Grief: Lessons from the Past, Visions for the Future

Abstract

Over the last millennium patterns of mortality have changed and have determined who grieves and how. At all times grief has been recognised as a threat to physical and mental health. More recently the scientific study of bereavement has enabled us to quantify such effects and to develop theoretical explanations for them. This paper reviews our evolving understanding of grief, focusing especially on the developments in research, theory and practice that have taken place during the twentieth century. Wars and similar conflicts are associated with repression of grief but methods of helping by facilitating its expression, which were introduced during the two World Wars are less needed and effective at other times. In recent years more attention has been paid to the social context in which grief arises and, particularly, to the nature of the attachments which precede and influence the reaction to bereavement and to other traumatic life events. At the same time a range of caring resources have become available and acceptable to bereaved people and the results of scientific evaluation of these give promise that we are moving towards an era in which more sensitive and appropriate care will be provided to the bereaved by both voluntary and professional caregivers.

Full text

Psychologica Belgica
2010, 50-1&2, 7-26.
—————
Colin Murray Parkes is Consultant Psychiatrist Emeritus at the St Christopher’s Hospice,
Sydenham, UK.
This manuscript is an adapted and updated version of an article first published by the author
in 2002 in Death Studies, 26, 367-385.
Correspondence concerning this article should be addressed to Dr. Colin Murray Parkes, 21
South Road, Chorleywood, Herts., WD3 5AS, U.K. E-mail: cmparkes@aol.com
GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
Colin Murray PARKES
St Christopher’s Hospice, Sydenham, UK
Over the last millennium patterns of morta lity have changed and have
determined who grieves and how. At all times grief has been recognised as
a th reat to physical and mental health. More recently the scientific st udy of
bereavement has enabled us to quantify such effects and to develop theo-
retical explanat ions for them. This paper reviews our evolving understanding
of grief, focusing especially on the developments in research, theory and
practice that have taken place during the twentieth century. Wars and simila r
conflicts are associated with repression of grief but methods of helping by
facilitating its expression, which were introduced during the two World Wars
are less needed and effective at other times. In recent years more attention
has been paid to the social context in which grief arises a nd, particularly, to
the nature of the attachments which precede and influence the reaction to
bereavement and to other traumatic life events. At the same time a ra nge of
caring resources have become available and acceptable to bereaved people
and the results of scientific evaluation of these give promise that we are
moving towards an era in which more sensitive and appropriate care will
be provided to the bereaved by both voluntary and professional caregivers.
Grief in the last millennium
Written over a millennium ago, the poem ‘Beowulf’ records the reaction
of his subjects to the death of the hero/king, Beowulf, who died of wounds
after slaying the Firedrake, a dragon 50 feet long.
“The people of the Geats then made ready for him on the ground, a rm-
built funeral pyre, hung round with helmets, battle shields, bright corselets
as he had bid them do. Then mighty men, lamenting, laid in its midst the fa-
mous prince, their beloved lord. …the roaring ame mingled with the sound
of weeping. Depressed in soul, they uttered forth their misery, and mourned
their lord’s death… Heaven swallowed up the smoke.
Then the people of the Geats raised a mound upon the cliff, which was
high and broad and visible from far by voyagers on sea… the warriors, brave
in battle, …rode round the barrow; they would lament their loss, mourn for
their king, utter a dirge and speak about their hero. They reverenced his man-
DOI: http://dx.doi.org/10.5334/pb-50-1-2-7

8GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
liness, extolled highly his deeds of valour – so it is meet that man should
praise his friend and lord in words, and cherish him in heart when he must
needs be led forth from the body” (Hall, 1950).
It seems that, in the late 8th century, even warriors could cry when their
great chief died and that it was seen as right and proper for them to talk of
him and praise his great deeds. Many barrows were raised in Britain above
the dead to ensure that they were not forgotten.
Of course, this was the privilege of the great and important dead. Humble
folk had humble graves then, as they do now. We tend to think of it as normal
to die in old age, but the rst millennium was a time of strife and early death.
Few people survived to old age and the greatest mortality was in the rst year
of life. This melancholy fact remained true until the last hundred years in the
West and is still the case in the so-called Third World. During most of the
millennium many deaths took place in infancy and it was sometimes said that
you were not a woman until you had lost your rst child. In this day and age
the death of a child is recognised as one of the most traumatic experiences
and we all view the very thought with horror.
Were our predecessors psychologically scarred by all these horrors? I
think not. Very little was written about the death of children and essayists,
such as Montaigne (1603), in 1580, can write “I have lost two or three chil-
dren in their infancy, not without regret, but without great sorrow”. One is
reminded of the recent research of Nancy Sheper-Hughes (1992) among the
poor people of North-East Brazil, where the infant mortality rate is still very
high. She entitles her book Death Without Weeping and records her own
sense of shock when, in great distress, she told a mother that the baby she
had been taking to hospital had died. The mother, surprised at her distress,
reassured her “It’s only a baby!”. In such cases there is no funeral. The baby is
entrusted to a procession of children who carry the body to the cemetery for
burial. It is believed that the souls of dead babies are immediately promoted
to become cherubs in heaven and it is they who welcome their mother when
she comes to join them. Some mothers boast of the number of cherubs they
have contributed.
But we would be wrong to assume that the deaths of infants inoculated
people against the effects of other griefs. There is plenty of evidence that
other types of bereavement, including the death of older children, could have
devastating effects. Montaigne (1603) also describes the reaction of John,
King of Hungaria, to the death of his son: “He only, without framing word or
closing his eyes, but earnestly viewing the dead body of his son, stood still
upright, till the vehemence of his sad sorrow, having suppressed and choaked
his vital spirits, fell’d him stark dead to the ground”.
The idea that you can die of a broken heart goes back to Biblical times and
we nd ‘griefe’ listed as a cause of death in Heberden’s (1657) statistics of

