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Clinical Meeting: On Death and Dying: research|notes|quotes

MndaOn a cold March evening, with winter chill still in the air and hope for Spring’s new life not yet in London, Hephzibah Kaplan thoughtfully presented the following topic, Death and Dying at the London Art Therapy Centre clinical meeting. Those in attendance were invited to consider how death can be recognised, processed and philosophised in many different manifestations of grief. When considering a client’s perspective of death, it is paramount for a therapist to allow space and time for learning from the client their personal position on death, be it secular or spiritual or perhaps not yet even defined for them. Also of great importance is the therapist’s own feelings for what death means to them and what beliefs and experiences of death they have encountered in life.

Presented in the meeting was the conventionally accepted, Kubler-Ross “On Death and Dying” (1969) theory that grief is processed through five stages; denial, anger, bargaining, depression and acceptance. While this model is commonly acknowledged by the general public, of significance is that these stages are not to be considered linear or time constrained. While not backed up with vigorous research, many find the Kubler-Ross model useful for giving containment to overlapping and messy feelings associated with grief and has been applied for processing not only loss through death but also to other forms of finite endings.

In considering grief as both a normal and healthy response to death, Worden’s (1991) term of “normal grief” occurs when a person’s experience is uncomplicated while still encompassing a broad range of feelings and behaviours common after a loss. With these, many features described by Lindermann (1944) may occur such as; bodily or somatic distress, preoccupation with the image of the deceased, guilt related to the circumstance of the death and an inability to function as one had prior to the loss. Each person processes grief in a unique way with wide ranging differences and behaviours from intense to mild reactions and expressions. Parker & Weiss (1983), Walter (199) and Worden (1991), site that the length and intensity of the grieving process may be determined due to situational, social and personal variables affecting each person’s grieving process. In Normal Grief many feelings and emotions can arise including; loneliness, fatigue, helplessness, yearning, emancipation relief and numbness. Physical sensations while often overlooked can be expressed as hollowness is stomach, heavy and repeated sighing, tightness in throat and/or chest, aching , over or under eating, fatigue or insomnia, muscular weakness, tension and irritability. Cognitions and thought patterns marking the grief experience can include, disbelief, confusion, preoccupation with the deceased, a sense of presence of the deceased and even hallucinations. Behaviours during the grieving process may include; sleep disturbances, appetite disturbances, absentminded behaviour, social withdrawal, searching and calling out, sighing, restless over-activity, crying, visiting places or carrying objects that remind the survivor of the deceased. With all of these aspects of the normal grieving process, children and adults are considered to have an innate ability to work through the pain and grief of a bereavement. Acceptance and caring have been shown to assist the healing process.

As part of coping with grief Kenneth Doka was presented as having identified the following tasks to grief; to understand and make sense of what has happened, to identify and express emotions, to commemorate the life that was lived and to learn to go on living and loving. Doka offed as Adaptive Coping Skills; crying, talking, writing, reading, sharing memories, and utilising friends and support systems with Pathological Grief Reactions sometimes experienced as; an inability to return to daily routine, total lack of affect, hallucinations, suicidal ideation/plan, parental neglect, alcohol or drug abuse, hostile behaviour and/or prolonged isolation. Complications of unresolved grief were acknowledged as having increased over the past twenty years with a corresponding growth in counselling support. In turn newer awareness to underlying causes of various physical and mental conditions are now considered to be linked to unprocessed or delayed grieving. Many clinical studies lend support to hypothesis that unresolved grief is associated with substantial mental health hazards, including an increased incidence of mental health problems or clinical magnitude (Averill, 1968; Barrett& Scott, 1989; Carey, 1977; Clayton & Darvin, 1979; Parkes & Weiss, 1983).

While a number os studies point to the impact of grief on morbidity and mortality (Helsing & Szklo, 1981; Jones, 1987; Kapiro & Koskenvuo, 1987; Osterweis, Solomon, & Green, 1984, Parkes, 1986; Stroebe & Stroebe, 1987) with 15-21% of outpatients at mental health clinics suffering from unresolved grief leading to their presenting symptoms of anxiety or depression (Rando 1991). Investigators Yalom and Vinogradov (1988) and Lieberman and Videka-Sherman (1986) have stated that recently widowed are prone to increased incidence of poor physical health for a year or more after a loss. Adding to complications of grief can be, while potentially well intended, vacuous, cliché, minimising and judgmental comments from others.

