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Reactions to Particular Types of Bereavement
i::::::::: a::::: ~ i:::: :~: ::::::::::: :~::: :~:; i: ::: TI~ ·- ~ ace: ~ t~ ~ Of the many musical expressions of bereavement, Gustav Mahler's Kin~ertoten~ie~er are among the mostpoignant and ten den Gready affected by the numerous illnesses of his twelve brothers and sisters, half of whom died, Mahler chose for this song cycle the poems of Fned~ich Bucket, who hadJost two of his own chidden.
CHAPTER 4 Reactions to Particular Types of Bereavem en t It is generally acknowledged that the type of relationship lost influences the reactions of the survivor. Be- cause the needs, responsibilities, hopes, and expectations associated with each type of relationship vary, the personal meanings and social implications of each type of death also differ. Thus, it is assumed that the death of a spouse, for example, is experienced differently from the death of a child.75 This chapter summarizes and discusses current knowledge about the various psychosocial responses to particular types of bereavement. The focus is on loss of immediate kin-spouse, child, parent, and sibling. There is also discussion of the response to suicide, often regarded as one of the most difficult types of loss to sustain. Other types of particularly difficult losses, such as multiple simultaneous deaths resulting from ac- cidents or natural disasters and deaths caused by war and terrorism, are not discussed. DEATH OF A SPOUSE* The death of a husband or wife is well recognized as an emotionally devastating event, being ranked on life event scales as the most stressful of all possible Tosses.29 The intensity and persistence of the pain associ *This section is based on material prepared by committee member Robert S. Weiss, Ph.D. 71
72 / Bereavement: Reactions, Consequences, and Care ated with this type of bereavement is thought to be due to the emotional valence of marital bonds linking husbands and wives to each other. Spouses are co-managers of home and family, companions, sexual part- ners, and fellow members of larger social units. Although the strength of particular linkages maY vary from one marriage to another, all mar , , _ nages seem to contain each of these linkages to some extent. The death of a spouse ends the relationship but does not severer all rela- tional bonds. The sense of being connected to the lost figure persists- sometimes exacerbating a sense of having been abandoned, sometimes contributing to a sense of continuing in a relationship, although with an absent partner. There are two distinct aspects to marital partnerships. First, both husband and wife Took to the other to collaborate in the setting of mari- tal policy: How should money be used? Where should the family live? Should they have children? If so, how should they be raised? Loss of a spouse leaves the survivor to plan alone. Occasionally, when a marriage has been filled with conflict, the survivor finds rueful gratification in now being able to decide matters without argument. But most often, and especially if there are children, widows and widowers complain of having to shoulder all responsibilities alone. The burden of sole respon- sibility for children is especially difficult.74 The partnership of marriage also serves to divide familial labor. Fol . ~ . . , ~ lowing the death of a spouse, the survivor IS lett W1tn untamll1ar tasks to be accomplished in addition to accustomed ones. The loss of the hus- band may mean the loss of the family's chief income producer, impos- ing on the widow not only sole responsibility for managing the family's finances, but also the problem of compensating for the husband's absent contribution. The sudden need to manage finances and, perhaps, enter the labor force maY be Particularly stressful for older widows who never received training In money matters and who frequently lack practical job skills. Early socialization for dependency on their spouses has left many elderly widows ill-prepared for earning and managing their money. Insurance and pension payments may provide a sudden aug- mentation of capital, but such payments constitute a one-time event that the widow may not know how to use wisely. For most men, the loss of a wife means the loss of the partner who had taken responsibility for child care and home management. Some be- reaved husbands, regarding themselves as ill-equipped to take over this role, employ housekeepers; others find some way of using the services of other women in their families; still others manage on their own, per- haps sharing responsibilities with children.
Reactions to Particular Types of Bereavement / 73 If there are children in the home, the surviving parent may fee] unable to meet their children's demands for attention and understanding. The single parent can be vulnerable to overload and emotional exhaustion, 74 especially since their enormous and constant effort seems so largely un- recognized. Companionship in many marriages consists onIv of sharing Lila ro,,- tines, outings, and bed activities which themselves can facilitate well-being. In other marriages, however, the relationship is character- ized by an intense sharing of intimate lives. In all cases, the death of a spouse necessitates finding substitute companions or tolerating a Tone- lier life; the loss of a spouse who had been a "best friend" represents additional impoverishment. As already suggested, the death of one's spouse means the Toss of one's sexual partner. According to the research of Glick et al.,~s some widows totally lose interest in sex as one aspect of grief and are celibate for some time after their husbands' deaths, although with the passage of time, at least some report unsatisfied yearnings. Widowers, grieving an- pears less likely to involve loss of sexual yearning. · ... . O Finally, the death of a spouse Is likely to alter a person's social role and standing in the community, with widows and widowers frequently excluded from the sociability of couples. Widows who had participated ~ leisure activities as members of a couple and widowers who had re- lied on their wives to arrange their social lives may find that bereave- ment ushers in a time of social marginality. Survivors who have trouble in establishing new friendships may be most prone to experiencing feel- ings of isolation; Lopata,43 in a study of midwestem widows, found that this was especially likely among those in Tower socioeconomic classes. Problems of social isolation may be particularly pronounced among el- derly widows who frequently cannot afford social outings and who may live some distance from grown children. Failing health among the el- derly may also make it difficult to engage in social activities following bereavement. Redefinition of role is one of the main tacks of this Ron area_ cess for the widowed. i 'Mourning . . . is not something that ends and then the widow is able to return to her life as before."65 To the extent that a widow embraced a traditional role during marriage, she adopted an identity based on social interactions with another {her husband and with the situation {her marriage) that were stabilized with repetition. When the "other" or the "situation" changes, the identity of the survi- vor must be modified. In addition, for a widow who did not work out- side the home, a husband's absence leaves no object for her work, so her ~o ~ ~ ~- ~ i_-L fir ~ ~ ~ ~-~ ~ ~ ~ ~
74 / Bereavement: Reactions, Consequences, and Care
