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Adults' Reactions to Bereavement
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CHAPTER 3 Adu]ts'Reactions to Bereavement Adulthood is the most common time for bereavement, with losses occurring with ever-increasing fre- quency as people age. Whereas loss through death may be a relatively uncommon event for the young person, bereavement and grief are fre- quent companions of old age. It has been asserted that "grief as a result of Toss is a predominant factor in aging."7 This chapter deals with the basic psychologic reactions of adults to bereavement. Unlike Chapter 2, the findings presented here are based mostly on clinical observation and inference. The focus is on the phe- nomenology of grief- changes in emotions, thought processes, behav- ior, interpersonal interactions, and physical symptoms that characteris- tically follow Toss ant! on several different theoretical models that try to account for these phenomena and for individual variations. Reactions to bereavement cover a wide, often confusing range. The bereavement experience may include not only sadness, an expected re- sponse, but also numerous other unanticipated emotions, experiences, and behaviors that can puzzle the bereft, their friends and relatives, and the health professionals called upon to assist them. Increased knowI- edge about the various processes and outcomes associated with bereave- ment is likely to help avert some of the misunderstanding that can make the experience more difficult. This chapter is based on material prepared by Victoria Solsberry, M.S.W., research associate, with the assistance of lanice Krupnick, M.S.W., consultant. 47
48 / Bereavement: Reactions, Consequences, and Care THE PHENOMENOLOGY OF GRIEF Despite some earlier descriptions of bereavement reactions,~3 i4 the first systematic study of bereavement was not conducted until 1944. Drawing on clinical observations of survivors of the Coconut Grove fire, Lindemann26 detailed the symptomatology of grief. He described uncomplicated grief as a syndrome with a predictable course and dis- tinctive symptoms, including ( 1 J somatic distress, {2) preoccupation with the image of the deceased, {3) guilt, (4J hostility, and {5) loss of usual patterns of conduct. A sixth reaction, displayed by persons with a possibly pathologic response, was appearance of traits of the deceased (such as mannerisms or symptoms associated with a prior illness). Since that time numerous clinicians and researchers, including Pol- lock,34 Clayton et al.,~° Glick et al., Parkes,3i 32 Parkes and Weiss,33 and Raphael,39 40 have sought to corroborate these earlier observations and to describe the grieving process in adults. They have systematically ob- served and measured changes in emotions, thought, and behaviors, and the emergence or intensification of physical complaints following be- reavement. Despite the nonlinearity of the grieving process, most observers of it speak of clusters of reactions or "phases" of bereavement that change over time. Although observers divide the process into various numbers of phases and use different terminology to label them, there is general agreement about the nature of reactions over time. Clinicians also agree that there is substantial individual variation in terms of specific mani- festations of grief and in the speed with which people move through the process. Noting recent misapplications of Kubler-Ross's25 stages in the accep- tance of one's own impending death, the committee cautions against the use of the word "stages" to describe the bereavement process, as it may connote concrete boundaries between what are actually overIap- ping, fluid phases. The notion of stages might lead people to expect the bereaved to proceed from one clearly identifiable reaction to another in a more orderly fashion than usually occurs. It might also result in inap- propriate behavior toward the bereaved, including hasty assessments of where individuals are or ought to be in the grieving process. ~ . . ~ . ~ . Changes in Emotions and Thought Processes There is general agreement that forewarning of death permits the soon-to-be-bereaved to structure the event cognitively and to reconcile differences with the dying person in a way that can serve to alleviate
Adults' Reactions to Bereavement / 49 some of the feelings of anger and guilt that commonly appear after l~e- reavement. There is disagreement, however, about whether the emo- tional responses to an impending death, which may resemble postUeath reactions in many ways, are comparable to grief following loss and about whether these reactions soften the blow of the actual death. Some observers of the bereaved {e.g., Bow~by,4 Brown and Stoudemire,5 and Bugen6) have found that grieving begins when a person learns of a termi- nal diagnosis. In their experience, anticipatory grieving allows people to begin to let go of the relationship. The clinical observations of Parkes and Weiss33 and Vachon et al.,44 however, have led them to conclude that persons threatened with loss typically intensify, rather than give up, attachment behaviors. The most frequent immediate response following death, regardless of whether or not the loss was anticipated, is shock, numbness, and a sense of disbelief. Subjectively, survivors may feel like they are wrapped in a cocoon or blanket; to others, they may look as though they are hold- ing up well. Because the reality of the death has not yet penetrated awareness, survivors can appear to be quite accepting of the loss. Usually this numbness turns to intense feelings of separation and pain in the months after the funeral. Based on her review of the litera- ture as well as her own years of clinical experience with the bereaved, the Australian psychiatrist, Beverly Raphael,40 describes this phase in