Subsequent research that has examined kübler-ross’s theory has found the theory:

Theoretical Understanding

Theoretical approaches to bereavement provide explanations for phenomena and manifestations of grief and grieving. For example, some provide insights into mal/adaptive coping mechanisms, which are potentially useful for guiding research, and ultimately, for applied use in helping the bereaved. Theories vary widely with regard to basic principles, levels of analysis, and degree of specificity. They also range from application to bereavement of general psychological theories such as psychoanalytic and attachment theories or theories of loss and trauma, to bereavement-specific models of coping.

Much theorizing in the bereavement field has been influenced by Freud's (1917) paper ‘Mourning and Melancholia.’ According to this psychoanalytic approach, when a loved one dies, the bereaved person is faced with the struggle to sever ties and detach the energy invested in the deceased person. The psychological function of grief is to free the person from the ties to the deceased, achieving a gradual detachment by means of the process of grief work. Grief work remained a central concept not only in subsequent theories but also in principles of counseling and therapy. It denotes a cognitive process of going over events that occurred before and at the time of death and focusing on memories and working toward detachment from the deceased. According to Freud, a major cause of pathological grief was the existence of ambivalence in the relationship with the deceased preventing the normal transfer of libido (energy) from that person to a new object.

The notion of grief work has been one of the most persistent features of psychoanalytic theory to influence subsequent research and thinking about coping with bereavement. While its theoretical interpretation is different, it has been incorporated in the major contribution of Bowlby, in his attachment theory (e.g., Bowlby, 1980). Bowlby focused on the biological rather than the psychological origins of grief. According to his approach, the biological function is to regain proximity to the attachment figure, separation from which has caused anxiety. In the case of permanent loss, regaining proximity is not possible; the response is dysfunctional because reunion cannot be achieved. But an active working through of the loss still needs to be done, as it is an essential part of grief and grieving. The focus on working through grief led Bowlby to formulate phases or stages of grieving (shock, numbness and denial, yearning and protest, despair, and gradual recovery). However, there has been a move away from a phased approach, particularly in view of the evidence that grief and grieving do not follow a predictable, sequential order from initial high distress to return to normal (although it is important to remember that the phases were initially conceptualized as descriptive, i.e., indicating regularities, rather than being prescriptive). One major shift was brought about by Worden's identification of tasks rather than phases of grief (e.g., Worden, 2009), in terms of acceptance of the reality of loss, processing the pain, adjusting to a world without the deceased, and retaining connection with the deceased while embarking on a new life. Worden's tasks have provided clinicians with a ‘tool’ to help clients work through their grief. A further major development has been Bonanno and colleagues' (e.g., Bonanno et al., 2008) identification of trajectories of grief. Their research showed that there are qualitatively distinct pathways across the months following the loss of a loved one, supporting the conclusion that the grieving process cannot be well described in terms of a single set of stages or tasks. Bonanno's research suggested that resilience is actually common and that delayed grief is rare.

In other respects, attachment theory has also remained enormously influential in contemporary bereavement research. Early childhood experiences with attachment figures are still considered critical. These experiences are understood in terms of the development of either secure or insecure bonding with the caregiver, and this emerging style of attachment has a lasting influence on later relationships. To illustrate, frequent separation from attachment figures in childhood can lead to anxious attachment in later relationships, which is associated with chronic grief. Mikulincer and Shaver (e.g., 2013) have conducted sophisticated empirical research, confirming the importance of attachment security in the prediction of adjustment to bereavement and providing a fine-grained understanding of many associated phenomena.

