This review will be conducted within the framework of the Scholarly Personal Narrative (SPN) (Nash, 2004), wherein it is a narrative that is honest, self-disclosing and scholarly, all at the same time. As Nash says,
I contend that what you have lived, loved, loathed and learned in a lifetime of extraordinary (or ordinary) challenges and satisfactions can be of enormous benefit to others (p. 24).
Therefore this review will include personal insight and experience where such disclosure feels warranted and useful.
The literature seems to hold grief as something only bereavement can claim as its own and the feelings that arise from divorce or separation as something else, not as painful perhaps. Yet it is the experience of this author that grief is indeed part of the emotional landscape facing the separated and divorced.
Indeed, the author is not alone in these feelings; Amy Ross Mumford (1976) argues from personal experience of both bereavement and divorce that the feelings are the same. Says Ross Mumford,
Some of the problems faced after the loss of a mate are the same—whether by death or divorce. And some are the same for men and women. For example, how many times have you turned over in bed and, half awake, reached out to touch your “special person” only to find their side of the bed empty? That sickening feeling of loneliness hits and, wide-awake, you realize your mate is gone (p.34).
This review will look at the literature of grief and focus particularly on men’s experiences of it. It will argue that whether the grief be for death-related or non-death events, the experience of grief is the same, just tailored to the event. It will also look at Acceptance and Commitment Therapy and see if it has anything to offer the grieving individual.
The language of grief
The language of grief, as used by some of its most potent commentators, can be applied to both the bereaving and the separated and divorced. Consider Attig (2000):
Early in the journey, pain and anguish are our constant companions. Hurt permeates every waking moment and casts the world around us in darkness. Virtually all of our physical and social surroundings and daily routines arouse pain and anguish when we meet them for the first time after a loss. First encounters are among our most difficult experiences—they cluster and fill the early days of our grieving. Pain and anguish hold centre stage, no matter where we turn. We often feel desperate and tortured by the least little thing. Sometimes our early agony is so great, our pain and anguish so preoccupying, that it seems we are nothing but the hurt we feel. No wonder we fear there will be no end to it (pp. 13-14).
Attig further writes,
Coming to terms with pain and anguish requires that we move, however small and halting our first steps may be (p. 17).
He further suggests,
We experience heartbreak and miss those we love terribly. We meet their absence everywhere. We long for their return. We feel uprooted and homesick. We feel joyless, hopeless, and as if life is drained of its meaning. We wonder whether we have the heart to live on without them. …We do not want to stop loving them (p. 281).
What is grief?
As far back as 1996 writers have been asking for a reformulation of grief to include non-death events. In their book GriefQuest: Men coping with loss (Miller & Hrycyniak, 1996), the authors write:
There are many misconceptions about grief in our world today. We men (and our women friends) reading this book need to realize that grief is not limited to death and funerals… The truth of the matter is that any event in life that involves loss or failure can be a source of grief feelings. Job loss or transfer, divorce or separation, disease or serious sickness, work struggles or conflicts, financial failures, midlife crisis, vocational uncertainty—all of these are likely sources for the rise of grief feelings. (p. 21).
If that is the case, and in this author’s eyes it is so, then what is grief, how can it be described or circumscribed? Miller and Hrycyniak delineate grief’s fundamentals: grief can include feelings of intense mental anguish or ‘heaviness’; acute sorrow or sadness; mourning and lamenting; anger, hostility and rage; a personal distress and unrest; a sense of loss or of ‘missing something’; helplessness and frustration; guilt, inadequacy, sense of failure; injustice or ‘wrongness’; tribulation, hardship and trial; discomfort and confusion; questioning and doubts; philosophical dis-ease; psychological angst; and a spiritual ‘dark night of the soul’.
Dictionary.com (n.d.) describes grief as:
keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret.
a cause or occasion of keen distress or sorrow.
The online Oxford English Dictionary defines grief as:
Hardship, suffering; a kind, or cause, of hardship or suffering.
So even the world’s arguably two most popular dictionaries don’t limit their definitions to just death events.
But why is grief so hard on us, and is it a robust construct?