9
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causes of death for the city of London in 1657. But it was not until my own
statistical study with Benjamin and Fitzgerald was published in 1969 that
clear evidence of an increased mortality rate from heart disease was found
among widowers during the rst year of bereavement (Parkes, Benjamin, &
Fitzgerald, 1969). Since then several other studies have conrmed the nding
and indicate that men are more likely than women to die of a ‘broken heart’.
In 1621, when Robert Burton published his inuential Anatomy of Melan-
choly, he adopted the classical humoral system which attributed Depression
or ‘Melancholy’ to an excess of ‘Black Bile’. But the ow of bile could also be
caused by grief and Burton (1621) describes grief or sorrow as “The epitome,
symptome and chief cause of melancholy”. In this he preceded Freud and
Lindemann by 200 years.
Vogther in Altdorf (1703) published a Ph D thesis entitled De Morbis Mo-
erentium, which translates as ‘The Illnesses of Grief’ or, to use modern lan-
guage, ‘Pathological Grief Reactions’. He lists a number of prescriptions for
grief. It seems that the idea that bereavement can cause mental illness goes
back a long way.
Coming closer to the present day, in 1835 we nd the American physician
Benjamin Rush, one of the signatories to the Declaration of Independence,
describing dissection of the body of persons who had died of grief. He found
“Inammation of the heart, with rupture of its auricles and ventricles” (Rush,
1835). This alarming nding caused him to recommend that “Persons af-
icted with grief should be carried from the room in which their relatives
have died, nor should they ever see their bodies afterwards.” He went on to
prescribe “liberal doses of opium”.
Rush’s recommendations do not seem to have deterred bereaved people
from adopting ever more amboyant customs of mourning during Queen
Victoria’s reign. In 1853 there were no less than four ‘Mourning Warehouses’
in London’s Regent Street (Morley, 1971, p. 73). Victoria’s own grief for the
death of her husband Prince Albert was severe and protracted.
Grief in the twentieth century
According to Geoffrey Gorer (1965), it was the rising death rate in the
trenches during the rst World War that put paid to shows of mourning. By
the time the war ended the ‘stiff upper lip’ had become the ideal and grief
was under rm control. Repression of grief is not uncommon among warriors
and other people at time of war.
And so we come to Sigmund Freud, whose classical paper, ‘Mourning and
Melancholia’, written in 1917, proposed that grieving or ‘mourning’, as it was
inaccurately translated, is a job of work in the course of which emotional en-