Reactions to Particular Types of Bereavement / 75 There does seem to be a sex difference, however, in the recovery pro- cesses following conjugal bereavement. In their research on the first year after spousal death, Click et al.25 found that widows usually could not engage in new relationships soon after their husbands' deaths with- out feeling disloyal. In contrast, widowers did not seem to feel that a new relationship would conflict with their commitment to their de- ceased spouses. In fact, widowers who established a new quasi-marital relationship a few months after bereavement expected their new part- ners to be sympathetic to their continued grieving. Among those past middle age, conjugal bereavement can no longer be considered untimely. Even when the death is long foreshadowed by a slow terminal illness, however, observers generally doubt the occur- rence of " anticipatory grief" in the sense of an initiation of grieving and withdrawal from the dying partner. Clinical observations of grieving couples52 7i reveal (as discussed in Chapter 3J that feelings of attach- ment may actuaiTy intensify {as is typically the case in response to threat) and the marital tie may be further reaffirmed by demonstrations of loyalty and commitment. Consciously admitting and planning for a husband's or wife's demise may make a spouse fee! disloyal. Further- more, following a spouse's death there are so many changes in the sense of self and situation that earlier plans may no longer seem desirable. DEATH OF A CHILD* Bereavement can certainly be painful whenever it occurs, but many feel that the experience of losing a child is by far the worst27 72 because it conflicts with our life-cycle expectations. Although once common, deaths of children between the ages of ~ and 14 now account for less than 5 percent of mortality in the United States.5i In contrast with ear- lier years when couples sometimes had several children die, most fami- lies today lose none. It is now expected in this country that children will live to adulthood. Nevertheless, 400,000 children under the age of 25 die each year from accidents, diseases, suicide, or murder, leaving approximately 800,000 bereaved parents.~° And, as life expectancy increases, the number of el- derly adults who experience the deaths of their middIe-aged children con also be expected to multiply. *This section is based on material prepared by Victoria Solsberry, M.S.W., research associate.
76 / Bereavement: Reactions, Consequences, and Care In addition to being loved, children take on great symbolic impor- tance in terms of generativity and hope for the future. Childrearing in- volves decisions, conscious or otherwise, about how to shape a "healthy" person who will be happy and creative as an adult. All par- ents have hopes and dreams about their children's futures; when a child dies, the hopes and dreams die too. Although some amount of guilt and self blame are present in most bereavement situations, they are likely to be especially pronounced following the death of a child. This guilt may itself be a psychological risk factor.38 Although many of the issues are the same as in other types of bereave- ments, the impact of a child's death may vary depending on the child's age when death occurs, with the death of a newborn feeling somewhat different from the loss of a teenager. As parents in a support group de- scribed by Macon44 reported, "it is not necessarily 'harder' or 'easier' to lose a very young child as opposed to a teenager. It is simply a quite different' kind of pain." Stillbirths Stillbirths, like miscarriages, are regarded by some as "nonevents" 8 or "nondeaths"54 of often unnamed "nonpersons."40 In stillbirth, which occurs approximately once in every 80 deliveries,4i an anticipated joyful event turns into tragedy. Stillbirth can assume two forms. The more common occurs when the baby was viable until labor, and then dies during labor or delivery. In the second type of stillbirth the fetus dies in utero and the mother is forewarned of the death, sometimes weeks be- fore the delivery. Although this forewarning could provide parents with an opportunity for anticipatory grieving, the tendency to rely heavily on denial when told of an intrauterine death commonly precludes this. Kirkley-Best and Keliner,35 in their clinical observations, have found that the emotional reaction to both types of stillbirth is similar-both are experienced as "the simultaneous birth and death of the child." By the time of a stillbirth, the subtle but powerful bonding of parents, especially of mothers, to a baby has usually progressed to a stage of "pri- mary maternal preoccupations and a narcissistic investment has been made in the child. Fletcher and Evans22 have found that, in some cases, technology has intensified prenatal bonding. Parents who receive pho- tographs of their infants in utero {a result of increasing use of sonograms for diagnostic purposes) may become more intensely attached co the fe- tuses because they have a concrete image on which to attach their dreams.
Reactions to Particular Types of Bereavement / 77 Part of what can complicate the grieving process following stillbirths is a conspiracy of silence. An assumption is often made that the mother is better off not discussing the loss, resulting in her being sedated to suppress distressing responses. When hospital personnel and friends do talk about the death, they may advise the mother that she will be able to "have another baby" or observe that "something must have been wrong with the baby, so it's better this way." Wolff et al.78 have found from their research, however, that negative feelings may be exacerbated by such responses. Stringham et al.70 have similarly found that the si- lence surrounding the bereaved mother seems to confirm feelings of guilt and underscores the "unspeakable" nature of the death. Frequently observed responses among mothers after stillbirth include anger, loneliness, and a sudden drop in self-esteem. Gilson24 has found that some mothers fee! ashamed of their inability to do what others ap- parently do with ease, and their feminine identities may be threatened. Anger may be directed toward the self for failing to produce a healthy baby, toward the doctor for providing inadequate care, and toward fam- iTy and friends for providing insufficient support.70 Loneliness can emerge because the mother is "grieving the loss of someone who was unknown to one's family and friends."70 Although the lost child had become increasingly personalized to the parents, especially the mother, throughout the pregnancy, to others the baby remained completely anonymous. Until recent years, the intensity of the parental attachment was un- derestimated, resulting in stillborn babies being whisked away before being seen by the parents. Research conducted since 1970, however, in- dicates that visual and physical contact with the dead infant may facili- tate the bereavement process.70 An increasing number of hospitals are now encouraging parents to name and spend time with the infant, and to collect memorabilia such as pictures, locks of hair, and the nursery bracelet. PERINATAL DEATH Unlike stillboms, babies who live for a few days or weeks are ac- corded personhood. They are named, looked at, held, talked to, and talked about. As with stillbirths, the advent of new technologies and surgical proce- dures can influence reactions to a child's death in the first few days or weeks of life. With the dramatic reduction in the birthweight at which babies can be saved, the death of a very tiny, sick, or deformed newborn
