Bereavement

Studies of Grief in Adult Life, Fourth Edition

Colin Murray Parkes, Holly G. Prigerson

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317850816
• Edition: 2
• Topic: Psychologie
• Subtopic: Conseil en psychothérapie

The loss of a loved one is one of the most painful experiences that most of us will ever have to face in our lives. This book recognises that there is no single solution to the problems of bereavement but that an understanding of grief can help the bereaved to realise that they are not alone in their experience.

Long recognised as the most authoritative work of its kind, this new edition has been revised and extended to take into account recent research findings on both sides of the Atlantic. Parkes and Prigerson include additional information about the different circumstances of bereavement including traumatic losses, disasters, and complicated grief, as well as providing details on how social, religious, and cultural influences determine how we grieve.

Bereavement provides guidance on preparing for the loss of a loved one, and coping after they have gone. It also discusses how to identify the minorityin whom bereavementmay lead to impairment of physical and/or mental health and how to ensure they get the help they need. This classic text will continue to be of value to the bereaved themselves, as well as the professionals and friends who seek to help and understand them.

1
The Cost of Commitment

The mourner is in fact ill, but because this state of mind is common and seems so natural to us, we do not call mourning an illness.

Melanie Klein, 1940

Although Sigmund Freud contributed little to our understanding of bereavement it is interesting to find that his discovery of psychoanalysis, and the subsequent development of psychotherapy, originated from the study of a bereaved young lady. Anna O. was an intelligent, imaginative girl of twenty-one, who sought help from Freud’s friend and colleague Dr Josef Breuer. A puritan in a puritanical family, Anna led a monotonous existence enlivened by the rich fantasy world she created for herself. Although she is described as moody and obstinate, she was a sympathetic person, fond of helping the sick and passionately devoted to her father.

Her mental illness took the form of a succession of psychosomatic and dissociative symptoms including headaches, ‘absences’, paralyses and anaesthesia in her limbs. These came on during her father’s terminal illness and got worse after his death. Breuer came to see her each day and treated her by encouraging her to talk about her fantasies. These were always sad and usually involved a girl sitting beside a sick-bed. After the father’s death the symptoms got worse and the stories became more tragic. Breuer discovered that each symptom was related to a particular disturbing event, and tended to improve when Anna had succeeded in discussing the event that was associated with it.

When the anniversary of her father’s illness arrived, Anna O. began to relive, during her ‘absences’, the traumatic events of the preceding year. These episodes were precipitated by any reminder of that year and their accuracy was authenticated by reference to her mother’s diary. It was at this time that a number of severe and obstinate symptoms disappeared dramatically after she had described the events that, Breuer concluded, had given rise to them. Breuer reinforced these recollections by causing her to relive experiences by means of hypnosis. Thus, the crucial observation of a link between a traumatic loss and the symptoms which followed, gave rise to what Breuer called the ‘talking cure’.

Sigmund Freud, who knew Breuer well, was greatly interested in this case and made use of the ‘talking cure’ himself. Breuer, on the other hand, did not pursue his discovery. He had devoted so much time and interest to this one attractive girl that his own marriage was affected. According to Ernest Jones (1953, 1955), Breuer, when he realized the extent of his involvement with this patient, abruptly brought the treatment to an end. Anna, who was by now strongly attached to Breuer, responded to this latest loss by becoming distressed and developing a fresh crop of dramatic symptoms, among them a hysterical childbirth or ‘pseudocyesis’. The subsequent course of her illness was not as uneventful as Breuer’s account leads one to suppose. She appears to have continued to have ‘absences’ for some years and to have been admitted to a mental institution on at least one occasion – here she is said to have ‘inflamed the heart of the psychiatrist in charge’. She never married, remained deeply religious, became the first social worker in Germany, founded a periodical, and started several institutes (Zangwill, 1987).

