Psychodynamic theories on grief and mourning provide insight and ideas into the psyche and explore how grief can affect an individual’s character and identity (Berzoff, 2003). While they serve as a foundation for more current theories, they do not address the scope of physiological and emotional experiential aspects of mourning (Berzoff, 2003).
Winnicott’s (1960) model is built around the idea of the transitional object (1960). In his theory a transitional object is symbolic of a special bond or relationship between a mother and her baby. Through the mothers presence and absence a baby will select an object representational for their bond, so when the mother is absent the baby will have her transitional object for comfort and security as an inner representation of the mother (Winnicott, 1960). The ability to maintain an inner representation of the mother will determine the child’s capabilities for self soothing. Eventually a child will build and strengthen their ability to maintain an internal representation and their object will become meaningless (Berzoff, 2003). This theory applies to loss, in that the bereaved may select a transitional object to soothe their pain from the absence of their deceased. Transitional objects may include photographs, diaries, and items of clothing. These items link the mourner to the deceased and create a symbolic tie to the loss. Eventually the mourner should be able to give up their objects as they develop the ability to internalize the memory and meaning of their loss (Berzoff, 2003).
The ‘stage’ model for grieving has been established and interpreted by a number of professionals. Kübler-Ross (1975) developed one of the most significant examples of the stage model. This model identifies five stages which describe the experience and reactions of individuals experiencing a loss. Kübler-Ross describes the first stage as denial and shock, a sense of disbelief. Anger follows with a sense of outrage and injustice. The third stage is bargaining; the bereaved is seeking control and a way out of their suffering by pleading with higher powers. Depression ensues in the fourth stage and acceptance of the loss is identified as the final stage (Kübler-Ross, 1975).
Worden’s (2003) ‘phases’ model highlights the notion of grief work and active participation in the grieving process. The notion of ‘stages’ is one approach to viewing the mourning process; the term ‘stages’ implies a specific order of feelings and is primary in the theories on the subject. His criticisms on the stages approach highlight the fact that many individuals will not mourn their loss in an organized, order of stages (Worden, 2003).
‘Phases’ are another way of viewing the mourning process (Worden, 2003). There are typically four phases associated with grieving: numbness, yearning, disorganization and despair and reorganization (Parkes, 1970, as cited by Worden, 2003). Similar to stages, this theory implies a ‘passing through’ of the phases to resolve the loss (Worden, 2003).
Worden (2003) proposes the concept of ‘tasks’ in his theory on the process of mourning. He points out the passivity associated with phases and steps. ‘Tasks’ give mourners a framework to do something, and actively work through their grief with hope. He acknowledges Freud’s concept of ‘grief work’ in this explanation. ‘Grief work’ is described as a cognitive process that requires the bereaved to confront their loss and restructure their thoughts regarding the deceased, the experience of the loss and the different environment that the bereaved must now adapt to and live in (Stroebe, 1992, as cited by Worden, 2002). The tasks model offers grieving individuals some agency and hope in their experience of loss and tells the mourner there is something that he or she can do (Worden, 2003). Additionally, the tasks model provides clinicians with a framework for setting goals and can be implemented in a therapy model for individuals grieving a loss (Worden, 2003).
Worden (2003) notes that it is possible to complete some of the tasks and not others; this incompletion of tasks will hinder any growth and development in healing from the loss. Tasks can be revisited and reworked to meet the client’s needs, and can be worked on at the same time (Worden, 2003). This flexibility resonates with the dual-process bereavement model described earlier in the context of an art therapy intervention.
Accepting the reality of the loss is the first task of mourning (Worden, 2003). Part of this acceptance involves understanding the deceased is gone and will not return and that an actual reunion is not going to happen. When an individual struggles or fails to accept the reality of their loss they may enter into a state of denial. Denying the loss can result in a number of other behaviours. “Mummification” can take place in the case of denial; this involves maintaining the possessions of the deceased in the exact condition they left them in case they return (Worden, 2003, p. 28). Denying the meaning of the loss is another method bereaved individuals may avoid their reality. Bereaved individuals will convince themselves that the relationship with the deceased was insignificant and may immediately remove the belongings of the deceased in a casual manner. Worden describes this as the opposite of mummification; by removing any reminders of the deceased the bereaved can minimize the loss and will not have to face the reality of their situation (Worden, 2003).
Completing this first task requires acceptance on an intellectual level and an emotional one (Worden, 2003). Rituals honouring the deceased can help validate the loss and encourage the bereaved towards acceptance. The unexpected nature of miscarriage can make completing this task problematic. As Worden (2003) notes, the task can be more difficult to complete in the case of sudden death.
The second task of mourning is to work through the pain of grief (Worden, 2003). This includes physical and emotional pain. Acknowledging, expressing and working through this pain is necessary, and if this does not take place the symptoms of the pain may worsen physically or develop into maladaptive behaviour. Negating the task of working through pain can lead to denial, avoiding painful thoughts, avoiding reminders of the deceased, idealizing the deceased and using drugs or alcohol to facilitate avoidance (Worden, 2003).