the following way: The absence of the dead person is everywhere palpable. The home and familiar envi rons seem full of painful reminders. Grief breaks over the bereaved in waves of dis- tress. There is intense yearning, pining, and longing for the one who has died. The bereaved feels empty inside, as though torn apart or as if the dead person had been torn out of his body. According to clinical researchers, 1 ~1 1 ~_ 11 _ _ _ 1 ~. ~. . "searching" behaviors including '~ urn, creams In wn~cn tne Deceased Is still alive, "seeing" the deceased person in the street, and other illusions and misperceptions are frequently reported during this phase. When the lost person fails to retum, however, these behaviors decrease and despair sets in.i Symp- toms such as depressed moods, difficulties in concentrating, anger, guilt, irritability, anxiety, restlessness, and extreme sadness then be- come common. Offers of comfort and support are often rejected because of the bereaved person's focus on the deceased. The bereaved may swing dramatically and swiftly from one feeling state to another, and avoidance of reminders of the deceased may alter- nate with deliberate cultivation of memories for some period of time. People generally move from a state of disbelief to a gradual acceptance
50 / Bereavement: Reactions, Consequences, and Care of the reality of the loss, although, as already noted, the progression is by no means linear. The bereaved may be intellectually aware of the finality of the loss Tong before their emotions let them accept the new information as true. Although no two bereaved persons are exactly alike, depression and emotional swings are characteristic of most peo- ple for at least several months, and often for more than a year following bereavement. As old, internalized roles that included the deceased begin to be given up and as new ones are tried out, the bereaved person enters the final phase of "resolution"5 or "reorganization.4 23 Eventually, the survivor is able to recall memories of the deceased without being overwhelmed by sadness or other emotions and is ready to reinvest in the world. Behavioral Changes Feeling slowed down, with accompanying postural changes, may al- ternate with agitation, restlessness, and increased motor activity in the early stages of bereavement. Crying and general tearfulness also are common. During the period of despair, the bereaved may lack interest in the outside world and often give up activities they used to enjoy, such as eating, watching television, or socializing. As noted in Chapter 2, potentially health-compromising behaviors, such as smoking and drinking, may become excessive following be- reavement, especially in people who tended to use these substances be- fore experiencing loss. Such behaviors may be considered normal in the bereaved because they occur with considerable frequency. Neverthe- less, they are also psychologically and physically self-destmctive, po- tentially leading to such illnesses as Jung cancer and cirrhosis of the liver. Substance abuse and other dangerous activities, such as reckless driving, may not appear to be obviously suicidal, but they can serve the same purpose as more overt efforts Risk-taking behavior may not ap- pear to be directly associated with bereavement; such behavior is not readily expressive of grief but may instead be part of a defensive opera- tion.33 So although they are endangering their lives and, in reality, struggling with grief, survivors may appear to be coping reasonably well. Interpersonal and Social Changes Although bereavement precipitates changes within people, it also al- ters their interpersonal and social experiences. Although the bereaved
Adults' Reactions to Bereavement / 51 person may have begun to resolve the Toss emotionally, shifts in social status may lead to changes not only in self-perception but also in the ways a person is perceived by others, and the changes may continue for some time. Suddenly thinking of another as a "widow" or "bereaved person" may also instigate particular stereotypes or expectations, re- sulting in different qualities being ascribed to the person. The nature of these interpersonal changes is largely dependent on the relationship that was lost and sometimes on the nature of the death {see Chapter 4~. These changes also are influenced by the broad sociocultural context in which the person lives {see Chapter JO and by the bereaved person's age. For example, a middle-aged widow or widower may find social life greatly curtailed because people tend to socialize in couples An elderiv , , . ~. . . . . ~t ~ _ ~ · ~^ ~,, person may ring tnat most ot His or her friends and relatives have died, leaving few familiar nennle to he witln Making nPlAT imp Aver he Ai[fi ~ . ~ ~ _ ~ ~ I Ad_ ~ ~= ~ ~ ~ CL ~ w ~ ~111 cult. - ~ anus, social isolation and feelings of loneliness are common, often long after the bereavement. Physical Complaints Because of the defense mechanisms used by a particular person, as well as cultural norms that influence the way psychologic pain is ex- pressed, grief may be expressed more in terms of physical symptoms than psychologic Complaints.2~29~4l An nip in {~h~'orc' ~ ~ Q ~= _ ~_ 1 _ 1 _ ~· ~ ~ "v _ .~ _.~c~ Cl..~. ~ ~.~L~ ,J,- bun `;~c;a~ observers and social scientists have found that acute grief is associated with a variety of physical complaints, including pain, gastro- ~Il~na~ cl~sruroances, and tne very vegetative symptoms that, at another time, might signal the presence of a depressive disorder {e.g., sleep disturbance, appetite disturbance, loss of energy). Especially in the elderly, this grief-related depression may be misdiagnosed as organic dysfunction if health professionals are not aware of the nature of be- reavement reactions and the history of the particular patient. Some bereaved persons, identifying with the deceased, may take on symptoms of the illness that killed the person for whom they are griev- ing. In a prospective exploration of identification nhenomen~ in the he , , : ~ ~ ~1 1 ~1_ _ ~. , . . .. . - v ~ 1 - ~ ~ ~ ~ r -~~~~~ ~ ~ ~ ~- -- reaved, forsook et al.46 found that 14 percent of their sample admitted to feeling physically ill since their loss, 15 percent felt " just like the per- son who died," ~ percent had acquired habits of the deceased, 12 per- cent felt they had the same illness, and 9 percent had pains in the same area of their bodies as the person who died. Physical symptoms may not necessarily disguise the personal pain as- sociated with grief, but they may divert the attention of physicians,
