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Intervention Strategies for Life Trauma Issues & Death
Grief continuing education counselor CEUs

Section 25
Four Tasks of Mourning

CEU Question 25 | CEU Answer Booklet | Table of Contents | Grief
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Four Tasks of Mourning
Worden offers a task-oriented framework of mourning at the individual and family level (Worden, 1991). The combination of the timeline with the four basic tasks provides a more comprehensive picture of the grief process. This enables the therapist to design therapeutic interventions that are in sync with the experience of the bereaved. Figure 2 illustrates the fit of the timeline and task orientation.

The tasks are the challenges facing the bereaved during each phase. As an example, accepting the reality of the loss is the challenge during the shock phase. The second task of experiencing the pain is the work of the disorganization phase. The adaptation to a new environment is the transition between the disorganization and reorganization phases. Finally, the reinvesting of emotional energy and the reorganization phase meld nicely.

The following information helps the therapist organize the approach of using the timeline and task orientation to have an integrated view of the process.

First Task of Mourning
The first task of mourning is accepting the death and the loss (Worden, 1991). This is a subtle process that is difficult to assess. The individual may first talk about the deceased in first person. As the acceptance of the loss begins, the past tense may be more frequently used. The family also develops a shared acceptance of the reality of the loss. Family members slowly incorporate the deceased in conversations. The deceased's possessions are a helpful barometer. The individual may first link the loss to an object, then use the object as a symbol of the loss or transitional object, and finally place the object in a safe place as a treasured keepsake (Worden, 1991). For example, immediately after a death the bereaved person may hold onto a possession of the deceased. At first, he or she constantly carries this with them and is upset if it is misplaced. As the grief progresses, the bereaved person is able to separate from the object but knows where it is and how to gain access to it quickly. Finally, the object is put away in a place for safe-keeping.

It is important to understand that the acceptance of the death is an ongoing process, not an end point. The bereaved will experience the loss on some level throughout his or her entire lifetime. Survivors of expected deaths may accept the loss sooner than survivors of unexpected and sudden deaths (Parkes & Weiss, 1983).

Systemic Interventions
Maintaining a focus on the context of death helps the therapist to join and form a supportive relationship with the bereaved that reduces their isolation. While individuals and organizations in their context either minimize or deny the death and grief, the therapist adopts a position of acceptance and closeness. Sophisticated interventions are not required, it requires that the therapist be comfortable with the expression of denial and subsequent intense pain by the bereaved. This relationship with the therapist needs to offer a safe place to express this pain.

Bereavement therapy is demanding. The therapist must tolerate intense emotional expression of family members' feelings of powerlessness when faced with unspeakable tragedy and loss. The therapist can also experience this feeling of loss of control. When this occurs, many therapeutic approaches direct the therapist to reduce the intensity. While this familiar approach helps the therapist maintain his or her own safety net, it can hinder the therapeutic encounter.

During these initial sessions, the therapist also supports and educates the bereaved. The therapist educates the bereaved about the context of death and the grief process. This is done because the bereaved person has most likely had little education on the extent of the grief process. The key points are to normalize the indicators of grief and give permission to grieve.

The picture session is an important systemic intervention (Hunsberger, 1984; Lawrence, 1992). The deceased needs to be included in therapy. After allowance of time for joining, each individual is requested to bring four to five pictures to the session. Every picture tells a story and it is the therapist's task to use these photographs as a tool to acquire information about the family. It is a powerful event for a family member to bring personal photographs of the deceased to a therapist. They often do not appreciate that they have completed this assignment successfully. They have shared photographs of their loved ones requested by a virtual stranger. A few weeks before they may not have been able to talk about the deceased. This process is the first step to help the bereaved gain a sense of mastery over death.

Clinical Case Examples
Ms. S is a 47-year-old office manager. Her husband of 8 years died while the couple ate lunch in a restaurant. He was recovering from recent heart surgery for a congenital heart condition. Three months into the grief process, Ms. S came into therapy with their adopted seven-year-old daughter. Her daughter had a history of behavior problems that they were working on in a previous therapy. She presented with concerns regarding the grief process and how she was feeling overwhelmed functioning as a single parent with this demanding child.

Identifying Ms. S's early position on the grief timeline, the framework guided the therapist to develop the following interventions:
1. Provide a safe environment to talk about the depth of her feelings. She felt pressure from relationships in her context to remain silent and there was limited recognition of her grief.
2. Provide an outline of normal grief for her to compare her experience.
3. Give permission to grieve and acceptance of the range of feelings, and to ask others to listen.
4. Reinforce the need for continued firm and consistent limits for her daughter.

Second Task of Mourning
The second and most difficult task of mourning is to experience the pain (Worden, 1991). The individual has progressed Through the shock phase and they start to accept that their loved one is not going to return. The bereaved is most likely faced with expectations from others that they should be over it by now. The fact is That they are now face-to-face with the most intense emotions in the grief process. It is no coincidence that this task and phase occur at the time when most people enter bereavement therapy.

It is crucial that the family share in the expression of pain to accomplish this task. A family member may not participate in the shared expression of pain through disallowing feelings and/or dysfunctional or unhealthy behavior. This can disrupt the family process of experiencing the pain. Helping family members accommodate to the differences in expression and timing of grief reactions is key to the successful negotiation of this task.

Systemic Interventions
In the disorganization phase, experiencing the pain is paramount. The therapist attends to the individual and family levels. Continued contact throughout the difficult and emotionally demanding disorganization phase is crucial. The basic framework for guiding the contact is:

(a) reduce the isolation,
(b) provide an environment that allows expression of all emotions,
(c) promote the transition to the next stage of individual and family development,
(d) restore order in the family with developmentally appropriate, firm and consistent limits with children.