10 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
ergy, or libido, is withdrawn from a loved person before it can be re-directed
elsewhere. “When the work of mourning is completed,” he wrote, “the ego
can become free and uninhibited again.” He also compared grief to clinical
depression, or ‘melancholia’, and suggested that, although depression resem-
bles grief, its causes are symbolic rather than real losses and that their roots
are to be found in earlier traumatic experiences (Freud, 1953).
Freud’s paper had much inuence on the psycho-analytic theory of depres-
sion but it was not until the end of the second World War that its relevance for
bereavement was given further attention. At this time two important papers
were written. The rst, in 1944 by Eric Lindemann, described ‘The Symp-
tomatology and Management of Acute Grief’ and provided a clear account
of the reaction to bereavement, its short-term course and the treatment of
the problems that arise when it is delayed or distorted. Lindemann was a
psycho-analyst and he found conrmation in his work with bereaved people
for Freud’s theory of repression. In his view “The essential task of the psy-
chiatrist is that of sharing the patient’s grief work.” This, he claimed, could
be done in 8-10 interviews. He also acknowledged the possibility that this
work could be done by non-psychiatrists and, in doing so, sewed the seeds of
bereavement counselling (Lindemann, 1944).
Lindemann’s approach led to great enthusiasm for Bereavement Counsel-
ling, most of it based on the naïve assumption that all the counsellor needed
to do was to encourage the bereaved person to express grief, or ‘do the grief
work’. In recent years, however, a number of random allocation studies have
shown that most bereaved people do not need and will not benet from such
counselling (Currier, Holland, & Neimeyer, 2007; Forte, Hill, Pazder, &
Feudtner, 2004; Schut, Stroebe, van den Bout, & Terheggen, 2001). Fortu-
nately they also show that, for the minority who are at special risk, appropri-
ate interventions can be successful.
From the outset it was apparent that there were limitations to Lindemann’s
theory. In 1949 Anderson, in the UK, published an account of the psychiat-
ric consequences of bereavement in which he described a type of problem
that had not been given weight by Lindemann and which was not so easily
explained. This was the Prolonged Grief Disorder (PGD) and it was, and
remains, the most frequent diagnosis among people seeking psychiatric help.
People with PGD do not show any signs of repressing their grief, rather they
grieve intensely from the start and continued to do so long after they are
expected to stop grieving. Anderson’s work did not have the same impact as
Lindemann’s, perhaps because it did not come up with a simple solution to
the problem.
Lindemann’s work triggered a great deal of interest in the topic of be-
reavement, which has continued to this day. Any attempt to summarise the
research that has followed must pick and choose between a large number of

11
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contenders and I apologise if my own review is highly selective and misses
out your favourite paper.
My own interest in the subject arose when, as a trainee psychiatrist, I met
two people who had been admitted to the Maudsley Hospital for treatment
of depression following bereavement. Reading what literature there was on
the subject alerted me to the possibility that the study of bereavement might
make a useful contribution, not only to our understanding of bereavement but
of the many other stresses that contribute to cause mental illness.
My rst study was focused on people seeking psychiatric help after be-
reavement and was published in 1965. It showed that bereavement could
trigger a wide range of psychiatric disorders, of which affective disorders
were the most frequent. It also showed that a minority of these patients were
suffering from the forms of pathological grief which had been described by
Lindemann and by Anderson. It conrmed Anderson’s claim that PGD was
more frequent than delayed grief.
Part of the problem faced by researchers at this time was the absence of
any systematic studies of normal or uncomplicated grief. What was the range
of normality, how long did grief last, was there a pattern to it? In 1962 John
Bowlby, who was studying the reactions of small children to the experience
of separation from their mothers, invited me to join his unit at the Tavistock
Institute of Human Relations. Here I was able to study a relatively unselected
sample of young women who had lost their husbands through the course of
their rst year of bereavement.
Robertson and Bowlby (1952) had observed that young children separated
from their mothers expressed a distinctive pattern of grieving moving in se-
quence from a phase of acute Separation Anxiety, in which they cried a great
deal, to a period of Disorganisation and Despair to a nal phase of Recovery
in which they began to reach out to others and make new relationships. I
found something very similar in my own study of young widows, the only
difference being that many widows reported an initial phase of Blunting or
Numbness which preceded the phase of crying and yearning. From the start
Bowlby and I recognised that there was a great deal of individual variation
in the response to bereavement and that not everybody went through these
phases in the same way or at the same speed (Bowlby & Parkes, 1970).
It was in 1964 that I visited the United States for the rst time. I had read a
paper on ‘The Dying Patient’s Grief’ by Prof. Knight Aldrich (1963) in Chi-
cago and he invited me to speak about my own studies of bereavement at
Billing’s Hospital. Here I met a remarkable young trainee working, in his de-
partment, on the problems of cancer patients. Her name was Elizabeth Kubler
Ross and she subsequently adapted Robertson, Bowlby and Parkes’s (Bowlby
& Parkes, 1970; Robertson & Bowlby, 1952) Phases of Grief to describe the
Phases of Dying (Ross, 1970). I mention this because Kubler Ross has some-

12 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
times been credited with discovering the Phases of Grief as well as the Phases
of Dying. Both of these concepts have subsequently given rise to a fair amount
of controversy and several alternative models have been described.
While working at the Tavistock I had met Gerald Caplan who played a large
part in the development of Community Psychiatry in the USA. His name is
associated with Crisis Theory and he was a friend and colleague of Eric Lin-
demann. Gerald invited me to join his unit at Harvard for a year in order to
direct the Harvard Bereavement Project. This was a systematic short longi-
tudinal study of unselected widows and widowers over the rst four years of
their bereavement. Its aim was to discover why some people did well after
bereavement and came through without the need for help from outside their
families while others did not. It enabled us to identify risk indicators, which
could be used to recognise people before or at the time of a bereavement who
were at risk of problems later. We also described the characteristic reactions
that followed sudden, unexpected and untimely deaths, the deaths of partners
on whom the bereaved person had been very dependent and the conicted grief
of people whose relationships were highly ambivalent (Parkes & Weiss, 1983).
Since that time many other researchers have contributed to our under-
standing of bereavement risk. The current thinking is summarised in the
table below. Of particular note is Doka’s category of Disenfranchised Grief
(1989). This arises in situations in which, for various reasons, grief is dis-
couraged and social supports are absent.
Table 1
Risk factors in bereavement
Mode of Loss
Sudden or Unexpected Losses for which people are unprepared.
Multiple Losses.
Violent or Horric Losses.
Losses for which the person feels responsible.
Losses for which others are seen as responsible.
Disenfranchised Losses (i.e. losses that cannot be acknowledged or mourned).
Personal Vulnerability
Dependent on Deceased Person (or vice versa).
Ambivalence to Deceased Person.
Persons lacki ng in self-esteem a nd/or trust in others.
Persons with previous history of psychological v ulnerability.
Lack of Social Support
Family absent or seen as Unsupportive.
Social Isolation.