Stress and grief
In 1967, psychiatrists Thomas Holmes and Richard Rahe examined the medical records of over 5,000 medical patients as a way to determine whether stressful events might cause illnesses. Patients were asked to tally a list of 43 life events based on a relative score; a positive correlation of 0.118 was found between their life events and their illnesses and the results were published as the widely-cited Social Readjustment Rating Scale (SRRS) (Holmes & Rahe, 1967). Of 43 items reviewed, it was found that research participants rated death of a spouse, divorce and marital separation as the three most stressful life events (where death of a spouse rated a ‘100’ score, divorce a ‘73’ and marital separation a ‘65’). Scores of 300 or more in a year were correlated with later illness. The clustering together of death, divorce and separation at the top of the scale suggests that the intensity and experience of grief is similar. Heartbreak, it seems, is the world’s biggest cause of stress.
The SRRS holds that death of a spouse is the most stressful life event a person can undergo, yet an exploratory study into whether the SRRS can be used as a predictor of suicide risk found that marital separation is the number one life stressor that predicts suicidal behaviour (Blasco-Fontecilla et al., 2012). The authors found that undesirable life events such as a “change in the frequency of arguments, personal injury or illness and marital separation characterized suicide attempers better than non-suicide attempters (p. 23).” They also noted that the pernicious effect of marital problems may be even more important in males than females. They commented that bereaved elderly men had more than three times the risk of suicide compared to their married counterparts and that bereavement for elderly women was not related to an excess risk.
Thirty years after the SRRS was first published, Scully, Tosi and Banning (2000) revisited it to see if it is still relevant in a much changed North America. Despite criticism over the years about the nature of events included in the SRRS, Hock (cited in Scully et al.’s paper) identified 138 research papers that included the SRRS citation in a single year, making it the most widely cited stress measurement instrument. Scully et al. report that, on balance, the SRRS is still a robust instrument for identifying the potential for stress-related health outcomes.
The tasks of grief
Worden (2009) identifies the four tasks that a mourning man or woman has to manage: 1) to accept the reality of the loss; 2) to process the pain of grief; 3) to adjust to a world without the deceased; and 4) to find an enduring connection with the deceased in the midst of embarking on a new life. These are equally the tasks that the separated and divorced must manage. Worden even defines ‘mourning’ as, “the process that occurs after a loss” and grief as, “the personal experience of the loss (p. 37). Thus it could be argued that he wordlessly acknowledges that grief and mourning are not the sole preserve of the bereaved. Indeed, he explicitly says so: “Grief is a term that can be applied to other [non-death] losses (p. 17).”
After a brief discussion on the differences between phases and his preferred term tasks, (Worden sees phases as somewhat passive whereas tasks he sees as more action-oriented, something that the mourner can take action upon and do something about, to or with), Worden goes into more depth. Task one, to accept the reality of the loss, is seen by him thus:
The first task of grieving is to come full face with the reality that… the person is gone and will not return” (p.39).
This applies equally, this author argues, with loss through divorce or separation.
On the second task, of processing the pain of grief, Worden has this to say:
Not everyone experiences the same intensity of pain or feels it in the same way, but it is nearly impossible to lose someone to whom you have been deeply attached without experiencing some level of pain (p. 44).
One of the aims of grief counseling is to help people through this difficult second task so they don’t carry the pain with them throughout their lives (p. 45).
Of the third task, adjusting to a world without the deceased, he writes:
Death can shatter the core of one’s life purposes and it is important to discover and invent new meaning in the face of loss (p. 47).
(Halford & Sweeper, 2013) argue that it is not only death that can shatter one’s life purposes, but so too marital breakdown. Hill and Turiano (2014) argue that greater purpose in life can predict greater longevity in adulthood. Worden, in citing Attig (1996), comments:
The internal task for the mourner is to address the questions “Who am I now?” “How am I different from loving him/her?” (p. 48).
Finally, of the fourth task of mourning, to find an enduring connection with the deceased in the midst of embarking on a new life, Worden has this to say:
The counselor’s task then becomes not to help the bereaved give up their relationship with the deceased, but to help them find an appropriate place for the dead in their emotional lives—a place that will enable them to go on living effectively in the world (p. 51).