Diverse trauma and stress theories have influenced the understanding of the phenomena and manifestations of bereavement. One major line of work is represented by the work of Horowitz and colleagues (e.g., Horowitz, 1986), applicable to traumatic events in general. A basic assumption of this approach is that stressful life events (SLEs) play an important role in the etiology of various somatic and mental disorders. A further line of research derived from the related field of trauma was that of Janoff-Bulman (1992), particularly through identification of shattered beliefs, which need to be rebuilt. This has been expanded to the study of ‘meaning making’ particularly by Niemeyer and collaborators (e.g., Neimeyer, 2001), giving centrality to the need for ‘making sense’ and ‘finding meaning’ after the loss of a loved person. A basic idea is that the reconstruction of meaning about the self and the world is critical to adjustment. Difficulties in establishing the role of meaning making in adjustment remain (e.g., studies have not always succeeded in separating the process from the outcome, beliefs from adjustment, or establishing the direction of causality among these factors). Others have distinguished two components of meaning-making. Davis et al. (1998) identified two distinct processes, making sense of the loss and finding benefit, which entail distinguishable psychological concerns for the bereaved person, with, for example, the former diminishing in importance in time, while the latter growing stronger as time goes on.

Stress theorizing received independent impetus through the work of Lazarus and Folkman (1984), who provided detailed analyses of coping processes, through which SLEs may precipitate poor physical or mental health outcomes. A major premise of their cognitive stress theory is that the intensity of stress created by an SLE depends on the extent to which the perceived demands of the situation tax or exceed an individual's coping resources, given that failure to cope leads to negative outcomes. Recently, research has identified neurophysiological mechanisms linking stress with various detrimental consequences to the immune, gastrointestinal, and cardiovascular systems (O'Connor, 2013). Folkman (2001) applied cognitive stress theory specifically to the stressor of bereavement, significantly extending the perspective to include positive emotions/appraisals as a component in coping with bereavement. Drawing partly on this theoretical approach, Stroebe and Schut (1999) developed their dual process model (DPM), a bereavement-specific coping model, to try to capture the complexity, diversity, or idiosyncratic nature of grieving. They postulated two types of stressor, the first called loss orientation, which relates to the deceased person (e.g., ruminating about the death), and the second restoration orientation, which has to do with secondary stressors that come about indirectly but as a consequence of the death (e.g., dealing with new financial concerns). Rather than assuming phases or tasks, the DPM includes an emotion regulation process, labeled oscillation. Adaptive coping entails oscillation between the two types of stressor and ‘time out,’ given the necessity to rest from the arduous process of dealing with the loss.

Intra- and Interpersonal Skills

The last type of teaching discussed here is the need to teach some children specific intrapersonal and interpersonal skills so they are better able to function in the world. One example of an intrapersonal skill is teaching a child a relaxation strategy. If overwhelming anxiety is part of the reason the child is unable to get his or her needs met consistently and appropriately, then he or she may greatly benefit both from learning how to manage that symptom and from the sense of empowerment accompanying the acquisition of the skill. The vast majority of children who enter play therapy have some degree of interpersonal skills deficits. This is most obvious in the children who act out a great deal, who are often involved in fights at school, and who have very few friends. These deficits are less obvious in children who tend toward being over-controlled, who interact well with adults but who are shy, isolated, and virtually unable to engage in positive interactions with their peers.

An educational approach is often an effective way for teaching both children and others specific skills. Books and materials are available that cover parenting skills, behavior management, social skills, anger management, grief work, and so forth. When presenting skills information, it is important to help both children and adults translate the cognitive content into practice. It is one thing to hear about or think about the use of a particular skill; it is quite another to determine when and how to use the skill in one’s own life. The play therapist should also provide opportunities for either the child or adult to practice the skills in a safe environment. Little will damage a client’s motivation more than meeting with failure or, worse yet, a hostile response the first time they attempt a new skill. Role-playing the use of the skill in session can be very useful, especially if the play therapist demonstrates exaggerated, humorous errors in implementing the skill in a playful way. This desensitizes children to the seriousness of making mistakes, and frees them up to adapt the skills to their own needs. This playful tone is useful for adults as well, as they often take the process of implementing important life skills far too seriously. Parenting, teaching, medically caring for, or even conducting play therapy with a child can become dreary, even painful experiences if the participants cannot play with roles at times and laugh at themselves in the process.