13
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While in the USA I received a visit from a physician whom I had previously
met in London. She was Cicely Saunders and she brought with her the plans
of a new kind of therapeutic community for people with late-stage cancers. I
was most impressed by her work and delighted when, in 1966, she invited me
to join her in setting up support services for the families of her patients.
St Christopher’s Hospice provided a test bed in which I was able to make
use of the ndings from the Harvard Study to identify family members at
risk and to offer them the help of a carefully trained and selected volunteer
counsellor. The idea of sending volunteers into the homes of newly bereaved
people proved controversial, even at St Christopher’s. It was only after the
suicide of a young widow of one of our patients that I was able to persuade
the staff to let me carry out a random-allocation study in order to nd out if
we were doing good or harm. Fortunately for me the results of this study con-
rmed the value of our intervention (Parkes, 1981). The effect of the coun-
selling was to improve outcome as measured by a shortened version of the
Health Questionnaire used in the Harvard Bereavement Study to about the
same level as that of a low risk group who received no counselling. Looked at
more closely, it was the males who beneted most signicantly from a type of
intervention that, at that time, was inuenced by Lindemann’s model.
Figure 1
Outcome study by risk by intervention results of the Harvard Bereavement Study
Note. The score was measured by a shortened version of the Health Questionnaire used in the
Harvard Bereavement Study.
Figure 1
Outcome study by risk by intervention results of the Har vard Bereavement Study
Note. The score was measured by a shortened version of the Hea lth Questionnaire used in the
Harvard Bereavement Study.

14 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
None of this work was taking place in a vacuum. A colleague who was
also working in Caplan’s unit was David Maddison. He returned from Boston
to Australia where he carried out a study of risk factors in bereavement and
came up with similar results (Maddison, Viola, & Walker, 1969; Maddison
& Walker, 1967). One of his trainees, Beverley Raphael, set up her own Be-
reavement Service and carried out an evaluation of the effects of intervention
in high-risk bereaved people using a very similar method to my own and also
with very similar results (Raphael, 1977). The main differences between her
study and mine were that we were in different continents and that, in her
case, all of the interventions were provided by a highly trained psychiatrist
specialising in bereavement problems, herself, whereas mine were provided
by volunteers.
Under Raphael’s inuence the Australian National Association for Loss
and Grief has developed training courses for professionals who provide a
high standard of care for bereaved people. In recent years many of these have
been employed by rms of funeral directors who are able to offer counselling
as part of the package of services provided when somebody dies.
In the UK it is voluntary services for the bereaved that have ourished,
some of them linked with Hospices and others based in the community. The
best organised of these is Cruse Bereavement Care which has branches in
most parts of the UK and which publishes the journal Bereavement Care.
This has now become an international journal for all who work with be-
reaved people. It is published by Routledge on line and in print.
In the USA things seem to have taken a rather different turn. Death edu-
cation has come to play a major part in the training of the caring profes-
sions under the aegis of the Association for Death Education and Counseling
(ADEC) and a variety of excellent professional services are now available
including some run by funeral directors. The use of trained volunteers is
largely conned to hospices and palliative care units but it is mutual help
groups that have come to dominate the scene. These owe much to another of
Caplan’s protégées, Phyllis Silverman, who has devoted her working life to
developing Widow-to-Widow and other projects aimed at bringing bereaved
people together (Silverman, 1969). Unfortunately there have been few at-
tempts to demonstrate, by scientic means, the value of this work, and those
that have been carried out, such as Mary Vachon’s comparative study, have
not shown clear-cut benets (Vachon, Lyall, Rogers, Freedman, & Freeman,
1980).
Important contributions to teaching have also been made by William
Worden whose ‘Tasks of Grieving’ constitute a check-list which has been
found very useful by counsellors (Worden, 1982, 4th edition 2009).