This, too, is the task for the divorced and separated. As Volkan (cited in Worden) suggests:
We can never purpose those who have been close to us from our own history except by psychic acts damaging to our own identity (Worden, 2009, p. 50).
Men and grief
Men’s experience and processing of death-related loss has been recognised as different to women’s— Doka and Martin (1969) examine how different men’s grief is compared to women. For them, men’s grief is not the same as women’s grief, there is a greater propensity to solitude, a reluctance to join organised support groups and a demonstration of problem-focused strategies. As Stroebe (cited in Doka and Martin (p.143)) says:
Firmly entrenched in Western societies’ beliefs about coping with grief is the notion that, in order to adapt to loss and avoid suffering from lasting mental and physical health consequences, one must confront and speak of one’s personal feelings and reactions.
To only see grief through the one lens of spoken outpouring of feelings is clinically unhelpful, the authors point out. They point out that there are many possible ways to adapt to loss. Research on adjustment to bereavement, they go on to say, fails to support the notion that one gender fares better than the other. Men, they have found, are often more private, intellectual and introspective in their grief, additionally often choosing activity as a way of dealing with unpleasant feelings. What they do point out is that experiences and expressions of grief, and strategies for adapting to loss, are highly individual and idiosyncratic.
Baum (2003) visits the literature of men and grieving after divorce and notes that until recently the literature has been women-centric. Arguing that men grieve in ways different to women, Baum notes that little research has been conducted on this topic and goes on to outline differences in the male-female divorce-grieving process, positing reasons why these differences occur, all viewed through a three-part lens: when men begin their mourning, what they mourn and how men mourn in comparison to women. Baum calls on previous literature to suggest that men start the mourning process later, in part because women (who initiate 69 percent of divorces (Saad, 2013)) have already started their grieving process before the man is even aware there’s anything wrong (see Mercadante et al., 2014). It is also noted that divorced fathers tend to mourn the loss of their ex-wives considerably less than they mourn the loss of their children, home, family life and routine, and that men respond to their loss by increased activity, somatization and self-medication with alcohol and drugs. Baum argues that men’s refusal or reluctance to express their grief directly (through speech) may well be because there are less social and cultural supports for men experiencing divorce compared to those that women have access to. Given more supports, men might directly express more. The implications of her arguments and suggestions are that men’s later grief process needs to be taken into account when making custody and visitation evaluations. This later onset of mourning also has implications for divorce therapists, who should pay particular attention to helping men accept the reality of their divorce. In addition, therapists should recall the female bias in grief theories and avoid falling into the trap of expecting the grieving male to achieve the ‘goal’ of emotional expression through speech.
Mercadante, Taylor and Pooley (2014) take up Baum’s theme of grieving men’s later onset of mourning by considering West Australian fathers’ perspectives on separation. Noting Qu’s comment that “the process of relationship breakdown can be the most painful experience encountered in life” (Qu, 2004, p. 6), the authors go on to suggest that women as initiators of separation/divorce are likely to have a less-traumatizing experience; Brimhall, Wampler and Kimball (2008) note that men typically describe their marriage dissolution as being a difficult experience, whereas women tend to describe the experience as being a relief.
Interviewing eight WA separated fathers, Mercadante et al. uncover two themes: changed parameters and adapting to changed circumstances. That is, the fathers had to cope with changing circumstances and then adapt successfully to them, a task that all in the study found challenging (for some, uncomfortably and unsuccessfully so, particularly in relation to access to their children).
Mercadante et al. also comment on the state of grief literature:
Although grief historically has been associated with bereavement, new understandings of the human “grief and loss” experience has led to a refinement of the field’s terminology, with the term “grief” now being applied to a non-death-related experience of loss and “mourning” to a bereavement (i.e., death-related) experience of loss.