78 / Bereavement: Reactions, Consequences, and Care is no longer always expected. Parents' hopes may be buoyed with the suggestion of each additional medical procedure, and the added time that the child lives increases their attachment. This increased ability to extend life can bring additional anguish for other reasons. For example, some parents are now faced with the di- lemma of whether or not to agree to surgical intervention that may ex- tend life for only a brief period or that may result in a life of pain and disability. The decision not to intervene, assuring the child's death, has recently resulted in the highly publicized "Baby Doe" situation in which a governmental or other third party brings legal action against the parents, trying to force medical care for the infant. Being forced into an adversarial position is likely to intensify the difficulties parents have in dealing with the loss of their child. If the parents decide to intervene, the baby may die sometime later or live its life with severe handicaps; both circumstances create their own set of emotional and often finan- cial problems for the family. Because an infant who lives for even a short time in a hospital is known to the staff and family friends, there is usually more support available to parents in the event of death than there is for parents whose infant is stilIbom. Nevertheless, many people still ignore the loss and avoid discussion of it, instigating feelings of anger in the bereaved par- ents.4 Other troublesome reactions include anxiety about the ability to produce a healthy child, a sense of the unjustness of a child never having had a chance, and feelings of guilt. According to the research of Benfield et al.,4 mothers blame themselves for such deaths far more than fathers do, assuming that they had done something during pregnancy to cause the death, such as smoking, drinking, having intercourse late in preg- nancy, or not taking enough care of themselves. According to data collected by Kennell et al.,34 the presence of other children in a family does not diminish the mother's grief following peri- natal death. Similarly, Wilson et al.76 found that losing one of a set of twins involves as much grief as losing a single newbom. In fact, in some ways, such a loss may be even more difficult because usually less sup- port is available. Others assume that parents are grateful that one baby survived and focus attention on the living child, although, as these re- searchers discovered, no matter how many children someone has, the loss of any one of them causes painful grief reactions. Suppler Infant Death After the neonatal period, the most common form of death in the first year of an infant's life is Sudden Infant Death Syndrome (SIDS), which
Reactions to Particular Types of Bereavement / 79 claims 7,000 to 10,000 lives per year in the United States. SIDS usually occurs between the ages of one week and one year, with a peak occur- r~ng in the two- to four-month age group. Because the cause of SIDS is largely unknown, there is no way to pre- dict with certainty which babies are at highest risk. Although some in- fants experience recurrent episodes of apnea, when breathing stops for a brief period, prior to their deaths most of these infants appear healthy. The suddenness of SIDS death in seemingly healthy babies may lead to extra difficulties in the bereavement process. Adding to parents' sorrow are misunderstandings that sometimes arise because of the absence of an immediately identifiable cause of death and the baby's appearance. The bodies of infants that are not dis- covered for several hours frequently appear bruised. Lash- enforcement officers, investigating an unexplained death, may suspect child abuse. In an attempt to help avoid upsetting encounters between police and bereaved parents, a program in Washington, D.C. {at the Children's Hospital National Medical Center in conjunction with the District of Columbia Medical Examiner's Office) has been developed to explain SIDS to homicide officers. Seminars that sensitize them to the special vulnerability of SIDS parents have changed the way couples are ap- proached and questioned. ~6 Guilt is especially intense in SIDS cases. Based on her own clinical experience and review of the literature, Raphael57 reports that the unex- plainable nature of the death leads parents to a relentless search for a cause. They may repeatedly review their own caretaking behavior in a search for clues, or may consciously or unconsciously blame the other parent. Donnelly20 has found that clarification of the fact that neither parent was responsible may sometimes be needed in order to preserve the marital relationship following this type of loss. The Death of an Older Child Deaths are less common among older children than among infants, with accidents the most frequent cause of death, especially in adoles- cence. lI1 an epidemiologic study including bereaved parents, Owen et al.5~ found that the median age of the dead child was 16.6 years. Acci- dents accounted for 45 percent of the deaths; leukemia and other can- cers accounted for another ~ ~ percent. Parents whose children die at an older age usually experience many of the feelings already discussed. However, older children lived long enough to develop a well-formed personality and leave their bereaved families with a larger store of memories. As with deaths of younger chil
80 / Bereavement: Reactions, Consequences, and Care dren, a commonly expressed emotion is anger. In a study of 14 bereaved parents, Sanders6i found that Toss of a child, compared with the Toss of a parent or spouse, "revealed more intense grief reactions of somatic types, greater depression, as well as anger and guilt with accompanying feelings of despair." Parents seemed totally vulnerable, as if they had just suffered a physical blow that left them with no strength or will to fight. Describing participants in a support group for bereaved parents, Macon44 said that "bizarre" responses, regressive behavior, and suicidal thoughts were common. In a comparison of depressed psychiatric out- patients and matched community controls, CIayton~5 discovered that the death of a child in the previous six months had occurred in a surpris- ingly high proportion of the depressed patients, supporting her view that the "death of a child is the most significant and traumatic death of a family member." The course of the bereavement process for parents may be considera- bly longer and more complicated than was previously believed. In a study of 54 parents whose children died from cancer, Rando56 found an intensification of grief over time, with a decrease in symptom intensity in the second year after bereavement followed by an increase in the third year. This same trend was observed by Levav38 in his reanalysis of Rees and Lutkins'S~ data. Looking at mortality rates in bereaved parents, he found no significant increases in the first year following bereave- ment, but very great differences between grieving parents and controls over a five-year period. It has been found that cause and locale of death can significantly in- fluence the outcome of bereavement, especially in terms of the parents' need to feel a sense of control. In cases where children have Tong termi- nal illnesses, such as cancer, it may be important for parents to fee] they participated in the child's care, so that after the death they can fee! they did all they could. In a study of 37 families of children who had died of cancer in the previous 29 months, Mu~hern and his associates47 found significant differences in the outcomes of parents who opted for home versus hospital care for their dying child. Although preexisting person- ality traits may have determined which set of parents chose which lo- caTe, thus confounding the results, parents who selected hospital care emerged as significantly more anxious, depressed, defensive, socially withdrawn, and uncomfortable, and had greater tendencies toward so- matic and interpersonal problems, self-doubt, and unreasonable fears. Martinson et al.45 found no significant differences in levels of abnormal grief between "home care" and "hospital care" parents, but noted somewhat less difficulty among parents whose children had died at
