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Bereavement in the Early Days of Cruse.
Colin Murray Parkes.
The aftermath of World War Two prompted many developments in the health and social services.
These included the use of volunteer 'counsellors' in 'Marriage Guidance' and other fields. They also
fostered innovations by three very remarkable women who broke the taboos around death, dying
and bereavement to create a new science and a revolution in the care of dying and bereaved people.
Former, British nurse, then social worker, Cicely Saunders, who fell in love with a dying patient,
learned how to face death and to talk about it to other dying patients. She trained and succeeded to
become a doctor in order to create St Christopher's, the first modern hospice.
A young Swiss/American psychiatrist, Elizabeth Kubler Ross, who "...hated psychiatry. It was the
last on my list of specialties. But we needed something to pay the rent and put food on the table"
(Kübler-Ross 1997b p.112). She was fired for neglecting her job as a psychiatry lecturer while
devoting too much of her time to researching and writing her book On Death and Dying (1969).
The accounts of her interviews with dying people opened the door to communication about death
and enabled her great number of readers to witness the success of her tender care. Sadly her distrust
of doctors kept her isolated from the professionals who were building a new science of Palliative
Care while she moved to California where she and her devotees upset local people by caring for
HIV sufferers.
We come last, to another social worker Margaret Torrie who, with Alfred, her psychiatrist husband,
in 1958, started an organisation in her home in Richmond, Surrey, Cruse Clubs for Widows. This
was a time when few women worked outside the home and, by the time their children had grown up
and left home, they found themselves alone and without meaning and direction in their lives. Cruse
was set up to foster the recovery and empowerment of widows as reflected in the name of
Margaret's book Begin Again, a book for women alone (1970) which is crammed with practical
advice and suggestions,
I had the privilege of knowing each of these pioneers and playing a part in the subsequent
development of the enterprises that they initiated. As a young psychiatrist I worked with John
Bowlby at the Tavistock Clinic and Institute (the 'Tavi') where, over 14 years we undertook
innovative studies that gave rise to Attachment Theory. Robertson and Bowlby (1952) described the
phases of grief of children separated from parents and and we subsequently found similar phases in
the grief of many adults after the death of a spouse (Bowlby and Parkes, 1970). While these early
studies now seem simplistic, they identified grief as a process rather than a state and triggered the
flood of research that followed.
I joined the board of Cruse Clubs for Widows in 1963 and enjoyed chairing an occasional Mother's
Group for women with children, most of them 'teenagers who had lost a father. Their grief, and that
of their mothers, complicated their growing autonomy and security. In due course we were able to
invite the youngsters to attend their own groups.
At St Christopher's Hospice we set up a service for bereaved people using volunteer counsellors
whom I had selected, trained and supervised. To evaluate our work I used a questionnaire to identify
clients who, in the Harvard Bereavement Project, had been found to be at risk of problems in
recovering from bereavement. In order to evaluate this work we assigned those at medium to high
risk,at random, to either proactive support by the counsellors or, to a control group, the pre-existing
open door from which very few had sought our help. Our follow-up confirmed the predictive value
of the risk assessment questionnaire and the value of our use of outreach by specialist volunteers to
those at risk (Parkes 1981).
Meanwhile, in 1966 I had responded to a disaster in Aberfan, in one of the mining valleys in South
Wales The linear village was located next to a coal mine and in a valley beneath a range of
mountains on which waste from the mine had been dumped in a series of tips. After heavy rain, one
of the tips had turned into an avalanche of black slurry, four times the weight of water, which
cannoned down the mountain side destroying half of the village school and 20 houses. The world
watched on television as the miners dug in the ruins, but there were few survivors. 106 children and
38 adults died.
I helped to recruit, train and support, a local social worker, Audrey Davey, as well as a small team
that included Derek Nuttall, a gentle minister with social work training. Derek supported a group of
bereaved teenagers and so impressed the community that he was chosen to chair the Community
Association that was set up to restore morale and plan the way ahead for this multiply bereaved
community. At that time Post Traumatic Stress Disorder had not been discovered and it would be
misleading to pretend that we solved all of the problems of the bereaved, but Derek played an
important part in a series of community conferences focussed on 'The Way Ahead' and Aberfan
soon took the lead in community development in the Welsh valleys (Ballard and Jones 1975). My
research with the Medical Officer of Health, Ron Williams, showed an increase in the birth rate in
Aberfan that, in the four years after the disaster, gave rise to the birth of an extra 132 children, 17
more than were lost in the disaster (Parkes & Williams, 1975).