This new formulation has yet to work its way through the literature and the considerable body of extant work on death-related experience of loss has traditionally used the term ‘grief’solely. To this author this new formula makes sense, splitting out as it does non-death from death-related experiences yet not minimising the pain and anguish felt from non-death circumstances and events. On the topic of Grief and Mourning Worden (op. cit.) had this to say:
If Grief is defined as one’s experiences after the loss, then mourning is the process one goes through leading to an adaptation to the loss (p. 23).
Halford & Sweeper (2013) ask why some of the recently-separated show long-term adjustment problems to separation, while others show only transient adjustment problems. They found that attachment, loneliness, and psychological distress all declined over time (in their study, two years), and these were generally declines of large magnitude. However coparenting conflict showed a chronic unchanging course, with men reporting more conflict than women. As the authors also note, “high distress abates for most people, but not for those with psychological vulnerabilities.”(p. 240) The authors note that the first year after separation is a high-risk time for suicide attempts (citing Cantor & Slator).
As Staudacher (1991) points out, there is really only one way through death-related grief—one has to journey through the core of grief, experience the necessary emotional effects of that loss and from that journey successfully resolve the loss. Walking around the perimeter of the loss ensures that the loss will remain unresolved and the griever likely to endure painful emotional, psychological or physical consequences. Staudacher holds that there are three phases that are part and parcel of the grieving process: Retreating, Working Through and Resolving.
Immediately after the death of a loved one, the griever is likely to retreat psychologically. During this period they may experience numbness, shock, and disbelief mixed with conflicting and confusing belief. If the male is involved in the funeral arrangements it may well be possible that any significant emotional response may be absent or temporarily suppressed.
This is where the griever confronts the thoughts and emotions plaguing them. It will involve thinking about, possibly writing about, talking about and possibly crying about the emotions and reactions caused by the loss. As Staudacher notes, it is a period of intense disorganisation, emotionally, socially and physically. The griever can expect to be confronted by the following responses: sadness; confusion; despair; a feeling of abandonment; a feeling of powerlessness, loss of control and helplessness; fear that is specific and fear that has no obvious origin; anger at God, at the unfairness of the world; anger towards the self; anger towards the deceased; guilt for being alive; guilt for doing or not doing something; guilt for not being good enough; guilt for inheriting something; guilt for any feelings of relief; auditory or visual hallucinations; depressed; impeded concentration; poor memory (p. 5-6). The time frame for this sustained period of grief is neither definite nor predictable. However, most grievers notice a degree of healing sometime between the end of the sixth month and the beginning of the second year.
The third phase is where emotional reinvestment starts to occur, but reinvestment in a changed, different life. It may include a change in goals and direction or a reinvestment in a new relationship.
Five coping styles
Staudacher holds that there are five coping styles that men use to cope with their grief: remaining silent; engaging in solitary mourning or secret grief; taking physical action; becoming immersed in activity; and exhibiting addictive behaviour.
Staudacher’s work is built around death-related loss. But the implications are clear that the phases can easily be used to work with non-death related loss—the experiences and emotions are the same. For example, this author noticed with my own grief that healing started to be noticeable around the nine-month mark, that the responses that Staudacher describes above in the ‘Working through’ phase are still a ‘work-in-progress’ but that the ‘belief/unbelief’ reaction so much a part of Staudacher’s phase one has settled down and only visits me briefly, in perhaps fortnightly spasms.
Whether one subscribes to Worden’s four tasks or Staudacher’s three phases, the implication is the same—it is only by working through the tasks or phases of grief that emotional resolution is likely to come.