There are probably many other situations in which children might benefit from being provided with specific information by means of an educational intervention. The play therapist should always first determine whether there is someone in the child’s environment who could take on the role of educator so play therapy time need not be used. When it seems best to conduct the education in session, the play therapist should first attempt to provide the information in the context of the experiential or cognitive aspects of the therapeutic process. When this is not an option and direct education seems to be in order, the play therapist should look for ways to bracket the educational elements to both emphasize their importance and separate them from the more cooperative problem-solving aspects of the play therapy process.

Models of Grief

A variety of models aim at explaining grief. Phase models of bereavement are still popular by providing a system that is both logical and dynamic. After initial shock and disbelief, the bereaved is assumed to go to further stages of adaptation, namely to realization of the loss and grief work that includes the gradually disengagement from the target person and finally the resumption of emotional life and the capacity to form new intimate relationships. These phases are generally conceptualized as sequences. However, most researchers agree that this view is oversimplified.

Some models focus on coping with losses. The task model (Worden, 1996) suggests four tasks to adjust to bereavement. In contrast to just passively experiencing the loss, it focuses on active coping with the challenges, namely accepting the reality of the loss, experiencing the pain, adjusting to an environment without the deceased person, and finally finding a new understanding with the deceased. Coping models often focus on various coping styles, such as avoidant coping or rumination (e.g., Nolen-Hoeksema and Jackson, 1996) that often lead to elevated depression and higher distress levels later on. In contrast, a problem-oriented coping leads to better adaptation and includes distractive coping, even cognitive avoidance (e.g., Bonanno, 2004). Positive meaning and meaning reconstruction following bereavement have been linked to positive outcomes following loss; the capacity to display positive emotions during bereavement predicts better outcome after the loss of a spouse (Bonanno and Keltner, 1997). Taken together, these results may indicate that too much avoidance as well as too much confrontation is detrimental to adaptation following loss. Stroebe and Schut (1999) proposed the dual-process model that integrates both stress and coping theories as well as psychosocial models, such as the two-track model (Rubin, 1981) addressing both, the biosocial responses to bereavement and the transformation of the attachment that may include a new still ongoing relationship with the deceased person. The integrative dual-process model of grief takes into account the empirical evidence and postulates an oscillation between loss-oriented coping and restoration-oriented coping. Loss-oriented coping includes positive reappraisal versus rumination, wishful thinking, revisions of personal goals, positive and negative event interpretation, and expressing emotions and mood states such as dysphoria or positive effect toward the deceased. On the other hand, restoration-oriented coping is focused on attending to life changes, doing new things, distracting from grief, and finding new roles and identities.

For stress–response disorders in general, Horowitz' (1978) model of working through a traumatic event posits an oscillation between phases of intrusion and avoidance as necessary process for adaptation. A good fit can be found between the dual-process model (Stroebe and Schut, 1999) and deepened investigation of risk factors as has been shown for cognitive–emotional changes after bereavement (Znoj, 2004). For instance, anger about the circumstances of the death of a loved one could lead to more severe grief, specifically when the death is perceived as unjust, such as in the case of the death of a child. For example, Znoj et al. (2004) investigated bereaved parents and found high correlations of the feeling that fate is unjust and increasing psychopathology. Orth and Maercker (2009) demonstrated that anger, in addition to post-traumatic stress disorder (PTSD) symptoms, leads to further aggravation of symptomatology.

In Western societies, the belief exists that grief should be resolved within 12 months (Wortman and Silver, 1989). Zisook and Schuchter (1986) described persons within the first year of widowhood. While the majority had adapted well after 4 years, some individuals still felt responsible for the loss and reported symptoms like preoccupation with thoughts of the spouse, or had clear visual images; moreover 40% reported elevated levels of depressive symptoms. Overall, the symptoms degraded slowly over time. Obviously, the process of grief lasts longer than usually assumed by the general population. Some of the symptoms clearly have a negative impact on well-being, such as intrusive longing, pain, bouts of crying, and worrying. However, depressive thoughts may also hint toward personal growth and the stimulation of human resilience (e.g., Znoj, 2006).

