Special issue article

The changing face of grief: Contemporary

directions in theory, research, and practice
Robert A. Neimeyer
Department of Psychology, University of Memphis, USA
After nearly a century of tacit consensus about the nature of grief work and its therapeutic facilitation, a great
deal of research is now challenging traditional conclusions, and supporting a range of new models and
methods. This brief article reviews these conceptual developments and the emerging therapies they
suggest, and argues that their inclusion in professional training can support professionals who work with
families at the end-of-life and beyond.
Keywords: Bereavement, Grief work, Stage model, Grief therapy, Dual process, Meaning making

Only a few short years ago, it seemed, the field of

bereavement care was marked by substantial consensus. Theorists, most of whom worked within a psychodynamic tradition, hewed close to Freuds1
foundational assumption that healthy mourning
required Trauerarbeit or grief work, in the form of a
painful review and relinquishment of ones bondage
to the deceased, a process of letting go termed decathexis. Accordingly, practitioners concentrated
largely on encouraging the bereaved to give voice to
their anguish, explore it in individual or group
support contexts, and ultimately move on with their
lives, withdrawing emotional energy from the one
who had died in order to invest it in living relationships. For many professional and non-professional
caregiversperhaps especially in the end-of-life
context in which it was formulatedKbler-Rosss2
model of the stages of grief, beginning with denial,
and progressing through anger, bargaining and
depression on the way to acceptance or recovery, provided a convenient road map for such work, in terms
that appeared intuitively accessible to patients and
families. With relatively little research on the actual
course of grieving across time and the factors that
impinged on it, and still less on the efficacy of bereavement interventions, serious dissent from this dominant
paradigm was rare for much of the twentieth century.
As a result, most professionals involved in palliative
care, hospice, and bereavement support were trained
in fairly generic understandings of grief and its
Correspondence to: Robert A. Neimeyer, Department of Psychology,
University of Memphis, Memphis, TN 38152. Email: neimeyer@memphis.edu

W. S. Maney & Son Ltd 2014

DOI 10.1179/1743291X13Y.0000000075

psychological and spiritual dimensions, with the presumption that its facilitation typically required
simply a compassionate engagement with the mourners relatively well-understood emotional transitions.
Suffice it to say that the past 20 years have substantially unsettled this once taken-for-granted consensus.
Theory and research regarding bereavement have burgeoned internationally, giving rise to a greatly
expanded trove of models and methods, which have
increasingly been subjected to empirical scrutiny,
with broad and deep effects on the practice of professional grief therapy. My goal in this short article
is to survey some of the most influential of these developments, with the specific goal of highlighting their
implications for practice. Later articles in this Special
Issue of Progress in Palliative Care will then build on
this conceptual foundation, exploring a wide range
of topics concerning the assessment of need for
bereavement care, public health approaches to education and prevention, bereavement in primary care,
the hospice context, specialist palliative care guidance,
and special issues that arise with the grief of children
and with the grief of professionals themselves. I will
begin by suggesting some of the research that argues
for alternative understandings of grieving, and then
progress to a consideration of evidence-informed
grief therapy.

Recent challenges to the grief work model

Traditional views of mourning are being challenged on
many fronts in contemporary thanatology. For
example, longitudinal studies of bereavement adaptation fail to provide much support for a model of

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The changing face of grief

stages of emotional response to grief.3 One study of a

large cohort of bereaved individuals suffering the
death of a loved one by natural causes found that
acceptance of the death, presumably the final stage
of adaptation, actually was the predominant response
of survivors from the earliest weeks of loss, with
depression and yearning being the strongest of the
negative indicators of grief-related distress across 2
years of bereavement, while symptoms of denial and
anger occurred at consistently low levels. In contrast,
for those whose loved ones died by accident, homicide,
or suicide, disbelief did predominate in early weeks,
with anger and depression eclipsing yearning for the
loved one across much of the grieving period.4 Such
findings argue against the relevance of one size fits
all models of mourning, as well as for the importance
of evaluating popular models against actual data on
adaptation to loss. Furthermore, research has called
into question the necessity of confronting and
working through a loss for all mourners. For
example, researchers present compelling data that
suggest that, at least after spousal loss, not everyone
appears to go through a painful process of depression
and mourning; some spouses seem to begin coping
well within a matter of weeks, and some even experience apparent relief following their partners potentially lengthy illness or a long but conflictual
marriage.57 Such findings argue that traditional
models of grief have underestimated peoples resilience
in the face of loss, and indeed evidence suggests that
many normal grievers will adapt well to loss over a
period of several months, with or without formal
grief counseling.8
Likewise, the idea that decathexis is central to the
process of grieving is being challenged by theorists
who argue that the establishment of ongoing bonds
with the deceased is both healthier and more normative across human cultures than the notion of detachment from the deceased.9,10 While refined
understandings of the types of continuing bond with
the deceased that may be adaptive or pathological
are still emerging,11 the field appears to be moving
away from the earlier view that successful mourning
necessarily involves a relinquishment of the emotional
attachment to the deceased. Instead, evidence suggests
that maintaining an emotional bond with the loved
one may be comforting or distressing, depending on
such factors as how far along survivors are in their
bereavement,12 whether they have been able to make
sense of the loss,13 and perhaps their level of security
in important attachment relationships.14 Accordingly,
theorists espousing a Two-Track Model of
Bereavement15 advocate assessing difficulties occurring on both the track of biopsychosocial functioning
(e.g. depression, anxiety, work performance) and
the track of the relationship to the deceased (e.g. how