When, five years after the disaster, Derek decided that it was time to leave Aberfan, he accepted the
offer of a post as Regional Officer for Cruse, rallying support and organising new branches across
the UK. Alfred Torrie died in 1972 and I took his place as chairman. When, four years later,
Margaret retired, she handed over the reins of director to Derek.
It was time for change, not only because, with the loss of our place in the Torrie's mansion, we had
to raise sufficient funds to move into new premises, but also because we had become aware that,
while women in general were becoming more independent, problems were threatening the mental
health of a wider range of bereaved people. A 'Cruse in Crisis' appeal enabled us to fund new
premises in Richmond and to cope with the growing numbers of branches and individuals who
sought our help. To signal the change we changed the name of Cruse Clubs to Cruse Bereavement
Care.
Child Psychiatrist, Dr Dora Black, joined the Board and helped to train our volunteers to work with
children. With Derek, we were able to extend the work to all bereaved people who sought our help;
they included many who had been exposed to traumatic, sudden or untimely bereavements of the
kind that are common in disaster areas. As a result, most of our more experienced volunteers are
well qualified to help people bereaved by disaster. Both as trainers and by adding advice and
support to local resources, we were able to respond to the Bradford Football Club Fire in July 1985,
the Capsize of The Herald of Free Enterprise outside Zeebrugge Harbour March 1987 and the
bombing of Pan Am Flight 103 over Lockerbie in December 1988.
In 1982, with Dora Black and I as editors, we started an in-house journal, Bereavement Care, to
provide education and support to our volunteers. This proved so successful that we decided to offer
it to all who help bereaved people and to include academic articles that would pass the criteria of
'peer review'. It was this element that ten years ago, persuaded Routledge to publish an on-line
version and we were able to turn Bereavement Care into the international journal that it is today.
The turn of the century saw the publication of several meta-analyses of random allocation studies of
bereavement counselling, in which bereaved people were assigned at random to counselling or
none. Sadly they showed little or no statistically significant differences in psychiatric symptoms on
follow up (Forte et al. 2004, and Currier, Neimeyer & Berman, 2008). This was assumed to mean
that bereavement counselling was ineffective but closer study suggested another explanation. First it
became clear that most bereaved people do not need or benefit from help from outside their existing
family and social support systems. Grief is an aspect of love and those who are loved by one person
are usually loved by more than one. Viewed in this light a brief attachment to a counsellor was
unlikely to provide more than a glimpse of the long term attachments that most of us need to feel
safe in the world. Secondly most of the early counselling was based on the assumption that most
problems in bereavement were caused by the inhibition or repression of grief. An important study
by Schut et al. in 1997 showed that this problem was most prevalent in bereaved men and that
these were the ones most likely to respond to traditional methods of counselling. Most women, on
the other hand, had little difficulty in expressing grief and may even have been harmed by
traditional methods of counselling. They responded better to cognitive approaches focussed on
finding new meanings in life. We had been giving the right treatment to the wrong people.
Of course, even this explanation was simplistic. Since that time service providers have been on their
mettle and a number of studies have confirmed Henk Schut's conclusion that “…the more
complicated the grief process… the better the chances of bereavement intervention leading to
positive results" (Schut et al. 2001). Between them these studies covered many of the problems that
cause people to seek help from bereavement services. They also indicated that there is no one kind
of intervention that will solve all problems. Some of the successful interventions involved a
particular treatment, others more than one form of help, some were given to groups of clients others
to individuals, some included medications others did not, some were cognitive therapies others
emotive. From now on it would be necessary to provide a variety of solutions carefully matched to a
variety of problems.
Two further conclusions can be drawn from all of this work. On the one hand it seems that most
bereaved people do not need and will not benefit from routine referral to a bereavement
organisation. In a cash-strapped world this is good news. On the other hand, the minority of
bereaved people who are unusually distressed, unsupported, or have complicated reactions to
bereavement, will usually benefit from the right kind of support. There is no 'one-size-fits-all' type
of counselling that is needed by all bereaved people. Doctors and bereavement organisations need
to match the solutions to the problems.
Cruse Bereavement Care was not included in these studies, most of which were carried out in the
USA, but we could no longer assume that our popularity with the bereaved people whom we set out
to help was a reliable indicator of its worth, after all most bereaved people do find that their grief
diminishes over time. In the new millennium, two studies of Cruse Bereavement Care have shown
satisfactory results from support given by our volunteers. The first involved people with mental
handicaps who had suffered a major bereavement while in residential care (Dowling et al. 2003). A
randomised group of residents who received the support of bereavement volunteers from Cruse and
a similar local organisation got better results than the comparison group who received the support of
residential staff despite the fact that the latter had themselves received training in bereavement care.