At the individual level, the task of the therapist is to foster an environment in which the bereaved can feel comfortable to express unspeakable feelings. This requires a safe place and permission to express all of their feelings. It is imperative to continue to discuss details of the death, funeral, and relationship with the deceased. When working at the individual level, patience is required because the bereaved may repeatedly review difficult aspects of the death and/or their relationship.
Each person's grief happens in a family context. It is important for the therapist to take an active leadership role in helping the parent(s) to promote shifts in hierarchy and flexible boundaries. This unremitting attention to grief in context creates room for the individual grief while attending to the survival of the family. The importance of roles is highlighted. Extended family or community relationships play an important role in supporting the grief process.

As the individual and family progress, the therapist needs to support and validate their looking toward the future. Family members may often feel uncomfortable with feeling better. The therapist helps place this transition in context as a normal phase of the grief process.

A person experiencing a tragic, unexpected death including suicide or violent death, may take a longer time to enter this phase. When this occurs, the Bereaved receives pressure from their context and themselves to get over the death. This can create a high level of anxiety at a time when the bereaved expects and is expected to move on with their lives. The bereaved should have the opportunity to work as long as they need to progress through the grief process.

Clinical Examples
Ms. D is a 67-year-old grandmother whose 40-year-old daughter died of a heart attack during her second ER visit in one evening. She was sent home after the first visit with the diagnosis of GI distress. She returned later in cardiac arrest and died within 1 hour after being admitted. Ms. D entered treatment 8 months after the death due to her own unstable emotional state and her concern about her two grandchildren, Kelsy 15, and Kevin, 12. Kelsy exhibited several concerning symptoms, including withdrawal, and isolating herself in her room and refusal to wear any clothes that were not at least two sizes too large. The latter was later connected to the fact that her mother was a buxom woman who often wore tight fitting clothes.

Ms. D herself was angry, scared, and she felt overwhelmed by the prospect of having to raise the children of her divorced daughter by herself. Ms. D was seen alone to process her grief experience and to plan strategies to support the granddaughter in her difficult grief reaction. Fortunately, her daughter was a very effective parent and she had few behavior problems with the children. However, due to Ms. D's emotional state she felt unable to provide the structure and to set limits for the children. The disorganization of the family was the first area for intervention. The therapist supported her in setting clear limits and to provide the opportunity to include the death in their daily conversations. The children were assured that Ms. D could handle their input about their mother and to share their grief, a process that occurred slowly over a period of several months.

Third Task of Mourning
The third task of mourning is adapting to the environment where the deceased is missing (Worden, 1991). The adaptation to the loss starts at the time of death. This task serves as the transition from the disorganization phase to the reorganization phase. The progression from shock to confusion now emerges into a realization of what changes the death has created for the individual and family. The loss is highlighted by the changes in the practical, everyday routines. This adaptation process requires new individual and interpersonal patterns to be established. This means new responsibilities and changes in lifestyle while grieving the loss. The family must be able to cope with disorganization while working to realign relationships and delegate new family roles.

Systemic Interventions
The therapist now shifts to actively challenging the bereaved to organize new behavioral patterns. This is accomplished by helping the bereaved assume responsibilities, take risks into new areas and activities, and to become aware of how the practical aspect of day-to-day living mirrors their grief process. The family simultaneously experiences the grief and begins to more effectively adapt to the changes. The family defines the new roles and responsibilities and a shift in boundaries helps begin to promote adaptation.

Clinical Examples
During a support group for survivors of recent deaths, Ms. V, whose husband died over a year ago, spoke about a recent night out with her friends. This was her first venture out of the house since her husband's death. She returned home late in the evening and was struck with the fact that the house was dark. Her husband would have been driving her and he also always left the lights on for their return. This new and unfamiliar event provided her with the realization that the loss of her spouse of 35 years meant she had to adapt her environment in a practical manner.

Fourth Task of Mourning
The final task of mourning is the reinvestment of emotional energy in relationships with the living (Worden, 1991). The individual turns their attention to reestablishing intimate relationships. The bereaved still has room for the deceased in their everyday experience but their focus is now expanding the other facets of their life.

At the family level, the deceased is included in family life. This process is particular to each family based on the role of the deceased and type of death. The family assigns the deceased a place in their world. The loss has less of an impact on the daily functioning of the family.

Systemic Interventions
The therapist's work centers on continued coping with the loss and promoting an expanded social network. The direction is to help the bereaved to reestablish the relationship with the decreased in a form That allows new relationships to be established. The therapist also focuses on the guilt feelings of the bereaved for moving on without the deceased. The bereaved finds a unique way to include the deceased in their daily life while building other relationships.

Clinical Examples
Mr. R's 31-year-old wife, while driving home after leaving their 4-year-old son at daycare was hit broadside by a teenager drag racing. Her 5-month-old son was uninjured, but she died instantly. The family entered treatment 9 months after the accident. At 18 months after the death, the father was utilizing occasional sessions for support. The last sessions revolved around the father's new relationship. He met a divorced woman with two children and it quickly became a serious relationship.

The therapist punctuated the father's shift from his relationship with his deceased wife to his new partner. This included dealing with the feelings of disloyalty contrasting with the need for a new relationship for himself and a mother figure for his three children. This complex process included the blending of the families leaving a respected position for the surviving children's mother while creating a new family structure.
- McBride, Joseph & Steven Simms, Death in the Family: Adapting a Family Systems Framework to the Grief Process, American Journal of Family Therapy, Jan/Feb 2001, Vol. 29, Issue 1.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #11
The preceding section contained information about the four tasks of mourning.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 25
What are four tasks of mourning?  Record the letter of the correct answer the CEU Answer Booklet.

 
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