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the loved one is held in memory, residual feelings in

the relationship, ritual practices for maintaining his
or her presence in the mourners life). This then
permits careful targeting of problems in both
domains in the context of grief therapy.
In the wake of growing skepticism about traditional
models of mourning, other new theories also have
been proposed. One such model is the Dual Process
Model of coping with bereavement (DPM) formulated
by Stroebe and Schut,16,17 which argues that normal
grief involves an oscillation between confronting the
loss (Loss Orientation) and compartmentalizing it so
that the mourner can attend to the life changes necessitated by the death (Restoration Orientation). This
important departure from traditional thinking
describes mourning as a cyclical rather than linear
and stage-like process, as the mourner repeatedly
revisits the loss and its associated emotions, strives to
reorganize the relationship to the deceased, and to
take on new roles and responsibilities necessitated by
a changed world. This formulation also extends our
understanding of pathology by suggesting that the
inability to distract oneself from or avoid grief may
be as much a sign of pathology as the inability to confront it. However, although recent research documents
engagement in both loss-oriented and restorationoriented stressors on the part of bereaved people, just
what constitutes the optimal balance and timing of
focusing on each remains to be determined.18
Yet another theoretical development is the emergence
of a meaning reconstruction approach to grief.19,20 In
this view, bereavement is viewed as challenging the survivors self-narrative, the basic organization of life
events and themes that allows people to interpret the
past, invest in the present and anticipate the
future.21,22 Although the meaning systems on which
people rely to negotiate life transitions are often resilient, providing resources that promote adaptation,
recent research documents that a painful search for
meaning in the near aftermath of loss forecasts more
intense grief months and years later, whereas the
capacity to find significance of the loss predicts
greater long-term well-being.23 Attention to this
struggle for meaning may be especially critical in
cases of suicide, homicide, and fatal accidents, where
an inability to make sense of the death appears to
mediate the impact of these violent as opposed to
natural deaths on the subsequent adaptation of the survivor.24 Likewise, studies of parents who have lost a
child have documented that a struggle to make sense
of the loss accounts for greatly more of the intensity
of the parents grief than such objective factors as the
passage of time, the cause of death, or the parents
gender.25 Investigations that trace just what meanings
the bereaved find in their experience are therefore particularly useful,26 such as those that suggest the

Neimeyer

generally salutary role of spiritual meaning making in

predicting less intense grief after tragic loss.27
Nonetheless, other recent research suggests that spiritual coping is no panacea for profound grief, as longitudinal study of people mourning the homicide of a
loved one suggests that high levels of complicated
grief symptomatology earlier in bereavement forecast
later spiritual struggles, whereas neither positive nor
negative religious coping predict subsequent grief.28,29
Taken alongside the accumulating evidence for the
role of sense making (SM) and benefit finding (BF) in
bereavement adaptation,30 such findings argue for the
relevance of meaning-making strategies in grief
therapy, a point to which we will return below.
Lastly, although social support has generally been
acknowledged as important by most grief theorists,31
the failure to grieve successfully has traditionally
been understood as a problem contained within the
individual mourner. However, recent approaches
have begun to focus on the transactional nature of
mourning at levels ranging from family processes32
to cultural discourses about bereavement.33 This
view suggests that the meaning of the loss for an individual cannot be separated from the family, community, and societal meanings ascribed to death and
loss and the resulting social responses to the
mourner. Thus, while grieving has clear intrapsychic
components, it also intimately involves the interactions
that mourners have with other living people, who
provide approval and support for or disapproval and
withdrawal from the bereaved based on the fit of the
mourners coping style with larger networks.34
Qualitative research on the relational negotiation of
grief within families has begun to document this
dynamic regulatory processes, such as a couples
cooperation in maintaining a bearable distance
from the acute pain of losing a child, while also safeguarding the childs memory.35
In short, developments in bereavement theory are
beginning to change our understanding of what constitutes an expectable response to loss, and with it our
view of what constitutes pathological grief. This shift
toward a more complex and refined understanding of
the heterogeneity of the grief response is particularly
important for psychological intervention, the topic to
which I shall now turn.