A description of the case of Anna O. was published jointly by Breuer and Freud in 1893, in a paper entitled ‘On the Psychical Mechanisms of Hysterical Phenomena’, along with a series of cases treated by similar means. Although Breuer lost interest in the ‘talking cure’, Freud took it up with enthusiasm. He made a virtue of the personal relationship between patient and physician and believed that improvement often depended upon this. Hypnosis he eventually abandoned because it interfered with this relationship and because he found the method of ‘free association’ equally effective in the recovery of memories of traumatic events.

With hindsight it seems likely that, by encouraging and rewarding Anna’s fantasies, Freud and Breuer may have perpetuated her problems. Indeed, Freud soon found that the recovery of recent memories, in this and other cases did not necessarily relieve symptoms. He therefore encouraged his patients to recall earlier periods of their lives, and he claimed that he discovered the memories of primal events in their childhoods, which he believed to have been the critical determinants of mental illness. Already by 1898, five years after the publication of the paper mentioned above, Freud had become convinced of the importance of sexual experiences in childhood and thenceforth he took less interest in the recent experiences of his patients. Nevertheless, he never gave up the view that major psychic traumata, occurring in childhood or in adult life, can be responsible for neurotic illness. He gave evidence to this effect before a commission set up by the Austrian military authorities after the First World War to investigate the harsh treatment of war neuroses by their own doctors.

We have dwelt on Freud’s contribution because of its great influence and also because we believe that it is more than a coincidence that the breakthrough to which Breuer’s talking cure gave rise resulted from the investigation of a case of mental illness arising at the time of the loss of a father. There is no doubt that the symptoms that Anna O. developed resulted from a combination of causes, some relating to her father’s threatened or actual death, others to her own personality and early life experiences. Her father’s illness and death can be regarded as the precipitating circumstances without which the illness would probably not have arisen – at least not in the form it actually took. Thus, by examining the relationship between a recent precipitating event and the particular symptoms that followed it, Breuer and Freud made a contribution to our understanding of psychopathology.

Few other attempts have been made to do just this, perhaps because the connection between a particular event and a particular symptom is often difficult to trace. Nevertheless, we believe that where major stresses are concerned (and loss of a close relative is normally a major stressor) this approach fully justifies its results.

A bereavement by death is an important and obvious happening which is unlikely to be overlooked. Less obvious forms of loss, and losses that take place some time before the onset of an illness, may be overlooked. Even if they are not, it is less easy to demonstrate that there is a causal connection between them and the illness. And even if a causal connection can be assumed, the precise nature of this connection needs to be understood.

If, by studying the clear-cut case where causation is undoubted, we can learn more about the chain of causation and its precise consequences it may eventually be possible to understand other types of case by starting from the consequences and working backwards towards the causes.

Traumatic Stress

The field of post-traumatic stress has come to prominence in recent years thanks to the recognition of a complex of symptoms, which are likely to arise when people experience severe threats to their lives or witness peculiarly horrifying scenes. It has been termed Post-Traumatic Stress Disorder (PTSD). PTSD accounted for much of the mental illness found among veterans of the war in Vietnam and, although it had been described after many other situations in the past, it was that event, more than any other, which forced psychiatrists to acknowledge the existence of PTSD as a diagnosis. The distinctive features of PTSD are haunting memories of the traumatic event that are so vivid that the sufferer feels as if they are experiencing the trauma again and again. These occur during the day or at night in the form of recurrent nightmares. They are so painful that people will go to great lengths to avoid any reminder that will trigger them off. They feel as if they are waiting for the next disaster and are constantly jumpy and on the alert.

Clearly PTSD differs from the other psychological reaction to major traumatic events, grief. Despite Freud’s insistence on the importance of mourning (1917), the reaction to bereavement had been little studied by psychiatrists until recent years. Grief, after all, is a normal response to a stress that, while rare in the life of each of us, will be experienced by most sooner or later; and it is not commonly thought of as a mental illness. But what is a mental illness?

Grief and Mental Disorder

Bereaved people often fear that they are going mad and organizations for the bereaved take pains to reassure them that grief is not a mental disorder but a ‘normal’ response to bereavement. While this is an understandable and well-meant response it perpetuates two fallacies, that mental disorders are forms of insanity and that they are abnormal. In fact, only a very small proportion of people diagnosed with mental disorders are insane, mad or psychotic and most mental disorders are normal ways of reacting to life circumstances and situations that are themselves abnormal.

