Professor Robert Neimeyer is one of the Western world’s leading researchers, clinicians and educators in psychological approaches to understanding and working with complex grief and loss. October 2019 marks 60 years since Cruse Bereavement Care was launched as a charity in the UK by social worker Margaret Torrie, initially to support bereaved women and children. We seized this opportunity to interview Bob about his work and developments in grief theory and practice.
Catherine Jackson (CJ): I’d like to start with a personal question. What brought you into psychology and, from that, what drew you to specialise in working with bereaved people?
Bob Neimeyer (BN): My responses to both parts of your question are pretty much the same – the natural death of my paternal grandmother, Katie Clancy, in our home when I was nine, followed much more tragically by the suicide of my father in that same home when I was just shy of my 12th birthday. My dad had been suffering encroaching blindness from untreatable glaucoma for years, from its attendant depression, probably from grief about the loss of his mother, from his complicated reliance on alcohol to cope with all of this, and possibly from other demons that I was not in a position to understand. The trauma of his death from an overdose of barbiturates – readily available, as he was a pharmacist – shattered our family, plunged us into poverty and ushered us into a prolonged and perhaps permanent encounter with our mother’s grief, just when my younger brother and sister and I stepped uncertainly into adolescence. Unsurprisingly, this was a hard transition and one that left me with many unanswered questions, and these continue to invite my reflection and meaning-making to this day.
CJ: The phrase ‘meaning-making’ has become so much a part of a counsellor’s lexicon that I wonder sometimes if we really understand what we mean by it. Some deaths surely are meaningless, aren’t they? How do we make meaning from the deaths of the young and well, from unexpected and traumatic deaths and killings? Where is their meaning?
BN: Part of the problem here is the meaning of ‘meaning’ – what we mean when we use the term. As you say, sudden, violent and premature deaths – like my father’s – surely challenge our assumptions of how the world is or should be and reveal it to be more random, unjust and uncontrollable than we might have imagined. If what we mean by ‘meaningful’ is that such deaths are readily understandable or justified, they clearly are not. When a 70-year-old client of mine lost his adult son and eight-year-old grandson in a tragic boating accident, he found their deaths senseless and horrific. But his determination to make their deaths mean something led him to mount a national campaign for boating safety. Nothing justified his family’s traumatic losses, but he and others found great meaning in learning something from that accident that might well save the lives of many others. Others, of course, reaffirm existing meaning systems by trusting in consoling spiritual beliefs or seeking to learn what lessons they can about living nobly and compassionately with inevitable suffering.
CJ: In a recent paper, you described a father traumatised by his daughter’s death while she was travelling abroad. You explained how enabling him to talk about things he couldn’t bear to think about but that he couldn’t get out of his mind was what helped him to live with his loss rather than being tormented by it. What it is about telling their stories that people find so healing? Is it quite simply about being able to process a traumatic memory so that it no longer haunts you?
BN: It is about being able to process a traumatic memory, but this process itself isn’t simple. Certainly, there are forms of telling that are far from healing – they may be anguished, circular, ruminative and repetitive. The key is to help people tell a story in a restorative manner – one that lets them put together the pieces of what happened and how they felt about it. The audiences to the telling – be they friends, family or professionals – should listen non-judgementally, with the intention of understanding deeply both the hurt and the hope that underlie it. By not rushing to provide simple answers to complex problems, we who witness these accounts can validate the struggle of the tellers to make sense of a hard and often tragic tale and feel their way forward – usually slowly and patiently – towards new meaning. It involves giving voice not only to the significant episodes associated with the death event – what the person heard when they were given the news by the authorities or saw when they entered the hospital or as the loved one lay dying – but also to their own emotions and reactions as these events unfolded. Such retelling is typically careful and deliberate and could be seen as a verbalised practice related to EMDR and other prolonged exposure therapies. The goal is not to make a sad or shocking story into a ‘positive’ one but to make it more coherent and less fragmented, emotionally charged, unspeakable and overwhelming.
CJ: Linked to the above, I was visiting your AfterTalk website and saw a comment on a response you had given to a grieving widow. It read: ‘Doctor, you have not experienced this. For many widows, things will never get better. We are left to suffer. That is all. That’s my thought and experience.’ How do you respond to that?
BN: Of course, the person who made that comment is right. I have not lost a partner to death – not yet, at least. And it is true that many widowed people never get better. Approximately 10% experience preoccupying yearning, emptiness and sometimes guilt and other troubling emotions that can endure for years, according to research in many countries – much as my mother suffered for decades beyond my father’s death. And at times the stress and anguish can be so acute and protracted that they increase the risk of very serious physical and mental health problems, ranging from hypertension and heart failure through to substance abuse, sleeplessness, self-neglect and self-injury. The question is whether this grim outcome is inevitable or whether he or she can, perhaps with assistance, find and address the obstacles that impede gradual movement toward a life that holds joy and meaning again. This is where attuned bereavement support from other bereaved people often needs to be supplemented by expert professional care in order to identify obstacles to healing.
