‘Doing the same puzzle over and over again’: a qualitative analysis of feeling stuck in grief

Dr Lucy Poxon

University of East London

L.Poxon@uel.ac.uk

Abstract

2022 has witnessed a crescendo of controversial debate in grief and bereavement research, surrounding the inclusion of prolonged grief disorder (PGD) in the revised Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V-TR). Criticisms of the inclusion of PGD focus on the potential for diagnosis narrowing the range of healthy functioning and any treatment gains associated with a PGD diagnosis being outweighed by the risk of pathologising individual differences and diversity in human behaviour (Ben-Zeev et al, 2010). This qualitative research approaches ‘stuckness’ in grief from a non-pathologising, inductive and curious position that embodies the core, humanistic values of counselling psychology (Cooper, 2009). Four participants who reported feeling stuck in grief were interviewed and the resultant transcripts were analysed using interpretative phenomenological analysis (IPA). The four superordinate themes: (eclipsed by the deceased; the power in powerlessness; the double-edged sword of coping behaviours, and living in purgatory) reveal novel insights into the significance and consequences of living with unresolved dilemmas of grieving. Findings support a meaning reconstruction approach to grief therapy and highlight the negative implications of holding a pathologising, time-limited, stage-based conceptualisation of grief. Implications for practice include combining person-centred therapy with targeted cognitive-behavioral grief interventions that can help to reduce dissonance and address a dependence on avoidance and polarised thinking.

Practice points

1. Findings confirm the negative implications of holding a pathologising, time-limited, stage-based conceptualisation of grief.

2. Stuckness that manifests in dissonance, a dependence on avoidance and polarised thinking may be best supported by therapeutic interventions that combine person-centred therapy with targeted CBT grief interventions.

3. Findings support a focus on continuing bonds and integration of loss through narrative exercises helping clients to deal with emotional loneliness.

Keywords

stuck, bereavement, counselling psychology, qualitative, non-pathologising

Introduction

The proposed changes to grief-related diagnoses in the DSM-V in 2013 have been cited among the most controversial issues in contemporary bereavement research (Bryant, 2014; Stroebe et al, 2008). Following much academic deliberation to establish consensus around diagnostic criteria and terminology, the bereavement exclusion was removed from the diagnosis of major depressive disorder and persistent complex bereavement disorder was included in the DSM-V (APA, 2013). The latter has since been modified to prolonged grief disorder for inclusion in the DSM-V-TR (APA, 2022) and this has enabled trials to be commissioned to treat PGD pharmacologically. Current trials to establish the efficacy of Naltrexone to treat PGD (currently used to treat opioid and alcohol dependency) view prolonged grief as an addiction disorder, with the deceased person positioned as the ‘rewarding stimulus’ (Gang et al, 2021). These steps towards a grief diagnosis have elicited considerable reservations from therapists about potential negative repercussions such as the potential to pathologise normal grief responses to bereavement, the lack of consideration of cultural factors and the limited diagnostic time frame proposed (Ogden & Simmonds, 2014). Further criticism concerns the perceived alignment with the widely held, stage-based construction of grief and the potential for APA’s financial conflict of interest (Ben-Zeev et al, 2010; Frances, 2022; Kilcrease, 2008; Stroebe et al, 2017).

Stage-based constructions of grief (Bowlby & Parkes, 1970; Jacobs, 1993), where grief is purported to progress through specific emotional stages, remain highly influential and continue to be ‘prescribed’ by medical professionals (Stroebe et al, 2017). Criticism for stage theories includes their failure to consider the unique context of every loss, including social and cultural factors, and for pathologising experiences falling outside the ‘normal’ grief response (Kilcrease, 2008; Wortman & Boerner, 2007). This highlights that a mistaken belief in this conceptualisation of ‘recovery’ can lead to problematising grief (Pearce, 2019), ineffective support and unhelpful responses from medical professionals. Specifically, the implication that ‘normal’ grief reactions are confined to six months (Shear, 2010) and that attachments to deceased loved ones should be relinquished may impose the concept of feeling stuck on bereaved individuals (Klass et al, 1996; Silver & Wortman, 2007). The unequivocal conflict between these attempts to delineate ‘normal’ grief and the assertion that all grief experience is unique represents a ‘fundamental paradox’ in grief literature (Breen & O’Connor, 2007).