1 Traditional Views

Several different theoretical formulations have made important contributions to the current state of knowledge about loss and grief (for a more detailed review see Rando 1993). The first major contribution that is generally referred to as a classic in the field of bereavement was Freud's paper, ‘Mourning and melancholia.’ According to Freud (1957), the psychological function of grief is to withdraw emotional energy (cathexis) and become detached from the loved one (decathexis). The underlying idea of this formulation is that people have a limited amount of energy at their disposal. Consequently, only by freeing up bound energy will the person be able to reinvest in new relationships and activities. Freud believed that the mourner has to work through the grief (grief work hypothesis) by carefully reviewing thoughts and memories of the deceased (hypercathexis). He maintained that although the process of working through causes intense distress, it is necessary in order to achieve detachment from the loved one.

The second theoretical formulation that has been highly influential was advanced by John Bowlby. In his attachment model of grief, Bowlby (1980) integrates ideas from psychoanalysis, ethology, and from the literature on human development. Fundamental to his view is the similarity between the mourning behavior of adults and primates, and children's reaction to early separation from the mother. He considers grief to be a form of separation distress that triggers attachment behavior such as angry protest, crying, and searching for the lost person. The aim of these behaviors is maintenance of the attachment or reunion, rather than withdrawal. However, in the case of a permanent loss the biological function of assuring proximity with attachment figures becomes dysfunctional. Consequently, the bereaved person struggles between the opposing impulses of activated attachment behavior and the need to survive without the loved one. Bowlby believed that in order to deal with these opposing forces, the mourner must go through four stages of grief: initial numbness, disbelief, or shock; yearning or searching for the lost person, accompanied by anger and protest; despair and disorganization as the bereaved gives up the search, accompanied by feelings of depression and lethargy; and reorganization or recovery as the loss is accepted, and an active life is resumed. Emphasizing the survival value of attachment behavior, Bowlby was the first to give a plausible explanation for responses such as searching or anger in grief.

A number of other theorists have proposed that bereaved individuals go through certain stages in coming to terms with the loss. One stage theory that has received a great deal of attention is Kubler-Ross' model, which addresses people's reaction to their own impending death. Kubler-Ross claims that individuals go through stages of denial, anger, bargaining, depression, and ultimately acceptance. It was her model that has popularized stage theories of bereavement. For the past several years, stage models like Kubler-Ross' have been taught in medical, nursing, and social work schools. These models also have appeared in articles in newspapers and magazines written for bereaved persons and their families.

As a result, stage models have strongly influenced the common understanding of grief in Western society. There is evidence that health-care professionals tend to use the stages as a yardstick to assess the appropriateness of a person's grieving. A negative consequence of this, however, is that people who do not follow the expected stages may be labeled as responding deviantly or pathologically. For example, a person who does not reach a state of resolution after a certain time may be accused of ‘wallowing in grief.’ Also, legitimate feelings such as being angry because one's spouse died of receiving a wrong medication may be discounted as ‘just a stage.’ Such a rigid application of stage models has the potential of causing harm to bereaved persons. Therefore, many researchers have cautioned against taking any ‘staging’ too literally. Because of the widespread use and acceptance of stage models, Wortman and Silver (1989) systematically examined all empirical studies that appeared to provide relevant data on the topic of coping with loss. What they found was that the available evidence did not support and in some cases even contradicted the stage approach. In contrast to the notion of an orderly path of universal stages, the reviewed evidence showed that the reaction to loss varies considerably from person to person, and that few people pass through stages in the expected fashion. As a result of this critique of the stage approach, bereavement experts to date at most endorse the idea of grief as a series of flexible phases instead of a set of discrete stages. However, the main weakness of both stage and phase models seems to be that they cannot account for the immense variability in grief response, and that they do not take into consideration outside influences that may shape the course of the grieving process.

