If attachment is 'natural' then grief is a 'natural' emotion that is experienced when one is parted from what is dear. If grief is dealt with effectively it can initiate insight. However, if it is dealt with unskilfully, complications may arise. The normal grief reaction may manifest physically, emotionally, cognitively and/or behaviourally. Grief may have phases. However, some health workers encourage a task oriented approach to more actively enable a bereaved person to process and resolve the grief reaction. One way of effectively dealing with grief is that of the Theravadin Buddhists' practice of mindfulness. Mindfulness means staying aware of mind and body conditions in a present moment context. The task oriented approach can utilize mindfulness, and mindfulness may also be evident in many modern psychotherapies. Traditional mind-tools to encourage mindfulness may be used in collaboration with a counsellor/therapist as well as in solitary practice. With mindfulness a bereaved person can more effectively acknowledge the reality of loss and allow the pain of grief to manifest without further complication. If the pain is experienced without undue reaction, the undermining effect and manifestation of grief can be resolved and the bereaved person can function relatively free from impediment. Grief is a common emotion that human beings experience when they are parted from that to which they are attached. Its effect can be painful and debilitating. Probably the most debilitating type of grief occurs when a loved one dies. If the grief is not dealt with effectively the grief can become pathological and create a situation where the bereaved person is unable to function in the world adequately. Bowlby (according to Worden, 1982) argues that attachment is developed in animals (humans included) because it has a survival value. If attachment is natural, then it is also 'natural' to grieve. "The pain of grief is just as much a part of life as the joy of love; it is, perhaps, the price we pay for love, the cost of commitment" (Parkes according to Kalish, 1985, p182). The resolution of grief can be accomplished by developing mindfulness. The practice of mindfulness (also called satipatthana) emphasises being aware and surrendering to the natural and present moment conditions of mind and body. This is primarily a Theravadin Buddhist approach. However, elements of its practice can be found within common task oriented and supportive grief counselling techniques as well as some modern psychotherapies.

If grief is dealt with effectively it can become a tool for the development of great insight. If on the other hand it is dealt with unskilfully it could initiate a whole chain of chronic dysfunction, confusion, depression, avoidance behaviours and general unhappiness. The complications of the grief reaction are many. However in the manifestation of a normal grief there are many common types of reaction (Worden, 1982). There can be feelings such as sadness, anger, guilt, anxiety, loneliness, shock, yearning, numbness, helplessness etc; physical sensations which include fatigue, tightness in the chest, a dry mouth, a hollow feeling in the stomach, tightness in the throat and more; various thoughts that can lead to depression, obsessions, confusion or even hallucinations; and behaviours such as disturbed sleep, social withdrawal, crying, neurotic responses to old possessions and memories, absent-mindedness, searching and calling out, restless overactivity and so on.

Parkes (according to Kalish, 1985) suggests four stages of grief: numbness, pining, depression and recovery, while Averill (according to Kalish, 1985) three: shock, despair and recovery. Worden (1982) on the other hand, encourages a more active approach by specifying various tasks that must be accomplished before grief can be resolved. The four tasks that Worden (1982) claims are necessary are: Task 1: Accept the reality of the loss; Task 2: Experience the pain of the grief; Task 3: Adjust to an environment in which the deceased is missing; Task 4: Withdraw emotional energy from the deceased and reinvest it in other social activity without uncertainty or guilt. The goal of the counsellor/therapist is to encourage the completion of these tasks. Neither the phase nor the task models should be considered as invariable patterns. They are, however, useful guidelines that may be used when appropriate.

Counselling can be used for the 'natural' grieving process. However when the resolution of the grieving process becomes complicated, Worden (1982) recommends grief therapy. Grief therapy is used when the grief is excessively prolonged, exaggerated, creating somatic reactions or in some other way influencing a subconscious or even conscious impediment in an individual's normal functioning. Though the initial effects of a death or other shock may in many cases pass in a few days, the 'pangs' of grief may continue for many months or even indefinitely. "Even if your loved ones are still alive, there is a place within of disappointment and loss because we live in a world where everything changes....Whatever you want, the more you want it, the more there is a kind of grief, a sickness, a hollowness in the pit of the stomach.....Grief comes from trying to protect anything from being what it is. From trying to stop the change." (Levine, 1982 p97.) It seems then that most people are candidates for both grief counselling and grief therapy. If one considers Worden's (1982) tasks various themes become evident. Within these themes there are elements of the necessity to acknowledge the loss, be honest, aware, "let go" and function adequately on all levels of personal care and social interaction. Whether one is assisted by a therapist, clergy, family or other, eventually the onus must come back to the individual, as another person can only act as a catalyst to awaken a subjective awareness and resolution to whatever dilemma may exist.