The changing face of grief

competencies that permit people to surmount loss,

rather the presume that therapy is universally helpful
for ordinary life transitions. However, the same research
also documents that therapy is indeed measurably effective in mitigating the suffering of at risk groups suffering traumatic loss (e.g. the death of a child or violent
death bereavement), and is particularly efficacious
when it is offered to those persons with clinically significant symptomatology (e.g. complicated grief,
depression, or anxiety disorders).38 Importantly, the
palliative care context offers a uniquely relevant
window on many of the pre-loss factors that have
been empirically associated with the development of
complicated grief in surviving family members. These
include background factors (e.g. closer kinship; female
gender; high pre-loss marital dependency), deathrelated factors (e.g. multiple losses in quick succession,
low acceptance of the impending death, violent death,
dissatisfaction with death notification), and treatmentrelated factors (e.g. aggressive medical intervention,
ambivalence regarding the treatment, economic hardship, family conflict, caregiver burden).39 Screening
for depression and prolonged, complicated grief is
also feasible in the course of bereavement, as the persistence of preoccupying separation distress that interferes
with daily functioning, accompanied by a sense that
life is empty or without purpose, and difficulty
moving forward without the deceased can readily be
evaluated in the 13-month follow-up mandated by the
Medicare hospice benefit.40,41 Finally, it is worth
noting that validated measures of processes addressed
by major new models of mourning are available for
both research and clinical applications, including difficulties in meaning making,42,43 spiritual struggle in
bereavement,44 engagement in the loss and restoration
orientation45 and impediments arising from the
relationship to the deceased as well as biopsychosocial
functioning.46 As discussed more thoroughly elsewhere
in this Special Issue, assessment can therefore target not
only signs of distress that warrant intervention, but also
the basic psychological processes addressed by the
theory-guided grief therapies to follow.
In this closing section I will discuss four new
approaches to treatment that are demonstrably effective in randomized controlled studies, which take
inspiration from many of the models reviewed earlier
in this article.

Evidence-informed grief assessment and

intervention

Complicated grief therapy

Recent reviews of the efficacy of bereavement interventions for both adults36 and children37 call into question
the practice of offering therapy to all bereaved people,
as those who are left untreated ultimately improve to
similar levels. Such findings underscore the considerable resilience of many people in the face of loss,6 and
suggest the appropriateness of studying the everyday

One research-informed model of treatment has been

devised by Shear et al.,47 drawing on the Dual
Process Model of Stroebe and Schut16 to both foster
accommodation of the loss and promote restoration
of life goals and roles. The former entails procedures
for revisiting or retelling the story of the death in evocative detail, while promoting cognitive and emotional

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mastery of the experience; engaging in imaginal conversations to rework the attachment relationship to
the deceased; and reviewing both pleasant and troubling recollections related to the deceased to help the
client consolidate a more positive memory of their
life together. In addition, in keeping with the restoration focus of the DPM, clients reviewed and revised
life goals to align them with changed circumstances
in their lives. Sixteen sessions of complicated grief
therapy were found to be far more effective than interpersonal psychotherapy in alleviating complicated
grief symptomatology, although clients showed
improvement in both conditions.