15
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Related topics – psychological trauma
While these approaches were being developed other research was taking
place which, although not primarily focused on bereavement, has come to
overlap with this eld and to have triggered important developments. This is
the eld of stress studies which developed largely independently of the eld
of loss and grief. There is no space here to go into this in detail but the work
of Horowitz and his colleagues in San Francisco, who developed the Impact
of Event Scale, has done much to bridge the gap between these overlapping
areas of study (Horowitz, 1986; Horowitz, Wilner, & Alvarez, 1979).
A landmark event whose inuence is still not fully appreciated was the
inclusion of Post-Traumatic Stress Disorder (PTSD) in the 3rd and subsequent
editions of the Diagnostic Statistical Manual of Psychiatric Disorders (Amer-
ican Psychiatric Association, 1994). This is the Bible of psychiatric diagnosis
and the inclusion of PTSD acknowledged that a particular psychiatric disor-
der could follow a particular life event. This has opened the door to the pos-
sibility that other life events will be recognised as causes of other syndromes.
Raphael and Martinek (1997) and Horowitz, Bonnano, and Holen (1993)
have tried to formulate criteria for the diagnosis of pathological grief but
the most impressive work in this eld stems from Holly Prigerson, Vander-
werker, and Maciejewski (2008) whose systematic studies have established
clear diagnostic criteria for Anderson’s Prolonged Grief Disorder (previously
known as ‘Chronic Grief’, ‘Traumatic Grief Disorder’ and ‘Complicated
Grief Disorder’). The distinctive feature of PGD, which distinguishes it from
other disorders, is pining for a person who is lost. This places it in the catego-
ry of attachment disorders, a concept which owes much to attachment theory.
Note that these criteria allow for the inclusion of grief that has been de-
layed provided that it then becomes prolonged.
Related topics – attachments
Attachment theory stems from the seminal work of John Bowlby whose
magnum opus Attachment and Loss was published in three volumes in 1969,
1973 and 1980. He greatly extended our understanding of the bonds which
tie people to each other and of the consequences when separations and losses
occur. He highlighted the dangers of separating small children from their
mothers and the inuence of such separations on later relationships. My own
studies have conrmed that high scores of separation in childhood correlate
signicantly with high anxiety and a tendency to cling after bereavements in
adult life (Parkes, 2006). Bowlby formulated the concept of the ‘secure base’.
In childhood this is provided, or should be provided, by a secure relationship

16 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
with one or both parents and by the familiar home in which the child grows
up. Given a secure base children learn to explore their world and cope with
the challenges which they meet. Lack of a secure base, however, can give rise
to serious problems which interfere with cognitive and emotional develop-
ment. Bowlby went on to show how therapists and counsellors can provide a
secure base within the therapeutic relationship (Bowlby, 1988).
The further development of this eld owes much to the American psy-
chologist, Mary Ainsworth. She developed a systematic way of studying the
Table 2
Proposed criteria for the diagnosis of Prolonged Grief Disorder in the DSM
(Prigerson, Vanderwerker, & Maciejewski, 2008)
A. Event Criterion: Bereavement (loss of a loved person)
B. Separation Distress: The bereaved person experiences at least one of the three following
symptoms which must be experienced daily or to a distressing or disruptive degree:
1. Intrusive thoughts related to the lost relationship
2. Intense feelings of emotional pain, sor row, or pangs of grief related to the lost relationship
3. Yearning for the lost person
C. Cognitive, Emotional, and Behavioural Symptoms:
The bereaved person must have ve (or more) of the following symptoms:
1. Confusion about one’s role in life or diminished sense of self (i.e., feeling that a part of
oneself has died)
2. Difculty accepting the loss
3. Avoidance of reminders of the reality of the loss
4. Inability to trust others since the loss
5. Bitterness or anger related to the loss
6. Difculty moving on with life (e.g., making new friends, pursuing interests)
7. Numbness (absence of emotion) since the loss
8. Feeling that life is unfullling, empty,and meaningless since the loss
9. Feeling stunned, dazed or shocked by the loss
D.Duration: Duration at least six months from the onset of separation distress
E. Impairment: The above symptomatic disturbance causes clinically signicant distress
or impairment in social, occupational, or other important areas of functioning (e.g., domestic
responsibilities).
F. Medical Exclusion: The disturbance is not due to the physiological effects of a substance
or a general med ical condition.
G. Relation to Other Mental Disorders: Not better accounted for by Major Depressive
Disorder, Generalized Anxiety Disorder, or Posttraumatic Stress Disorder.