52 / Bereavement: Reactions, Consequences, and Care other health professionals, friends, family, and even the afflicted person from the psychologic aspects of loss. These symptoms normally abate as the loss is resolved. THE END OF THE BEREAVEMENT PROCESS The committee deliberated at length about how to label and define the end of the bereavement process, designating it variously as "recov- ery," "adaptation," and "completion." Each term connotes something different and none of the meanings was fully satisfactory to the entire committee. "Recovery" is an indispensable concept in understanding outcomes; it may suggest, however, either that grief is an illness or that people .. .. ~ of_ who recover are unchanged by the loss, neither of which is correct. "Adaptation" is another essential idea, but it carries with it the nega- tive connotation often associated with " adjustment" making the best of an unpleasant situation and it also seems too limited. Someone could adapt to bereavement without recovering lost functions. "Com- pletion" is helpful in denoting relative resolution, but it suggests that there is a fixed endpoint of the bereavement process after which there is no more grieving, a notion that is inaccurate. Each expression is impor- tant and useful, but no one term alone adequately describes the end of bereavement. Thus, using varied terminology provides a better perspec- tive on the multiple issues pertaining to outcome. In fact, as described below, a healthy bereavement process can be ex- pected to include recovery of lost functions (including investment in current life, hopefulness, and the capacity to experience gratifications, adaptation to new roles and statuses, and completion of acute grieving. Both favorable and unfavorable outcomes along several dimensions can be identified. One of the most important dimensions is time. Despite the popular belief that the bereavement process is normally completed in a year, data from systematic studies and from clinical reports confirm that the process may be considerably more attenuated for many people and still fall well within normal boundaries. It is not the length of time per se that distinguishes normal from abnormal grief, but the quality and quantity of reactions over time. Thus a precise endpoint in time cannot be specified. As in other areas of mental health, there is substantially better agree- ment about what constitutes pathology than there is about normality or health. In the bereavement literature, this is reflected in the lack of uni , ,
Adults' Reactions to Bereavement / 53 fortuity in definitions of favorable or "normal" outcomes except in the most general terms. Favorable Outcomes Although the bereavement process involves the completion of certain tasks and the resumption of others, all the feelings and symptoms trig- gered by bereavement do not simply disappear or return to exactly the same state as before. People do adapt and stabilize, yet clinical observers of the bereaved have found that some of the pain of Toss may remain for a lifetime. Reactions to the loss may recur around birthdays, holidays, or other circumstances that are particularly poignant reminders of the deceased. Clinical observations of psychiatric patients show that an- niversaries can trigger serious pathology in vulnerable persona, 35 but usually such responses are transitory; recurrent waves of grief are nor- mal and usually limited both in intensity and duration. An examination of bereavement outcomes should consider not only the presence or ab- sence of various signs and symptoms, but also the quality and personal meaning of different behaviors. For example, readiness to invest in new relationships does not invari- ably indicate completion of or recovery from grief. As with many types of behavior, a given action may mean different things to different peo- ple. A seemingly quick remarriage or a decision to have another child may reflect a sense of hope or strength in one case, whereas in another such actions may stem mainly from a wish to avoid grief. Many clinical and nonclinical observers have found wide variation in the ways people grieve and adapt. A healthy outcome for one person may be different from adequate resolution for another. It has also been found that bereavement can have positive, growth- producing effects. Pollock,36 having studied the lives and works of many gifted artists and scientists, concluded that the successful completion of grieving might result in increased creativity. Among the less gifted, a new relationship or new satisfactions may occur following bereave- ment. Creativity does not always reflect a successful working through of grief, however. It may also be an attempt to cope via restitution, repa- ration, or discharge.37 Silverman and Cooperband43 observed dramatic personal growth in some older widows who had been in traditional marriages. For women who had relied on their husbands to assume the bulk of responsibility for the couple, a myriad of new skills may be acquired as the widow is forced to assume tasks and behaviors formerly the province of her spouse.