The third task is to adjust to an environment in which the deceased is missing. This task focuses primarily on roles; the role of the deceased and how it will affect the bereaved (Gray & Lassance, 2003; Worden, 2003). In the event of a reproductive loss, it is the role of the deceased baby that must be considered (Gray & Lassance, 2003). This task is comprised of three types of adjustments, external adjustments, internal adjustments and spiritual adjustments (Worden, 2003). External adjustments apply to how the loss will affect everyday operations in the bereaved individual’s life. Developing new skills, taking on new roles or letting go of old ones and managing different responsibilities are adjustments that may need to take place. Internal adjustments refer to the self; self-image, sense of self, self-esteem or definition of self (Worden, 2003). When a woman miscarries, she loses her sense of identity as mother and parent, and will need to adjust her sense of self (Gray & Lassance, 2003). Spiritual adjustments challenge an individual’s sense of the world and their fundamental beliefs and values (Worden, 2003). Adopting new beliefs and identifying a kind of ‘gift’ from the loss, such as a message, emotional strength or a life lesson are ways individuals may adjust to their spiritual sense of the world (Gray & Lassance, 2003).
The fourth task in the mourning process is to emotionally relocate the deceased and move forward in life (Worden, 2003). The idea of ‘relocating’ the deceased alludes to finding a place for the loved one that allows the bereaved to maintain a connection with them, but in a way that will not interrupt their way of life. Memorializing the loss is an ideal way to hold their memory while continuing on with life. Getting stuck in this final task can happen when the bereaved will hold onto their past attachment instead of forming a new one. Withholding love and avoiding new attachments as a defence from potential pain of grief and loss can prevent individuals from completing the fourth task (Worden, 2003).
More current bereavement theory models for processing grief involve a form of meaning-making and different stages of processing (Lister, Pushkar, & Connolly, 2008). The dual-process model is a rotation between two sorts of stressors, “loss-orientation” and “restoration-orientation” (p. 246). Loss-orientation involves ruminating and replaying the experience and emotional responses; restoration-orientation refers to the repercussions of the loss. This includes experiences, activities or other people that the individual will lose touch with due to the primary loss and the changes they will make in order to adapt to the loss. By moving back and forth between these orientations, a confrontation-avoidance dynamic occurs between positive and negative. With support and acknowledgment of these transitions, meaning-making can occur in the back and forth between orientations, allowing the individual to experience rumination and positive reappraisal as they move through their emotional states (Lister, Pushkar, & Connolly, 2008).
From a constructivist perspective, the meaning-reconstruction model is based on the individual creating a meaningful narrative and actively participating in the response to the loss (Lister, Pushkar, & Connolly, 2008). People organize their life and significant events into meaningful episodes (Neimeyer, R., Harris, D., Winokuer, H., & Thornton, G., 2011). These episodes reveal themes, validate relationships and offer “personal significance” and when put in the context of narratives, illustrate our unique life story (Neimeyer, R., Harris, D., Winokuer, H., & Thornton, G., 2011, p. 10). When the self-narrative is stable, whole, and makes sense, it can be viewed as a depiction of one’s identity (Neimeyer, R., Harris, D., Winokuer, H., & Thornton, G., 2011). When a significant loss occurs, or any other type of momentous life event, the plot of the self-narrative is convoluted and identity is put into question (Neimeyer, R., Harris, D., Winokuer, H., & Thornton, G., 2011).
Research conducted by Keesee, Currier, & Neimeyer (2008) explores the factors relevant to bereavement outcomes for parents who have lost a child. Their research suggests meaning-making can lessen the intensity and aid in the management and healthy adaptation of grief for bereaved parents (Keesee, Currier, & Neimeyer, 2008).
This meaning-making model deals with concepts of identity, the self, and the self-narrative; the individual may wish to rewrite their internal story, incorporating new aspects to their identity. This updated self-narrative may open doors for new identities and meaning-making, with emphasis on the process and activity of finding meaning. Finding meaning in the loss and re-constructing meaning around life and the world are therapeutic measures the bereaved may pursue to alleviate complicated grieving and uncover hope in their changed self-narratives (Neimeyer, R., Harris, D., Winokuer, H., & Thornton, G., 2011).
Stories are open to change, so when an unforeseen loss occurs, such as a miscarriage or abortion, the plot can be rewritten (Brownlee & Oikonen, 2004). The flexibility of a narrative makes room for the hopes and wishes of the bereaved, supports meaning-making and allows the individual to express the significance of their loss and how they choose to grieve (Brownlee & Oikonen, 2004).
When considering meaning-making within the framework of a narrative model it is important to recognize the way in which personal stories usually emerge from a social and cultural discourse (Brownlee & Oikonen, 2004). As parents develop their own story about their loss, a social contribution can emerge and alleviate some of their sense of guilt and blame. The social and cultural context will play a role in how the parents respond, understand and react to their loss; the narrative model facilitates a discussion and provides a vehicle for expressing their loss. It should be noted that story telling and retelling of the loss as a general activity is beneficial and therapeutic on its own (Brownlee & Oikonen, 2004). Ultimately, this model views grief and loss as an opportunity for growth, and learning (Lister, Pushkar & Connolly, 2008).
Without any linear path, the dual-process and meaning-reconstruction models can fit well within the context of art therapy and focus on the individual’s unique understanding of their narrative surrounding the loss (Lister, Pushkar, & Connolly, 2008). Through creative expressions, the individual can give life and validity to their emotions, both negative and positive. Creating narratives through the art is an ideal process to promote meaning-making and growth.
Bereavement is a long process, sometimes taking a lifetime, art therapy can facilitate an integration of the loss into the individuals identity through creative expressions, narratives and metaphors (Lister, Pushkar, & Connolly, 2008).