Reactions to Particular Types of Bereavement / 81 home. Lauer et al.36 found that these parents were far less likely to expe- rience marital strain than parents whose children died in hospitals. Parents who can explain and understand why their child's death had to happen also seem to adjust better. Spinetta et al.,67 in a study of 23 sets of parents whose children died of cancer within the previous three years, found that those who did best had a consistent philosophy of life that enabled them to accept the diagnosis and cope with its conse- quences. Martinson et ai.45 found that 73 percent of their sample re- ported deriving consolation from religious beliefs. The death of an adult child is a topic that has been virtually neglected in bereavement research. Based on her own research and the work of others, Raphael57 concludes that, although the child will probably have left home, "the older parent who experiences the death of an adult child is likely to be deeply disturbed by it." From his clinical observations, Gorer27 has come to believe that "the most distressing and Tong-lasting of all griefs, it would seem, is that for the loss of a grown child." Gorer,27 Raphael,s7 and Levav38 all infer that untimeliness is what makes this form of bereavement so difficult. Older parents typically fee} that it is "unnatural" for a young or middle-aged adult to die while an older parent lives on, which may be a particular form of "survivor guilt. " Ambivalence may also be more of a problem, especially where it centers on a child leaving home and choosing to form a family of his or her own. Elderly parents who lose a middle-aged child may also have lost their caretaker, as a role reversal frequently occurs with the advanc- ing age of children and parents. Because the bulk of the information available on loss of a child of any age remains anecdotal rather than systematic, current ideas regarding this type of Toss must be considered tentative rather than definitive. More empirical data are needed before any firm conclusions can be reached. Pro bJems in Grieving for a Child Having a child die can have a devastating effect on a marriage. For couples with a history of good communication and for those able to de- velop these skills, a child's terminal illness or sudden death may strengthen the relationship. It is not uncommon, however, for marriages to break down under the strain imposed by a child's illness and death. Marital discord and divorce have been reported in 50 to 70 percent of families whose child died from cancer.33 69 However, as noted earlier, this rate may be considerably Tower for parents who cared for a child at home.
82 / Bereavement: Reactions, Consequences, and Care One potential factor that can exacerbate marital difficulties may be the different styles of grieving among family members. In a study of 100 parents whose children died of cancer, Martinson and her colleagues45 found that "fathers were nearly twice as likely as mothers to reply that the most intense part of their bereavement was over within a few weeks to one month after the child's death," although their responses may have reflected the social expectation of fathers to '`take it like a man." In three studies of ~12 SIDS parents, DeFrain et al. i~ found no difference in the length of time it took men and women to recover from the Toss. Nevertheless, DeFrain and his colleagues did note some variations in the responses of fathers and mothers, with fathers reporting more anger, fear, and Toss of control than mothers, as well as a desire to keep their grieving private. The mothers responded with more sorrow and depres- sion. Lack of synchrony may make it difficult for couples to support or un- derstand each other. As one grieving mother in DeFrain's studying re- ported, "I was an open, throbbing wound, and he wanted to have sex. It was very hard for me to understand that he was also in pain and that he felt our closeness would be healing." Involvement in one's own grief may diminish empathy for the other. In relationships lacking a pattern of sta- ble communication, help from friends, relatives, or mental health profes- sionals may be needed to facilitate mutual understanding. Another potential complication involves the discrepancy between a parent's real feelings for his or her child and the feelings he or she believes should exist. As with any human relationship, feelings for a child are marked by ambivalence. But as Raphael57 points out, "societal attitudes strongly suggest that all parents must be perfectly loving, and all tchil- dren] are perfectly lovable." When a child dies, guilt over negative feel- ings comes to the fore. Parents who depend heavily on a child for need-fulfilIment can also experience complicated responses. Some women with negative self- concepts may be able to stabilize an acceptable sense of self only by be- ing '~good mothers." The mother feels useful and competent because the child is emotionally dependent on her. A death in this type of case, especially of an only child or of a child who had been unconsciously singled out to "care for" the mother, will disturb the mother's view of herself. For a parent whose relationship with a child had added meaning be- cause of the parent's painful past, death brings an additional strain. In cases where the parent used the relationship with the child to rework relationship conflicts from his or her own childhood, the child's death may be experienced as the loss not only of a son or daughter, but of some other relationship from the past as well.
Reactions to Particular Types of Elereavement / 83 Parents may also feel particularly threatened by the sense of vuinera- bility and helplessness associated with a child's death. A feeling ex- pressed by a significant number of parents in the study by DeFrain et al. ~8 of SIDS parents was the sense of impotence. When a child dies, par- ents realize the limits of their protective powers and may fee] haunted by this realization. When children who have significant roles in existing parental conflict die, the bereavement process may take a pathologic course. Orbach50 conceptualized one mother's unresolved grief as follows: "When the ir- rational jealousy of her husband reached a peak of accusations, she shad] prayed for her son to become ill on the premise that this would lead to increased marital unity." When the child died of leukemia, she attrib- uted the death to the parental quarrels. The advisability of having another child soon after a chid's death is controversial. In a study of six replacement children in psychotherapy, Cain and Cainii found that "the parents' relationship with the new, substitute child twas] virtually smothered by the image of the lost child." Although these authors warn that attempts to replace a dead child with another are "fraught with danger," it must be remembered that these findings are based on oh~erv~ti~nc of an Tar c~ ~11 die_ turbed sample. ~ ~ · ~ _~ ~ ~ ~ ' ' ' ~ ' ~OF ~ ~ ~ 1 ~ ~ ~ Lewis40 warns that replacement pregnancies can be used to deny the fact of the first child's death and may interrupt grieving. Poznanskiss has observed clinically that the gradual giving up of a dead child pre- pares parents to "reinvest their energies in other relationships." She as- serts that if they are not ready to do this, they cannot raise a new child in an emotionally healthy environment. While a number of clinicians {e.g., Cain and Cain, Legg and Sherick,37 Lewis,40 and Poznanski~s) recommend waiting until the lae- reavement process is completed before having another child, it may be that such advice is overly prescriptive. Being treated as a replacement is certainly apt to be burdensome to a child, but waiting until there is re- covery may not be the solution either, especially since it is often ob- served that grieving for a lost child never entirely ends. DEATH OF A PARENT DURING ADULT LIFE * The type of bereavement most common in adulthood is the loss of a parent. In their study of life events in 2,300 persons matched for demo *This section is based on material prepared by Victoria Solsberry, M.S.W., research associate.
