Grief and Bereavement in Contemporary Society

Bridging Research and Practice

Robert A. Neimeyer, Darcy L. Harris, Howard R. Winokuer, Gordon F. Thornton, Robert A. Neimeyer, Darcy L. Harris, Howard R. Winokuer, Gordon F. Thornton

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781136894565
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Grief and Bereavement in Contemporary Society is an authoritative guide to the study of and work with major themes in bereavement. Its chapters synthesize the best of research-based conceptualization and clinical wisdom across 30 of the most important topics in the field. The volume's contributors come from around the world, and their work reflects a level of cultural awareness of the diversity and universality of bereavement and its challenges that has rarely been approximated by other volumes. This is a readable, engaging, and comprehensive book that will share the most important scientific and applied work on the contemporary scene with a broad international audience, and as such, it will be an essential addition to anyone with a serious interest in death, dying, and bereavement.

1 Introduction

The Historical Landscape of Loss: Development of Bereavement Studies

Colin Murray Parkes

DOI: 10.4324/9780203840863-1

For most of us, the loss of a loved person is the most severe stress that we will experience, yet the majority will come through this experience without suffering lasting impairment of our physical and mental health. Copious research now enables us to understand why this is not always the case. We are all vulnerable to bereavement, but some are more vulnerable than others; all bereavements are traumatic, but some are more traumatic than others; we all enter a strange and unpredictable world when we suffer a major loss, but some worlds are more hazardous and unpredictable than others. In this volume, we begin to understand the problems that can arise and the solutions that follow from that understanding.

Those who are coming new to the topic of bereavement may find the experience bewildering. Too many theories, too many opinions, and the sheer quantity of research available leave us disoriented. In writing this chapter, I shall try to offer an historical perspective that may help to prepare the reader for what is to come.

Most of the early studies of bereavement adopted a medical viewpoint, which is a good way of diagnosing and treating some problems but runs the risk of ignoring or downplaying the importance of others and leads to charges that doctors are “medicalizing” normal life crises. After bereavement, the line between health and illness begins to blur. For many people, grief is so painful and disabling an experience that it feels like an illness. Yet doctors spend more time reassuring bereaved people of the normality of their experience than they do in diagnosing physical or mental illness.

Feelings of depression and despair are so common after bereavement that the authors of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) did not permit the diagnosis of the psychiatric condition of “major depression” to be made within 2 months of a bereavement unless people are seriously impaired or at risk of suicide (American Psychiatric Association, 1994). Yet major depression is only one among several psychiatric disorders that can be triggered by bereavement. Bereavement is so painful a stress that it can contribute to a wide range of psychiatric problems. It is personal vulnerability rather than grief that determines why some bereaved people suffer anxiety and panic attacks, others suffer major depression (MD), and others take to the bottle and end up with an alcoholic psychosis. These problems were usually evident before the bereavement. Holly Prigerson and others (Prigerson et al., 1996) have confirmed, by careful research, that these disorders are not part of grief and are clearly distinguishable from grief.

Other problems are more closely linked to grief itself, and in 1703 Vogther obtained an MD degree at Altdorf University near Nuremberg, Germany, for a thesis entitled De Morbis Moerentium, which translates as On Pathological Grief, but his work was forgotten. In 1944, psychoanalyst Eric Lindemann wrote a paper that was very influential in its time. Entitled “The Symptomatology and Management of Acute Grief,” it described several complications of grief and claimed that they should be treated by encouraging patients to express their grief and to “do the grief work.” With only a few interviews, complicated grief could be transformed into normal grief and take its course toward resolution.

Lindemann’s approach is a good example of the dangers of clinical studies that are not backed up by quantitative research. When, in the years to come, unselected bereaved people were assigned at random to counseling or no counseling and then followed up, those who received counseling were not measurably any better than those who did not (Currier, Neimeyer, & Berman, 2008; Jordan & Neimeyer, 2003; Schut et al., 2001).

Random allocation studies are, quite rightly, seen as the acid test of therapies, but we need to be careful when interpreting their findings. For instance, when a large number of people receiving therapy are compared with a similar number who do not, and no significant differences are shown between them, this lack of difference is usually assumed to mean that the therapy was ineffective. But the same result would be obtained if some of the sample were made better by the therapy and a similar proportion made worse. Lindemann had assumed that most bereaved people were repressing their grief and needed help to express it. To be fair, it may be that at that time, at the close of the Second World War, adopting a “stiff upper lip” mode of coping was giving rise to more problems than it does today. The mistake was to assume that Lindemann’s method was the solution to all of the problems of bereavement.

More recent research has shown that, like childbirth, grief is a painful experience from which most people will recover with minimal help. But, also like childbirth, there is a minority of people for whom the right help, given at the right time for the right problem, will reduce the risk of lasting physical and mental damage. The solution is to match the solution to the problem. It is for this reason that we need a professional handbook like the present one that will help us to do precisely that.

Even in Lindemann’s time, there were a few of us who questioned his claims. Anderson, writing in 1949, found that many bereaved people who sought psychiatric help after bereavement were not repressing their grief; far from it, they couldn’t stop grieving. Encouraging such people to express their grief was more likely to harm than to help them. Likewise, in my own studies, chronic grief, now termed prolonged grief disorder (PGD), was more common than grief that was delayed, inhibited, or distorted (Parkes & Prigerson, 2009).

