Grief and the Mindfulness Approach Death, Dying and Bereavement
Counselling
Malcolm Huxter
If attachment is 'natural' then grief is a 'natural' emotion that is experienced
when one is parted from what is dear. If grief is dealt with effectively it
can initiate insight. However, if it is dealt with unskilfully, complications
may arise. The normal grief reaction may manifest physically, emotionally, cognitively
and/or behaviourally. Grief may have phases. However, some health workers encourage
a task oriented approach to more actively enable a bereaved person to process
and resolve the grief reaction. One way of effectively dealing with grief is
that of the Theravadin Buddhists' practice of mindfulness. Mindfulness means
staying aware of mind and body conditions in a present moment context. The task
oriented approach can utilize mindfulness, and mindfulness may also be evident
in many modern psychotherapies. Traditional mind-tools to encourage mindfulness
may be used in collaboration with a counsellor/therapist as well as in solitary
practice. With mindfulness a bereaved person can more effectively acknowledge
the reality of loss and allow the pain of grief to manifest without further
complication. If the pain is experienced without undue reaction, the undermining
effect and manifestation of grief can be resolved and the bereaved person can
function relatively free from impediment. Grief is a common emotion that human
beings experience when they are parted from that to which they are attached.
Its effect can be painful and debilitating. Probably the most debilitating type
of grief occurs when a loved one dies. If the grief is not dealt with effectively
the grief can become pathological and create a situation where the bereaved
person is unable to function in the world adequately. Bowlby (according to Worden,
1982) argues that attachment is developed in animals (humans included) because
it has a survival value. If attachment is natural, then it is also 'natural'
to grieve. "The pain of grief is just as much a part of life as the joy
of love; it is, perhaps, the price we pay for love, the cost of commitment"
(Parkes according to Kalish, 1985, p182). The resolution of grief can be accomplished
by developing mindfulness. The practice of mindfulness (also called satipatthana)
emphasises being aware and surrendering to the natural and present moment conditions
of mind and body. This is primarily a Theravadin Buddhist approach. However,
elements of its practice can be found within common task oriented and supportive
grief counselling techniques as well as some modern psychotherapies.
If grief is dealt with effectively it can become a tool for the development
of great insight. If on the other hand it is dealt with unskilfully it could
initiate a whole chain of chronic dysfunction, confusion, depression, avoidance
behaviours and general unhappiness. The complications of the grief reaction
are many. However in the manifestation of a normal grief there are many common
types of reaction (Worden, 1982). There can be feelings such as sadness, anger,
guilt, anxiety, loneliness, shock, yearning, numbness, helplessness etc; physical
sensations which include fatigue, tightness in the chest, a dry mouth, a hollow
feeling in the stomach, tightness in the throat and more; various thoughts that
can lead to depression, obsessions, confusion or even hallucinations; and behaviours
such as disturbed sleep, social withdrawal, crying, neurotic responses to old
possessions and memories, absent-mindedness, searching and calling out, restless
overactivity and so on.
Parkes (according to Kalish, 1985) suggests four stages of grief: numbness,
pining, depression and recovery, while Averill (according to Kalish, 1985) three:
shock, despair and recovery. Worden (1982) on the other hand, encourages a more
active approach by specifying various tasks that must be accomplished before
grief can be resolved. The four tasks that Worden (1982) claims are necessary
are: Task 1: Accept the reality of the loss; Task 2: Experience the pain of
the grief; Task 3: Adjust to an environment in which the deceased is missing;
Task 4: Withdraw emotional energy from the deceased and reinvest it in other
social activity without uncertainty or guilt. The goal of the counsellor/therapist
is to encourage the completion of these tasks. Neither the phase nor the task
models should be considered as invariable patterns. They are, however, useful
guidelines that may be used when appropriate.
Counselling can be used for the 'natural' grieving process. However when the
resolution of the grieving process becomes complicated, Worden (1982) recommends
grief therapy. Grief therapy is used when the grief is excessively prolonged,
exaggerated, creating somatic reactions or in some other way influencing a subconscious
or even conscious impediment in an individual's normal functioning. Though the
initial effects of a death or other shock may in many cases pass in a few days,
the 'pangs' of grief may continue for many months or even indefinitely. "Even
if your loved ones are still alive, there is a place within of disappointment
and loss because we live in a world where everything changes....Whatever you
want, the more you want it, the more there is a kind of grief, a sickness, a
hollowness in the pit of the stomach.....Grief comes from trying to protect
anything from being what it is. From trying to stop the change." (Levine,
1982 p97.) It seems then that most people are candidates for both grief counselling
and grief therapy. If one considers Worden's (1982) tasks various themes become
evident. Within these themes there are elements of the necessity to acknowledge
the loss, be honest, aware, "let go" and function adequately on all
levels of personal care and social interaction. Whether one is assisted by a
therapist, clergy, family or other, eventually the onus must come back to the
individual, as another person can only act as a catalyst to awaken a subjective
awareness and resolution to whatever dilemma may exist.