2500 years ago the Buddha (according to De Silva, 1984), used a performance-based technique to help a bereaved woman accept the reality of her child's death. The woman's child died not long after it could walk, and in a distressed state the woman wandered the streets for days with the child in her arms asking everyone for a medicine to save her child. The Buddha seeing her behaviour told her that he knew of a medicine to help her but first she had to collect a handful of mustard seeds, each one from a house that had not seen death. As she went from house to house unable to collect the seeds she realized that death, in general and the death of her child in particular, was a reality. Through insight she discarded her irrational behaviour. De Silva (1984) compared this technique to Ellis's rational-emotive therapy. A common performance based technique used to help the bereaved accept the reality of a loved one's death is that of encouraging the survivor to see the body. Barbara Walsh (1987) claimed that research has shown that when a body is viewed it assists the bereaved to deal with the reality. Barbara Walsh pointed out though that one should be sensitive to the way that this is done. One should not for example say, "Would you like to see the body?" but instead say something like "I think it would help if you said goodbye to ...".

Other techniques can be less performance based and more introspective, as it is the eventual 'internal' resolutions that will heal external manifestations and behaviours. One such technique or therapy could be that of mindfulness or 'satipatthana' which has been used in the Theravadin Buddhist tradition. 'Sati' means awareness and 'patthana' means keeping present. The Buddha claimed (according to Nyanaponika Thera, 1962) that there was only one way to overcome grief, and that was with mindfulness. To one who knows nothing of 'satipatthana' this could seem like a sweeping statement. However if one investigates the dynamics of this therapy-practice, one may begin to see how most aspects of modern psychotherapy and counselling incorporate aspects of mindfulness, and how Worden's four tasks can be accomplished using mindfulness. There are four foundations of mindfulness. These are body, feelings, mind states and mind objects (according to Nyanaponika, 1962).

The goal is to clearly perceive and pay attention to, in an objective manner, the arising and passing away of all conditions of mind and body. Eventually insight into their transient and insubstantial nature arises and one is no longer at conflict with their changing nature. Mindfulness of body includes amongst other aspects, being aware of postures, somatic sensations and the breath. Mindfulness of feelings is not regarded as mindfulness of the emotions as such but more being attentive to the qualities of pleasantness, unpleasantness or neutrality that arises in the mind in relationship to physical sensations or mental processes. Mindfulness of mind states refers to being aware of the states of mind that may colour the mind, such as a distracted mind, a happy mind, an angry mind, a guilty mind and so on. Mindfulness of mental objects refers to being aware of the content of mind such as thoughts, and being aware of how they condition both physical and mental processes. The theme behind mindfulness is to honestly relate with whatever arises as it arises. The aim to perceive and acknowledge the reality of any situation in a present moment context. The benefits of 'satipatthana' are based on the development of insight.

Traditionally a practitioner of 'satipatthana' decides upon an object of meditation or mindfulness and when the mind becomes distracted from that object the distraction is acknowledged and the person returns to the original object. If the distraction becomes overwhelming the distraction then becomes the object of meditation and non-intellectual investigation. During life one's mind and body undergoes continual change. Mindfulness can be facilitated with the manifestation of both the acute reactions of what Worden (1982) called normal grieving as well as dealing with complicated grieving reactions that may seem pathological. There are many mind tools that can be used to develop mindfulness.