Grief and attachment
Pistole (1996) says that “ending an important love relationship can be a devastating, intense experience that feels like nearly dying” (p. 199). Focusing on Attachment Theory (Avoidant attachment, Preoccupied attachment, Secure attachment, Fearful attachment) she notes that grief can be construed as a changing of the griever’s world view. Using a self-report questionnaire on 118 psychology undergraduates, with 22 per cent currently married or living with a partner, Pistole found that Preoccupied attachment predicted self-reproach, Fearful attachment predicted partner blame, and both Fearful and Secure attachment predicted a friendly resolution. The implications are that counselling clients seeing a counsellor for relationship grief may benefit from counselling tailored to their attachment style. There is also the possibility that during times of world-view change that relationship grief opportunes, the grieving can be directed towards a position of greater attachment security. As Pistole notes, “achieving increased attachment security may benefit the person in a more general way by enhancing his or her relationships and the quality of family life” (p. 205)
Grief, language and health outcomes
Lee, Sbarra, Mason and Law (2011) undertook one of the first attempts to investigate language use as an index of attachment-related behaviour. Noting that separation experiences are among life’s most stressful events (Holmes & Rahe, 1967), the authors considered the question why (and how) some people navigate divorce and separation with minimal distress, whereas others become mired in pain. Using Attachment Theory (Bowlby, 1969, 1973), they started from the premise that studying the specific words used to describe separation experiences can provide a rich behavioural index in attachment-related hyperactivation. They felt that at least one dimension of the hyperactivation construct may be over-involvement with one’s own thoughts and feelings and that this may be seen through the use of verbally immediate language (language focused on the here and now, reflected by greater use of concrete, personal, and experiential language). These were then assessed according to how they impacted on the participants’ blood pressure (itself an indicator of health outcomes). The study examined blood pressure (BP) responses among recently separated/divorced adults during a laboratory task that asked them to think about their relationship history and recent separation experience. It was not until the authors asked the participants about their relationship history and separation experience that changes in BP were noted. When relationships dissolve, highly anxious adults engage in considerably more brooding and rumination about the loss event, as well as prolonged thoughts about reunion and behavioural attempts to rekindle the relationship. These tendencies are hallmarks of attachment hyperactivation. The authors also found a significant positive correlation between anxiety and verbal immediacy. Acting in combination, high immediacy of language and high attachment anxiety were associated with BP changes that, if prolonged, have clear negative health outcomes.
Grief and Australian men
Natalier (2012) investigated the worlds of fathers who pay child support in Australia, finding that the fathers’ anger at perceived wrongs (either institutional or ex-wife vindictiveness) was political, in that it represented an appropriate and rational response to the misuse of power. Natalier argued that child support can be used to express, build, sustain and destroy relationships after separation. For only a few was met the ideal ground of the ‘good divorce’: reasonable, conciliatory and aware of how decisions will impact upon children and others (Dewar, 1998). Natalier’s participants fell in to one of two camps: those who described their experiences of fathering with reference to loss, anger, despair, hopelessness and frustration, and those who may have felt constrained in how they fathered yet still maintained a sense of control over their fathering identities and practices.
Hewitt, Turrell and Giskes (2012) investigated the self-reported mental health of Australian men and women who were either separated or widowed. Following 3017 men and 3225 women over several years, the study found a decline in mental health for men who separated or widowed, compared to men who remained married. Similar effects were found for women. Of note was the finding that separation was the crisis point for mental health, not divorce. Perceived social support was examined to see if it had any ameliorating effect on levels of distress and mental health, but apart from assisting widowed men there was no noticeable uplift effect.
This author’s mental health journey speaks to Hewitt et al.’s findings, but not in agreeance. Separated in late November, 2013, I was initially overcome with feelings of sadness, regret, longing and loneliness. I sought out and reconnected with friends and joined a local tennis club—anything to keep busy and distract myself from thinking about my ex-wife and the life I was no longer part of. To this day my friends are incredibly important to me and my mental health. As a sufferer of bipolar disorder I experience my bipolarism as prolonged periods of mental anguish and depression (indeed, my prolonged depression was cited by my wife as a principal reason for the separation). The ongoing support of my friends has been of tremendous help to me, which runs counter to Hewitt et al.’s finding that social support only impacts positively the widowed male. Even though I am still plagued by feelings of hopelessness, loss and abandonment, I view the support of my friends as crucial to my wellbeing—I would be in a lot worse headspace without them, probably suicidal.
Desaulniers and Daigle (2008) investigated regional differences in men’s attitudes, suicide rates and sociodemographics in the Canadian province of Quebec. They found that in regions where men were more inclined to express their pain verbally, suicide rates were lower. Additionally, they found a positive correlation between suicide rates and low levels of education. On the former point, as they point out, “When the signs of their pain are well deciphered and acknowledged, men can then obtain services suited to their needs and, consequently, suicide may cease to appear like the only solution to their intolerable suffering” (p. 449).
