This is an abbreviation of a paper (lit review) that I wrote in 2015 as partial fulfilment of my MSc Bereavement Studies. More and more, in clinical practice, I see how effective a 'bottom-up' approach is to ensure positive therapeutic outcomes for those seeking support during bereavement.
How does grief manifest in the body?
Modern medical science testifies to the physical effects of grief in the body in a very tangible way and this literature review will show that there is no shortage of research into specific biological phenomena that occur in the constitution of the bereaved, yet most of the bereavement support on offer is from a uniquely cognitive perspective. So what happens when the physiological aspects of grief are not addressed during grief work, are we only half-supporting that person? Most bereaved people do not think or talk themselves into grief; is it therefore logical to expect them to think or talk themselves out of it? Many bereaved people speak of the visceral discomfort they experience in their bodies following the death of a loved one and how lonely this unacknowledged physical experience can be. This literature review shall highlight how grief is manifested in the body and show ways that clinicians are working with it to date.
A bereaved Irish mother writes in her blog:
“As a Clinical Psychologist in adult mental health, I was becoming more interested in forms of therapy that complement the talking therapies. I was looking for ways “in” to trauma and the source of all the pain the
body carries. We are like the layers of an onion. Talking gets to some of the layers and how deep we reach depends on how safe a person feels in their relationship with a therapist. I was beginning to experience the healing work of creative therapies like art, drama, music and movement. Creative expression can bring people out of their head and into their heart, they can help us to access the deeper layers of the self.”
(Sheila Boland, 2015)
REVIEWING THE LITERATURE
The Physiology of grief
“Among the most common physical responses to loss are trouble sleeping and low energy....Muscle aches and pains, shortness of breath, feelings of emptiness in your stomach, tightness in your throat or chest, digestive problems, sensitivity to noise, heart palpitations, queasiness, nausea, headaches, increased allergy symptoms, changes in appetite, weight loss and gain, agitation and generalized tension”.
Grief can result in significant decrements in health (Stroebe et al, 2007). The likelihood of bereaved spouses to suffer a sudden cardiac death rises significantly in the six months following the death (Mostofsky et al, 2011) and traumatic grief symptoms can precede illnesses such as cancer (Prigerson et al, 1999). The stress of grief can suppress the immune system (Vitlic et al, 2014). Other illnesses that have been linked to bereavement are ulcerative colitis, rheumatoid arthritis and asthma, as well as endocrine changes (Jacobs, 1993). High levels of cortisol (O’Connor et al, 2011) are responsible for weakening the immune system and also causing the thalamus to produce less white blood cells, leaving the bereaved individual highly susceptible to a variety of illnesses and disease (Gray, 2013). Although decrements in health following bereavement have been significantly researched, “the mechanism remains largely unexplained, possibly due the perceived difficulties in conducting research at a time of great distress” (Buckley et al, 2012).
From another perspective, the physiological expression of grief has been subdivided into controlled (intentional, reflective) and automatic (unintentional/reflexive) by McCrystal et al (2011) who strived to validate the dual process model by correlating it with physical manifestation of the grief response:
This ‘automatic’ expression of grief is described by a participant in Hentz’s (2002) qualitative research:
“It was just taking over my body...going into the depths all over again. Although it is not as bad as the actual event, I went pretty low again. I stopped sleeping and I had symptoms like depression... it just kind of takes over for a couple of months. It is almost a sense of feeling that you are just falling apart.”
This lady is describing the embodiment of her grief (Munhall, 1992) – the concept that the body is the representation of our consciousness and all that we are and feel is reflected in the body: “Pain lives in the flesh as well as in words” (Desjarlais, 1992). In her study, Hentz’s concludes that “Traditional models of grief counseling with emphasis on cognitive, emotional and behavioral outcomes need to be revisited.”
Attachment, Neuroscience and Grief
Lindemann (1944) and Engel (1964) were among the first theorists to observe a biological response to grief and Parkes (1972) was one of the first to produce quantative research in mortality rates among widows/widowers. Hofer (1984) believed that those we have attachments to act as external regulators for our behavior which are lost when someone dies. These losses cause upheaval in the body and only eases with new attachments (new external regulators) are made. Research into traumatized adolescents (Warner et al, 2014) found that they had pervasive problems with self-regulation which is an immediate goal in the first phase of treatment (Cloitre et al, 2012). Dance movement therapy has been shown to have beneficial effects on these neurophysiological regulation systems (Schore, 2003).
Archer (1999) examines the similarities between separation reactions in children and responses to bereavement in adults. Archer cites research that showed when human infants were separated from their mothers, those with higher levels of separation anxiety showed increased cortisol levels (Tennes et al, 1977). Bowlby (1969) and Parkes, heavily rooted in psychoanalysis and influenced by evolutionary biology, made links between attachment theory and the grief response. This was similar to how ethologists viewed the functions of separation responses in animals, ensuring caregiving, mating, etc. When separation (or death) occurs, features such as depression, anxiety, sleep loss and nervous system arousal are typical (Parkes, 1985).