Dreams, the Unconscious, and the Uncanny

Pile contends that a major reason behind the enduring critical attention devoted to Freud's groundbreaking book, The Interpretation of Dreams, is because the work demonstrates the incisiveness of Freud's ‘spatial thinking’. Freud attempts to understand the shifting and elusive meanings of dreams and how they ‘work’ by drawing on spatial analytic categories such as ‘condensation’, ‘displacement’, and ‘associative paths’. Notably, Pile illustrates how Freud's ‘dream spaces’ are not only caught up in the revisions and reversals of personal desires, but also the illuminations and reflections of social things. For these reasons, Pile theorizes urban spaces as dream spaces. Theoretically, Pile uses the Freudian–Marxian analytic categories of ‘city-work’, ‘magic-work’, ‘dream-work’, ‘emotional work’, ‘time-work’, ‘blood-work’, ‘grief-work’, and ‘space-work’ to show how emotions and fantasies do ideological work in city life. Psychoanalysis enables Pile to show how an effective ‘grounding’ of theories (whether psychoanalytic or not) not only requires an adequate understanding of materiality and space, but also an understanding of the immaterial.

To illustrate this theoretical point, Pile draws on the psychoanalytically inflected social theories of Walter Benjamin in order to interpret cities as urban ‘phantasmagorias’, that is, alluring space–time processions of optical illusions, secret desires, irrational anxieties, imaginary figures, moody misdeeds, and fantastic stories. Pile's psychoanalytic geography also explicates how dreams are a key part of everyday political geographies. How so? Dreams involve politics because they incite struggles: not everyone shares the same dreams and/or nightmares. For Pile, dreams are also political because our ability to shape and intervene in the world is partially determined by how we are gripped by the world of dreams.

One of the most extensive and influential investigations in human geography of how the Freudian unconscious works in sociospatial formations is Heidi Nast's research on ‘mapping the unconscious’. Like Pile's assessment of dreams, Nast asserts that the unconscious plays a significant role in everyday life and politics. Nast provides insight into how the unconscious plays a constitutive role in the spatial organization of violence, injustice, and exploitation in US racist landscapes in the context of southern plantation, post-Reconstruction settings, and the educational policies and urban renewal programs in 1950s Chicago. Underpinning Nast's investigations are two psychoanalytic maneuvers. The first idea concerns how a geographical explanation of a social phenomenon can proceed not so much by empirically mapping the links between the particular (e.g., the local) and the universal (e.g., the global), but rather by dialectically connecting the universal to the singular, that is, the exceptional. How does this distinctly Freudian (and indeed Hegelian) theoretical mode of analysis play out in Nast's interpretations? For Nast, there are three interrelated singular events. First, thousands of black men were not only lynched, they were also castrated. Second, many lynchings were not clandestine or secret, but rather public celebrations consisting of hundreds even thousands of white family members. Third, numerous lynchings of black men were frequently libidinized insofar as they were typically the direct response to the alleged rape of a white woman. For Nast, the singularities of the excessive or seemingly useless act of castrating a dead body, the proximity of the family unit to the scene of lynching, and the frequency of the alleged rape of a white woman can provide clues to explain the senseless or irrational violence of racism.

The second psychoanalytic idea that underpins Nast's complex, yet extremely rewarding paper concerns the theoretical premise that it is a mistake to conflate cause and realization. For Nast, the motives and causes of racist violence such as lynching are not and cannot be entirely caught up in the social. Rather, such violence emerges precisely because there are limits to the social: not everything can be socially articulated or collectively put into words and acknowledged. Furthermore, as Nast argues (following Freud), the constitution and ostensibly normal functioning of sociospatial relations actually requires certain things to be rendered unspeakable or unthinkable, that is, sociability requires the repression of specific dangers and threats. In Nast's paper, in the context of societies dominated by racist white Oedipal (father, mother, and son) families, the ‘repressed bestial being’ that is made ‘legitimately secret’ is an incestuous wish fulfillment between the mother and the son. In Nast's ‘mappings’ or case studies, incest is racially encoded as blackness and symbolically aligned with young black males or ‘boys’. Young black males, then, are unconsciously produced as threats toward white women qua mothers and thus become ‘repositories’ of colonial and racist violence.