CJ: We both have used the word ‘healing’ in our conversation here. I wonder what ‘healing’ from bereavement looks like? When do you pronounce someone as ‘healed’ from grief? How do you know?
BN: CS Lewis, in his account of his own protracted struggle following the death of his wife, wrote: ‘Like the warming of a room or the coming of daylight, when you first notice the changes they have already been going on for some time.’1 Adapting to the harsh terrain into which we are commonly thrown by bereavement is a gradual process, one that is at times almost imperceptible. It may begin with retelling the loss and remembering appreciatively the life that has ended, but it usually entails a difficult rebuilding of a life that matters again, and sometimes it requires major reinvention of our life roles and goals. The process probably never ends if the loss is central to our lives, but it weighs less heavily on us as we move forward.
CJ: You use the words ‘retelling’, ‘rebuilding’ and ‘reinventing’, which I think are important components of your model of the post-bereavement healing process. Can you unpack and explain these terms a bit more?
BN: Restorative retelling, as opposed to merely ruminating about what has happened, involves a self-compassionate search for ways to revise the story of our changed lives, rather than simply repeating it. Rebuilding means paying close attention to what we feel and what these feelings say about what we need, and then taking intentional steps to fulfil these needs in new ways. And reinventing means that, in some measure and often very substantially, we need to move through grief to growth by cultivating our sources of resilience and trying new things, often recreating ourselves in the process.
CJ: Our response to death, our ways of understanding grief and even our expressions of it are heavily influenced by culture and custom. Have you taken your concepts of bereavement and grief to non-Western cultures? Is there universality in meaning-making?
BN: The need to reaffirm or reconstruct a world of meaning in the wake of loss is universal. But how we go about this is highly influenced by our culture and time in history. Different cultural expectations can enable and constrain us in our options as orphans, widows, bereaved parents or survivors of stigmatised losses. Every culture offers rituals that help us understand and ‘perform’ our grief. Every culture prescribes the meaning of our loss, sometimes in spiritual terms, as well as the roles others can take to support us. But every culture also judges deviations from the approved norms of grieving, disenfranchising or invalidating certain losses or mourners as undeserving of support – as in the common neglect of perinatal death, the death of an ex-spouse, or deaths from culturally stigmatised causes such as drug overdose or violence. I find that a comparison of different cultural systems often provides a trove of concepts and practices that can help us meet the needs of the bereaved more fully. So, for example, the construction of a remembrance ‘altar’ in the home allows European and North American mourners to honour their continuing bonds to a loved one in much the same way as their Japanese, Chinese or Mexican counterparts do in their own cultural settings. I have my own small altar for my mother on the bookcase of my study, which features not just her photo and her ashes but also various mementos, such as some of the porcelain dogs she collected as a young girl in the 1930s.
CJ: Of course, culture keeps changing. How do you see the emergence of social media as influencing how we grieve and how we make meaning out of death? Has it done so for good or ill?
BN: I don’t think social media has changed the core experience of grief; we still feel the aching emptiness of a world without the physical presence of our loved one, still need to wrap our head and our heart around how and why he or she died, and still commonly find a way to reorganise our bond of attachment to the deceased in a way that is sustainable now. But various memorial sites, support group websites and above all Facebook, Twitter and Snapchat have profoundly transformed how we grieve, how we honour our dead and how we interact with others about them. The form of ‘mediated grief’ that results permits us to simply and easily convert the deceased person’s Facebook page to a memorial site and to write spontaneously to the deceased to express our grief, affirm our love, recognise his or her birthday and find solace in the similar expressions of others. Other sites allow us to find support from people who have suffered the same forms of bereavement. But all of these advantages are counterbalanced by what I see as the ironic price of admission to this universe as we withdraw from living dialogue with flesh-and-blood others to sit at our laptops or with our phones and tap out or dictate our grief in short bursts of text rather than in long and soulful conversations. At the end of the day, sharing an emoticon is not the same as sharing a display of vulnerable emotion, and ‘liking’ a blog post is a far cry from a human hug.
CJ: The notion of ‘complex grief’ as some kind of mental illness (through its inclusion in the psychiatric diagnostic manual DSM-5) has prompted a lot of debate and controversy. What is your position on this? How ‘meaningful’ is this as a diagnosis?
BN: In truth, I don’t have a position on this issue – or, more accurately, I have two contradictory ones! On the one hand, as a humanistic psychologist, my tendency is to strip human behaviour of its pathological implications. Even when we are suffering from depression, trauma, conflict and anxiety, we are simply coping as best we can, given our personal and social resources and what we have been through. In this, we need deep and compassionate understanding, not judgement – which is how diagnosis can be interpreted. From this perspective, whatever our ‘diagnosis’, we yearn to be met by others in our particularity and our vulnerability and for them to learn from that encounter what we need at that given moment to move towards a life that feels more liveable again and less frightening, lonely or meaningless.