A wave of contemporary grief theories has been identified in the last 20 years which share several commonalities: a focus on cognitive processes, emotional consequences and the role of the wider social context, the potential for post-traumatic growth, and a shift away from psychoanalytic thinking. (Neimeyer, 2001; Rothaupt & Becker, 2007). Stroebe & Schut (2001) suggest with their dual process model of coping that it is the regulatory process of oscillation between loss-oriented (resolving aspects of the loss) and restoration-oriented (mastering challenges in everyday life) that is the key to adaptive responses. In their conceptualisation of meaning reconstruction, Gillies & Neimeyer (2006) suggest that the search for meaning occurs when the loss of a loved one is inconsistent with their pre-loss meanings held. Their model proposes three meaning-making activities: sense making, benefit-finding and identity change which can help the bereaved individual construct new post-loss meanings. In recognition of the potential value of meaning-making models, including her own integrated meaning-making model (Park & Folkman 1997), Park (2008) asserts that they have the capacity to explain one of the most central human abilities; how we withstand and recover from profound loss and other highly stressful experiences. This fundamentally shifts the lens from passivity to an active survivor who is effortfully coming to terms with their loss.

Despite a consensus on the potential to become chronically stuck, estimations of prevalence range between 9.8% and 15% of bereaved individuals (Lundorff et al, 2017; Prigerson et al, 2008; Shear et al, 2011). The meaning that individuals attribute to those feelings of being stuck remains unexplored in grief literature, as does the nature and origin of expectations about the grief process. Recent developments in grief theory highlight the centrality of meaning-making in adaptation to negative and highly stressful life events, and the importance of recognising individuals’ experience and understanding this, within the context of their cultural and social norms (Stroebe et al, 2008; Gillies & Neimeyer, 2006).

This research therefore used a research methodology that respects and identifies with the centrality of meaning-making evident in grief research. Interpretative phenomenological analysis (IPA) is an example of such a methodology as it locates sense-making activities as the basis for learning about one’s relationship to the world with a focus on meaning and communicative action (Smith et al, 2009).

The move towards diagnosis and pathologising, which appears to be gathering pace in contemporary grief research, is in direct conflict with the core, humanistic values I hold as a counselling psychologist. These include the prioritisation of the client’s subjective, and intersubjective experiencing, an orientation towards empowering clients and the actualisation of potential rather than a focus on treating pathology (Cooper, 2009). This research is therefore informed and inspired by the auspicious emergence of a non-diagnostic alternative to the DSM: the power threat meaning framework (PTMF, Johnstone & Boyle, 2018). The PTMF proposes a shift from the current psychiatric diagnostic system that is rooted in asking ‘what is wrong with you?’ to a less pathologising approach that asks ‘what has happened to you?’ This approach is meaningful as a framework for this research as it doesn’t impose meanings on others’ experiences and champions both resilience and strength.

This qualitative research aims to explore the meanings underlying narratives on feeling stuck in the grieving process, expectations about grief and the responses from family members and friends to these feelings of being stuck.

Methodology

The body of phenomenological research within the grief and bereavement field is burgeoning (Begley & Quayle, 2007; Reilly et al, 2008; Ingham et al, 2016; Flahault et al, 2018) due largely to its ideographical focus and concern with the human predicament. By using the inductive approach of IPA and the client’s language of ‘feeling stuck’, it is hoped that subjective experience is highlighted. The researcher’s hermeneutic analysis of the participants’ subjective responses, although grounded in the interview transcripts, was realised through an ‘experientially-informed lens’(Smith et al, 2009, p36) and is the product of an interaction between researcher and participant. It was therefore important to be reflexive as a researcher by keeping, and continually consulting with, a reflexive research journal and to be transparent about the researcher’s experience in working therapeutically with bereaved individuals.

Sample

Participants were recruited from an English branch of a national bereavement charity providing support to bereaved individuals. They were invited via initial triage or volunteer bereavement supporters who identified individuals who had been bereaved for more than six months, aged over 18 and were reporting feeling stuck in their grief. A pseudonym was assigned for anonymity. Table 1 introduces the four white British female participants who were all bereaved suddenly.