Complicated grief still hasn’t made it into the DSM despite the fact that Prigerson and her colleagues (Prigerson, Vanderwerker, & Maciejewski, 2008) have shown that in its commonest form, PGD meets every criterion for a mental disorder, gives rise to great suffering, increases risks to physical and mental health, and responds to the right treatment. You can read more about that in Chapter 12.

If PGD is not caused by repression of grief, what is its cause? In the Harvard Bereavement Study (Parkes & Weiss, 1983), lasting grief was found to be associated with dependent, clinging attachments to the lost person, and this finding has been confirmed in several other studies, but that does not explain why some people are more dependent than others. An answer to that question comes from studies of the development of human attachments from childhood onward.

We shall see, in Chapter 3, how the seminal studies of Mary Ainsworth identified patterns of attachment between parents and infants that, arising in the first few years of life, predict subsequent attachments (Ainsworth & Eichberg, 1991). Among them is an insecure pattern that Ainsworth termed “anxious-ambivalent attachment,” according to which these infants become severely distressed and angry during brief periods of separation from their parents. This happens in infants whose mothers are themselves anxious, overprotective, and overcontrolling of their child. It seems that these children learn that, in order to survive, you have to stay close to Mum.

My own studies of bereaved people seeking psychiatric help (Parkes, 2006) showed that those who reported anxious-ambivalent attachments in their childhood responded to bereavement in later life with severe, protracted grief and a persisting tendency to cling. Grief, it seems, is a consequence of love. You cannot have one without the other. It is by studying love and its vagaries that we begin to understand some of the problems to which it can give rise.

Other problems result from the circumstances of the death. Sudden, unexpected, and untimely deaths; multiple losses; and deaths that are manmade or associated with horrific circumstances all place an extra burden on bereaved people. Such losses are frequently found in people seeking psychiatric help after bereavement (Parkes & Prigerson, 2009). They will be considered in several of the chapters that follow.

But psychiatrists are not the only professionals with a useful contribution to make to our understanding of bereavement. Over the last few years, empirical studies by psychiatrists have gradually given place to a body of theory generated by sociologists and psychologists that opens the door to new ways of thinking about these problems.

One of the most seminal is the dual-process model (Stroebe & Schut, 1999), which recognizes two distinct but interacting psychological processes that follow all bereavements that they term the loss orientation and restoration orientation. The first process is peculiar to grief and reflects the fact that we do not cease to be attached to people when they die. Like many nonhuman animals, we are programmed to cry and to seek those we have lost, even when we know that they cannot be found. It is a paradox that our desperate struggle to get them back “out there” can blind us to the fact that we never lost them “in here”; those we love literally do “live on” in our memory. This realization is referred to as the continuing bond to the dead and is studied in Chapter 4.

The second dual process refers to the need to give up one set of major assumptions about the world and develop another. This is not peculiar to bereavement; it happens whenever we are faced with a major change in our lives, particularly one for which we are unprepared (Parkes, 1988). In Chapter 2, we shall explore how our assumptive world, the world that we assume to exist on the basis of our experience of life up until this moment in time, is the world that gives us a sense of direction and meaning in the narrative of our lives. We think, “I know where I’m going, and I know who’s going with me,” except that when we lose one we love, we no longer know where we are going or who is going with us. Important new understanding has come out of studies of the gradual process by which we rebuild our internal model of the world after bereavement and discover new meanings, a new narrative, and a new assumptive world. Just how this process plays out in the context of the treatment of complicated grief is further explored in Chapter 12.

Thus far, we have spoken of bereavement as a personal problem, but bereavement is also a family problem, and multiple bereavements may become community problems and national disasters. Human beings are social animals, and bereavements easily disrupt the social systems of which we are a part. We shall see here why some families are at special risk after bereavement (Chapter 22), how bereavement by suicide can pose a special challenge to family members (Chapter 17), and how disasters (Chapter 15) and wars (Chapter 20) can devastate communities.

By the same token, some of these social systems exist to support their members through times of trouble. We have much to learn from studying the ways in which people from cultures other than our own cope with bereavement (Chapter 26), and how spiritual and religious beliefs (Chapter 27) and rituals influence our response (Chapter 24).

Much of the early research was focused on the reaction to loss of a husband by the widow, so much so that this came to be seen as the “norm” for grief. New understandings have emerged from studies of gender differences in grieving (Chapter 7), bereaved children (Chapter 11), the loss of a child (Chapter 9), siblings (Chapter 10), gay partners (Chapter 19), and pets (Chapter 21).

Gradually a rich pattern emerges as we recognize both the common heritage that we all share, and also the subtle differences that explain why some come through grief’s long valley with lasting problems while others are matured by grief. Out of this understanding new solutions are emerging, some of which are already meeting the rigorous requirements of scientific research. The many collaborative contributions of scholars and clinicians that comprise this volume should go some distance toward advancing this ongoing effort.

References

• Ainsworth, M. D. S., & Eichberg, C. (1991). Effects on infant–mother attachment of mother’s unresolved loss of an attachm...