On the other hand, diagnosis is what medicine does and is a part of what it contributes. Faced with troubling, persistent, perhaps even life-threatening symptoms of any kind, doctors try to get the big picture, understand what processes account for the problems and prescribe interventions to promote the better functioning of our systems or support our natural capacity to heal. The right diagnosis, such as distinguishing between a migraine and a brain tumour, can literally make a life-and-death difference to us.
The large and growing scientific literature on grief suggests that the great majority of mourners don’t need a diagnosis – they simply need tending, befriending and that special blend of practical and emotional support that others who ‘get it’ can give, along with an invitation to re-engage with (and, as I noted earlier, often reconstruct) a meaningful life. But we know from research that around one in 10 will remain deeply stuck in their anguish, despite the best efforts of those who try to support them, to the extent that suicide may seem a better alternative to an unending life sentence of soul-wracking guilt or grief. For this 10%, a professional who can clearly distinguish this ‘dead end’ from a difficult but ultimately healthy process can be a life-saving ally. Prolonged and complicated grief is distinctive psychologically and neurologically from ‘garden-variety’ states of depression and anxiety, and studies clearly demonstrate that it calls for more than a prescription for antidepressants and well-intentioned support. A diagnosis that helps professionals put a finger on this uniquely anguishing condition and that suggests demonstrably effective ways to work with it can make a crucial difference.
CJ: With respect, I question where grief meaningfully crosses a line into a pathological state requiring medical intervention. But this is a hugely contentious issue and not for this interview. And it does neatly allow me to ask a related question! Much of your research has been around validating scales to measure the depth and exacerbating factors of complex grief. Should a talk-therapist really be reaching for (say) an ‘Unfinished Business in Bereavement Scale (UBBS)’ – one of the many you have researched – to understand the causes of their client’s distress?
BN: Frankly, I hope not! I would hate to think that any therapist would expect to hear the deeper themes woven through our distress via a questionnaire. Perhaps questionnaires are simply ‘assistive devices’ for professionals with ‘hearing problems’! In all seriousness though, some therapists, especially those who practise CBT, prefer to use well-validated measures like these to open a discussion with clients about the character and complications of their grieving, even though that is not my personal style. For me, such scales are mainly for researchers, but the resulting research should also benefit therapists and clients. For example, we find that unexpressed affirmations (failure to say goodbye, to express love or to connect deeply) or unresolved conflicts (experiences of betrayal, abandonment or disappointment), as measured by the UBBS, occur for more than 40% of mourners. They are especially common in close family relationships, and that distress about this, in combination with an inability to make sense of the loss, accounts for most of the complicated grief symptoms that prompt people to seek grief therapy. To me, this is ‘news we can use’ to tune into important but often unspoken factors that can compound suffering and inform our work on the underlying problems that did not die with our (sometimes ambivalently) loved one.
The broader question about whether a conceptualisation of ‘complicated’ or ‘prolonged’ grief is warranted is ultimately a practical one, in my view. Do we find that we, as supportive peers and professionals, are universally helpful for all mourners who suffer profound and protracted anguish following the death of a loved one? If so, such a conceptual framing of grief may be expendable. Or do we find that some folks seem to remain quite shattered, lost and tormented for years or decades after the loss, in a way that seems unresponsive to our best efforts to support them? If so, for this small percentage of the population, who may account for a big percentage of those who seek formal therapy, a clear understanding of the psychological, social and even physiological processes involved in unrelenting grief might help us determine how we can offer specific assistance.
CJ: A final question, about the practice of grief therapy. Where does your concept of grief therapy as meaning-making fit with regard to the main therapeutic modalities – person-centred, CBT, psychodynamic – and how helpful, in terms of meaning-making, would a client find each of these?
BN: Of course, all of these approaches have something to contribute to working with people in profound grief when mutual support is not enough. Each of these traditions – as well as others, like family/systemic and group therapy – has a role to play in helping bereaved people name, claim and reframe those emotional, prereflective and behavioural patterns that can keep us from adapting to the hard challenges of loss and transition. Each thereby makes a contribution to grief therapy, when matched well to the style and struggles of the unique mourner or grieving family. So each offers something of value when we feel at an anguishing impasse in our bereavement and as we attempt to make sense of our loss and to rebuild a life of meaning.
CJ: Thank you for your generosity in giving us your time, Bob.
Bob Neimeyer is a Professor in the Department of Psychology at the University of Memphis, where he also maintains an active clinical practice. He is also Director of the Portland Institute for Loss and Transition, which offers training and certification in grief therapy. He has published 30 books, including the Techniques of Grief Therapy series and Grief and the Expressive Arts with Barbara Thompson. He is editor of the journal Death Studies.
Reference
1. Lewis CS. A Grief Observed. London: Faber & Faber; 1961.