The final sample size of four is considered appropriate for phenomenological research (Bartholomew et al, 2021) where larger numbers of participant accounts are thought to undermine IPA’s idiographic commitment and can lead to a shallower, more descriptive analysis (Hefferon & Gil-Rodriguez, 2011).

Data collection

As a doctoral research project, ethical approval was obtained from University of East London, the bereavement charity’s head office and a local branch. The interviews were held in 2012 in the participants’ own homes. Informed consent was obtained before the start of each interview, which assured confidentiality through data anonymity. Each participant was debriefed following the interview, which included confirmation of their ongoing support from the bereavement charity. Interview recordings were transcribed, pseudonyms assigned and all identifying details were removed.

Data analysis

The transcripts were analysed by following Smith et al’s (2009) iterative and inductive strategies and Gee’s (2011) colour-coded system for initial noting: descriptive, linguistic and conceptual. Commonalities within the transcripts were identified on sticky notes and grouped into an ‘emerging theme’ map which became the main tool of cross case analysis. Different iterations of themes were trialed and this process was repeated several times until a coherent, robust and hierarchical structure of themes was formed.

Quality

To ensure that my research consistently reflected my epistemological position of hermeneutic phenomenology and remained consistent with the underpinning principles of IPA methodology, all stages were conducted in alignment with Yardley’s (2000) guiding principles for quality in qualitative research. At the forefront of this research is reflexivity, evidenced through my research journal, and transparency in the audit trail and reflections on my epistemological position, my position towards grief theory and practice and my values as a counselling psychologist. In order to ensure the research maximises its impact and importance, it was crucial for the findings to effectively communicate the unique meaning-making, experiential aspect of this research, which will distinguish it from the pervasive pathologising perspective.

Analysis

Following IPA analysis, four superordinate themes (eclipsed by the deceased; the power in powerlessness; the double-edged sword of coping behaviours; living in purgatory) were identified from the interview transcripts and are discussed using extracts from the data transcripts.

Eclipsed by the deceased

This superordinate theme refers to the way that the participants appear to be eclipsed by their loved ones after their death. The deceased take on an elevated position through being idealised by the participants, and this fantasised representation acts to diminish the participant’s’ self-worth as their own life is negated and dominated by an apparent need to keep the deceased ‘alive’ in their internal world. The three sub-themes (idealising the deceased, loss as amputation, fear of letting go) capture the underlying tension between the sense of responsibility and entitlement that the participants experience about being the only one to represent the deceased in the world, and the sense of being overwhelmed and fragile as a response to being eclipsed.

Each of the four participants described their loved ones in an idealised way where they appeared to hold the deceased in an elevated position and only recall the positive. This is illustrated by Lorraine’s comparison of her grief for her husband with her children’s grief for their father:

‘I’m not saying they don’t grieve, and I’m not saying they don’t find it hard, but for me he was sort of like the centre of my universe.’

This powerful metaphor conveys the extent of love and dependency bestowed, and the exclusivity that she feels about their relationship. There seems to be perhaps a sense of entitlement about the scale of her grief, as she notes that she is the only one who has lost the centre of her universe. Mabel elevates her mother to such an esteemed position that she considers herself to be lifeless now:

‘I haven’t got a life now. My whole world ended when my Mum died, she was my best friend. She wasn’t just my Mum, she was my best friend.’

Bearing the responsibility for grieving the loss of her mother and best friend is overwhelming for Mabel as she feels her own life being extinguished. It seems that as the deceased looms larger and larger as an idealised figure, the bereaved participants’ feel an overwhelming responsibility to match their grieving to the burgeoning representation.

Common to three of the participants is the feeling that part of themselves has been lost since the death of their loved one, and two use amputation as a metaphor for the pain associated with losing their loved ones.

‘Half of me is missing. And I just feel that I’ve lost my arm or something, I just don’t feel complete.’

It seems that Lorraine saw her and her husband’s lives as so entwined that they almost operated as one body, so when he died she felt as if half of her own body had gone with him. Similarly, Sandra expressed her loss as an amputation:

‘They were a part of me, like an arm, a leg do you know what I mean, I have…a part of the puzzle in my heart that’s made me’

It is likely that this is related to a fear of letting go, as letting go conflicts with the idealised status and the notion that the deceased is integral to their sense of self. The associations the participants make with letting go vary, and include fears about letting go of the deceased, letting go of their emotions and letting go of their sanity. Sandra expresses her fear of letting go of her loved ones:

‘So to me I think it would class me as, in my mind as heartless because that’s my love for them do you know what I mean? … if I let them go, I will feel that, you know, that’s part of my love and part of me, that would go as well.’