2500 years ago the Buddha (according to De Silva, 1984), used a performance-based
technique to help a bereaved woman accept the reality of her child's death.
The woman's child died not long after it could walk, and in a distressed state
the woman wandered the streets for days with the child in her arms asking everyone
for a medicine to save her child. The Buddha seeing her behaviour told her that
he knew of a medicine to help her but first she had to collect a handful of
mustard seeds, each one from a house that had not seen death. As she went from
house to house unable to collect the seeds she realized that death, in general
and the death of her child in particular, was a reality. Through insight she
discarded her irrational behaviour. De Silva (1984) compared this technique
to Ellis's rational-emotive therapy. A common performance based technique used
to help the bereaved accept the reality of a loved one's death is that of encouraging
the survivor to see the body. Barbara Walsh (1987) claimed that research has
shown that when a body is viewed it assists the bereaved to deal with the reality.
Barbara Walsh pointed out though that one should be sensitive to the way that
this is done. One should not for example say, "Would you like to see the
body?" but instead say something like "I think it would help if you
said goodbye to ...".
Other techniques can be less performance based and more introspective, as it
is the eventual 'internal' resolutions that will heal external manifestations
and behaviours. One such technique or therapy could be that of mindfulness or
'satipatthana' which has been used in the Theravadin Buddhist tradition. 'Sati'
means awareness and 'patthana' means keeping present. The Buddha claimed (according
to Nyanaponika Thera, 1962) that there was only one way to overcome grief, and
that was with mindfulness. To one who knows nothing of 'satipatthana' this could
seem like a sweeping statement. However if one investigates the dynamics of
this therapy-practice, one may begin to see how most aspects of modern psychotherapy
and counselling incorporate aspects of mindfulness, and how Worden's four tasks
can be accomplished using mindfulness. There are four foundations of mindfulness.
These are body, feelings, mind states and mind objects (according to Nyanaponika,
1962).
The goal is to clearly perceive and pay attention to, in an objective manner,
the arising and passing away of all conditions of mind and body. Eventually
insight into their transient and insubstantial nature arises and one is no longer
at conflict with their changing nature. Mindfulness of body includes amongst
other aspects, being aware of postures, somatic sensations and the breath. Mindfulness
of feelings is not regarded as mindfulness of the emotions as such but more
being attentive to the qualities of pleasantness, unpleasantness or neutrality
that arises in the mind in relationship to physical sensations or mental processes.
Mindfulness of mind states refers to being aware of the states of mind that
may colour the mind, such as a distracted mind, a happy mind, an angry mind,
a guilty mind and so on. Mindfulness of mental objects refers to being aware
of the content of mind such as thoughts, and being aware of how they condition
both physical and mental processes. The theme behind mindfulness is to honestly
relate with whatever arises as it arises. The aim to perceive and acknowledge
the reality of any situation in a present moment context. The benefits of 'satipatthana'
are based on the development of insight.
Traditionally a practitioner of 'satipatthana' decides upon an object of meditation
or mindfulness and when the mind becomes distracted from that object the distraction
is acknowledged and the person returns to the original object. If the distraction
becomes overwhelming the distraction then becomes the object of meditation and
non-intellectual investigation. During life one's mind and body undergoes continual
change. Mindfulness can be facilitated with the manifestation of both the acute
reactions of what Worden (1982) called normal grieving as well as dealing with
complicated grieving reactions that may seem pathological. There are many mind
tools that can be used to develop mindfulness.
One tool is that of labelling the object of mindfulness with a name. This serves
to concentrate the mind as well as clarify and objectify the condition. The
rising and falling of the abdomen is usually labelled "rising, falling",
thoughts of the past "remembering", the future "planning".