From a Freudian-psychoanalytic perspective, social relations are ultimately compromise formations that are borne out of, require, ‘and’ continually fail to gentrify the repression of an underlying and antagonistic trauma. From a psychoanalytic perspective, social and cultural realities are not simply contingent and constructed; they are also extremely volatile and vulnerable to the dictates of aggression. In theorizing this relationship between social space and traumatic fissuring, several geographers have drawn on Freud's notion of the uncanny. For example, Rob Wilton has examined the uncanny effects of an HIV/AIDS hospice in Los Angeles's suburban landscapes and Derek Hook has examined the ideological roles and uncanniness of monuments in Pretoria, South Africa. Notably, Laura Cameron has examined the overlaps between Freud's theories and Arthur G. Tansley's work on plant ecology. In addition, Mary Thomas has considered Freud's notion of the unconscious to rethink qualitative methodology in human geography using the example of narrative data analysis.

‘Tracking’ and ‘Mapping’

The final two psychoanalytic methods discussed in this article, ‘tracking’ and ‘mapping’ (inverted commas in the originals), are exemplary of how geographers adopt a psychoanalytic framework in order to interpret socio-spatial phenomena. Mapping and tracking, used by Heidi Nast and Steve Pile respectively, are both used to elaborate socio-spatial analyses, rather than subject-based research.

In Real Cities, Steve Pile toys with our assumptions about what is ‘real’ in urban life. Pile's central thesis (following the sociologist Robert Park) is that a city's state of mind or personality is as important, that is, as real as its built environment. Inspired by the rebellious methods of the Situationist International and several contemporary novelists, Pile aims to reveal why urban imaginations, fantasies, and emotions matter because they are thoroughly material and political. Pile's notion of the real city brings to the fore how cities are unsettling and overdetermined, that is, the outcome of multiple social, psychical, and political forces. To illustrate this thesis, Pile uses the Freudian–Marxian analytic categories of ‘city work’, ‘magic work’, ‘dream work’, ‘emotional work’, ‘time work’, ‘blood work’, ‘grief work’, and ‘space work’ to show how emotions and fantasies do ideological work in city life.

The main method in Pile's empirical analyses is what he calls ‘tracking’ which aims to ‘get at the circulation of urban imaginaries’ and things such as postcards, billboards, advertisements, architecture, shop windows, cereal boxes, graphic novels, (installation) art, tourist leaflets, newspapers, theater sets, buildings, graffiti, fantasies, information, stories, and ideas that circulate in cities, including London, Singapore, New York, and New Orleans. Tracking, then, is a method that is open to the contingency and multiplicity of possible objects, scenes, events, and processes. As a result of ‘tracking’, Pile's interpretations and narrative, echoing Freud's dream analyses (a topic that Pile has previously explored), focus on the spaces of short-circuits, disconnects, and coincidences.

Pile posits that it is not sufficient to simply ‘ground’ our theories vis-à-vis the method of grounded theory. Put differently, Pile rejects the idea that when we do research we must bring into concrete realms our abstract concepts and theses. An adequate understanding of the material, Pile asserts, demands an adequate understanding of the immaterial. Alongside extensive archival research, Pile uses 82 black and white illustrations that are as sparkling and flat as the urban spaces they underscore. By addressing the visual, Pile's maneuver (in contrast to Bingley's) echoes Gillian Rose's work on methodology and her use of psychoanalytic concepts such as ‘lack’ and the ‘gaze’ in order to examine the visual.

As mentioned earlier, a key motive for geographers to adopt a psychoanalytic theoretical framework is because of its explanatory power of seemingly irrational behavior. Exemplary here is Heidi Nast's work on the segregated spaces of racism and racial fear in the context of US cities and the fears of black men raping white women during and after transatlantic slavery. For Nast, the causes of racist violence such as lynching are not entirely caught up in the social. Rather, racist violence emerges precisely because there are limits to the social: not everything can be socially articulated or collectively put into words and collectively acknowledged.

Underpinning Nast's research is the psychoanalytic idea that in order to explain phenomena, one focuses not so much on the links between the Particular (e.g., diverse locales) and the Universal (e.g., global forces), but rather, on the links between the Singular and Universality, that is, on how a detailed phenomenon marked by excess, exception, and intangibility reveals a universal logic. For Nast, there are three interrelated singular events vis-à-vis the lynching of black men in post-Reconstruction settings. First, of the thousands of black men who were lynched, many of them were castrated. Second, many lynchings were celebrated publicly with hundreds and thousands of white children and family members in attendance. Third, many lynchings of black men were justified as a response to the alleged rape of a white woman. Nast argues that these three singularities are indicative of the universal logic of the Oedipal family qua a hegemonic mode of socio-spatial organization that legitimates racist violence.