17
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attachments between parent and child in her Strange Situation Test (Ains-
worth, Blehar, Waters, & Wall, 1978). As a result she distinguished between
secure and insecure attachments and, with the help of her colleague Mary
Main (Main & Hesse, 1990; Main & Solomon, 1990), identied three main
types of insecure attachment, the Anxious/ambivalent pattern, Avoidant pat-
tern and Disorganised/disoriented pattern.
Anxious/ambivalent children have anxious, overprotective parents who
are insensitive to their needs for autonomy. The children tend to become anx-
ious and clinging. Avoidant children have parents who are intolerant of close-
ness. They learn to inhibit attachment but their apparent independence masks
underlying anxiety. Each of these types of children have learned to cope with
their parents, the former by staying close, the latter by keeping their distance.
Children in the Disorganised/disoriented category have no such strategies for
survival. They grow up in families in which high levels of stress and depres-
sion make their parents unpredictable and inconsistent in their parenting. The
children grow up unhappy and helpless. These patterns have turned out to be
remarkably stable and, indeed, to predict attachment problems later in life.
This work has initiated a lot of new studies in all parts of the world; as
a result the eld is developing very rapidly. Among other things is the iden-
tication of similar categories of attachment in adult life (Bartholomew &
Perlman, 1994). My own work in recent years has included an attempt to
map out the attachment patterns of people who seek psychiatric help after a
bereavement. I have developed a retrospective questionnaire which conrms
that people who report having had secure attachments to their parents show
less grief and have lower scores on distress than those who have had insecure
attachments (Parkes, 2006). Among those with insecure attachments predic-
tions based on attachment theory have mostly been conrmed. To summarise
a large number of statistical correlations:
Adults who describe themselves as having been anxious/ambivalent chil-
dren tended, in later life, to have conicted relationships with their partners.
Following bereavement they suffer protracted grief and a continued tendency
to cling. They are most vulnerable to PGD. Adults who, as children, learned
to avoid attachments remain aggressive and assertive in adult life. They have
difculty in expressing both affection and grief. Adults who grew up with
family rejection, violence, danger and depression describe themselves as
deeply unhappy children. They exemplify Main’s disorganised/disoriented
pattern of attachment. As adults they lack trust in themselves and others. Un-
der stress they turn in on themselves and may even harm themselves. Follow-
ing bereavement they become anxious, panicky and/or depressed. They may
turn to alcohol for escape. I have dwelt on these ndings because I believe
that they reconcile some of the arguments that have arisen in recent years
between exponents of various approaches to bereavement care.

18 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
Attachment theory emphasises the importance of the family as our main
source of security and support at times of trouble. Indeed it is the possession
of a supportive family that explains why most bereaved people do not need
counselling. By the same token, the absence of such support makes bereave-
ment hard to bear. Kissane, McKenzie, Bloch, Moskowitz, and McKenzie
(2006) have developed ways of assessing support and a method of interven-
tion that has passed the test of a random allocation study. Their Family-Fo-
cused Grief Therapy enables families to resolve conicts, solve problems and
share grief in ways that benet them all.
Controversies and recent developments
In recent years psychologists and sociologists have challenged several of
the assumptions made by the pioneers. Freud’s concept of ‘grief work’ has
been questioned by Wortman and Silver (1989) and by the Stroebes (1991).
Wortman and Silver based heir argument on the observation that people who
show the most distress before bereavement are more, not less, distressed af-
terwards. They equate high initial distress with ‘grief work’. This argument
only holds water if we assume that distress is the same thing as ‘grief work’
and that lack of ‘grief work’ is the only or main cause of problems in bereave-
ment. My studies suggest that this type of severe reaction is to be expected in
people whose attachments are anxious/ambivalent or disorganised.
More constructive than Wortman and Silver’s approach is the Dual Proc-
ess Model of Bereavement put forward by the Margaret Stroebe and Henk
Schut at the University of Utrecht (1999). They point out that, in the acute
phase of grief, people tend to oscillate between the so-called ‘pangs’ of grief,
when they are focused on thoughts of loss and pining for the lost person, and
periods when they put their grief aside, are less distressed and able to begin
to look forward and make plans. They term these loss orientation and restora-
tion orientation. Both facing loss and turning away are appropriate responses
so long as they do not last too long. Some people, however, become preoc-
cupied with the loss orientation others with restoration. The former equates
with PGD, the latter with avoided or delayed grief (the delayed form of PGD).
This model does seem to correspond reasonably well with the observed
evidence and with my own research which, as we have seen, explains why it
is that some people nd it hard to stop grieving, while others avoid it. In both
cases it would seem likely that the provision of a secure base in which people
can feel safe enough, either to let go of the person ‘out there’ and move into
the restoration mode or to relinquish avoidance and begin to face the pain of
loss orientation.
The Dual Process Model also conforms with the ndings of another study