Other simple tendencies are labelled accordingly such as "anger",
"worrying", "sadness", "brushing" for brushing
one's teeth and so on. Another such tool is developing what Deatherage (1982)
called "the watcher self". "The watcher self can see the remembering
of some painful event and label it objectively without becoming involved in
its melodrama. The watcher can therefore put psychological distance between
the "me" who experiences the painful event and the "me"
who is presently remembering it." (Deatherage, 1982, p22). The aim of the
watcher self is not to strengthen the ego but "The watcher self is used
only as a tool for grounding some of the patient's mental energies in the present,
providing a temporary, psychological stable centre for them to operate from
and providing a perspective from which their own psychological functioning can
be objectively observed." (Deatherage, 1982, p25) As aspects of the physical,
cognitive and behavioural manifestations of depression, anxiety and obsessive
behaviour are similar to the normal and abnormal grieving processes, successful
techniques applied to the former could also be applied to the latter. Deatherage
(1982) has cited how the 'satipatthana' method has been successfully applied
in a clinical setting. In one case a divorced woman would have bouts of depression
and anxiety when she remembered her ex-husbands bizarre sexual demands. She
was trained to label her thoughts as "remembering, remembering", and
within a few days she could see the causal relationship between the thoughts
and the anxiety and depression. Another woman who was hospitalised for manic-depression
and schizophrenia, was instructed to watch the second hand of a clock and when
her mind went off the clock to name the distraction. Soon she realized that
most of her distractions were related to the past. She was then instructed to
label them as "remembering, remembering". With this technique "she
learned to identify herself with the objective watcher of her disturbing thoughts
instead of the depressed thinker." (Deatherage, 1982, p24). Soon she began
to gain insight into the nature of her illness and was released from hospital.
Another woman who was hospitalised for anxiety, depression and inability to
function adequately, rebelled against any suggestion of introspection, and as
she was a Mormon the word 'Buddhist' or 'meditation' was not mentioned. As the
therapist interacted with her it became evident that much of her day was spent
fantasizing and imagining to avoid the anxiety of her life. The habit of fantasizing
was discussed with her, and then she was asked to undertake a "psychological
procedure". To her surprise she was asked to bake a cake. However, she
had to do it extremely mindfully with minute attention to detail. When the persistent
fantasies would arise she was instructed to just observe them. After a while
she found that she could intentionally return to the present moment and so function
more adequately. She also began to gain insight into the nature of her anxiety
and depression. Mindfulness training therefore develops a space between life's
events and the ego's reaction to those events. Eventually tools such as the
labelling or the "watcher self" can be discarded and it is possible
to totally immerse oneself in whatever one is doing, whether it is observing
the breath, washing the dishes or solving an occupational problem.
Everyone is different and so have different physical and psychological manifestations
while grieving or suffering the effect of an unresolved grieving process. If
one is aware, grief can become a tool for an awakening to greater understanding
and insight into the truth of life. Levine (1982) claims that when someone we
love dies it is almost like an initiation into insight. As one experiences the
intensity of physical and emotional anguish, it becomes so intense that there
is no way to avoid the raw experience of human pain. Levine (1982) related a
story of a woman who lost her 3 year old child in a surfing accident. Three
days after the child went missing the woman was contacted to identify the half-eaten
washed-up body. The identification, said the mother, was the most profound and
enlightening experience of her life, as intense pain and love were felt simultaneously.
It seems that the more one can remain 'open' and mindfully experience the pain
of grief (Worden's 2nd task), the greater possibility of effectively processing
and overcoming its effects. If one has previously practised satipatthana, it
can be extremely useful at the time of bereavement. If one is mindful there
is less tendency to delay the inevitable task of accepting the reality of a
death (Worden's 1st task), and experiencing its pain (Worden's 2nd task). The
more one avoids these tasks, the greater is the tendency to experience disturbing
emotions, thoughts, physical sensations and develop avoidance behaviour. If
one has accomplished Worden's (1982) first two tasks, the last two are a natural
progression as the manifestation of grief do not overly influence and undermine
an appropriate and normal relationship with life, and the person is (relatively)
free.
The 'satipatthana' technique is a client-centred approach and so gives the bereaved
the freedom and dignity to work by themselves without being overly influenced
by a counsellor/therapist's expectations or preordained pattern of what 'should'
happen. 'Satipatthana', however, is not always suitable for everyone, nor is
its solitary introspection techniques appropriate at all times. The grieving
process can be extremely overwhelming or complicated. There are times of course
when a bereaved person needs close contact and support of a counsellor/therapist.
The support person could act as a source of strength, compassion, insight or
merely help reflect the bereaved's situation, and so even when the awareness
seems to be externalised the process of 'satipatthana' can be utilised.