It is considered that the recently bereaved represent the at-risk population with unresolved grief precipitating depression and low self-esteem in many people, and over time this could lead to substance abuse and suicidal ideation, which will require more extensive, long-term therapy (McCrae & Costa, 1988; Yalom and Vinogradov, 1988; Leick & Davidson-Nielson, 1990; Worden, 1991). Additionally, unresolved grief can lead to increased physical health problems and ultimately death (Helsing & Szklo, 1981; Windholtz, Marmar & Horowitz, 1985). With timely therapeutic intervention many of these psychiatric, psycho-social and somatic complications could be reduced. Therapeutic intervention aids the mourning process when conducted with a calm, present, compassionate, non-intrusive and non-judgemental stance.

Central to the discussion of the mourning process is an understanding of grief as a necessary normal and universal response, as well as a time for healing, adaptation and growth (Melges & DeMaso, 1980; Moos, 1995; Viney, 1991). Worden (1991) states that the process of mourning is necessary after one sustains a loss, and views it similarly to the process of healing, a course that takes time until restoration of function can take place. He states that there are certain tasks of mourning that must be accomplished for equilibrium to be reestablished. Furthermore, the process of mourning needs to be completed since uncompleted grief tasks can impair further growth and development.

Mourning is a long-term process, and the culmination will not be the pre-grief state (Worden, 1991). The mourning process is completed when a person is able to: reinvest his or her emotions back into life and in the living; think of the deceased without intense pain; integrate their experience of loss into their life; and move toward investing in a new life without the lost loved one (Worden, Leick and Davidsen-Nielson, 1991). Worden (1993) refers to the term “mourning” to indicate the process which occurs after a loss, while “grief” refers to the personal experience of the loss. For the bereaved, the models of grief work can serve both as compasses which show the direction of their path at a particular time, and as topographical maps revealing the landscape of grief’s highs and lows. Bereavement is a normal process during which people mourn the loss of their loved ones and heal sufficiently to continue life without them. Several models of Grief Work, Stages, and Phases have been proposed and models regarding the process of grief abound and depend on the writer. 3 to 12 stages or phases of grief are described (Attig, 1991; Bowlby, 1980; Corr, 1991; Rando, 1984) while Sigmund Freud (1957) began the concept of having to do ‘grief work’, that is, a specific job should be finished before the next job begins.

According to Kubler-Ross, the stages of denial, anger, bargaining, depression, and acceptance as described in On Death and Dying (1969) are experienced not only by those dying, but by families and friends while grieving. Emotional reactions may also involve shock, numbness, and pain. Allowing time and space to externalize such feelings facilitates dealing with loss and moving on with life’s activities. In the course of bereavement, these stages often acts as defense mechanisms helping the bereaved cope with extremely difficult situations. Kubler-Ross lists the stages of grief in a specific order, however, in the normal process of grief, they last for different periods of time, will replace each other, overlap or exist at times simultaneously.

As an antidote to what many came to perceive as a kind of passivity inherent in the stage model of grief, Worden (1991) developed a more active grieving model which defined four tasks necessary for the individual to complete. Worden states: “Phases imply a certain passivity, something the mourner must pass through. Tasks, on the other hand are much more consonant with Freud’s concept of grief work and imply that the mourner needs to take action and can do something” (p.35). Each person will react differently to loss, but in general, the work of bereavement entails the following developmental tasks:

1. To accept the reality of the loss. At first, people may react to the death of their loved one with numbness, shock and denial. The first task of grieving is to come to acknowledge and realize that the person is dead. This task takes time because it involves an intellectual acceptance as well as an emotional one. Traditional rituals, such as the funeral, help many bereaved people move toward acceptance.

2. To work through to the pain of grief. It is necessary to acknowledge and work through the pain associated with loss or it will manifest itself through others symptoms or behaviours. Not everyone will experience the same intensity of pain or feel it in the same way. One of the aims of grief counselling is to help facilitate people through this difficult second task so they don’t carry the intense pain with them throughout their life.