84 / Bereavement: Reactions, Consequences, and Care graphic characteristics to U.S. census data, Pearlin and LiebermanS3 found that 5 percent of the population lost a parent within one year. Despite the relative frequency and universality of the event, very little research has been done in this area. In contemporary Western society, the Toss of a parent in adulthood is not expected to produce serious ef- fects, although some studies have shown a higher tendency to thoughts of suicide, an increased rate of attempted suicide, and higher rates of clinical depression. ~ 5 9 i9 42 Of course, the way an adult responds to any bereavement depends on prior experiences with Tosses throughout life, including those during childhood. Empirical data regarding continuing effects of parental Toss experienced during childhood are discussed in the next chapter. In a study of 35 persons seeking treatment following the death of a parent, compared with 37 field subjects who had also lost a parent but who had not sought treatment, Horowitz et al.30 found that "the death of a parent is a serious life event that can lead to a measurable degree of symptomatic distress." Furthermore, the data suggested that the death of a mother was harder to sustain than the death of a father, possibly because of her earlier status as the nurturing caretaker.3i Another theory suggests that because in three out of four marriages the husband dies first,39 most adults lose their fathers by death before their mothers. When the second parent dies, some adults may mourn the loss of having "parents." The death of the second parent may "leave the child be- reaved for the loss of the specific relationship, stripped of all living par- ents, and also with a reactivated mourning process for the earlier paren- tal death."3i In contrast to these findings, several studies reported that the loss of a parent in adulthood was the least disruptive and caused the least intense grief reactions. 5i 6i In a sample of 39 adult sons and daughters with a median age of 48.3, Owen et al.~i found a "striking characteristic of their response to be the absence of grief . . . adult sons and daughters reported the fewest adjustment problems . . . the smallest increase in the consumption of tranquilizers or barbiturates as well as the smallest increase in the consumption of alcohol . . . the least preoccupation with the memory of the deceased . . . and the lowest levels of physical com- plaints." Concurring with these findings, Sanders speculated, "for the most part, these 'adult children' were caught up in their own busy world which soon engulfed them. They had families, jobs, and daily re- sponsibilities which allowed little time to dwell upon the deceased par- ent." Rather than the passage of time, however, it may be other factors that account for the relatively low level of grieving in adults who lose parents. In most cases, attachment feelings have for some time been di
Reactions to Particular Types of Bereavement / 85 rected toward other figures, such as mates and children. Such feelings, although briefly redirected toward parents following their deaths, usu- ally turn back toward current figures after a relatively short time. The death of a parent may have many meanings for an adult child. For some, who perceived their mothers and fathers as caretakers, providers of praise, and permission-givers even after the parents had to be physi- cally cared for themselves, the death may mean the loss of security.30 For others, it is the Toss of that perfect, unconditional love experienced only as a child. A subtle role change often occurs when an adult child's parent dies. The death is often experienced as a "developmental push," propelling the adult into the next stage of life. It is well known anecdotally that many adults, upon the Toss of their parents, suddenly fee} the weight of responsibility as the oldest generation in the family. This, coupled with the awareness that there are no longer parents to fall back on, may effect a more mature stance in parentally bereaved adults who no longer think of themselves as children. DEATH OF A SIBLING DURING ADULT LIFE* A review of the literature reveals a rather striking absence of data about adults' responses to the death of a sibling. Presumably, this type of loss has been ignored because it is viewed as having less impact than the death of a spouse, child, or parent. In most cases, adult siblings no longer live together and they may not even have much social contact. Nevertheless, it is rare to find adult siblings who have completely sev- ered ties with one another.60 Observation suggests that many sisters and brothers continue to visit each other, share memories, reunions, and responsibility for aging parents, and psychologically influence each other explicitly and implicitly, such as in the selection of marital part- ners.49 Despite an earlier view that sibling relationships were simply a function of and subordinate to a child's relationship to parents, re- searchers are now commenting on the special characteristics unique to the sibling bond.49 The empathy siblings form for one another when they are young may continue into adult life, making this tie a poten- tially profound one. tant. *This section is based on material prepared by Janice L. Krupnick, M.S.W., consul
86 / Bereavement: Reactions, Consequences, and Care As in other types of bereavement, the quality of the preexisting rela- tionship with the deceased is likely to color an individual's perception and experience of the loss. The seeds of the sibling relationship are planted in childhood, but the same characteristics that were salient then continue to affect the nature of the adult tie. In an exploratory study of adult sibling relationships, Ross and Milgram60 found that shared childhood experiences and critical life events {including parental deaths) influence the level of sibling closeness in adult life. Geographi- cal proximity can increase either closeness or distance, depending on other factors, but complete lack of closeness is unusual. Sibling rivalry, a variable that may contribute to postUeath feelings of guilt, was found to continue throughout life in varying degrees of intensity, with rival- rous feelings peaking during early adult years. In addition, sibling rela- tionships assume great importance among the elderly, probably making sibling Toss in old age a particularly significant event. Some of Bank and Kahn's3 observations regarding childhood bereave- ment could also apply to adult sibling ties. For example, they noted that sibling death may be difficult to resolve if previous identification with the deceased sibling was too close or fused, or if it was too polarized and rejecting. Although the intensity of such closeness or hostility would probably be attenuated by the time siblings reach adulthood, such feel- ings could complicate grief reactions. Another factor that may influence the response to sibling loss is the cause of death. A surviving sibling may find it more difficult to accept a Toss if the sister or brother died of an illness to which the survivor may also be genetically predisposed or be a carrier, which would place the bereaved's children at risk. Anxiety following a sibling's death may be particularly acute among the elderly if it exacerbates an already present fear of one's own impending death. Bank and Kahn3 assert that, regardless of age, death of a sibling forces brothers and sisters to reorganize their roles and relationships to one another and to their parents. Under certain circumstances, a death can jolt surviving siblings into becoming more alert, sensitive, and con- cerned particularly if they conclude that they could have prevented the death had they been more caring. Death of "the most responsible" sibling can force survivors to face their need to contribute to their par- ents' well-being now that the deceased sibling no longer assumes this role. As with formerly traditional wives who can mature through the bereavement experience, siblings who had previously considered them- seIves less capable can grow through this imposed need to become a caretaker.