Mabel’s metaphor, evoking the very essence of her fear of not letting go, suggests that she is not just tormented by the loss of part of herself when bereaved, but also tormented by the process of grief itself:

‘And now I just feel like I’m hanging on the edge of this big dark hole and my fingers are just my last fragments of sanity and that relentless tormentor called grief is trying to peel my fingers away from the edge of that hole. And I don’t know where I’ll go when my fingers come off.’

The common thread in this superordinate theme is a sense that the participants have been eclipsed by an overwhelming, all-consuming, idealised representation of the deceased who is regarded as more important than themselves and occupies a dominant position. The participants interpret their pain and grief as the evidence of this love, and so fear letting go of any part of that experience, and as the deceased looms larger their resources to cope with the burgeoning responsibility dwindle.

The power in powerlessness

The tension between two apparently contradictory ideas that permeates the previous theme is equally present in this superordinate theme (feeling out of control, feeling let down by others, feeling obliged to get on with it). The participants tend to view themselves in a powerless and passive position at the mercy of nature and yet their behaviour appears to be far from a position of weakness; setting high expectations, rejecting others and punitively judging themselves.

Each of the participants refer to feeling out of control since the sudden loss of their loved ones, and the sense that whatever they do, they are powerless against the constant ‘poking and prodding’ from grief. The most explicit example of this is given by Lorraine:

‘It’s like time is moving me on and I’m leaving him further and further behind. Whether I want to move on or I don’t, I haven’t got a choice, time is moving me on.’

There is a sense that the participants feel they should take charge of the situation, and yet they experience an undermining of their power and control and attribute it externally. Jenny describes a similar powerlessness:

‘I think the problem is you don’t…unless you’ve actually encountered it…you know this is my first encounter really…of somebody dying and being responsible is that…erm, you’re not really given the choices.’

The use of the word ‘responsible’ seems critical here in illustrating her powerlessness, as it is this weight of responsibility that makes the lack of choice a very uncomfortable feeling to bear.

Experiences of feeling let down seem to be representative of the bitterness the participants are feeling towards others for not understanding their situation well enough, for not listening properly, for not caring enough and for not measuring up to the deceased. It seems likely that the loss of agency and powerlessness described in the previous sub-theme leaves them feeling vulnerable, exposed and entirely dependent on others for survival, and so to manage these consuming emotions the participants attempt to regain some control by positioning themselves as misunderstood and elevating their expectations of others. Sandra attempts to minimise the chance of being let down by restricting the opportunities:

‘Because I only let you have one chance and if you blow it [points to front door]. It’s because of my insecurities and trust.’

Mabel felt let down by her friends who didn’t find time for her in ‘this state’:

‘Who the hell wants to talk to someone that’s crying? No one. It’s depressing isn’t it, really. Sure people have got better things to do, and I used to have. But I like to think, when I was ok if anyone had been in this state, I would have spent, I would have given them some of my time.’

This sub-theme about feeling let down by others seems to be reflective of the participants drive to regain some control, by establishing high expectations of others, maintaining distance from others and rejecting those who do not meet the standards, given the powerlessness they experienced from the sudden loss of their loved ones.

Implicit ‘rules of grieving’ are evidenced in each of the transcripts in the form of an internalised punitive, self-critical voice that implies that they should be able to cope with their grief by ‘just getting on with it’. These rules and the punitive voice are presented in such a way that the participants perceive themselves as left with little choice but to follow them, which probably leaves them feeling both powerless from the obligation to get on with it, and yet at the same time powerful and controlling as the directive tone of the voice conveys.

‘Because you’ve got to grin and bear it in a way. I mean you’ve just got to get on with it. And you know that you’ve got through the first year, you know that the sort of emergency’s off in a way.’

Jenny seems to convey a sense of obligation and powerlessness behind the mantra-like speech.

‘If I cried I sort of thought “for goodness sake, pull yourself together, get on with it, you’ve got to get on with it. You know, ok so he’s died, so tough that’s the way it is. You’ve got to get on with it”.’