54 / Bereavement: Reactions, Consequences, and Care Pathological Outcomes Prolonged or Chronic Grief. Parkes and Weiss,33 in a clinical study of 68 normal widows and widowers, found that prolonged or chronic grief (defined as persistent grieving without diminution in intensity de- spite the passage of time) is the most common type of pathologic grief. In the research of Vachon et ai.,44 it was found that prolonged severe grief {chronic grief) accounted for the poorest outcome in almost all cases. Survivors who manifested chronic grief were described by Parkes and Weiss as having become "stuck" in the grieving process. A certain comfort and reassurance against anxiety was observed among those who displayed this reaction. The inability to work through grief seemed pref- erable to the bleak hopelessness anticipated should the bereaved truly relinquish the lost relationship. One measure of the possible frequency of prolonged or chronic grief reactions derives from the epidemiologic findings of Clayton and Darv- ish9 discussed in Chapter 2. Although the vast majority of widows and widowers no longer had symptoms one year after bereavement, approxi- mately 12-15 percent still reported symptoms that were sufficient to meet the criteria for clinical depression. According to Parkes and Weiss,33 in prolonged or chronic grief the nor- mal phases may become protracted or excessively intense, making reso- lution and adaptation impossible for the survivor. There may be exces- sive anger, guilt and self-blame, or depression that lasts longer than usual. Because these types of behavior do not differ from normal be- reavement responses, it can be difficult to diagnose chronic grief. One indication would be the lack of a sense of future in a person whose loss occurred several months earlier. For example, if someone who was be- reaved a year ago actively resists engagement with his or her present life wondering, it seems, "What is there for me now?" chronic grief could be suspected. This assessment would stem not so much from the person's sadness as from his or her active resistance to changing that feeling. Not only is there no movement, but there also is a sense that the person will not permit any movement. It is the felt intensity of anger, self-blame, or depression that makes the reactions pathologic. Absent Grief. Not all the bereaved report feelings of distress and other symptoms of typical grief, regardless of the apparent importance of the relationship with the deceased. Bowing, who has devoted his ca- reer to the clinical study of response to separation and loss, describes this phenomenon as follows4: After the loss they take a pride in carrying on as though nothing happened, are busy and efficient, and may appear to be coping splendidly. But a sensitive observer notes
Adults' Reactions to Bereavement / 55 that they are tense and often short-tempered. No references to the loss are volun- teered, reminders are avoided and well-wishers allowed neither to sympathize nor to refer to the event. Downy reports that the bereaved person might appear to be coping effectively, but there are clues that all is not well. For example, the be- reaved may continue to experience undue anxiety when recalling mem- ories of the deceased or may forbid references to the death. Expressions of sympathy from others may be experienced as intolerable. Parkes and Weiss33 conclude that absent grief is a relatively infre- quent form of pathologic grieving; nevertheless, they confirm that it does occur. They describe the process as a "fending off" of threatening emotions that are too painful to bear. Examples of such painful emo- tions are guilt over previous death wishes or a perceived inadequacy in loving and caring for the deceased. Over the course of many years of clinical observation of the bereaved, Horowitz20 has found that denial is a form of coping that may be temporarily useful if reality receives more and more attention as time passes. He has observed that it is typi- cal for most bereaved persons to go through a period of denial; denial that continues for weeks or months, however, may be cause for con- cem. Horowitz has found that some denial may be adaptive in reducing fear and allowing pacing of decisions, enabling the patient to feel less troubled. But extended postponing of awareness of what must be faced may lead to hazardous choices of action. Clinical experience with bereaved psychiatric patients has led a num- ber of practitioners to speculate on the psychologic meaning of absent grief. Deutsch, i2 basing conclusions on a limited number of patients un- dergoing psychoanalytic treatment, found that grief-related affects were sometimes omitted in persons who were emotionally too weak to un- dertake grieving. She concluded that where the intensity of affects was too great or the coping ability too weak, defensive and rejecting mecha- nisms came into play. Other authors have observed that a potentially hazardous outcome of this unconscious refusal to grieve may be depres- sion, often masked by a multitude of physical symptoms. Based on their clinical experience in a major academic health center, Brown and Stoudemire~ advise that "patients who experience persistent symptoms of major depression, often with the development of coincidental un- usual physical symptoms, should be carefully considered as having an unresolved or latent grief reaction." Volkan4s observed that patients who do not overtly manifest grieving responses will often appear in a physician's office with physical illnesses that he termed 'depressive equivalents," but that today would more likely be called "somatiza- tion." He discovered that these symptoms seldom served as "substi
56 / Bereavement: Reactions, Consequences, and Care lutes" for depression, and advised that if the physician looks closely enough and asks the correct questions, the depressive symptoms gener- ally will also be found. Because of pressures to return to the prebereavement state, as well as the unpleasantness for others of experiencing the grieving of the be- reaved, absent grief may not be perceived as a problem. The survivor who seems to be doing so well relieves others of the burden of support. The bereaved who goes on with his or her life in a seemingly productive way without suffering the agony of grief looks to many as someone who has finished the process. Too often, however, the process may not even have been started. Delayed! Grief. Whether delayed grief, a concept implying a long pe- riod of absent grief Perhaps months or even yearsJ after which grief-like symptoms emerge, even exists is controversial, as noted in Chapter 2. Some experts conceptualize this unusual reaction as a bereavement re- sponse while others view it as a new episode of affective disorder. These different perspectives naturally carry treatment implications. Those who formulate the problem as purely psychologic would be more likely to recommend psychotherapeutic intervention, whereas those who diagnose a major depressive disorder, unrelated to bereavement, might be more inclined to treat the symptoms with antidepressant med . - catlon. EXPLANATORY MODELS OF THE BEREAVEMENT PROCESS A number of models in this report divided into classical psychoana- lytic, psychodynamic, interpersonal, crisis, and cognitive and behav- ioral have been developed to explain the observable reactions to and reported experiences of bereavement. Each conceptual framework tries to account for the various normal and pathologic processes and out- comes related to bereavement. The hypothesized mechanisms that ac- count for different responses also provide frameworks for various inter- veIltion approaches with the bereaved {see Chapter TOJ. Rather than representing rigidly different schools of thought, the vari- ous models are overlapping. They tend to differ in the amount of empha- sis placed on different aspects of response and in their therapeutic tech- niques, although many clinicians use an eclectic approach employing concepts from several different schools of thought. Of particular note is the growing convergence between psychodynamic, behavioral, and cog- nitive perspectives. Although each favors particular therapeutic tech- niques, observations of the bereavement process have led adherents of these perspectives to agree on the importance of certain phenomena.