Reactions to Particular Types of Bereavement / 87 BEREAVEMENT FOLLOWING SUICIDE* Bereavement is painful no matter what the cause, but bereavement following the suicide of a close friend or family member has been called a "personal and interpersonal disaster."64 Other kinds of death that complicate bereavement include homicide, suicide, multiple simulta- neous losses, and accidents in which the survivor was complicit, such as an automobile accident in which the survivor was driving. All these types of bereavement are important and merit comparative study. In this report, however, only suicide will be discussed as an example of an especially difficult loss. It is estimated that more than 27,000 people commit suicide in the United States each year. Men are three times more likely than women to commit suicide, and whites are almost twice as likely as blacks.48 Elderly white men have the highest suicide rate of all. A Many observers have commented that reported figures are extremely conservative due to the ambiguous circumstances of some deaths and to society's need to deny suicide. Even given this conservative figure, however, suicide leaves in its wake a sizable number of survivors who must deal with a complex set of feelings and social problems. Survivors of suicide have long been thought to be at greater risk for physical and mental health problems than individuals who are bereaved from other causes of death. ~deed, as discussed in Chapter 2, there is some evidence to suggest increased mortality among the widowed whose spouses committed suicide. There also is good evidence that children whose parent committed suicide are at risk for enduring ad- verse consequences and for suicide itself {Chapter 5~.63 Clinical observations of suicide survivorsi2 65 reveal that they experi- ence some reactions that are unique to this type of bereavement, as well as displaying typical bereavement reactions in exaggerated form. While the death of a close relative by any cause may leave the survi- vor with feelings of abandonment and rejection that may be irrational, the feeling of rejection following suicide is almost universal. As one sur- vivor put it: "He could not have loved me; he did not think ~ was worth living for. " 73 In their study of suicide survivors. tindemann and (~=re~r42 fn',nA "there is a tencit=.n~U ~ . . . to look for a scapegoat. And, as is the fate of *This section is based on material prepared by Victoria Solsberry, M.S.W., research associate, drawing on a paper by Barry 0. Garfinkel, M.D., Director, Division of Child and Adolescent Psychiatry, University of Minnesota Medical School, Minneapolis. , ,
88 / Bereavement: Reactions, Consequences, and Care most scapegoats, the victim is usually one of their own members and frequently the one least able to bear the added burden." This tendency to search for blame, though common following other types of deaths, is greatly increased following a suicide. The surviving spouse, parents, or even child may be blamed for not seeing the signs of the impending sui- cide or for not meeting the needs of the deceased. Bereaved individuals also often blame themselves for the death, re- sulting in what is often called "survivor guilt. " In fact, blaming others may be one way of avoiding self-blame. Survivors may question what they did to add to the deceased's stress or may wonder whether they could have foreseen and stopped the act. As suicide researcher HensTin28 points out, "When one can exercise control over events and in so doing prevent harm to others, our culture demands that it is one's responsibil- ity to do so. Therefore, if one could have acted to have prevented the suicide, one feels that he or she should have done so." People who have made repeated threats of suicide or actual attempts may leave friends and relatives in conflict when they finally succeed. Menninger46 has clinically observed that a typical response is "over- whelming bitterness" at having failed in the task of keeping the vuiner- able one alive coupled with a sense of relief that the ordeal is finally over. Children, especially, who have been warned that they are "upset- ting Mommy" or accused by the parent of "driving me crazy" are espe- cially vulnerable to feelings of guilt following a suicide. In Bow~by's7 clinical experience, repeated threats often leave the sur- vivor frightened and frustrated, finally wishing that the other person would just "go ahead and do it." Suicide also may leave survivors with feelings of rage over being abandoned, which in tandem with the sense of relief that the person's problems will no longer demand attention, can intensify survivor guilt. Feelings of anger and relief are generally unanticipated and misunderstood under the circumstances and so may lead to a sense of shame and a denial of their existence. Finally, survi- vors may fee! anxious after the death worried that they may mimic the deceased's self-destructive act. The nature and intensity of the survivor's reactions will depend largely on cultural factors, the prior relationship with the deceased, the age and physical condition of the deceased, the survivor's individual personality characteristics, and the nature of the death. Henslin28 has found that, ~ some ways, suicide shares with accidental death the qual- ities of "suddenness, unexpectedness, and violence." It should be noted, however, that there are many different types of suicides and that they may involve different types of responses. For example, in the case of a terminal illness, especially among cancer patients, the sick person
Reactions to Particular Types of Bereavement / 89 may have made a clear decision to abbreviate a life of pain. ]7 The impact of this kind of suicide is not known; families in this situation may need information and assistance in anticipating and responding to this type of death. Communications before the death or suicide notes that blame the survivors directly may place those left behind at even higher risk for problems with guilt and shame. Some clinical observers infer that many suicides are motivated largely by the hostile intent of producing prob- lems, especially guilt, for the family. In a study of suicide notes, la- cobs32 described two types that clearly made the suicide a hostile act. In one, there is an attempt to hide the intent by claiming that the suicide is aimed at "relieving" or "freeing" the survivor, whereas the other is overtly hostile. Following suicide, denial is frequently used to mask feelings of guilt, rage, relief, and shame. Resnik,s9 in a study of nine families in which an adolescent child committed suicide, found that this denial may take the form of hostility towards the medical examiner, police, or anyone who calls the death a "suicide." Denial and anger may also contribute to a tendency to idealize the deceased. In his