Lorraine’s use of harsh and punishing words act to minimise experience and convey a belief that any emotional expression of grief is negative. The tension between being in a powerless position, yet attempting to regain control over their life pervades and would probably result in dissonance for the participants.

This superordinate theme is representative of the devastating sense of powerlessness that a death can evoke and the struggle that ensues to regain some control. It is likely that the overwhelming lack of control experienced leaves them feeling angry, exposed and vulnerable so the participants would feel motivated to reduce these intense emotions by asserting their power by establishing high expectations of others and taking on a punitive, self-critical voice.

The double-edged sword of coping behaviours

This theme represents the different behaviours engaged in that mask or avoid the participants’ true emotions: by (i) being ‘locked inside’: negating emotions, (ii) ‘like Worzel Gummage’: avoiding as relief, (iii) prioritising others over self.

Three of the participants refer to having ‘locked inside’ or ‘switched off’ their emotions despite seeming to hold an awareness that it is something they do that has adverse effects on their wellbeing. Jenny is explicit about the conflict between the obligation felt to negate emotions despite understanding the negative effect of locking emotions inside:

‘So, you think “I’d better not cry” but if you don’t cry you get more stuck, or that’s what I think. I mean I do think it’s better to let it out at an appropriate time and I’m not always very good at that.’

This extract reveals the tension experienced by Jenny when emotions surface as it appears that while she feels an obligation to rationally evaluate whether emotional expression is appropriate in each situation, she finds it difficult to achieve this. Lorraine also describes a time where there seems to be no choice but to switch herself off:

‘I got through it but only by steeling myself, have to sort of, you have to sort of switch yourself off from… compartmentalise yourself. And that was how I got through it.’

It appears that negating emotions is a double-edged sword for participants, as although it enables them to get through a difficult experience and provides them with a sense of control, there is an understanding that prolonged locking inside can lead to feeling stuck.

The desire to escape the constant thoughts and emotions in grief through distraction and avoidance is evident in each of the transcripts. The title of the sub-theme ‘like Worzel Gummidge: avoidance as relief’ has been taken from Sandra’s desire to be able to relieve the incessant thoughts by switching heads like a UK television character who had three different heads for different functions:

‘In my head, if I could just…get a new one [head]. Make life much easier. Yeah, like Worzel Gummidge, you remember? Change the heads. Would be so much easier.’

Avoidance through distraction has a temporary positive effect but can have repercussions if this is the dominant focus of activity. Conversely, Mabel celebrates her distraction techniques:

‘It’s just marvellous, absolutely marvellous. It doesn’t matter what the weather is, I walk and it’s wonderful because my poor little mind actually has a rest.’

It seems likely that the more relief the participants experience from being avoidant or using distraction, the more they fear experiencing any grief emotions.

The third sub-theme, prioritising others over self, can become a double-edged sword as, although it does protect the others from hurt, it leaves the individual’s needs unmet and vulnerable to feeling low with unresolved and unacknowledged pain. Lorraine views her expression of grief as a burden for her children, thereby prioritising their feelings over her own:

‘I don’t say an awful lot. No, no, I don’t tell them…erm because I don’t want to worry them, I don’t want to upset them. I think they’re working through their own stuff.’

Lorraine’s instinct to protect her children from the pain she is experiencing is echoed in Sandra and Jenny’s experience and seems understandable as mothers in their established roles of primary caregivers. Prioritising others in order to protect them from pain is behaviour that resonates with both the avoidant behaviour and negating emotions evident in this theme.

By engaging in locking emotions inside, avoiding and prioritising others’ care over self-care, the participants hope to gain relief from both the incessant painful thoughts and feelings and the pressure they feel to abide by the unspoken rules of grieving. In most cases, the relief has proved seductive, but an overdependence on these behaviours to manage their grief has likely contributed to their depression, isolation and feeling stuck.

Living in purgatory

This final superordinate theme completes the analysis and is comprised of the purgatorial consequences of the unresolved internal conflict they experience and focuses on the existential fears and feelings associated with the resultant feelings of being stuck. Purgatory is defined as ‘a place or state of temporary suffering or misery’ (Merriam-Webster.com) and it is the foreboding sense of waiting in a punishing in-between world that is so evocative here.