Adults' Reactions to Bereavement / 57 For example, in both the psychodynamic perspective and in cognitive theories, importance is placed on the meanings attributed to the Toss and on what happens to a person's self-concept as a result. Overlap oc- curs in conceptualizations regarding impulses and defenses that emerge during grieving, in ideas about belief systems, and in assessments re- garding a person's perceived locus of control. In considering the essential points of each of these models, the reader should bear in mind that theoreticians from the various perspectives may use different vocabulary to describe the same basic phenomena. What is conceptualized by behaviorists as one kind of maladaptive so- cial reinforcement, for example, may be seen by psychoanalysts as a problem with dependency. It should also be emphasized that the different theoretical models are based on data from clinical observation rather than from rigorous statis- tical tests of hypotheses. There is no empirical evidence that can be called upon to assert the validity of the approaches described. However, supporters of each school of thought report substantial clinical consen- sus regarding both the validity and utility of the various explanatory models. Classical Psychoanalytic Theory The classical psychoanalytic model of bereavement rests largely on Freudian theory. According to this perspective, grieving presents a di- lemma because there is a need to relinquish the tie to the cherished love object if one is to complete the grieving process, but "letting go" of the deceased involves considerable emotional pain. Initially the bereaved person is likely to deny that the loss has occurred, increase his or her investment in the lost person, become preoccupied with thoughts of the deceased, and lose interest in the outside world. Eventually, however, as memories are brought forth and reviewed, the person's ties are gradu- ally withdrawn, grieving is completed, and the bereaved regains suffi- cient emotional energy to invest in new relationships. Classical analysts, basing their formulations on experiences with pa- tients undergoing psychoanalysis, infer that relinquishing the loved ob- ject takes place largely through identification with the deceased, and they pay considerable attention to the different outcomes of identifica- tion following Toss. They have found that, in cases in which the de- ceased was an object of hate or of the mixed emotions of intense ambiv- alence, identification with the lost person may become a precursor to certain kinds of depression.
58 / Bereavement: Reactions, Consequences, and Care Current Psychodynamic Perspectives A number of contemporary psychoanalytic and psychodynamically oriented practitioners who have worked clinically with the bereaved have elaborated on the premises of Freud and his followers. These ob- servers of the grieving process continue to focus their attention on inter- nal psychic structures, defense mechanisms, and intrapsychic pro- cesses, but they also are concerned with interpersonal dynamics and the ways in which relationship issues may affect self-concept and views of others. Based on their clinical experiences, they have described addi- tional ways in which antecedent personality and relationship variables . . . may . 1ave an impact on grlevmg. Of course, psychologic processes do not take place in a vacuum. A variety of sociocultural factors, including cultural norms, values, belief systems, and financial status, all contribute to the way a bereaved per- son perceives, interprets, and understands a loss. Preexisting health, as mentioned earlier, also affects responses to and the outcome of bereave- ment. Thus, to understand fully the individual factors that come into play, consideration must be given to psychosocial influences as well as purely psychologic, social, or cultural issues. The Role of the Preexisting Personality. Although there are almost no systematic studies of the role played by preexisting personality vari- ables in affecting the process or outcome of grieving,44 clinicians gener- ally agree that such factors do influence every aspect of the grief experi- ence, ranging from the way the loss is initially perceived to the way it is or is not resolved. Habitual styles of perception, thought, coping, and defense determine how a person experiences and handles all life situa- tions, and these same modes are called upon to deal with the stress of bereavement. Clinical experience has shown that people who are char- acteristically more flexible and able to use more mature coping strate- gies will deal with bereavement more effectively than others. Those who are psychologically healthier prior to bereavement are expected to experience the pain of Toss, but are viewed as unlikely to become over- whelmed or unduly frightened by their feelings. Observers with psychological training agree that personality variables also probably relate to the quantity and quality of a bereaved person's social support network, which, in turn, has been found to influence out- come. People with well-integrated personalities are expected to be bet- ter integrated socially, because their personality traits enable them to both attract and sustain supportive relationships. Preexisting personal- ity may also be seen as a determinant of the degree to which someone can perceive and use the community support system. It may be that so