Nor is it true that mental disorders are incurable or that only psychiatrists are qualified to treat such conditions. Most psychiatric conditions improve over time even without treatment and those treatments that are necessary can usually be given by psychologists, counsellors, or members of primary health care teams.

The assertion that because grief will be experienced by most of us sooner or later it cannot be said to be an illness is not valid. There are many illnesses that most of us experience: chicken pox, measles, even the common cold. If a bruise or a broken arm, the consequence of physical injury, is within the realm of pathology, why not grief, the consequence of a psychological trauma?

But doctors don’t treat grief, you may say. In fact they do. There are indications that many people go to their doctor for help after a bereavement, and a large proportion of their complaints, as we shall show, are expressions of grief. Even those who do not seek help are not necessarily ‘well’; people suffer various physical complaints without requesting help, and there are numerous minor ailments such as warts, bruises, or burns for which professional care is unnecessary.

Illnesses are characterized by the discomfort and the disturbance of function that they produce. Grief may not produce physical pain, but it is very unpleasant and it usually disturbs function. Thus newly bereaved people are often treated by society in much the same way as a sick person. Employers expect them to miss work, they stay at home, and relatives visit and talk in hushed tones. For a time, others take over responsibility for making decisions and acting on their behalf. When grief is severe, bereaved people may be disabled for weeks, and relatives worry about them; later they may say, ‘I don’t know how I lived through it’.

On the whole, grief resembles a physical injury more closely than any other type of illness. The loss may be spoken of as a ‘blow’. As in the case of a physical injury, the ‘wound’ gradually heals; at least, it usually does. But occasionally complications set in, healing is delayed, or a further injury reopens a healing wound. In such cases abnormal forms arise, which may even be complicated by the onset of other types of illness. Sometimes it seems that the outcome may be fatal.

This said, in view of current prejudice, it would do more harm than good to label those who suffer a major loss as mentally ill. That term would only be justified if the symptoms were so lasting, severe, and disabling that it was to the patient’s advantage to provide them with the treatments and privileges that accompany illness. We shall see, in the course of this book, that there are indeed a minority of bereaved people who meet these criteria. But even they can be reassured that their psychiatric disorder is not madness or incurable, it is a psychological condition that can be diagnosed and treated.

Since the first edition of this book was published the influential Diagnostic and Statistical Manual of the American Psychiatric Association (1987, 1994) has included ‘Bereavement’ among a group of ‘Other Conditions that may be the focus of clinical attention’. In this way they allow it to be taken into consideration without committing themselves to a diagnosis.

In many respects, then, grief can be regarded as an illness. But it can also bring strength. Just as broken bones may end up stronger than unbroken ones, so the experience of grieving can strengthen and bring maturity to those who have previously been protected from misfortune. The pain of grief is just as much a part of life as the joy of love; it is, perhaps, the price we pay for love, the cost of commitment. To ignore this fact, or to pretend that it is not so, is to put on emotional blinkers, which leave us unprepared for the losses that will inevitably occur in our lives and unprepared to help others to cope with the losses in theirs.

We know of only two functional psychiatric conditions whose cause is known, whose features are distinctive, and whose course is usually predictable, and those are PTSD and grief. Yet PTSD is a relatively new discovery and grief has been so neglected by psychiatrists that, until recently, it was not even mentioned in the indexes of most of the best-known general textbooks of psychiatry. The diagnostic systems that are in use in psychiatry grew up without reference to these conditions.