This theme explores the enormity and destabilising effect of losing such an idealised figure, where an inevitable impending doom looms over the participants. Sandra experiences this sense of foreboding as a fear for others’ safety when in her company:

‘I think, right who’s next? And I find it really hard to get close to people, because I think if you get close to me, you know, something might happen.’

While Mabel appears to be startlingly resigned to her impending doom:

‘I wake up, and I think I’m waiting for something, you’ve got that feeling you’re waiting for something and it occurred to me that I’m just waiting to die.’

This phrase is shocking with its directness and gravity and verbalises her existential meaning-making processes. This type of existential thinking is also evidenced in Jenny’s transcript:

‘…because you think what’s the point, we’re all going to die.’

The chilling, matter-of-fact tone of the extracts seem to reflect the pointlessness that they experience.

Each transcript provided evidence of loneliness in the second theme, alone, expressed as both a consequence of the loss of their companions, but also the isolation they feel in their grief. When Mabel describes how alone she feels, there is a sense of despair and hopelessness about her isolation from others:

‘It is scary because there’s nothing there. There’s nobody. I’ve got no one.’

Specifically, her use of ‘nothing’ seems indicative that she is not just reeling from the loss but the loss of her faith in existence where everything has lost meaning. Sandra’s repetition of the word ‘alone’ throughout her transcript emphasises the sense of desolation experienced, and the description of being the only person without someone evokes a profound sadness:

‘I felt, yeah very alone, very alone. Yes, when it was like going to say goodbye to her, switching the machines off, I felt very alone then.’

Within the third sub-theme ‘The same puzzle over and over again: stagnant ‘is the participants’ experience that their grief never changes and they feel that despite efforts to resolve the ‘puzzle’ in their mind, they remain in a state of ambivalence. This seems to probably result from the internal conflicts identified in previous themes such as attempting to regain control and yet feeling powerless, feeling eclipsed but at the same time holding a responsibility for representing their loved one. A puzzle metaphor was used by Sandra to describe her experience:

‘We’ll get stuck because we either do the same puzzle over and over again, or be looking for other bits of puzzle, you know pieces, and that’s when you get stuck.’

Puzzling is likely to represent her attempts to find meaning and resolve internal conflict, but repeated failure to do so seems to have left her feeling impotent. Mabel’s frustration is more pronounced:

‘I just can’t move forward, I never feel better, I never have a good day.’

and Lorraine experiences her stagnancy as

‘relentless hurdles’.

There is both a sense of monotony and tedium about repeated actions, and yet there is also a sense of escalating dread inducing a foreboding predictability about their situations. This theme has revealed a cruel paradox where repeated attempts to take control of their life and overcome internal conflicts and obstacles leave them reminded of how they are powerless and stuck.

The analysis has been presented in this specific sequence as each theme is seen to be both distinctive in the emergent narrative of feeling stuck in grief and integral to the preceding and subsequent themes that they sit between. In isolation, the superordinate themes alone do not describe feeling stuck in grief, it is the sequencing and the way in which they work in synergy with each other that tells this story of feeling stuck in grief.

Discussion

The analysis reveals novel insights into the experience of feeling stuck in grief and introduces a fresh perspective from which to approach therapeutic interventions. They highlight both the reality and the consequences of living with unresolved dilemmas of grieving: being stuck in a vicious cycle of fear and avoidance and feeling a sense of impending doom, loneliness and stagnancy.

One of the most striking findings identified in the analysis is the accumulation of conflict and dissonance that contributes to this distressing experience of living in ambivalence. Pearce (2019), in her consideration of this dissonance, suggests that it is likely that there is no overcoming the ambivalence of grief as there is no undoing the permanent reshaping that has been done by the person who is now absent. Some of these conflicts are explicitly described by the participants, for example the obligation to negate feelings; others remain unrecognised by the participants, for example feeling increasingly overwhelmed by the responsibility to grieve for such a deified figure, yet only acknowledging an idealised version of the deceased. ‘Doing the same puzzle over and over again’ is interpreted as symbolic of the repetitive, yet unsuccessful, attempts to resolve the paradoxes revealed in the data analysis.

