grief, however, have been challenged on the basisthat it may not be at all pathological for the bereaved to express emotionand/or cry for long durations (Schuter & Zisook, 1982).
Parkes (1972/1993) also suggested that "normal" grief and loss mayprotect the mourner's ego. After a death, the mourner first experiencesshock, which may be accompanied by cries of extreme distress. To a largeextent, numbness shields the mourner from unbearable psychologicalpain. Gradually numbness turns into pain in which the mournerexperiences distress that includes a restless hyperactivity, difficulty con-centrating, a loss of interest in the outside world, and a pining for thedeceased. The mourner may seek connection to the lost person throughtransitional objects and phenomena: looking to objects of the dead orphotographs, all of which serve as ways of searching for the lost object.When the mourner cannot restore the lost person through pining orsearching, apathy may accompany despair and a kind of disorganizationmay be the consequence.
There are different sequences for the "pathological mourner" andParkes (1972) identified three forms of pathological grief: "chronic grief,"
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in which the mourner experiences prolonged grief with exaggeratedsymptoms; "inhibited grief," in which there appears to be an absence ofemotion, and "delayed grief," where the mourner's emotions are avoideduntil a later time. Bereavement researchers, however, have questionedwhether delayed grief and its longer duration predicts pathological griev-ing. In fact, the question of whether bereavement leads to pathology orreflects pre-existing pathology continues to be central to bereavementresearch. So many variables—the mourner's capacity for ambivalence,pre-existing capacity for mental representation, the ways in which theobject is experienced in the mourner's internal object world (Baker,2001), personality organization, internal object world, attachment style,capacity to tolerate ambivalent feelings—all, in addition to socioculturalfactors and social supports effect how any individual grieves (Middletonet al., 1993). No one theorist has yet been able to integrate them all.
CONSTRUCTIVIST VIEWS
Until now, this chapter has addressed ways in which grief may bepathological and/or transformative depending on who the mourner is, hercapacity for self and object representations, and the kinds of identifica-tions and introjections that either foster or undermine the mourner'spsychological structure. Much of the psychodynamic literature onbereavement, however, has overly emphasized the negative consequencesof loss and bereavement, and viewed mourning, depression, orcomplicated grief, as functions of previous difficulties, for example, earlylosses, insecure attachment patterns, personality disorders, excessiveaggression, poor adaptation, dependency, or detachment without examin-ing the ways in which people make meaning out of their losses.
A post-modern view of mourning sees grief as neither universal, noressential. There are no fixed stages in which mourners move in lock step.Instead people who are grieving are always active participants in theprocess. Grieving offers the mourner an opportunity to create a new nar-rative about the death and its meaning (Neimayer, 2001). All individualsconstruct meanings: personal, familial, cultural, and somatic, that arehighly variegated. The view that grief is an ongoing process of makingmeaning also suggests that grief is a process in which new roles, adapta-tions, and assumptions are created in relation to the person who has died.
Stroebe and Schut (1999) have shown that loss may actually benefitbereft individuals because they are forced to learn new strategies forcoping and living. Caplan (1974) noted how loss may lead to a changed
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sense of self, a changed sense of relationships, and a changed philosophyof life. Loss may produce existential and spiritual growth, and contributeto a sense of resilience in the mourner. That death may be transformativecalls into question a world view that suggests death should be overcome.
A post-modern perspective also deconstructs the ways in whichparticular values are embedded in our theories of mourning. For example,in a Western culture in which autonomy, independence, and separation arethe goals, it is not surprising that mourning is viewed as an inevitableseries of separations. But some mourners maintain ongoing relationshipsto the deceased (Klass et al., 1996) that promote resilience and strength inthe mourner. Rather than continuing bonds to the dead representing denialor unresolved mourning, they may represent strengths and contribute tocreating an ongoing dialogue and a coherent narrative about the personwho has died. For example, children who have lost a parent maintain aninternal bond to the person who had died. Memories of the parent do notstay fixed or static; they are active and ever-evolving internal representa-tions which change over time (Klass, Silverman, & Nickman, 1996).Merwit and Kllass (1997) studied adolescents who had lost a parent, andexamined the role the deceased continued to play in their lives.Adolescents, like younger children, maintain relationships to the dead inwhich the deceased act as (1) a role model with whom the adolescentmight identify, (2) a source of guidance in specific circumstances, (3)someone to help the adolescent clarify values, (4) a memory of someonewho brought feelings of comfort to the individual (Baker, 2001).Silverman and Nickman (1992) provide other dimensions along whichchildren construct continuing bonds with their dead parent. Clinicianswho conceptualize their work as helping the mourner to achieve autono-my from the person who has died, may miss the importance of themourner maintaining ongoing connections to the deceased that lead topositive changes in the mourner.