When knowledge is lacking regarding the aetiology and pathology of a disease, it is standard medical practice to classify it by its symptoms. This is what has happened in psychiatry. It is the principal presenting symptom that usually determines the diagnosis, and because psychiatric patients usually complain of emotional disturbance, the diagnostic labels contain the names of the emotions involved. Thus we have anxiety states, phobias, depressive reactions, depressive psychoses, and so on. The system would work better if there were not so many patients who exhibit one feature at one time and a different one at another. This leads to strange combination terms such as phobic anxiety, anxiety-depression, schizo-affective disorder, or, as a last resort, to pan-neurosis or personality disorder. When asked how to classify psychiatric problems that follow bereavement, most psychiatrists say ‘depression’, and certainly depression is a common feature. Yet more prominent is a special kind of anxiety, separation anxiety, which is discussed at length in Chapter 4. In fact, it is fair to say that the pining or yearning that constitutes separation anxiety is the characteristic feature of the pang of grief. If grief is to be forced into the Procrustean bed of traditional psychiatric diagnosis, therefore, it should probably become a subgroup of the anxiety states. This said, separation anxiety should not be confused with general anxiety, and prolonged grief disorders have quite different patterns of symptoms from Generalized Anxiety Disorders (GAD; Prigerson et al., 1996). Furthermore, separation anxiety is not always the symptom that causes a bereaved person to seek help and it may be that PTSD and grief will open the door to a new classificatory system. We shall return to these issues in Chapter 8.

The Process of Grieving

Although there is a tendency for the features of grief to diminish over time, the symptoms of grief do not all appear from day one and then fade away, there is a pattern to the process of grieving. It involves a succession of clinical pictures, which blend into and replace one another, and which vary greatly from one person to another, one family to another and even one culture to another. In this book we shall see how numbness, commonly the first state, gives place to pining, and pining is often followed by a period of disorganization and despair until, in the long run, this too declines as acceptance grows. Many people use the term ‘recovery’ to describe this time although we are all, to some extent, permanently changed by the losses in our lives; a widow does not go back to being the same married person that she was, even if she remarries (Bowlby and Parkes, 1970; Maciejewski et al., 2007; Prigerson and Maciejewski, 2008; and Appendix 1).

Each of these states of grief, has its own characteristics and there are considerable differences from one person to another as regards both the duration and the form of each state. Furthermore people can move back and forth through the states so that, years after a bereavement, the discovery of a photograph in a drawer or a visit from an old friend can evoke another episode of pining. In the light of this variation we no longer use the term ‘phases of grief’ as this gives too rigid a framework and it is not surprising that some have questioned the existence of the phases of grief (Wortman and Silver, 1989). Nevertheless, more recent quantitative research (see Appendix 1) has confirmed that there is a tendency for the symptoms that distinguish these phases to peak in the order given above (Maciejewski et al., 2007), however, one phase does not have to end before the next can begin and there is considerable overlap between them. In the American study, which included a wider age range than the younger widowed sample from London, many bereaved people were able to accept the reality of bereavement from the start and yearning was the most prominent negative feature throughout the first two years of bereavement. For these reasons we no longer consider the ‘phases of grief’ to be a very useful concept. Perhaps its greatest value has been to draw attention to the fact that grief is a process through which people pass and that, in doing so, most tend to move from a state of relative disorientation and distress to one of growing understanding and acceptance of the loss (Prigerson and Maciejewski, 2008).

We said earlier that grief is not a common stress in the lives of most of us. In saying this we should, perhaps, have written grief with a capital G. Losses are, of course, common in all our lives. And in so far as grief is the reaction to loss, grief must be common too. But the term grief is not normally used for the reaction to the loss of an old umbrella. It is more usually reserved for the loss of a person, and a loved person at that. It is this type of grief that is the subject of this book, and this type of loss is not a common event in the lives of most of us.

Even bereavement by death is not as simple a stress as it might, at first sight, appear to be. In any bereavement it is seldom clear exactly what is lost. The loss of a husband, for instance, may or may not mean the loss of a sexual partner, companion, accountant, gardener, baby-minder, audience, bed-warmer, and so on, depending upon the particular roles normally performed by this husband. Moreover, one loss often brings other secondary losses in its train. The loss of a spouse is often accompanied by a considerable drop in income, and this may mean that the widow or widower must sell his or her house, change his or her job (if s/he has one), and move to a strange environment. The need to learn new roles without the support of the person...