The first major paradox that emerged from the data is the ‘zero sum game’ where the more the bereaved individuals view themselves as ‘nothing’ in their loved ones’ absence, and the more they idealise them, the more significant their responsibility becomes to grieve accordingly and the less resources they have to cope. There is an exclusivity about the relationships described and an overwhelming sense of responsibility to honour the idealised relationship. These descriptions are characteristic of Prigerson’s (2004) description of close, confiding and dependent relationships that she found to have the highest risk of ‘complicated grief’. The participants appear to have difficulty in the process of individuation and separation, evidenced by the descriptions of loss as physical pain within their own body and three of them compared the loss to an amputation. Research linking insecure attachment styles and separation anxiety developed in childhood with complicated grief reactions (Van Doorn et al, 1998; Vanderwerker et al, 2006) may help to explain the difficulties experienced by the participants. Therapeutic interventions to address the ‘zero sum game’ of feeling eclipsed, yet continuing to idealise, could focus on two main areas: the first to help the client develop a stronger sense of self and the second area to promote a more balanced and less polarised perspective of the deceased and others. All or nothing thinking has been linked with unresolved conflict and it has been suggested that an approach incorporating cognitive behavioural therapy (CBT) techniques can address the tendency to engage in black and white thinking, and encourage the client to consider a more balanced perspective (Fourali, 2009).

The second paradox emerging from this study is that of the ‘powerful powerless’ where participants perceived themselves in a powerless, vulnerable position, feeling a lack of any control over their lives, and yet making clear attempts to assert power including establishing high expectations of others and by taking on a punitive, self-critical voice. This acts to unintentionally isolate themselves from others and increases engagement in maladaptive coping behaviours such as negating their emotions, avoidance and prioritising others over self.

The study’s findings suggest that there is an element of feeling stuck in grief that derives from the dissonance between the internalised rigid, stage-based expectations of grieving and the unique, painful and unpredictable grief that the participants experience. The current research reveals several implicit social norms or rules of grieving that appear to have been internalised in the participants’ conceptualisation of grief (should feel better over time, should be able to cope by now, shouldn’t burden others by expressing emotion, should leave the past behind). The participants experienced a sense of failure when their behaviour contradicts these rules. In accordance with cognitive dissonance theory (Festinger, 1962), it is likely that the participants experience dissonance between their subjective experience of grief and their expectations. In an effort to reduce it, they attempt to bring their behaviour in line with their expectations. As a result, they use self-punishing mantras such as ‘get on with it’, ‘grin and bear it’, and ‘pull yourself together’ and engage in avoidant coping behaviours. This leaves bereaved individuals vulnerable to distress as they can become intolerant of their ‘inappropriate’ grief response (Silver & Wortman, 2007) which can result in a lack of adequate support (Costa et al, 2007).

On the basis that internalising a stage-based, time-limited model of grief imposes restrictions on bereaved individuals (Costa et al, 2007), to the extent that they become self-punishing towards their behaviour, it becomes critical that the therapeutic approach doesn’t collude with this perception. The participants in this research revealed several examples of the shame and inhibition caused by their expectations that they should feel better over time; they should be able to cope by now, they shouldn’t burden others with their grief, and that they should ‘live for today’. These examples are resonant of Pearce’s (2019; p215) compelling perspective on recovery as ‘an obligation in a society where grief is understood within time limits’ and where the prolonged griever is a problem for the normal routines of western living. Therapeutic interventions that are shaped by stage theory have been found to be harmful, to misguide bereaved individuals (Corr, 2018; Stroebe et al, 2017), and can suppress adaptive responses (Harris, 2010). An alternative approach is proposed, that both releases the client from their restrictive, internalised model of grief and helps them acknowledge, process and accept their internal conflicts that they have tended to dismiss or avoid in order to adhere to their model. Encouraging the client to engage in more self-care and to offer more compassion to themselves would aim to reduce the punishing self-talk that results from the obligation to conform to their perceived norms of grieving.