There is increasing emphasis, from a constructivist perspective, on thehighly variegated ways in which individuals construct meaning: personal,familial, cultural, somatic. Rather than view mourners as passive recipi-ents of death experiences (Neimeyer, 2000) bereavement offers themopportunities to construct new meanings about themselves andothers. The view that grief is constructed also suggests that grief is alife-long process in which new roles, adapations, and assumptions arecreated in relation to the person who has died. Constructivist views ofgrief de-center the individual self, and see the griever as multiple selveswithin the context of the individual, family, culture, and community. Inthis view, depression, denial, and anxiety are no longer seen as
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pathological by products of the grief experience, but instead as affects anddefenses intrinsic to the mourner's processes of constructing new mean-ings (Silverman, 2000; Baker, 2001; Bonnana, 1996; Normand et al ,1996; Merwit & Klass, 1996; Stroebe & Schut, 1999). Grief when treatedlike pathology, contains a prescription that there is a right way to grieveand an optimal time frame for bereavement. Grief becomessomething to be "worked through" or "resolved" (Stroebe & Schut, 1999;Worden & Silver (1989); Klass et al., 1996) instead of a process thatis ongoing.
Additionally, most mourners do not hold an either/or view of theperson who has died, but rather experience mixed feelings that arenormative. While Freud maintained that ambivalence could beproblematic, and Klein noted that inability to maintain ambivalencerepresented an early developmental failure, Rubin suggests that healthymourning always involves views of the deceased that are flexible and everchanging.
Stroebe and Schut (1999) have suggested that people cope with griefthrough a "dual process." Long-term adjustment to loss requires thecapacity to move back and forth between expressing grief and living life.For people who cannot move between those two positions, complicatedgrief is often the result. The idea that death may be transformative callsinto question a world view that suggests death should be overcome. Theidea that death offers new meaning and narrative incorporates dying as apart of living.
CULTURAL CONSIDERATIONS
The Western literature on grief and mourning, like so manypsychological theories, developed within a White, middle-class,Eurocentric, Anglo-Saxon world view. It is therefore important torecognize the degree to which the values of that context are embedded inideas of what is "normal "or what is "pathological." For example, inWestern cultures, the emphasis on separation and individuation leads, notsurprisingly to the view that grief is an event to be worked through andresolved, so that the griever can become free (read autonomous) to loveagain. In many Western cultures, the presence of the dead or communica-tion with the dead is seen as pathological. But other cultures may expressand work through their grief in ways where interconnectedness, notautonomy, is the end point. Grief and bereavement are not universal con-structs. They always represent the underlying values of the mourner'spoint in history, and are socially and culturally constructed.
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Western cultures place a great emphasis on talking cures, while otherimmigrant populations and some American subcultures do not value averbal, introspective, or intellectual approach to grief. People grieve inmultiple multicultural ways that often represent transitions betweencultures (McGoldrick & Rohrbough, 1987) and therefore cannot bestereotyped.
A multicultural perspective needs to respect the multiple ways ofdealing with loss. Certainly not every loss or death requires clinicalintervention. For example, it was assumed that all survivors of the WorldTrade Center collapse needed mental health counseling and many were"treated" as if they did. Grief was also "pathologized" by providingmandatory services to survivors and families without regard to needor culture.
Every culture has specific idioms and methods for dealing with death.Each culture and society has specific ways of expressing distress andemotions. These may include the time frame through which loss is to bedealt with and the ways in which the loss is experienced in the body ratherthan the psyche.
For example, it is well known that in Asian cultures, people rarelypresent grief as a complaint after a loss, but are much more likely to expe-rience the loss as a.somatic symptom: a pain in the belly or a wind in theheart- For Hispanic cultures, grief is often seen as a part of life, and afterdeaths are accepted, with the expectation that the mourner be strong. InHispanics cultures, however, the loss of a family member may also beseen as a threat to the interdependence of the family (McGoldrick et al.,1987), and when a child dies, death may be viewed as tragic. Latina clientsmay also experience bereavement somatically, experiencing attackswhich may look like seizures but which express a high degree of emotion.Aboriginal tribes may tear out their hair or mutilate their bodies (Stroebe& Stroebe, 1987). African Americans, whose world views are influencedboth by Christianity and African philosophy, may see death as God's will.In this context, death can be seen as emancipation from further sufferingon earth and as inaugurating a new life in another form. A life not dyingfor is a life not worth living (McGoldrick et al., 1991). At AfricanAmerican funerals, stoicism is considered pathological(Imber-Black, 1991).
For many cultures, grief work is not about resolving the loss as muchas it is about assuring that the fate of the soul of the dead will be honored.Many African Americans, Puerto Ricans, and Caribbean Islanders believethat the soul will not enter an afterlife until issues are resolved with the
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dead. Therefore at the end of life, the grief work is concentrated not onpulling away from the dead, nor on resolving unconscious conflicts, buton preparing the soul for an afterlife. The moumer invests in saying good-bye, and even pays off debts so that the deceased may enter the spiritworld (Corwin, 1995; Braveheart-Jordan, 1991). Many cultures believe inghosts and communicate with the dead accordingly. In many cultures,parts of nature are understood to embody aspects of the dead in the formof spirits that act as intermediaries between God and the living. ManyNative American, African, and Indian subcultures encourage contactingthe dead for help and counsel. Most cultures outside of a Eurocentric per-spective see the goal of mourning not as one of severing ties to the dead,but rather as maintaining a sense of spiritual involvement with the dead.