3. To adjust to an environment in which the deceased is missing. Adjusting to a new environment means different things to different people depending on what the relationship was with the deceased. The bereaved may feel lonely and uncertain about a new identity without the person who has died. This loss confronts them with the challenge of adjusting to their own sense of self.

4. To emotionally relocate the deceased and move on with life. Individuals never lose memories of a significant relationship, yet eventually grieving individuals need to look forward and continue with their lives. They may need help in letting go of the emotional energy that used to be invested in the person who has died, and they may need help in finding an appropriate place for the deceased in their emotional lives. Completing the necessary grief work enables them to focus less on the loss and connect with other people by investing new energy in ongoing relationships.

In summary, models of the grief process can be viewed as “generalized maps”, in that each theory is an attempt by an investigator to understand and guide the grieving individual through their pain. However, humans are unique and cannot be forced into particular patterns of behaviour. Each individual will travel through grief at his/her own speed using an appropriate route.

Grief Counseling

When a loved one dies, those left behind often need help getting through the pain and need support to encourage healing. The bereaved are at-risk for future physical, emotional and social problems, especially if they have difficulty coming to terms with their grief and reinvesting in the future. Counseling can help to offset the detachment, isolation and depression so often experienced by people who have lost a loved one (Bayer, 1984). Because of the loneliness often associated with bereavement, this work is particularly suited to groups (Burke and Gerraoughty, 1991).

Lattanzi and Coffelt (1979) and Worden (1991) have identified certain principles that help make grief counseling more effective. These include:

1. Acknowledge the Loss. Assist the individual in acknowledging and accepting the loss by finding time to grieve and share feelings with others.

2. Identify and Express Feelings. This discussion should involve a balance between expressing “positive” and “negative” feelings toward the deceased. Regret, anger, guilt, helplessness, sadness and existential questions are all part of normal bereavement.

3. Facilitate Emotional Relocation of the Deceased. Assist individuals to overcome obstacles that prevent them from letting go of the loss and readjusting to life. Assist individual in gaining skills for living without the loss relationship by helping them to focus on life without the deceased. This entails reconstructing new life meaning and accepting a new identity as well as filling the void in their lives by exploring new activities and recognizing that life can have meaning again.

4. Identify the Normal Continuum of Grief. Educate grieving individuals about typical grief reactions in an effort to normalize their experience.

5. Allow for Individual Differences. Bereavement is an individual experience, with no right or wrong way and no set time for completion. It is essential to acknowledge and value the individual differences during the grief process.

6. Access to Ongoing Support. Ideally, grief counseling should be available for a full year following the loss. The most difficult transitions during that year are likely to be holidays, birthdays and anniversaries. Helping the bereaved to get through these milestones can greatly assist their future adjustment.

7. Exploration of Coping Skills. With an expanded repertoire of coping skills (i.e. meditation, relaxation, art making), grieving individuals will be able to more effectively deal with the stress of bereavement.

8. Recognition of Extreme Difficulties and Make Referrals.

According to Simon (1981), bereavement art seems to represents an attempt to work through the conflict and usually occurs in three overlapping stages. The first stage consists of expression of the conflict, bringing closer to consciousness the feelings that lie behind the sense of stress. In the second stage the art provides an image that enables the suffering of the expressive stage to find containment as it is slowly converted into mourning. The third stage brings resolution and the client comes to view death tranquilly as the natural end of life and is able to use initiative to better effect in his/her life.

Some Research on Grieving

Grieving individuals are faced with overwhelming feelings and without proper support these intense feelings can lead to low self-esteem, depression, suicidal ideation and/or physical illness (Stroebe & Stroebe, 1987; Vachon, Sheldon, Lancee, Lyall, Rogers & Freeman, 1982; Windholz, Marmar & Horowitz, 1985). It has been found that many grieving individuals respond more quickly using creative arts therapies than through traditional verbal therapy (Irwin, 1991; Junge, 1985; McIntyre, 1990; Simon 1981).