Another example of the dilemmas faced is the double-edged sword effect of coping behaviours, where the participants engage in negating emotions; avoiding, distracting, using humour or pleasing others in order to numb themselves, detach from reality and reduce the intensity of the painful emotions experienced. Yet the consequences of doing so appear to reinforce the fear of experiencing the pain, thus rendering them stuck in a vicious cycle of fear, heightened emotional response and avoidance. Avoidance of reminders of the realities of the loss is a normal response to grief (Shear, 2010) and has been identified as a key symptom of prolonged grief (Prigerson et al, 2008). When used adaptively, avoidance can be used to avert painful thoughts or feelings related to the loss and restore the capacity for a satisfying life, as depicted in Stroebe & Schut’s (2001) dual process model. However, if avoidance is over-used as a coping strategy, it impedes the processing of difficult information and prolongs acute grief (Shear, 2010; Worden, 2009). Previous research recognises idealising the deceased as a form of avoidance, where the stimulation of solely positive memories is protective from the discomfort of unpleasant thoughts (Worden, 2009), but can act to prevent the person from engaging in satisfying activities and forming new relationships (Shear & Frank, 2006).

Excessive avoidance is thought to become a major impediment to the adjustment to loss according to Stroebe & Schut’s (2001) dual process model. Shear et al (2005) have developed complicated grief treatment (CGT), an intervention drawing from attachment theory, interpersonal therapy, CBT and motivational interviewing, to overcome the obstacles to adaptive oscillation between the two types of coping. Although initial results from efficacy studies have demonstrated twice the rate of improvement in clients compared with those who received a more general form of psychotherapy, very large dropout rates (42%) are seen in client populations who are not taking antidepressants (Simon et al, 2008). Wetherall (2012) labels CGT as a ‘challenging’ treatment due to the inclusion of ‘painful imaginal and situational revisiting’, and asserts that it is more tolerated by those who take antidepressants. The therapeutic relationship has been found to be particularly crucial in this context as clients with an avoidant style have been found to respond less well to CBT, but this effect can be mediated by the therapeutic relationship (Hardy et al, 2007).

Another impactful consequence likely to have resulted from the unresolved dilemmas described above is the foreboding sense of waiting in an in-between world, feeling neither alive nor dead. Gillies & Neimeyer (2006) cite several studies demonstrating that the struggle to find significance in the loss is particularly acute following deaths that are traumatic or ‘off-time’ in the lifecycle. The repetitive nature of puzzling over the same internal conflict over and over again or having to overcome obstacles introduces a further paradox for the participants. Although there is an iterative or predictable sense to their repetitious experience, it acts to exaggerate the sense of impending doom and reinforces their feelings of powerlessness.

The desolation, sadness and isolation that the participants describe is experienced primarily as a consequence of the loss of the centre of their universe but they also feel isolated as a result of distancing themselves from others. Weiss (1973) differentiates between social and emotional loneliness, where the former refers to a lack of an engaging social network and social embeddedness, and the latter refers to a sense of utter aloneness and isolation for which social support offers no relief. Worryingly, the impact of emotional loneliness has been largely overlooked in grief literature, with the notable exception of Parkes & Prigerson (2013), despite almost a third of conjugally bereaved individuals showing high levels of loneliness for years after their bereavement (Van der Heuwen et al, 2010) and it being found to mediate the impact of marital bereavement on health and wellbeing (Stroebe et al, 2005). With regards to therapeutic interventions helping clients to deal with emotional loneliness, as distinct from social loneliness, a focus on continuing bonds and integrating the loss is recommended (Van der Houwen et al, 2010). Guiding the client to reflect on how the experience has changed them, using narrative exercises (Neimeyer, 1999) and encouraging the client to continue dialogue with the deceased in the form of letters, prayers or meditation has been found to help the client integrate the loss into their lives.

Conclusion

This research supports contemporary meaning-making conceptualisations of grief and draws on the theories that inform the recommended therapeutic interventions such as the dual process model (Stroebe & Schut’s, 2001), continuing bonds (Klass et al, 1996) and Neimeyer’s (2001) meaning reconstruction approach. It confirms the potential harm in applying stage-based grief models asserted by Stroebe et al (2017) and supports the non-pathologising approach of the power threat meaning framework (Johnstone & Boyle, 2018). The research makes distinctive contributions to bereavement research by identifying the significance of unresolved internal conflicts in individuals who feel stuck in grief, by highlighting the distressing consequences of living in ambivalence and by positioning a non-stage-based conceptualisation of grief as central to the efficacy of future grief interventions. Future research could focus on the struggle with conflicting thoughts that this research has highlighted by considering the resultant experience of living in ambivalence.

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