In order to explicate these points, Nast adopts the method of what she calls ‘mapping’ – a mélange of theoretical and empirical investigation that is sensitive to historical geographic contexts and highly informed by psychoanalytic theories. Like Pile's method of tracking, Nast's mappings focuses on specific material objects that include white colonial mother dolls, frontispiece illustrations, films, poems, and a magazine cover. Unlike Pile's ‘tracking’ which predominantly embraces the magical (sur)realism of space, Nast's mapping is primarily an interpretative strategy through which to explain the causes that infuse the irrational violence of racist landscapes. In so doing, Nast addresses questions about the repression of geopolitical mechanisms and forces and the circulation of desire. Nast also takes her cue and expands upon two methodological sources: First, Fredric Jameson's notion of the ‘political unconscious’ that seeks to methodologically avoid the alleged apolitical individualism in psychoanalysis. Second, Gilles Deleuze and Félix Guattari's critique of what they see as psychoanalysis's all-too routine uncritical acceptance of the Oedipal family as a unit that structures and defines desire. Much of Nast's method of mapping is informed by what she calls ‘nodal thinking’ which involves attending to spaces not so much as parts of larger story, but rather as spaces through which stories are (un)told and structures can take hold.

3.2.1 Definition and assessment

In the 25 included articles, pre-loss grief was mostly defined as either: feelings of loss, grief or stress; a reaction to losses occurring before the actual death of a patient (Butler et al., 2005; Chapman and Pepler, 1998; Gilliland and Fleming, 1998; Johansson et al., 2013; Johansson and Grimby, 2012; Liu and Lai, 2006; Marwit et al., 2008; Welch, 1982); or as grief work or a grief process in anticipation of the patients’ death (Holm et al., 2019, 2020, 2020; Hudson et al., 2011; Levy, 1991; Levy et al., 1994). In 12 articles, pre-loss grief was described as grief experiences during caregiving, called “complicated pre-loss grief” or “pre-loss prolonged grief” (Areia et al., 2019; Breen et al., 2020; Coelho et al., 2017; Lai et al., 2016; Nanni et al., 2014; Nielsen et al., 2016a, 2017a, 2017b, 2019, 2017a, 2019; Thomas et al., 2014; Tomarken et al., 2008; Zordan et al., 2019) (see Table 1). All definitions had in common that they centered on the content of different grief experiences during the caregiving process, prior to the loss of a patient.

Table 1. Included Studies of pre-loss grief in caregivers of cancer patients in chronological order.

For the assessment of pre-loss grief, eight different measurements were applied in 25 studies. The two most used scales were the Anticipatory Grief Scale in five studies (Theut et al., 1991) (AGS, 27 items) and the Prolonged Grief Scale in ten studies, described as either the Pre-loss version of the PG-13 or as the PG-12, containing the same questions (Prigerson and Maciejewski, 2008). The PG-13 was originally designed for assessing prolonged grief after the loss of a loved one. Items from the Pre-Loss Caregiver Version (PG-13) were adjusted for the use pre-loss. The remaining scales were used once or twice as, for instance, the Anticipatory Bereavement Inventory (Levy, 1991) (former Anticipatory Grief Inventory, 22 items) or the Pre-Death Inventory of Complicated Grief (Prigerson et al., 1995) (Pre-ICG, 13 items) (see Table 1). The Pre-ICG was also originally designed as an instrument for assessing prolonged grief after the death (ICG, Prigerson et al., 1995) and items were therefore adjusted for the pre-loss context. All measurements had a focus on the caregiver's feelings regarding the illness and possible loss of the relative as well as a focus on grief experiences (e.g., crying, worrying, having trouble sleeping or concentrating etc.).