Adults' Reactions to Bereavement / 59 cial variables are even more important in predicting outcome than in- trapsychic conflicts, although most researchers and clinicans believe that these variables are inextricably linked. The Activation of ha ten t Negative Se~f-Images. Clinical experience with a number of bereaved psychotherapy patients has led Horowitz et al.22 to infer that people who are particularly vulnerable to difficulties following bereavement have latent images of themselves as bad, incom- petent, or hurtful. They speculate that loss activates these once-dor- mant negative images and find that distorted thoughts about the self and others intensify the grieving process, frequently resulting in patho- logic responses. Self-concepts that appear to complicate grieving in- clude feeling too weak to function without the deceased (resulting in overwhelming instead of tolerable sadness), considering oneself hostile and somehow responsible for the death {leading to intensified guilt), and feeling damaged or defective {leading to a sense of emptiness and apathy) . i9,2l,22 These clinical researchers have found that most people who lose a person who supplied a significant amount of gratification revert to some self-representations of weakness and helplessness. Normally, however, "these self-images may be less desperate in quality, less discrepant with other self-images, and less compelling as organizers of information than the needy self-images of a person with conflicts or developmental de- fects in this area."22 This view of pathologic grieving is based in part on the same concep- tualizations that underlie cognitive therapy. In the latter, however, the focus is on the maladaptive attitudes and thoughts themselves, whereas the conceptualizations of Horowitz and his colleagues emphasize the way people think about themselves and others within the context of their interpersonal relationships. The AmbivaJent Relationship. Many clinicians, regardless of their theoretical orientation, point to the quality of the relationship with the deceased as predictive of postbereavement response. Freud, i6 basing his formulations on a limited number of bereaved psychoanalytic patients, maintained that the most "important precondition leading to depres- sion following bereavement was an ambivalent relationship with the deceased prior to the death." In its most general sense, ambivalence in relationships is universal and not especially significant. Few affectionate relations are uncompli- cated by some hostility, and many hostile relations are tempered by af- fection. "When, however, the strength of these conflicting feelings in- creases to the point where actions seem unavoidable yet unacceptable,
60 / Bereavement: Reactions, Consequences, and Care some defensive maneuver is undertaken . . . [e.g.] the ambivalence is repressed . . . and only one of the two sets of feelings is permitted to become conscious. Usually it is the hostility that is repressed."30 Be- cause of this hostility whether overtly expressed, secretly experi- enced, or unconsciously repressed a person might fee} remorseful after the death of the other. In their clinical investigation of 68 normal widows and widowers, Parkes and Weiss33 found that recovery after conjugal bereavement was more likely to occur in marriages that had been "happy" than in those that had been conflict-ridden. In this study, participants were separated into two categories-those who rated their marriages as having had one or no areas of conflict versus those who had two or more problem areas. Differences between the two groups were highly significant. At 13 months after bereavement, good outcomes were more than twice as likely in the no-conflict group than in the conflict group {61 versus 29 percept d. At two to four years postbereavement, the widows and wid- owers who reported a high level of conflict {many of whom had dis- played little or no distress during the first year) were almost twice as likely as their low-conflict counterparts to be depressed, anxious, guilty, in poorer health, and yearning for the dead spouse. From these data, Parkes and Weiss33 concluded: Marital conflict had produced anger, and perhaps, desire for escape, but coexisting with these feelings were continued attachment lo the other and even, perhaps, affec- tion. Anger interfered with grieving, and only with the passage of time did persisting need for the lost spouse emerge in the form of sadness, anxiety, and yearning. The Dependent Relationship. A second type of relationship that may predispose a survivor to difficulties in grieving is one that involves excessive dependency. Parkes and Weiss33 caution, however, that it is often difficult to define what is meant by this because dependency is, in many ways, an unsatisfactory and ambiguous term. It can be taken to mean any situation in which one person relies on another to perform physical functions; thus an amputee con be described as dependent on his wife for functions that formerly he would have performed for himself. Or it can be used to describe any situation in which one person seeks reassurance and comfort from another, as in the case of the frightened child who clings in a dependent way to the mother. Or, as in the case of Queen Victoria, it can be used to describe intolerance of separation from another person {this was the case even during Prince Albert's life). Researchers who assert that excessive dependency may lead to diffi- culty following bereavement cite as evidence the literature on the psy- chologic development of the young child. This material suggests that children who successfully complete the separation-individuation pro
Adults' Reactions to Bereavement / 61 cess are able to achieve a secure attachment with their parents and to turn to them for protection and nurturing when they fee] endangered. The child who, for whatever reason, feels that this protection is not forthcoming or is questionable is said to be more likely to experience the world as a threatening place and to experience anxiety when seca- rated from a parent. In an effort to fee! secure, Suck Wren have been observed to become clingy, a tendency that Parkes and Weiss33 infer is carried into adult relationships. They describe such adults as typically responding to real or threatened separation with fear, distress, and in- tense anger, and report that this group has particular diffic,~l~v in cording with bereavement. ~, , ~. ~ cat ~ ~) ~ ~ In studies of conjugal bereavement, Parkes and Weiss33 and Lopata97 found that survivors in their samples who had been overly dependent tended to do poorly. The grief responses of the widows and widowers in this previously dependent group were characterized bv r,~si~ions of helplessness, indecisiveness, and intense yearning. Although excessively dependent spouses may be vulnerable if left on their own, the tendency of many families to reconstitute following be- reavement may offer some protection from frightening