Cognitive behavior therapy

Likewise, Boelen et al. 48 drew on a cognitive-behavioral model of complicated grief to formulate a two-phase
treatment featuring cognitive restructuring and sustained exposure exercises. Cognitive interventions
used familiar procedures to identify, challenge, and
change negative automatic thoughts in the course of
grieving. Exposure treatment entailed inviting clients
to tell the story of their loss in detail followed by a
homework assignment to write down specific memories, feelings, people, and places that they tended to
avoid, and then confront them imaginally and behaviorally in the remaining sessions. Results indicated
that 12 sessions of cognitive behavior therapy (CBT)
outperformed a supportive condition, and that
exposure interventions were especially effective in
ameliorating grief.
A second study drawing on CBT principles has
recently been reported, which tested the feasibility of
behavioral activation as a treatment for post-bereavement distress in a small, but well-designed trial.49
Reasoning that mourners often become immersed in
grief loops of passive withdrawal, rumination, and
avoidance coping, investigators focused therapy on a
functional analysis of those factors maintaining these
patterns to identify targets for activation (e.g. greater
social engagement, goal-directed behavior, skill development). Relative to a randomized delayed treatment
comparison group, participants in the behavioral activation condition displayed large reductions in posttraumatic stress disorder symptomatology, depression
and especially prolonged grief disorder over the
1214 sessions of treatment. A recent meta-analysis
of the literature on interventions using similar CBT
methods supports their general efficacy, although it
is unclear whether they are more effective than other
therapies when investigator allegiance is taken into
account.50

Meaning-making approaches
Recently, Lichtenthal and Cruess51 conducted a controlled trial of a narrative intervention for

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bereavement, drawing on meaning-oriented models

that emphasize the role of SM and BF in the wake
of loss.52 Randomizing participants to one of four conditionsemotional disclosure (ED), SM, BF, or a
control condition (CC)they requested that they
write for three, 20-minute sessions over the course of
a week about either their deepest thoughts and
emotions related to their loss (ED), making sense of
the event by exploring its causes and place in their
lives (SM), any positive life changes that came about
as a result of their loss experience (BF) or simply the
room in which they were seated (CC).53 They found
evidence that writing about the loss experience was
more efficacious in reducing complicated grief symptoms three months post-intervention than writing
about a neutral topic. The novel BF meaningmaking intervention appeared especially beneficial.
An additional randomized controlled trial of an internet-mediated writing therapy featuring prompts for
perspective-taking regarding the loss reinforces these
general conclusions.54

Family Focused Grief Therapy

Finally, Kissane and Bloch have devised a family
focused intervention, practiced as a four-to-eightsession intervention for distressed relatives of patients
receiving end-stage treatment in palliative care settings.55 As an alternative to the individualistic orientation of other research-tested therapies, theirs is
based on an assessment of family functioning,
defined in terms of members self-reported levels of
cohesiveness, expressiveness and capacity to deal
with conflict. Importantly, Kissane and his colleagues
offered professional therapy only to those families who
were at risk for poor bereavement outcomes; supportive families that enjoyed high cohesion and conflictresolving families that dealt with problems through
effective communication were judged as inappropriate
for intervention. Therapy concentrated on telling the
story of the illness and related grief while enhancing
communication and conflict resolution. Although a
randomized comparison of Family Focused Grief
Therapy (FFGT) with treatment-as-usual produced
equivocal effects, improvement in general distress
and depression, though not social adjustment, was
shown by the 10% of FFGT-treated family members
who were most troubled at the outset of treatment.
Importantly, members of sullen families characterized by muted anger and a desire for help showed
the most improvement in depression as a result of
FFGT. In contrast, hostile families marked by high
conflict actually did worse in FFGT than in the
CC.56 Results therefore suggest the utility of familylevel bereavement intervention, but only when discretion is exercised in the recruitment of those most
likely to benefit (highly distressed and sullen families),

Neimeyer

and to avoid offering treatment to those who would

fare as well or better without it (functional and
hostile families).
In summary, a variety of experiential, cognitive-behavioral, narrative, and family focused methods are
being developed and found to hold promise in the
treatment of bereavement-related distress. Common
features of these demonstrably effective treatments
include (a) their grounding in contemporary,
research-informed models of grief, (b) their tendency
to screen for significant levels of distress or complicated grief as a criterion for treatment, (c) inclusion
of oral or written retelling of the loss experience,
often in evocative detail, and typically (d) the prompting of some form of meaning-making, in the form of
consolidation of positive memories, cognitive restructuring of fatalistic thoughts, integration of the loss
into ones self-narrative, or finding of unsought
benefits in terms of personal growth, reordered life priorities, and the like. Clinicians interested in a variety of
creative practices that address these and many other
therapeutic goals may benefit from the clear explication of grief therapy57 and expressive arts methods58
now available. My hope is that attention to common
therapeutic factors (e.g. offering empathic understanding or negotiating agreement on methods and goals),
in combination with novel procedures featured in
some of the therapies (e.g. directed imaginal dialogues
with the deceased or writing of letters to the loved one)
will continue to inspire experimentation with new
models and methods of grief counseling in the years
to come, particularly in palliative care settings in
which the death of one person occasions a challenging
life transition for many others.

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