One of the very first studies on the functional neuroanatomy of grief was conducted by Gundel et al, (2003). They conducted MRI scans on bereaved individuals, prompting a grief response by talking about their deceased loved ones. They concluded that:
“grief is mediated by a distributed neural network that subserves affect processing, mentalizing, episodic memory retrieval, processing of familiar faces, visual imagery, autonomic regulation and modulation/coordination of these functions. This neural network may account for the unique, subjective quality of grief and provide new leads in understanding the health consequences of grief and the neurobiology of attachment”.
Studies by Lang (1979) also show a correlation between that emotionally laden imagery and quantifiable autonomic responses, saying that we store emotional memories as associative networks that can be activated by external stimuli. It is with this knowledge that dance movement therapists work, implicitly understanding the connection between neurological processing and the physical body. The next steps should involve making this knowledge more explicit through empirical research, as identified by O’Connor (2005), with her invitation to a conversation between bereavement researchers and neuroscientists.
Trauma, Grief & Traumatic Grief
Grief and trauma are separate entities, but a person can simultaneously manifest symptoms of both if the death causes traumatic distress (Jacobs, 1999). Some people would argue that any death of a loved one, for many people, is a traumatic experience.
"No one ever told me that grief felt so much like fear. I am not afraid, but the sensation is like being afraid. The same fluttering in the stomach, the same restlessness, the yawning. I keep on swallowing. At other times it feels like being mildly drunk or concussed. There is a sort of invisible blanket between the world and me. I find it hard to take in what anyone says. Or perhaps, hard to want to take it in”.
Rando (1993) outlined some factors that can predispose individuals to traumatic grief such as sudden or unexpected death, accidents, child death, family member, death of someone close, “along with the bereaved’s predisposition to traumatic grief”. It is worth discussing the effects of trauma in the body because of similarities in the grief response. It is important to note, like grief, trauma is a very individual reaction. Some people will not experience trauma if they lose a loved one in very difficult circumstances, others may suffer trauma even though the death of their loved one was peaceful and expected.
In his article The body keeps the score, van der Kolk (1994) discusses psychic numbing, avoidance, amnesia and anhedonia as ‘responses to extreme experiences are so consistent across traumatic stimuli that this biphasic reaction appears to be the normative response to any overwhelming and uncontrollable experience’. It is also safe to say that the death of a loved one is often outside our control and, even when expected, can be overwhelming. Thus the physical responses to bereavement have many similarities to trauma, ‘shutting down’ or numbing, in between periods of intense hyper arousal or fight or flight responses.
“Despite the difficulties in conducting physiologically based studies in the early bereavement period, current evidence suggests that such a severely distressing life event is associated with increased cortisol secretion that potentially contributes to increased cognitive arousal resulting in sleep disturbance, especially in those with intense or prolonged grief reactions”
(Buckley et al, 2012).
Van der Kolk felt that talk therapy, exploring thoughts and feelings, was not helping his patients to move on, in some cases, it was making them get worse and there was an increase in suicide attempts among his patients. He recognized that these people whose bodies had been completely derailed by trauma would never be able to talk themselves back into equilibrium: “Their physiological housekeeping systems had been messed up by trauma” and that even a supportive therapeutic encounter wasn’t enough to reverse the profound physical and emotional changes wrought in his patients by pervasive trauma. This is backed-up by research on fear and brain functioning (Ledoux, 1998), which shows that the body, in a state of anxiety, stress or fear, increases adrenaline and cortisol production which reduces blood flow to the frontal lobes, leaving it difficult for us to access our thoughts (Homann, 2010).
Van der Kolk travelled to Puerto Rico in 1989 following hurricane Hugo and was witness to the devastating aftermath. The people, however, were quietly and successfully working together to clear the debris and making attempts to reorganize the chaos. Officials soon instructed the people to stop the work so that the damage could be assessed.
“Very quickly, an enormous amount of violence broke out – rioting, looting, assault. All this energy mobilized by the disaster, which had gone into a flurry of rebuilding and recovery activity, now was turned on everybody else. Preventing people from moving when something terrible happens, that ‘s one of the things that makes a trauma a trauma....Fundamentally, words can’t integrate the disorganized sensations and action patterns that form the core imprint of the trauma.”
As advances in technology became widespread, research was able to validate van der Kolk’s hypotheses. A neuroimaging team scanned the brains of eight trauma survivors. When triggered, they immediately dissociated and their left frontal cortex shut down, especially noticeable in the area responsible for speech, meaning that they found it difficult to think or speak (Wylie, 2004).
“The imprint of trauma doesn’t ‘sit’ in the verbal, understanding, part of the brain, but in much deeper regions- amygdala, hippocampus, hypothalamus, brain stem – (similar to the grief response) which are only marginally affected by thinking and cognition. These studies showed that people process their trauma from the bottom up – body to mind – not top down” van der Kolk.
Van der Kolk then went on to postulate the need to help patients to regulate these core functions, acknowledging that words and language alone would probably not be sufficient.
The Limits of Talk
According to Stroebe and Schut (2007) there is “growing understanding about factors that either complicate the course of grief over time, raise the risk of other mental and physical disabilities or both. Progress has also been made in the design and provision of psychological intervention for those who need it”, however, there is no mention of progress in the provision of physical intervention for those who need it, despite the very clear understanding that grief has a definite physical manifestation. To date, the research has been conducted in segments; but what about the body as a whole? The body as a representation of consciousness?