The second study was a fascinating quasi-random allocation study by Newsom, Schut, Stroebe et
al. (2017) of Cruse Bereavement Care in Scotland. Under pressure from their principle funder, the
Scottish government, Cruse in Scotland had become independent from the management of Cruse
UK in 2001. Newsom et al. studied two groups of bereaved people both of whom had obtained high
scores on a measure of bereavement-related distress. 156 had received six sessions of counselling
aimed to provide "...a flexible, bereavement‐specific counselling intervention, combining elements
of a number of established therapeutic methods including cognitive behavioural therapy..., person‐
centred counselling..., and the psychodynamic approach". They were compared with a control group
of 188 similarly distressed people who had not received counselling. Only when the scores were
compared six months later did the researchers find that the scores of the counselled group had
continued to improve while improvement in the control group had tapered off. These differences
reached statistical significance. Perhaps, during the period of counselling many participants had
shared thoughts and feelings that had been repressed. Inevitably their level of distress increased and
it was only after the intervention had come to an end that they gradually relaxed and began to
discover the benefits of the counselling.
By this time the advent of the BACP (British Association for Counselling and Psychotherapy) was
creating a profession of paid counsellors. Cruse is able to provide many of their trainees with work
experience in the field of bereavement. At the same time we stopped using the term 'counsellor' for
our trained volunteers. Despite this most of our trained volunteers know more about the problems of
bereavement than most medical, nursing and social work professionals. I remain proud of both the
volunteers and staff of Cruse and of Bereavement Care who are now welcomed for their
contribution to many of the international and national conferences that they attend.
At aged 91 I grow old, my short term memory is failing and I no longer trust myself to treat
psychiatric patients. On the other hand old age has given me the time and opportunity to reflect on
some of the lessons that life has taught me including the nature and logic of love. Some of these
lessons have been covered in the four editions, now with Holly Prigerson, of Bereavement: Studies
of grief in adult life where, from the outset, we recognised that grief is the price we pay for love.
And it can be a high price. In Rwanda the genocidal killings were triggered by the assassination of
the Hutu president. Asked why Hutu men and women killed their Tutsi neighbours one woman
explained "I suppose we just loved our president too much". Of course there is more to genocide
than a perversion of love but there may be a measure of truth in this shocking thought.
Psychiatry and psychology are concerned to explain the logic of irrational, illogical behaviour
including the large grey area between normality and mental disorder. Neurophysiologists have
found that when people suffering from Prolonged Grief Disorder, who may continue to pine for a
lost person for many years, are shown a picture of that person, they show a distinctive pattern of
activity in their brains that resembles the response of a drug addict to a picture of the syringe that
will assuage their longing. Is seems that we are beginning to discover that some mental illnesses
take place because 'You're not sick, you're just in love'.
References
Ballard, PH & Jones, E (1975) The Valleys Call: A self-examination by people of the the South
Wales Valleys during the 'Years of the Valleys, 1974. Rob Jones Publications, Ferndale.
Bowlby, J & Parkes, CM (1970) Separation and loss within the family. In Anthony, CJ , The child in
his family. (pp.197-216) Riley, NY.
Currier, JM, Neimeyer, RM & Berman, JS (2008) The effectiveness of psychotherapeutic
interventions for bereaved individuals. Psychological Bulletin 134,(5), 648-661.
Dowling, D, Hubert, J & Hollins, S (2003) Bereavement Interventions in People with Learning Disabilities.
Bereavement Care 22, (1), 19-21
Forte, AL, Hill, M, Pazder, R, & Fuedtner, C (2004) Bereavement Care Interventions: A systematic
review. BMC Palliative Care 3, 3. Available www.biomedcentral.com/1472-684X/3/3).
Kűbler-Ross, E. (1969) On Death and Dying MacMillan, New York.
Kűbler-Ross, E. (1997) The Wheel of Life: A memoir of living and dying. London, New York,
Toronto, Sidney, Adelaide
Newsom C, Schut, H, Stroebe MS, Wilson S, Birrell J, Moerbeek M,& Eisma MC. (2017)
Effectiveness of bereavement counselling through a community-based organisation: A naturalistic
controlled trial. Clin Psychol Psychoth.2017;1-12 https://doi.org/10.1002/cpp.2113.
Parkes, CM ( First edition 1978 and, with Prigerson, HG, 4th edition 2010)
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Penguin Books, Harmondsworth (ppb).
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Robertson, J & Bowlby,J (1952) Responses of Young Children to Separation from their Mothers.
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Torrie, M (1970) Begin Again: A book for women alone. Dent, London.