Generally, in today’s fast-paced society there is little time, space or support available for the grieving individual (Rosenblatt, 1988). During the period of grief, the physical and emotional well-being of the bereaved individual may be threatened (Carey, 1977; Clayton & Darvish, 1979; Parkes and Weiss, 1983; Osterweis, Solomon & Green, 1984; Rogers & Reich, 1988; Parkes, 1990). Health risks and psychological problems can be lessened and/or avoided if proper support and help is made available (Leick & David-Nielsen, 1990; Lieberman & Videka-Sherman, 1986; Nerken, 1993; Sanders, 1992; Rando, 1984; Reif, Patton, & Gold, 1995). Therefore, it is important to provide grieving individuals with emotionally supportive interventions in order to prevent long-term problems.

In the past, communities came together to support and help those who experienced a death in the family (Rosenblatt, Walsh & Jackson, 1976). Today, individuals are often isolated from extended family members and the community (Platt & Persico, 1992). As a result, grieving individuals feel alone in the grief process and often experience a lack of adequate support (Rodgers & Cowles, 1991). Bereavement support groups offer individuals the opportunity to share thoughts and feelings with others. Sharing within a supportive network can be of great help during this difficult time (McCallum, Piper & Morin, 1993).

Many researchers and practitioners have found that some type of involvement or participation in bereavement support groups is beneficial, useful or meaningful to this high-risk population (Levine, Toro & Perkins, 1993; Levy & Derby, 1992; Longmann, 1993; Marquis, 1996). Benefits from support group involvement include increased emotional, mental and physical stability during and after participation (McCallum, Piper & Morin, 1993; Thuen, 1994; Zimpfer, 1990; Yalom & Vinogradov, 1988). More specific benefits of group participation include: 1) feeling that one has a better understanding of the grief process; 2) feeling that one has a safe place in which to express one’s emotions, developing better stress management skills; 3) being better able to cope with loneliness, developing support systems; and 4) improved self-esteem (Souter & Moore, 1989; Rognile, 1989). According to Worden (1991), bereavement support groups can provide one of the most efficient ways possible to work on or resolve incomplete mourning and to prepare the person to move forward with life.

The benefits of group support can be increased substantially with the addition of art therapy (Raymer & McIntyre, 1987; Schimmel & Kornreich, 1993; Schut, de Keijeser, van den Bout & Stroebe, 1997; Speert, 1993). Art therapy is a modality well-suited to the needs of grieving individuals (Aldridge, 1993; Malchiodi, 1991). Since many individuals are unable to fully express their feelings of grief through words, art therapy offers them a unique opportunity to express their feelings non-verbally through the use of art materials (Simon, 1981; Borden, 1992; Zambelli & DeRosa, 1992). Through art making and sharing in a group setting, individuals begin to understand their own difficulties and their individual strengths as well as discover new possibilities to cope with their loss (Grant, 1995; Graves, 1994).


Art making, by nature of its two-step process of expression and reflection, allows both the isolation of internal focus and the connection with others. As the visual symbols of loss are shared with others in the group, they also promote deeper self understanding as well as connection. Participants have the opportunity to demonstrate these elements of cooperation, creativity and re-creating of their personal vision by experimenting with art media.

Many art therapists and grief counsellors are increasingly utilizing the group workshop format in place of individual therapy because they find the group therapy format provides more reflective surfaces to both contain and mirror each individual’s experience of loss and validate his/her sense of self (Birnbaum, 1991; Lane & Graham-Poole, 1994; Sontag & Henry, 1994; Speert, 1993; Zamierowski & Gorden, 1992). As Surrey (1991) observes, “the joining of visions and voices creates something new, an enlarged vision thus the sense of connection and participation in something larger than oneself does not diminish, but rather heighten the sense of personal power and understanding” (p. 172).

In summary, the creative experience of making art during the time of traumatic loss provides a tremendous opportunity for self exploration, healing and growth. Art therapy can support the individual’s need to express and creatively transform the issues of grief and can help prevent some of the psychological, social and behavioural problems resulting from unresolved grief. Additionally, the values of empathy and connection are enhanced by the process of creating art together in a group format.

Reference – Thanks to this very useful website from where much of the above came – Malinda Hill

Write-up by clinical meetings co-ordinators, Colleen Steiner Westling and Mirella Issaias

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