One tool is that of labelling the object of mindfulness with a name. This serves to concentrate the mind as well as clarify and objectify the condition. The rising and falling of the abdomen is usually labelled "rising, falling", thoughts of the past "remembering", the future "planning". Other simple tendencies are labelled accordingly such as "anger", "worrying", "sadness", "brushing" for brushing one's teeth and so on. Another such tool is developing what Deatherage (1982) called "the watcher self". "The watcher self can see the remembering of some painful event and label it objectively without becoming involved in its melodrama. The watcher can therefore put psychological distance between the "me" who experiences the painful event and the "me" who is presently remembering it." (Deatherage, 1982, p22). The aim of the watcher self is not to strengthen the ego but "The watcher self is used only as a tool for grounding some of the patient's mental energies in the present, providing a temporary, psychological stable centre for them to operate from and providing a perspective from which their own psychological functioning can be objectively observed." (Deatherage, 1982, p25) As aspects of the physical, cognitive and behavioural manifestations of depression, anxiety and obsessive behaviour are similar to the normal and abnormal grieving processes, successful techniques applied to the former could also be applied to the latter. Deatherage (1982) has cited how the 'satipatthana' method has been successfully applied in a clinical setting. In one case a divorced woman would have bouts of depression and anxiety when she remembered her ex-husbands bizarre sexual demands. She was trained to label her thoughts as "remembering, remembering", and within a few days she could see the causal relationship between the thoughts and the anxiety and depression. Another woman who was hospitalised for manic-depression and schizophrenia, was instructed to watch the second hand of a clock and when her mind went off the clock to name the distraction. Soon she realized that most of her distractions were related to the past. She was then instructed to label them as "remembering, remembering". With this technique "she learned to identify herself with the objective watcher of her disturbing thoughts instead of the depressed thinker." (Deatherage, 1982, p24). Soon she began to gain insight into the nature of her illness and was released from hospital. Another woman who was hospitalised for anxiety, depression and inability to function adequately, rebelled against any suggestion of introspection, and as she was a Mormon the word 'Buddhist' or 'meditation' was not mentioned. As the therapist interacted with her it became evident that much of her day was spent fantasizing and imagining to avoid the anxiety of her life. The habit of fantasizing was discussed with her, and then she was asked to undertake a "psychological procedure". To her surprise she was asked to bake a cake. However, she had to do it extremely mindfully with minute attention to detail. When the persistent fantasies would arise she was instructed to just observe them. After a while she found that she could intentionally return to the present moment and so function more adequately. She also began to gain insight into the nature of her anxiety and depression. Mindfulness training therefore develops a space between life's events and the ego's reaction to those events. Eventually tools such as the labelling or the "watcher self" can be discarded and it is possible to totally immerse oneself in whatever one is doing, whether it is observing the breath, washing the dishes or solving an occupational problem.

Everyone is different and so have different physical and psychological manifestations while grieving or suffering the effect of an unresolved grieving process. If one is aware, grief can become a tool for an awakening to greater understanding and insight into the truth of life. Levine (1982) claims that when someone we love dies it is almost like an initiation into insight. As one experiences the intensity of physical and emotional anguish, it becomes so intense that there is no way to avoid the raw experience of human pain. Levine (1982) related a story of a woman who lost her 3 year old child in a surfing accident. Three days after the child went missing the woman was contacted to identify the half-eaten washed-up body. The identification, said the mother, was the most profound and enlightening experience of her life, as intense pain and love were felt simultaneously.

It seems that the more one can remain 'open' and mindfully experience the pain of grief (Worden's 2nd task), the greater possibility of effectively processing and overcoming its effects. If one has previously practised satipatthana, it can be extremely useful at the time of bereavement. If one is mindful there is less tendency to delay the inevitable task of accepting the reality of a death (Worden's 1st task), and experiencing its pain (Worden's 2nd task). The more one avoids these tasks, the greater is the tendency to experience disturbing emotions, thoughts, physical sensations and develop avoidance behaviour. If one has accomplished Worden's (1982) first two tasks, the last two are a natural progression as the manifestation of grief do not overly influence and undermine an appropriate and normal relationship with life, and the person is (relatively) free.

The 'satipatthana' technique is a client-centred approach and so gives the bereaved the freedom and dignity to work by themselves without being overly influenced by a counsellor/therapist's expectations or preordained pattern of what 'should' happen. 'Satipatthana', however, is not always suitable for everyone, nor is its solitary introspection techniques appropriate at all times. The grieving process can be extremely overwhelming or complicated. There are times of course when a bereaved person needs close contact and support of a counsellor/therapist. The support person could act as a source of strength, compassion, insight or merely help reflect the bereaved's situation, and so even when the awareness seems to be externalised the process of 'satipatthana' can be utilised.