levels of in- creased anxiety. After a husband's death some dependent widows move ~.1 · ~· ~ -~ ~ In wren sisters or otner family members whom they have not seen or socialized with for years, although elderly widows may no longer have surviving siblings or even children to take them in. More concrete prob- lems, such as the inability to drive a car or lack of job skills, deficits that are likely to be especially pronounced among older women, may prove to be better predictors of poor outcome among elderly widows. Older widows also fall into a "high-risk" group in terms of financial difficul- ties following the death of a spouse, another situation that exacerbates feelings of anxiety, depression, and social isolation. It should also be noted that the deceased may have been an important source of social and emotional support even when ill and dying. Thus, with the death, the survivor loses not only the person depended on for many years, but also the support that enabled him or her to cope during the illness. Interpersonal Id Attachment Theory Models Unlike the psychoanalytic models that emphasize intrapsychic dy- namics, interpersonal models focus primarily on relationships the na- ture of attachment bonds and the psychosocial consequences of break- ing them. As already noted, the two perspectives are not mutually exclusive. Both deal with relationships, but psychoanalysts focus more
62 / Bereavement: Reactions, Consequences, and Care on their personal meaning, while the interpersonal theorists focus more on their social meaning, on social roles, and on role transitions. Although attachment theory grew out of and incorporates much psy- choanalytic thinking, it also incorporates a number of principles from animal ethology.4 The biologic substrate of grief reactions and the func- tion of grief responses namely, to revive or ensure the survival of the interpersonal relationship or the social group- are emphasized by both Bow~by4 and Darwin. ii As conceptualized by Bobby, the propensity of human beings to make strong affectional bonds to particular others is instinctive. Within this framework, bereavement can be viewed as an unwilling separation that can give rise to many forms of emotional distress and personality disturbance. Dowdy, studying young children who were placed in insti- tutional settings away from their parents, observed that when a bond was threatened by separation, powerful attachment behaviors includ- ing cringing, crying, and angry protest were instigated. When the ac- tual loss of an important relationship occurred, Bowing found that there was a brief period of protest followed by a longer period of searching be- havior. Over time, these behaviors, aimed at reestablishing the attach- ment bond, usually ceased and despair set in. Eventually, new attach- ment bonds were formed. However, in some cases chronic stress ensued, leading to emotional or physical illness. Interpersonal theorists have focused considerable attention on concep- tualizations of the phases of grieving described earlier and have observed different interpersonal behaviors in each phase. For example, they have found that people in an early state of disbelief or shock are likely to be socially withdrawn. Preoccupied with a desire to reject the new situation, a bereaved person may even attempt to care for others who are suffering.42 In an angry, yearning phase of grief, the bereaved may actively disrupt social relationships. In a sad phase, they may seek support and allow others to feel that they are being appropriately helpful. According to this perspective, the bereaved feel capable of engaging in new relationships only as they begin to redefine themselves. Silver- man,42 in her extensive experience with the conjugally bereaved, has observed that the bereaved "need opportunities to practice assuming, at least in part, a new identity that can involve new behavior pattems" that are aligned with the changes that have occurred. Parkes and Weiss33 call this identity "a theory of self" that is used in thinking about our- selves, in presenting ourselves to others, and in defining our choices in the world. They found that bereaved persons sometimes chose new sat- isfactions that were appropriate in light of the role loss but would not have been appropriate before. Thus, one measure of a favorable outcome
Adults' Reactions to Bereavement / 63 in bereavement is a survivor's ability to make this transition and rede- fine his or her role. Crisis Theory According to crisis theory, the death of an important other disturbs the survivor's "homeostasis" or equilibrium.8 The bereavement is con- ceptuaTized as a stressful life event that highlights preexisting personal- ity problems that previously may have lain dormant or did not seriously interfere with the person's ability to function. Because the crisis creates an acute situation, the bereaved may be in danger of increased disorgani- zation. At the same time, however, because the Toss intensifies and ex- aggerates already existing problematic ways of coping and defending, the death may provide an opportunity to recognize and work on what may have been formerly entrenched, unconscious issues. Thus, the po- tentially traumatic life event is viewed as presenting potential for posi- tive growth and change. Cognitive and Behavioral Theories Theory emerging from cognitive therapy provides a model for under- standing a variety of depressive and anxiety disorders. Developed by Beck,3 a psychoanalytically trained psychiatrist, this mode! emphasizes the link between distorted thinking and psychopathology. Its focus on the relationship between disturbed thinking and dysphoric feelings par- allels the thinking of some current dynamic theorists {e.g., Horowitz et al.22J, thus reflecting some of the convergent thinking noted earlier among theorists with different orientations. Cognitive therapists have not explicitly delineated the psychologic processes specific to bereavement, although Beck's cognitive model of depression could be applied to pathologic grief reactions. According to this conceptualization, a person's affect and behavior are based on the way he or she structures the world. People who experience episodes of clinical depression carry negative views of themselves, their futures, and their experiences. Extrapolating from this model, it could be as- sumed that bereavement might instigate a chain of negative thoughts that could intensify or prolong grief in those persons who had a premor- bid tendency to see themselves and the world in a negative light. In such individuals the death of someone important might be interpreted as de- liberate rejection based on their inherent defectiveness. These persons might then experience themselves as social outcasts and, because of this, feel excessively sad and lonely. Negative ideas may predate the