The financial position of men after divorce is a confusing one; Bianchi, Subaiya and Kahn (1999) found in a review of studies that some find men’s circumstances improve markedly on divorce, some indicate only a modest improvement and some finding both men and women’s financial position deteriorating. Weston and Smyth (2000), in looking at the Australian context, find the position for women still deleterious, and complex for men. Economic disadvantage for men seems higher than a decade previously, although whether this is a function of the Henderson poverty line (a calculation of the relative ‘needs’ and living standards of families that appears to be based on a New York family from 1954—see Stanton (1980) for a critique), the introduction of the Child Support Scheme, the rising proportion of men relying on social security or some combination of these factors.
Increasing or maintaining high levels of social support has the potential to improve men’s mental health immediately following a loss (Hewitt, et al., 2012).
The pinball model of grief
Grief can be modelled in any number of ways, including having it represented by a pinball machine (Baier & Buechsel, 2012). Noting that there is widespread societal expectation that grief is a linear, staged process akin to Kubler-Ross’s work (1969), Baier and Buechsel proposed a pinball metaphor to help explain grief to those who had experienced loss, not just bereavement (although that was the paper’s focus) but also “the model may be used to help those coping with separation or divorce” (p. 32). Grief is pictured (above) to be one of the pinballs which, when activated (or ‘fired’) bounces around between the two bumpers of ‘shock’ and ‘denial’. Eventually the ball becomes unpredictable and it bounces into ‘bargaining’ (whilst still potentially bouncing between ‘shock’ and ‘denial’). Eventually the ball travels further down the table to hit the twin bumpers of ‘anger’ and ‘depression’, whilst the flippers can flip the grief ball back up the table to re-encounter the ‘shock’, ‘denial’ and ‘bargaining’ bumpers again. Eventually the ball passes through the twin flippers and into ‘acceptance’, however an anniversary or other trigger can send another ball back into play and the grief process starts again. One of the authors notes that they have had considerable success with using the model in their counselling practice.
It is not just researchers from the twentieth century who see grief as just a ‘death thing’. Versalle and McDowell (2004) see grief as a wholly death-related issue. Yet in commenting on prior researchers’ work, they fail to see how the categories they choose can apply to death and non-death grief. For example:
It might be more useful to characterize grief reactions as a continuum stretching from instrumental grief (cognitive, problem-solving ways of dealing with loss; so-called masculine grief) to intuitive grief (emotive, help-seeking ways of dealing with loss; so-called feminine grief). (p. 55)
Of course, divorce can sometimes be a helpful event in a person’s life. Maatta (2011) investigated men and women’s experiences of divorce. As she says, “everyone’s lives get better if a marriage eroded by painful disagreements is dissolved (p. 418).” But irrespective of whether divorce might be a good thing in certain circumstances or not, what doesn’t change are the painful emotions released by divorce. As she says:
Processing the painful matters in a divorce resembles the emotions related to death, the definite loss. During a divorce, one confronts the demise of the illusions of love and family. …Several researchers have described a divorce as a mourning process (p. 421).
In looking at Grief as a theme of her research findings, Maatta quoted one divorcee:
I had to say goodbye to the marriage and the person who had been so close to me and who shared a significant period of my life. I say goodbye to the mystical, deep connection that we shared and learn to accept the fact that it is over now (p. 423)
These were the same thoughts that plagued and continue to plague me. As Maatta points out, grief can be quite a selfish feeling: “What will happen to me? How will I survive?” Even getting dressed in the morning can seem such a pointless exercise.
Depression is, of course, nothing new to academia. It is something the modern academic world examined at the beginning of the twentieth century. Freud (cited in Berzoff (2003)) indicated in his 1917 paper On Mourning and Melancholia that mourning and melancholia feel alike. The mourner and the melancholic both feel dejected; both experience a loss of interest in the outside world; and both feel that loving is something they will never do again. “In mourning,” he wrote, “the world has become poor and empty. In melancholia, it is the ego itself.”