Hindu cultures believe in the transmigration of the soul. Sacrifice is anessential part of bereavement, and offerings are made from birth to deathto ensure the dead's entrance into Nirvana. Here one does not talk aboutthe person who has died. In fact, it is honorable to separate emotionsabout the deceased from every day life (McGoldrick et al., 1991).
There are vast cultural differences in mourning practices as well. InJewish culture, mourning begins as a full week of commemoration for thedead person. In this tradition, the family comes together, a part of theirgarments is torn, and they sit on low wooden chairs. Some mourners wearno leather.. Mirrors are covered in cloth to discourage focusing on appear-ance. Men do not shave for the first month after a death and women wearno makeup. During this week of shiva, mourners await the presence offriends, neighbors, and other extended kin who arrive with food and sto-ries, which are told and retold. After 30 days, the mourner returns to lifebut recites the Kaddish, or prayer for the dead, daily, for a year. At the endof 11 months, the deceased is commemorated by unveiling a headstone,which signals the end of the mourning period. These rituals encourage themourner to immerse him/herself in the loss for a carefully prescribed peri-od of time. In Jewish cultures, suffering is a shared value. One railsagainst the unfairness of a death, and the orientation at this time is not tothe future, but to the present.
Native Americans may deal With loss and dying by attending sweatlodges where a person who has difficulty in mourning may be expectedto sweat out bad memories of the deceased. Where there are symptomssuch as nightmares or anxiety, sitting in the nude and sweating maypromote the release of an old identity and the creation of a new one.
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CONCLUSION
Grief and mourning are obviously complex psychological and socialphenomena that are neither linear nor are they universal. Each individualis a product of her culture, gender, race, ethnicity, social class, and envi-ronmental surround. While psychodynamic theories offer rich ways ofentering into the individual's psyche to explore the degree to which lossundermines or transforms character and identity, they do not suffice toexplain universally how grief, loss, trauma, and mourning are experi-enced. Freud was central in beginning the discourse on how loss could notonly affect, but actually change, the mourner, sometimes leading to inter-nalization of the lost object as a part of the self. Under the best ofcircumstances, this could enrich the ego. Where the relationship with thelost object had been problematic, internalization could lead to depressionor complicated mourning. Klein (1940) and Winnicott (1953/1971)provided ways to understand behavior in light of the loss of a real object,not only through death, but through separation. Bowlby (1969-1980)offered ways of understanding a range of reactions to loss and separationby emphasizing the primacy of attachment to loss, and helping toelucidate the yearning and searching aspects of grief and mourning.Lindemann (1944) and Caplan (1964) offered ways to understand theadaptive nature of grief and mourning by looking at how the moumermight make sense of traumatic circumstances that shake one's confidencein the stability of everyday life. Jacobs, Mazure, and Prigerson (2000),Parkes (1972), and Lindemann (1944), have suggested that deaths maylead to psychiatric sequelae manifesting as PTSD and depression. Others(Neimeyer, 2001; Engel, 1961; Silverman, 2000) have called into questionthe medicalization of grief, and pointed to the complex ways in whichdeath and loss require individuals to maintain ongoing relationships withthe deceased, leading to a new and more coherent life narrative.
Grief can undo the mourner, resulting in persistent self-hate or blame.Grief can be traumatic, resulting in a range of symptoms. Grief can under-mine psychic functioning. But grief can also change the mourner: throughidentification and internalization, through the internal representations ofthose who were lost, and through maintaining continuing relationshipswith the deceased. The mother who lost a daughter who had been a writerand then became a writer, the widow whose husband died during a polit-ical campaign and took on his career by advocating for women's rights,the sister who lost her sister and began an end-of-life program and wrotea book, the parents whose values changed in the act of forgiving their
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daughter's murderers—all these demonstrate ways in which grief andmourning may change the mourner (Silverman, 2000). Not everyone runsfor the senate, becomes a writer, or begins an end-of-life program, norshould they. But grief can be transformative in ways that promotepsychological growth. Grief may heighten our appreciation for living(Cassem, 1975). Adversity and loss may change who we are and how wesee ourselves in relation to the deceased. Anne Morrow Lindbergh(1973, p. 212) observed:
I do not believe that sheer suffering teaches. If suffering alonetaught, then all the world would be wise, since everyone suffers.To suffering must be added mourning, understanding, patience,love, openness and the willingness to remain vulnerable.
While none of us ever welcomes grief or bereavement, both areinevitably parts of living and in this way shape the mourner.
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