Abstract
It is the rare mental health practitioner who does not own at least one edition of Grief Counseling and Grief Therapy. From the first edition (1982) to the current rendition, Worden’s iconic concept of the “tasks of grief” has withstood the test of time. This newest edition also incorporates many of the newest concepts in bereavement, loss, grief, and mourning, including the impact of social media, resiliency, trauma, meaning-making, and continuing bonds, among others.
J. William Worden, PhD, ABPP, hardly needs introduction, given his long and substantive career focused on illness, dying, death, and bereavement. He holds academic appointments at the Harvard Medical School and the Rosemead Graduate School of Psychology in California. He is the author of several other well-regarded books in the thanatological field in addition to this fifth edition of Grief Counseling and Grief Therapy. This book has been translated into 14 foreign languages and has become a foundational reference worldwide.
The first chapter of the fifth edition introduces two widely accepted theories of bereavement, those of John Bowlby and George Engle. Bowlby’s attachment theory is widely accepted as the fundamental reason grief occurs at all. Engle’s grief as disease process notes bereavement reactions are akin to physical healing, with the goal of grieving to return to homeostasis. Worden then turns to defining “normal” grief (with normal encompassing behavior as well as statistical normality). He references the work of Eric Lindemann focused on observations following the Coconut Grove fire in Boston. This is followed by a detailed account of normal grief processes encompassing feelings, cognitions, physical sensations, and behaviors.
Worden addresses the fundamental issue of “is it depression, or is it grief?” His discussion notes one major distinction is that there is often a significant loss of self-esteem in depression. There are some grievers who do experience a major depressive episode, but these are individuals with preexisting conditions.
In Chapters 2 and 3, the adjustment to loss, or the mourning process, is discussed in detail. While Worden acknowledges that other theorists have used both stages and phases as descriptors of the process, his own concept of the “tasks of grieving” continues to be a substantial addition that be believes to be an “equally valid understanding of the mourning process and is much more useful for the clinician” (p. 40).
Task I is to accept the reality of the loss. The work of John Bowlby and Colin Murray Parkes addresses this task with searching for the deceased as a behavior that persists until it is extinguished by lack of reinforcement (the dead person returning). The use of denial often protects the mourner from the pain of acknowledging the death but, in rare cases, denial becomes delusional. Completing this first task requires the mourner to both intellectually and emotionally accept the loss. This becomes especially difficult if the death is sudden or the survivor does not see the body.
Task II is to experience the pain of grief. This can be a difficult task to complete since there is often subtle pressure to stifle the pain and resume normal living. It is clear that avoiding the pain using various strategies provides short-term relief but also sows the seeds of future, more difficult confrontations.
Task III is to adjust to a world without the deceased. This third task requires the griever to make three major adjustments: external, internal, and spiritual. External adjustments entail recognizing the role that the deceased fulfilled in the life of the griever. It may require the learning of new skills, redefining, and finding new meaning in life. Meaning making is now a widely recognized step in adjusting to a loss. Internal adjustments involve responding to the challenges of becoming a “me” rather than a “we.” This includes seeking answers to the question “Who am I now?” and “Am I still competent and possess an internal locus of control?” For Worden, spiritual adjustment is meeting the challenges of redefining one’s assumptive world. It may stimulate complicated spiritual grief (CSG), often seen after sudden, violent, and mass deaths. CSG may result in the griever confronting a spiritual crisis, including the existence of a benevolent God.
Dr. Worden’s Task IV continues its evolution from the first edition’s definition, “Withdraw emotional energy from the deceased and reinvesting it in another relationship” to the current concept of “finding a way to remember the deceased while embarking on the rest of one’s journey through life.” Although worded a bit differently than the previous edition, the major changes in wording for this task occurred in his second edition, when it became: “To emotionally relocate the deceased and move on with life.” This marked the inclusion of the concept of “continuing bonds.”
He concludes his presentation of the tasks of grieving with an acknowledgment of alternative models, including Rando’s six “R” model of mourning; Rubin’s “two track” model; and Stroebe and colleagues’ “dual process” model.
The mediators of mourning are detailed in Chapter 3, reinforcing Worden’s assertion that different individuals grieve individually. There is no “one size fits all” for grieving.
In summarizing, Worden again asserts that mourning is multidimensional and multidetermined. He also addresses the question of “When is mourning finished?.” He suggests that completion of the tasks of mourning is one important marker but acknowledges that, for some, mourning may last a lifetime.
Chapter 4 expands on the differences that Worden understands between grief counseling and grief therapy, as well as treating uncomplicated compared to complicated mourning. He observes that in earlier times mourning was addressed through family ties, religious traditions, and other social variables. Since such is no longer predictably the case, he suggests that grief counseling may be an effective substitute for the absence of those historical support networks. The chapter ends with helpful hints for grief counseling in group settings.
The next chapter examines complicated mourning. One theme that resonates in this and the following chapters is that issues of complication occur during the mourning and not the grieving process. Worden first provides an excellent summary of the issues in defining complicated mourning and then identifies four patterns of grief that are complicated: chronic grief, delayed grief, exaggerated grief, and masked grief reactions.
He also describes several factors that can contribute to complicated mourning. He discusses relational factors, circumstances of the loss, personal historical factors, personality actors, and social factors.
Chapter 6 offers the clinician several important factors to consider when treating complicated mourning. He suggests first ruling out physical disease and then setting up a contract in order to establish an alliance with the mourner. Further interventions include reviving memories of the deceased, assessing where the mourner may be struggling in completing the four tasks of grief and mourning, and dealing with the degree (or lack thereof) of the client’s affect. This chapter also includes an excellent discussion of the role of dreams in therapy. He details three measures for evaluating the effectiveness of grief therapy, including the patient’s subjective experience, behavioral changes, and symptom reduction.
In Chapter 7, Worden considers specific types of losses. He thoroughly investigates the issues surrounding suicide, violent deaths, SIDS, and other forms of perinatal loss.
Chapter 8 is rich with current research on grief and family systems. Here, too, he suggests several different approaches and techniques to working with bereaved families.
His final chapter examines the practitioner’s own grief and Worden encourages each of us (counselors and therapists) to examine our own history of losses. He helpfully includes a 15-sentence completion exercise to encourage the reader to explore his or her history of loss.
One important feature of this edition is Worden’s inclusion of a discussion and reflection summary for each chapter. This feature makes this book an excellent text for anyone pursuing an understanding of grief, mourning, and how best to be helpful as a counselor or therapist. Each chapter includes complete and detailed references for further study.
The book ends with 20 vignettes of grief situations drawn from clinical files for grief counselors to role play in training settings. Worden underscores the differences between counseling and grief therapy, reserving grief therapy to those who have advanced education and training.
Worden’s footprint on the field of bereavement has been significant. This important book will continue to be the go-to text for experienced practitioners as well as new students of grief and grief counseling. This new edition confirms Worden’s lasting legacy in the field of dying, death, and bereavement.