19
PARKES
by the Utrecht group (Schut, Stroebe, van den Bout, & de Keijser, 1997).
They assigned people with problematic bereavements, at random, to one of
three groups, an Emotion-focused group which employed Lindemann’s tra-
ditional method of helping people to express grief, a Problem-focused group
who adopted a more cognitive, forward-looking approach and a third waiting
list control group. When all three groups were followed up they found that
both of the counselled groups did rather better than the control group. Look-
ing more closely they found that, as in my own study at St Christopher’s Hos-
pice, men, who in most societies are more inclined to avoidance of grief, had
responded best to emotion-focused help while women did best with problem-
focused help. It is worth noting that, if they had been given a free choice, the
men would probably have chosen the problem focus and the women the emo-
tion focus. What our clients want is not necessarily what they need.
Another sacred cow that has come under attack is the concept of stages
of grief (Wortman & Silver, 1989). A recent study showed that, although
the features described by Bowlby and Parkes tend to peak in the predicted
Figure 2
GHQ-level of the intervention by gender ef fect in the Schut et al. (1997)
study on conjugal bereavement
Figure 2
GHQ-level of the intervention by gender effect in the Schut et al. (1997) study on conjugal
bereavement

20 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
order, they do not replace each other (Maciejewski, Zhang, Block, & Priger-
son, 2007). Many bereaved people accept the reality of loss from the start
while others are able to accept the loss as time passes. Yearning is often
present from the start and remains prominent while declining over the rst
year. Numbness is not always present but when present is most pronounced
at the outset and declines fairly rapidly thereafter. Anger is less common, it
often coexists with yearning. Critics have suggested that it is inappropriate
for counsellors to attempt to impose this model on their clients. Each person
will grieve in their own way and their own time. I am inclined to agree that
the phases have been misused but I think that they served their purpose in
providing us with the idea of grief as a process of change through which we
need to pass on the way to a new view of the world.
My own studies of the reaction to amputation of a limb (Parkes, 1975) and
Fitzgerald’s studies of blindness (Fitzgerald, Ebert, & Chambers, 1987) gave
rise to the concept of Psycho-Social Transitions (Parkes, 1996). They showed
how people faced with change need to let go of redundant assumptions about
the world if they are to learn to live as an amputee or a blind person. The
same applies to bereaved people. Many habits of thought and behaviour
which depended on the presence of the person now lost have to be given up if
we are to nd new ways of living in a world without the person who has died.
It is the match between our assumptive world and the world that we meet
that gives direction, purpose and meaning to life. After bereavement there
arises a disjunction between the world that is and the world that should be.
This is experienced as a loss of meaning and recent work has paid attention
to the importance of helping bereaved people to discover new meanings as
they rebuild their assumptive world. Neimeyer (2000; 2001) speaks of this as
a change in the narrative of our lives.
But letting go of obsolete assumptions does not mean forgetting the dead.
In fact there are many people who nd that they feel closer to the dead per-
son when they give up trying to force them to return ‘out there’. Only then
do they realise that there is a literal truth in the saying ‘He (or she) lives on
in my memory’. The concept of continuing bonds is a useful one which has
been explored by Dennis Klass, Silverman, and Nickman (1996) in the book
of that name.
Another contribution to our understanding of Psycho-social Transitions
comes from Janoff-Bulman (1992), who points out that the assumptive world
includes basic assumptions regarding our security, worth and the protection
of others. In her book Shattered Assumptions she described how traumatic
life events can easily shatter these assumptions and leave us feeling insecure,
unworthy and unprotected. This concept has been found helpful in the under-
standing of many traumatic stresses (Kauffman, 2002).
One other area of controversy is Engel’s notion of grief as a disease (Engel,

21
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1961). Engel pointed out that grief is a cause of great mental pain, it produces
a variety of bodily and psychological symptoms and it interferes with our
ability to function effectively. Bereaved people nd that their concentration,
memory and judgement are impaired and a period of time off work is often
needed. These are the criteria normally thought of as evidence of illness.
Yet, the consequences of severe grief are not covered by health insurance and
bereaved people receive no medical help or legal compensation for the suf-
fering which they undergo.
Most of those who work with bereaved people prefer to reserve the term
‘pathological’ for the minority of bereaved people whose grief fails to follow
the course which, in Western society, is regarded as ‘normal’. They see it as
unfair to bereaved people to stigmatise them with a psychiatric diagnosis and
they see no reason to believe that doctors are the best people to treat grief.
Perhaps the problem lies in our prejudice about mental illness. By exclud-
ing grief from our diagnostic categories we may collude with those who see
all mental illness as permanent and shameful and, in doing so, we may per-
petuate the prejudice. Yet, if we are honest, we should admit that there are
times when most of us need to be relieved of our responsibilities, to take a
break, unload our problems onto others and even take a drug (such as alco-
hol) which will relieve some of our feelings of distress.
Given current prejudice, it seems wise to reserve attributions of psychiat-
ric disorder for the minority who meet DSM criteria for psychiatric disorders
and, in addition, to include Prigerson’s criteria for PGD.
Contrary to popular belief, most psychiatric disorders respond well to
treatment and this includes PGD. A recent random allocation study has
shown signicant benets from what Shear, Frank, Houck, and Reynolds
(2005) call ‘Complicated Grief Therapy’. They treat people with PGD by
focussing attention on the loss and restoration components of grieving, use
‘Revisiting Exercises’ to treat trauma symptoms (including role played con-
versations with the deceased person), use a ‘memory questionnaire’ to identi-
fy positive and negative memories, and ‘Motivational Enhancement Therapy’
to identify goals and monitor progress. Techniques of this kind constitute an
amalgam of the emotive and cognitive approaches that are now recognised as
most likely to benet bereaved people.
Visions for the future
So what of the future? It is possible that the inclusion of ‘Prolonged Grief
Disorder’ within the orbit of psychiatric diagnosis and its inclusion in the Di-
agnostic Statistical Manual of the American Psychiatric Association (DSM)
will pave the way to a greater recognition of the fact that losses of one sort or