64 / Bereavement: Reactions, Consequences, and Care Toss, at least to some degree, but the reality of the loss tends to reinforce those ideas. Thus, pessimistic expectations of the future and negative views of the self that may have existed prior to the bereavement become intensified. According to the cognitive theory of Gauthier and Marshall,~7 grief may become distorted if attempts are made to inhibit it. For example, if a grieving person is led to believe that it is bad to think about the de- ceased because the pain produced by memories will be intolerable, that person may develop secondary anxiety when intense bereavement- related experiences occur. Clinical experience has led Gauthier and Marshall to infer that when intrusive thoughts about the deceased then occur, the immediate reaction is to attempt to avoid them for fear of losing control. This is said to produce ideal conditions for suppression of grief-related ideas, possibly leading to further distress because troubling trains of thought are not resolved. Behaviorally oriented clinicians and researchers generally are less concerned with describing internal, underlying processes and personal meanings of loss than are representatives of other schools of thought. Their emphasis is exclusively on troubling, manifest behaviors that emerge following bereavement and on any environmental factors that foster or reinforce such behaviors. They regard grief as " a particular case of the more general malady of depression"~7 and devote considerably more attention to the development of models to explain the phenomena of clinical depression. Of the few who do address the subject of bereave- ment, the major emphasis is on developing and assessing methods of intervention. Behaviorists who are specifically concerned with grief reactions (e.g., Mawson et al.~8 and Ramsay38J focus primarily on pathologic grief. They liken persistent distress of more than one year's duration that is initiated or exacerbated by bereavement to other forms of avoidance such as phobias or obsessive-compuIsive behaviors. Ramsay's38 clinical experience has led him to conclude that persons likely to become "stuck" in pathologic grief reactions are those whose prebereavement response patterns were to avoid confrontation and to escape from diffi- cult situations. He has found that, following the death of someone im- portant, these people fail to enter situations that could trigger their grief. In other words, they avoid stimuli that could elicit undesired re- sponses, such as crying. Because such stimuli are avoided, however, they find it impossible to work through their grief. Mental health professionals with a behavioral orientation also view severe or persistent grief as a function of inadequate or misplaced social reinforcement. For example, Ramsay38 has found that persons suffering
Adults' Reactions to Bereavement / 65 from pathologic grief have lost a major portion of the positive reinforc- ers in their lives. He describes a typical case of this as the widow whose reinforcement consisted of doing everything for her husband and who finds everything meaningless when he dies. According to this theory, because people feel powerless in the face of death, they conclude that all action is futile and stop responding in ways that would eventually al- leviate their stress. Gauthier and Marshalli7 have found that grief reactions may be pro- longed or exacerbated if family or friends provide excessive social rein- forcement for grieving behavior. They caution that if people in the so- cial environment fad! eventually to withdraw attention for grieving or do not provide consistent encouragement for more adaptive behavior, they are in effect encouraging the continuation of manifestations of grief. CONCLUSIONS AND RECOMMENDATIONS There is tremendous individual variation in adults' reactions to be- reavement. Such factors as ethnicity and culture, preexisting personal- ity variables, and the nature of the bereaved person's prior relationship to the deceased are major determinants of outcome. Most clinicians recognize phases of grieving in which clusters of reac- tions are more or less prominent at different points in the process. Grieving may involve alternating phases of response, including periods of both numbness and distress. A variety of clinical signs and symp- toms, including changes in appearance, withdrawal from social activi- ties, and increased physical complaints, fall within the norm following the Toss of someone close. The grieving process does not, however, pro- ceed in a linear fashion. It is important to consider each person's back- ground when assessing the relative normality of manifestations of grief and the speed with which he or she recovers. In most instances there is satisfactory resolution following loss, in terms of an ability to return to an earlier level of psychologic function- ing. The length of time this will take varies, although it is generally agreed that progress should be evident a year after a loss. Pathologic responses to bereavement include those characterized by an absence of grief, seemingly delayed grief, or excessively prolonged or intense grief. Professional help may be warranted for persons who show no evidence of having begun grieving or who exhibit as much distress at one year postbereavement as they did the first few months after the death. Representatives of a number of theoretical schools have provided models to explain the different responses of adults to bereavement,
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