Rogerian techniques incorporate 'empathetic listening' and non-judgemental reflection, and so the acceptance, recognition and clarification of mind-body conditions have a healing effect. Worden (1982) claims that repeated verbalisation about the event helps bring home the reality of the situation. Whilst Kollar (according to Kalish, 1984) says that 3 out of 16 important points to follow in helping the bereaved are to "14 listen, 15 listen" and "16 listen" (Kalish, 1984 p271). In accordance with the 'satipatthana' approach and the completion of Worden's tasks, Gestalt therapy (Davison and Neale, 1974) encourages: being concerned with the present rather than the past or the future, dealing with what appears rather than what is absent, experiencing things rather than imagining them, feeling rather than thinking, expressing feelings rather than justifying or explaining them, being aware of pain as well as pleasure and surrendering to the kind of person one is.

With bereavement counselling Worden (1982) praises the use of the 'open chair' technique of Gestalt therapy, and the role playing technique of psychodrama to resolve unfinished business that may cause various undermining effects such as guilt or anger. Even body therapies can be useful. A simple massage can trigger off many unresolved feelings or unacknowledged emotions. Levine (1982) has written a guided grief meditation-massage used to become aware and surrender to the physical and emotional pain that may be felt in the area of the heart. (refer to Appendix 1).

Traditionally, when using a 'satipatthana' technique a teacher often encourages a student to centre their awareness on bodily sensations as this is a more tangible and less confusing object of awareness. When one is experiencing the overwhelming effect of bereavement, in addition to the multitude of thoughts and mental states, strong physical sensations also appear (according to Lindemann in Kalish, 1985) and seem to be a reflection of and synonymous with mental counterparts. Worden's (1982) second task is to feel the pain of loss. When a bereaved person is undergoing a difficult time he/she could be encouraged to pay more attention to what it feels like as opposed to just being aware of cognitions or theoretical solutions to the situation. A person may for example have memories of his/her loved one, which creates sadness and tight feelings in their chest. Firstly they could label "remembering", then "sadness", then "tightness" and pay full attention to the physical sensations while allowing the corresponding mental melodrama to run its course. If one opens up to the physical sensations the non-intellectual awareness/investigation often serves as a means to process the present mental and physical dilemma, as well as a means to pry open suppressed pain and conflict from the past. Often what may start as a minor sensation can be like the tip of an iceberg which eventually becomes exposed. Often a therapist can assist the bereaved by actively asking her/him to describe the sensations, its dimensions, where it is, its shape or quality, whether it changes and so on. With the passive support of the therapist a bereaved person is often able to go right to the centre of the pain. If one is encouraged to experience the pain she/he begins to gain a different perspective about it. The pain is accepted and eventually passes, and likewise the conflict with it and its mental and behavioural counterparts. Grief is a natural reaction to loss. Its effect can be painful and debilitating. If one is to overcome the effects of grief one must accept the reality of the situation and experience whatever pain may arise. If one delays the inevitable necessities of the 'natural' grieving process, one merely prolongs the suffering and one's open relationship with life is undermined. If one is aware (mindful) the natural process of grief can be facilitated and if complications arise they can be dealt with in an efficient manner. Awareness can be facilitated by performing various learning tasks, introspection or expression. As this is done it eventually becomes evident that the subjective experience of grief cannot be resolved by anyone other than the experiencer. The resolution comes from both an active attention-investigation and a passive surrender.

References:

Davison, G.C. and Neale, J.M., Abnormal Psychology, John Wiley and Sons, 1982.
De Silva, P., Buddhism and Behavioural Modification, Behav. Res. Ther., Vol 22, No 6, pp661-678, 1984.
Kalish, R.A., Death, Grief and Caring Relationships, 2nd Ed, Brooks/Cole Publishing Company, 1985.
Levine, S., Who Dies? An investigation of conscious living and conscious dying, Anchor Books, 1982.
Nyanaponika Thera, The Heart of Buddhist Meditation, Rider and Company, 1962.
Walsh, B., from Community Health Care, Tamworth, NSW, Bereavement Counselling, a talk, New England and District Hospital, 19th August, 1987.
Worden, W.J., Grief Counselling and Grief Therapy, Tavistock publications Ltd, 1983.
Deatherage, O.G., Buddhism in Psychotherapy, The Wheel Publications 290/291, Buddhist Publication Society, 1982

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