Rogerian techniques incorporate 'empathetic listening' and non-judgemental reflection,
and so the acceptance, recognition and clarification of mind-body conditions
have a healing effect. Worden (1982) claims that repeated verbalisation about
the event helps bring home the reality of the situation. Whilst Kollar (according
to Kalish, 1984) says that 3 out of 16 important points to follow in helping
the bereaved are to "14 listen, 15 listen" and "16 listen"
(Kalish, 1984 p271). In accordance with the 'satipatthana' approach and the
completion of Worden's tasks, Gestalt therapy (Davison and Neale, 1974) encourages:
being concerned with the present rather than the past or the future, dealing
with what appears rather than what is absent, experiencing things rather than
imagining them, feeling rather than thinking, expressing feelings rather than
justifying or explaining them, being aware of pain as well as pleasure and surrendering
to the kind of person one is.
With bereavement counselling Worden (1982) praises the use of the 'open chair'
technique of Gestalt therapy, and the role playing technique of psychodrama
to resolve unfinished business that may cause various undermining effects such
as guilt or anger. Even body therapies can be useful. A simple massage can trigger
off many unresolved feelings or unacknowledged emotions. Levine (1982) has written
a guided grief meditation-massage used to become aware and surrender to the
physical and emotional pain that may be felt in the area of the heart. (refer
to Appendix 1).
Traditionally, when using a 'satipatthana' technique a teacher often encourages
a student to centre their awareness on bodily sensations as this is a more tangible
and less confusing object of awareness. When one is experiencing the overwhelming
effect of bereavement, in addition to the multitude of thoughts and mental states,
strong physical sensations also appear (according to Lindemann in Kalish, 1985)
and seem to be a reflection of and synonymous with mental counterparts. Worden's
(1982) second task is to feel the pain of loss. When a bereaved person is undergoing
a difficult time he/she could be encouraged to pay more attention to what it
feels like as opposed to just being aware of cognitions or theoretical solutions
to the situation. A person may for example have memories of his/her loved one,
which creates sadness and tight feelings in their chest. Firstly they could
label "remembering", then "sadness", then "tightness"
and pay full attention to the physical sensations while allowing the corresponding
mental melodrama to run its course. If one opens up to the physical sensations
the non-intellectual awareness/investigation often serves as a means to process
the present mental and physical dilemma, as well as a means to pry open suppressed
pain and conflict from the past. Often what may start as a minor sensation can
be like the tip of an iceberg which eventually becomes exposed. Often a therapist
can assist the bereaved by actively asking her/him to describe the sensations,
its dimensions, where it is, its shape or quality, whether it changes and so
on. With the passive support of the therapist a bereaved person is often able
to go right to the centre of the pain. If one is encouraged to experience the
pain she/he begins to gain a different perspective about it. The pain is accepted
and eventually passes, and likewise the conflict with it and its mental and
behavioural counterparts. Grief is a natural reaction to loss. Its effect can
be painful and debilitating. If one is to overcome the effects of grief one
must accept the reality of the situation and experience whatever pain may arise.
If one delays the inevitable necessities of the 'natural' grieving process,
one merely prolongs the suffering and one's open relationship with life is undermined.
If one is aware (mindful) the natural process of grief can be facilitated and
if complications arise they can be dealt with in an efficient manner. Awareness
can be facilitated by performing various learning tasks, introspection or expression.
As this is done it eventually becomes evident that the subjective experience
of grief cannot be resolved by anyone other than the experiencer. The resolution
comes from both an active attention-investigation and a passive surrender.
References:
Davison, G.C. and Neale, J.M., Abnormal Psychology, John Wiley and Sons, 1982.
De Silva, P., Buddhism and Behavioural Modification, Behav. Res. Ther., Vol
22, No 6, pp661-678, 1984.
Kalish, R.A., Death, Grief and Caring Relationships, 2nd Ed, Brooks/Cole Publishing
Company, 1985.
Levine, S., Who Dies? An investigation of conscious living and conscious dying,
Anchor Books, 1982.
Nyanaponika Thera, The Heart of Buddhist Meditation, Rider and Company, 1962.
Walsh, B., from Community Health Care, Tamworth, NSW, Bereavement Counselling,
a talk, New England and District Hospital, 19th August, 1987.
Worden, W.J., Grief Counselling and Grief Therapy, Tavistock publications Ltd,
1983.
Deatherage, O.G., Buddhism in Psychotherapy, The Wheel Publications 290/291,
Buddhist Publication Society, 1982