22 GRIEF: LESSONS FROM THE PAST, VISIONS FOR THE FUTURE
another impair the lives of many of us. By widening the range of mental dis-
order to include the temporary impairment of function that follows many of
the traumatic life situations that we face, we may eventually reduce the stig-
ma. People may come to see grief as an injury for which help may be needed
in much the same way that we now view the consequences of a bodily injury.
Regardless of this, in a world in which many people can no longer rely on
their own families to provide them with emotional support, non-judgemental
acceptance and tolerance, there will continue to be a need for counsellors
who will do just that and who understand about grief.
Recent years have seen a steady increase in the numbers of such counsel-
lors and a similar increase in the willingness of bereaved people to seek their
help. The internet enables those who prefer to remain anonymous to do so
and must create its own safeguards against the unscrupulous minority who
abuse it. However some encouraging results are already being obtained from
on-line help for people suffering depression, anxiety disorders (Proudfoot,
Ryden, Everitt, Shapiro, Goldberg, Mann et al., 2004) and PGD (Wagner,
Knaevelsrud, & Maercker, 2006), all of which are common after bereave-
ment. With the rapid deployment of low-cost computers across the world, it
seems likely that these will become the most popular sources of help.
Help is needed by people of all races and status but especially by those
who are at the bottom of the pile, who are likely to be most at risk and least
likely to afford to pay for therapy. Sadly the ‘Inverse Care Law’ currently
implies that those in most need of support are least likely to get it.
Paradoxically this also applies to those at the top of the hierarchy. Most
support systems work downwards. That is to say, the people at the top of the
hierarchy are expected to support those below them. But who supports the
people at the top? As attitudes to counselling continue to change we may nd
that people in positions of power will come to recognise their own needs for
support.
Anger, we know, is a part of grieving. It can also bring about cycles of vio-
lence, which can become self-perpetuating. How many times in history have
terrible deeds been done because people in power were overwhelmed with
grief and acted out their rage? How easily a delicate political balance can be
destroyed by an act of violence. I have a dream of a cadre of specially-trained
‘counsellors’ whose role would be to monitor the needs of people in posi-
tions of leadership, to ensure that they are supported as they struggle to full
their roles as leaders at times of crisis. Such counsellors would themselves
carry great responsibility and would need to be incorruptible and properly
supported.
I am not pessimistic. In my life time I have seen a new science and art of
hospice and palliative care arise for families faced with death. I have seen
training in bereavement become a part of the curriculum of many doctors and

23
PARKES
nurses and, although there has never been enough money to do things in an
ideal way, I have seen important progress made whenever people who care
have come together to work with each other to achieve change. Above all I
have come to respect the potential of the many people who volunteer to help
the dying and the bereaved.
Perhaps my most heartening experience was in Rwanda. Visiting that poor
country a year after the genocidal killings that devastated that land I had little
hope that the small group of psychologists and social workers employed by
UNICEF under the leadership of the American psychologist, Leila Gupta,
would achieve anything worthwhile. Yet, over the months that followed,
that little group recruited and trained groups of volunteer counsellors, those
volunteers each went out and trained another group until they had 21,156
teachers, caregivers, social workers, community and religious leaders, health
workers and local associations who reached out and supported over 200,000
children and surviving families (Gupta, 2000). If anything can break the cy-
cle of violence and restore peace in Rwanda and elsewhere it must be ven-
tures of this kind.
So my vision for the future is of a world where Beowulf’s dragons are
extinct; no-one needs to resort to terrorism or violence to assuage their grief;
where the global village, with all its soap operas and other trivia, brings eve-
ryone who needs it within reach of proper and effective help; where parents
as well as children, leaders as well as followers, receive the cherishing and
support that they need; where the griefs that are a necessary part of life are
recognised as such and those who suffer them receive understanding and
wise counsel.
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Received October 24, 2008
Revision received December 22, 2008
Accepted February 2, 2009