Van der Kolk was one of the first ‘mainstream’ psychiatrists who highlighted the effects of intense psychological disturbances on the body. This brought him into a whole new arena of practitioners who had been working with somatic memory for many years.
Babette Rothschild was one of the individuals. Rothschild clearly outlines the psychobiology of our innate stress response which can be triggered by trauma. The Body Remembers (2000) was one of the first publications to bridge the gap between the scientific theory and clinical practice of psychobiology, as well as talk therapy and body therapy, with a body-mind integration being central to the process.
Peter Levine (1997) postulates that trauma happens, not because of an actual event, but because it is not processed sufficiently in the body. Levine felt that trauma could physically manifest because of the body’s inability to fight or flight, in war, for example, or during rape, thus resulting in a multitude of un-discharged arousal energy. Levine also went on to say that the traumatized individual, in an attempt to discharge this energy, will often re-enact a similar traumatic event over and over again, similar to how someone with complicated grief can not seem to let go of the yearning for the deceased. Similar to trauma, grief “can interfere with the ability to think clearly, to make decisions and judgments, and problem solve” (Shear, K). While studies have shown that CBT as part of complicated grief therapy is more effective
than psychotherapy, there is empirical evidence that at times of dysregulation, the benefits of cognitive approaches to regulation are significantly decreased
(Raio et al, 2013).
Sensorimotor Psychotherapy is a body therapy developed by Pat Ogden (2000) who witnessed the dissociation experience of her patients when talking about difficult events that had happened in their past, including bereavement. She found that by- passing talk was necessary to bring about true relief from symptoms and, like Levine and Rothschild, Ogden recognized that traumatic events were activating the right amygdala and triggering fight or flight mode. Her clients, on talking about their trauma, would experience a wide range of body sensations that they didn’t understand and couldn’t make sense of verbally.
A dance movement therapist is trained to identify and work with any bio- psychosocial situation that may surface during the therapy. Emotional, physical and perceptual processes are simultaneously engaged (Homan, 2010) in a dynamic interchange between body and mind. Could this be the highly energetic and physical solution to trauma that van der Kolk identified in the Puerto Ricans after Hugo? Traditional grief work is a verbal process that relies primarily on language initially, whilst dipping in and out of emotional states. With dance movement therapy (dmt), the body is the primary language which offers ‘direct access to implicit processing” (Homann, 2010). Only when emotions and feelings have been physically integrated does language come into play, to further cement the integration process. Rosenburg et al (1985), developed Integrative Body Psychotherapy which is acknowledgement of the need to include both mind and body for therapy to be effective: “Our success has come from recognizing that our being, our essential self, is grounded in the body; that ignoring the body is to have very limited lasting success in treatment of psychological pain”.
One study involving dmt to support bereaved parents (Callahan, 2011) showed that movement explorations assist in the discovery of the unfamiliar, while repatterning of negative body sensations into positive ones, guides the healing process after
tragic events (e.g., the release of negative tension through breath work ultimately promoted a shift to a slightly more positive outlook).
The above therapies do not rely on the retelling of the stories, but rather the physical implications in the present moment. This is perhaps, one of the key differences between treating trauma and grief, where the importance of the telling and retelling of the bereavement story (Neimeyer, 2000) is key to moving through grief and accommodating to the loss. However, when talk therapy won’t shift complicated grief, it is worth looking at physiological approaches such as body-based therapies and the creative arts therapies where the relevance of these therapies to bereaement may come fully into play.
What are the gaps?
Many of the studies on body-based therapies were conducted with few individuals, lacked comparison groups, were not randomly assigned and were only preliminary studies that needed future development with more stringent controls. There is a chicken and egg scenario where science tends to ignore therapies that have no empirical support and scientific funding organizations are slow and hesitant to support research in practices that are not backed-up by empirical research. This means that many potentially useful treatments that are birthed in clinical practice remain unproven and are often considered unethical by theorists.
Whilst there is plenty of research into the physiological manifestation of grief, there is a dearth of treatment outcome research on somatic interventions. Where these interventions are being successful, they are often not scientifically documented and most somatic interventions for grief have yet to be subjected to empirical investigation. Further research is needed to build on this growing body of evidence that movement or body-based therapies could significantly contribute to increments of health in bereaved individuals and help people to achieve a ‘new normal’ where talk therapy hasn’t been effective. Given that between 4.6% (Prigerson et al, 1999) and 22.2% (Horowitz et al, 1997) of bereaved people suffer from prolonged grief disorder, there is a compelling need for prospective longitudinal evaluations to determine if body-based therapies could effectively support people suffering from complicated grief, employing a ‘bottom up’ approach, linking theory to ‘proven’ clinical practice. Our bodies carry our experiences, our stories and our felt sense of everything that has happened to us. They carry a wealth of information when we can get ‘out of our heads’ long enough to listen to what our bodies are trying to tell us. As long as clinicians continue to treat grief as a primarily cognitive experience, treatment outcomes will be limited.