research, Warren73 found that some survivors created a "family myth," a rationalization of the true nature of the death, that is used not only for the outside world, but also for the family itself. These forms of denial serve a definite purpose for the bereaved. As Augenbraun and Neuringer2 have observed, "if the survivor does not accept the possibil- ity that the deceased took his own life, he can avoid facing the notion that the suicidal person willfully abandoned him," allowing him to avoid the pain associated with the deliberateness of the death. A deci- sion to call suicide an "accident" or to attribute it to an illness is often quite conscious, however, and is sometimes told to "protect" children from the truth. Complicity by health care personnel aids this denial, although, as discussed in Chapter 5, fabrications can frighten and con- fuse children who may already know the real cause of death or sense that what they have been told is untrue. This undermines confidence in adults and reinforces the idea that suicide is a valid source of shame. A common fear among survivors concerns the "heritage of insanity," leading people to wonder whether others in the family are now "doomed" to kill themselves someday. Indeed, there are data that show a far higher than chance incidence of prior suicide in families of individ- uals who commit suicide.6 2i This may be due, in part, to a shared vul- nerability to mental illness, specifically depression, or to specific feel- ings of inevitability and gUiit.73 Warren73 has observed that a "survivor may feel or fear the inevitability of his own death by suicide at a time
90 / Bereavement: Reactions, Consequences, and Care coinciding with the parental age at the time of suicide. This feeling of inevitability is usually unconscious, becoming more manifest as the t survivor 's] age approximates that of the parent at the time of the sui- cide." Lindemann and Greer42 have found that identification with a person who has committed suicide may lead a person to perceive this behavior as a viable solution to life's problems. The very fact that the taboo was broken by someone close may serve to legitimize the act, perhaps sug- gesting to the survivor that he or she will be vulnerable when over- whelmed later in life. ~ summary, there are many interacting factors that influence the re- sponse to suicide. Feelings of being rejected, guilty, responsible, and so- cially stigmatized appear to hamper the resolution of bereavement. The Social Stigma of Suicide In many cultures, the social stigma of suicide has historical roots. The early Greeks, believing that those who committed suicide must have been greatly wronged to have wanted to die, considered their ghosts to be extremely revengeful, dangerous, and frightening.~4 In other cultures, the bodies of suicide victims had to be buried outside the city walls or were pulled through the streets and stoned. Suicide has also been illegal in many places, including the United States. Most modem Western civilizations rho longer adhere to such beliefs and prac- tices, but suicide is still regarded by many to be a moral rather than a mental health issue. Roman Catholics, regarding suicide as a mortal sin, used to forbid memorial mass and last sacraments for a Catholic who died in this way and insurance companies continue to deny bene- fits to families of people who commit suicide within two years of buy- ing life insurance. These social stigmata compound the problems of suicide survivors. Whether from shame or anticipation of blame from others, people are often sensitive about and reluctant to discuss the event. Those who would usually be available for support following the death of someone close may find they are unable to comfort the survivor of a suicide. Pos- sibly threatened by the idea of being powerless to prevent a suicide, they may join in the search for a cause and may even blame the survivor for the death. This failure of the informal support system leaves many sur- vivors socially isolated and dealing with their complex feelings and problems alone. Some find that they can escape feeling ostracized and condemned only by moving, i2 but they are then faced with the isolation
Reactions to Particular Types of Bereavement / 91 and insecurity of a new home and neighborhood that can make the be- reavement process more difficult. Given these circumstances, the deci- sion of some families to deny the fact of a suicide seems understandable. Assisting Survivors of Suicide Survivors of suicide, more than any other bereaved group, may re- quire some form of professional help. Based on his observations of fami- lies of adolescent suicides, Resnik59 has found that "an early interview after the death is a therapeutic and cathartic experience" that allows the interviewer to establish rapport before defenses have been established. This allows him to provide appropriate subsequent help as the grief work progresses. In her clinical experience, silverm~n65 has found that suicide survivors are often initially wary of those who offer help. They are generally so isolated by the experience, however, that they may need more formal opportunities to ventilate their feelings and more reassur- ance than other bereaved persons. In recent years, mutual support groups, such as "Survivors of Suicide" and "Seasons," have been devel- oped to bring together survivors of suicides to clarify their understand- ings of the loss and to find ways of dealing with the often confusing and traumatic aftermath. Freedman et al.23 advocate professional psychotherapeutic interven- tion to alleviate the effects of stress on the "survivor-victims" of sui- cide, to provide "an arena for the expression of hidden emotions," and to put a "measure of stability into the grieving person's life." In their clinical work with survivors they have found that "most are willing- some are passively eager- to talk," adding that therapists often serve as reality testers, "not so much the echo of conscience as the quiet voice of reason. As is true following all types of bereavement, the degree and type of reassurance needed by a survivor depends on his individual circum- stances. Augenbraun and Neuringer2 have found that "there is little need for therapy twhen] the previous relationship between suicide and survivor was positive, minimally ambivalent, and where the fact of the suicide can be ascribed to circumstances outside the control of the sur- vivor." They add, however, that "more often, the survivor has been in- volved in a conflict relationship with the suicide and the act of suicide itself is in part an outcome of this conflict." More clinical research needs to be done to determine the circumstances that make survivors vulnerable to pathologic outcomes, and to determine which particular interventions are most effective under these circumstances.