Shame-o-phobia: Why men fear therapy
Implicit in any discussion of men and therapy is the difficulty in getting men to therapy in the first place. David Wexler (2013, 2014) argues that the very language and style of therapy that is geared to women (‘touchy-feely’) is anathema and an unknown language to men, who much prefer a relational style of interaction. As a cartoon in one of Wexler’s papers says, “I promise this won’t hurt a bit – I’m just going to probe into and expose your deepest fears, anxieties and emotional vulnerabilities twice a week for at least the next three years…” No wonder men are scared to venture into therapy. This is certainly a view of therapy shared by this author, along with the fear of not knowing the language of therapy and how the process operates. Very often I don’t know what my thoughts and feelings on any given topic are and so attempts to ‘discuss them’ leave me feeling foolish and unskilled, and lacking in control of the situation—very unmanly.
Grief, depression and ACT
Despite being a very popular therapeutic tool, a search through the literature finds nothing on how Acceptance and Commitment Therapy (ACT) can impact and ameliorate grief, which this author finds surprising; only Russ Harris’ book The Reality Slap (2011) exists to help guide the client and practitioner alike. There is, however, a growing body of material when looking at depression and ACT.
Salena Bhanji (2011) reaches out to her colleagues and asks them to consider the ‘third wave’ of mindfulness therapies (Mindfulness-based Cognitive Therapy, Metacognitive Therapy and ACT) as ways to help in treating depression. Citing as evidence some key studies, Bhanji shows how ACT can be a viable alternative to CBT to treat depression.
Rumination is a major factor in the experience of depression for many, and a study found that there was an inverse relationship between acceptance and rumination amongst two cohort groups (Liverant, Kamholz, Sloan, & Brown, 2011). Their study proposes a potential mechanism of action for mindfulness and acceptance-based treatments for depression.
In clinical practice, there is the opportunity to compare an ACT approach with treatment-as-usual (TAU), which is what Petersen and Zettle (2009) did at a chemical dependency unit. Working within the context of a 12-step program, results indicated significant reductions in levels of depression for both control and ACT groups, but participants in the ACT group required a shorter treatment phase and smaller dose of individual therapy, giving a greater therapeutic impact. Behavioural Activation (BA) is another therapy that has been compared to ACT to assess their relative therapeutic effects (Kanter, Baruch, & Gaynor, 2006). The authors note that BA is easier to conduct in the context of other symptom-reduction approaches (e.g. medication).
Siang-Yang Tan (2011) gives an overview of the mindfulness therapies and gives a reserved ‘thumbs up’ to ACT, taking time to note that any positive effects felt in relationships with oneself or others is not the result of self-effort on our part but the fruit of the Holy Spirit and his empowering work in our lives.
Lars-Göran Öst has conducted two metastudies into the effectiveness of ACT (2008, 2014). In his 2008 paper he found a moderate effect size for ACT but that none of the third wave therapies reviewed fulfilled the criteria for empirically supported treatments. Researchers went away and added more rigour to their experiments (Montgomery, Kim, & Franklin, 2011; Smout, Hayes, Atkins, Klausen, & Duguid, 2012). So it is with some disappointment that in 2014 Öst again finds little to support the efficaciousness of ACT over other forms of cognitive or behavioural treatments: “An evidence-base evaluation showed that ACT is not yet well-established for any disorder. It is probably efficacious for chronic pain and tinnitus, possibly efficacious for depression, psychotic symptoms, OCD, mixed anxiety, drug abuse, and stress at work, and experimental for the remaining disorders” (p.105).
It is clear from the literature that grief is most often viewed as something death-related, yet instances abound where the grieving that takes place following the breakdown of a marriage is of equal magnitude and pain.
Researchers are increasingly calling for a more open and inclusive interpretation of grief, to one where loss—no matter how it originates or what form it takes—is seen for what it is: something that has the potential to cause the griever intense psychic pain and considerable anguish.
Similarly, ACT has been posited as a treatment suitable for depression (but not grief), with some positive research outcomes. However, the jury is still out on how efficacious ACT really is.
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