92 / Bereavement: Reactions, Consequences, and Care Research Issues As with so much of bereavement research, what is known about sui- cide survivors comes primarily from cImical case reports of small num- bers of patients In treatment. The reports have not systematically ex- ammed and controlled for demographic heterogeneity of the sample, time course following suicide, possible psychiatric disorders ~ family members, or differences in the intensity, duration, and symptomatol- ogy of the bereavement. Yet these clinical accounts con provide the ba- sis for further systematic investigation. Both clinical cases and system- atic investigations are needed. Unusual methodological problems create particular difficulties in de- signing systematic studies of bereavement associated with suicide. Ide- ally, suicide bereavement should be compared with bereavement fol- lowing deaths that share some of the same characteristics in order to know of any unique contributions of suicide as distinct from some of its attributes. For example, suicide is a sudden death that should be com- pared with bereavement following other sudden deaths such as motor vehicle fatalities. As a "volitional" death, suicide is more similar to drinking oneself to death {c~rrhosisJ or smoking oneself to death after heart disease has been discovered than it is to deaths caused by condi- tions over which individuals have no control. And comparisons of survi- vors of other "socially unacceptable" deaths, such as Acquired Immune Deficiency Syndrome {AIDSl, might permit the effects of social stigma and suicide to be separated. In addition, the effects of suicide in different types of relationships such as parents-to-child, sibling, conjugal, and child-to-parent should be studied. Further research is also needed on the meanings and re- sponses to different types of suicides, for example drug overdoses in ado- lescents or suicide among the terminally ill and elderly. More informa- tion on the coping styles of suicide survivors could help others deal with the loss through suicide of someone close. Comparative studies of all these variations and characteristics of sui- cide are difficult, however, because of the relative infrequency of the event. As powted out in Chapter 2, studies of relatively rare events re- quire very large samples. CONCLUSIONS Although only a small number of different types of losses have been discussed In this chapter, they indicate that different kinds of relation- ships and different sets of circumstances influence the personal mean
Reactions to Particular Types of Bere~emaut / 93 ings ~ d feelings associated `'itb bereave~acut. Store data are needed on the response to loss of various types oirelationships' gad under various conditions of death. DJucb attention teas been paid to responses to con- uga1 beIeavenacotin adults' but tbereisIelatively UttleinfoI~astion on other types oflosses' such as the death of siblings and parents. As the average age at deatb continues to rise and as ~acdicaltechnolo ~ allows be prolongation oflivestbat previously should brave ended naturally' an increasing nu~abeI of people ~'iH brave to deal mild issues raised by eD derly and aging parents' including the tboray issues surrounding as- sisted suicide. Responses to loss under alltbese ciIcu~astances deserve exploIstion in order to provide appIopIiate assistance to the bereaved. ~PERENCES 1. Anderson' C. Aspects otpathologicalgrief and raou~oing.l~bo~] ~ of Psycho~y~is30:48-55, 1949. 2. ~ugenbI~un,B~ and NeuIingeI' C. Helping survivors ~iththeimpactof suicide. In: Jur~vo~ o/~uicide Cain, A.' ed.l Springfield, Ill.: Nibbles C lbo~ass, 1972. 3. Bank, A, and Kahn' hi. ~s ~g Bond. New York: Basic Books 1982 4. Benfield, C~ Leib' S.' and Vol=an, J. Crier response of parents to neonatal deatb ad parent paI1icipation in deciding care. Sacs 62:171-177, 1978. 5. B~tchneU, 1. Psychiatric breakdown foIlo~ing recent parent death. B~ ~] of ~c~ Ps^~o]~ 48:379-390' 1975. 6. Blachly, P., Disber' B.' and Roduner, C. Suicide by physicians. B~- of S~- oJ~4:1-18, 1968. 7. Bomb S. Ibe psycbologica1 effects of stillbirth on women and tbeiI doctors. ~- ~ of ~c Ova copings of ~a~ ;~o~= 16~03-112, 1968. 8. Bonily, F ~c~z~ bosh Vb7.~:tos~ New York: Bash Books, 1980. 9. Buncb,J.TbeinGuenceotpaIentaldeatbanniveIsaIiesuponsuicidedates.B~h ~Jo/~6ycti~118:621-625,1971. 10. Butler Rag and Lewis A4.~g ~d Ai~ F~ ~ 12nd edhionJ.St.Loni~ C.V. Alosby,1977- 11. Cain, A.'and Cain' B OnIeplacingachild. ~uzn~ o7tbe ~zns~c~n ~dez~y oy Camp Psychj~3:443-4S6~1964. 12. Cain,A~andPast'I.Ibelegacy olsuicide:observalionsontbepatbogenicirnpact ofsuicideupon marhalpartners.Psycld~29:4Q6-411,1966. 13. Cain,A~andPas~ L Ibelegacyofsuicide:observationsontbepatbogenicinapact of suicide upon marital partners. In: 3~vo~ of Suicide {Cain, An ed.[ Springfield,Ol~ Charles C Ibomas,1972 14. Cboron~l.~cjis. New York: Cb~lesScIiboeI~ Sons,1972. IS. Clayton,PJ.BeIeavernentand Usna~nagernent.In:~book of~>c~ve Djsor- dJ~ fPayket E.S~ ed.# EdinbuIgb: CbulcbiD Livingstone,1980. IG. Coben, C. DOA: Prehminary report on an emergency IOOfO pIOtOCOL Ch~ic~J [io- ces~g~ of ~s Chi]~'s ^~ adorn ~c~ Costar 35:1S9-165, 1979. 17. Danto, B.L. Suicide anacng canceIpatients.In:3Ljcid>~Eu~i~: Ths~&b~s ofre~o~too~ {WaIlace,S./andEser,A., eds.J. Knoxville: OniveIsity of Iennessee Press,1981.
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