Bereavement and Adaptation

A Comparative Study of the Aftermath of Death

Marc Cleiren

• Publisher: Taylor & Francis
• Year: 2019
• Print ISBN: 9781560322795
• eBook ISBN: 9781317740476
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

This book offers a critical review of the main psychological theories on adaptation after loss followed by an overview of the results of the empirical research on bereavement.

It also reflects on the results of the Leiden Bereavement Study, which compares the consequences of death.

Chapter 1

Introduction

This study concerns the effects of the death of a family member on the life of the surviving members of that family. We will examine how the bereaved react to the loss in different areas of functioning. Central in this publication are the role of the mode of death and the kinship relationship to the deceased in the adaptation of the bereaved after the loss. We will also focus in detail on how the situation before the death influences the adaptation and well-being of the bereaved afterwards.

In any given year in the past decade, the number of people that died in the Netherlands varied between 110,000 and 130,000 (CBS, 1983, 1988, 1989). Estimating that one death leaves five next of kin or close friends behind, every year more than half a million people (about 4% of the Dutch population) become bereaved. Most of them after some time are able to re-engage and function adequately in daily life. A minority however does not recover, or only marginally so, and continues to be debilitated in physical, psychological, and social functioning. Estimates of the magnitude of this group vary considerably, but it is generally assumed that at least 20% of all bereaved fall into it. Since the problems of people in this proportion may persist for much longer than one year, and in fact often last many years, the actual size of the problem will be much larger.

Although some knowledge exists about the factors that may determine functioning after a loss, much remains to be learned about their relative importance and interaction. If it is possible to determine in an early stage which individuals are likely to develop problems following loss, more adequate prevention and intervention strategies can be developed, and severe mental and physical health problems may be partially prevented.

1.1 The Leiden Bereavement Study

The study reported here was undertaken to assemble in-depth information on the role of the death with reference to specific situational and personal aspects that may influence adaptation after a loss of a family member. This requires a systematic, and preferably repeated assessment of the aspects involved.

The Leiden Bereavement Study is a controlled longitudinal study of 309 family members (parents, spouses, siblings and adult children) of people who died from three different causes of death: bereaved after suicide (n=91), a traffic accident (n=93) and people who died after a long-term disease (n=125). A standardized and elaborate interview was held approximately four months after the death occurred. A follow-up interview, mainly focussing on the events and changes since the first, took place fourteen months after the death.

Previous publications have reported part of the results of this study (Van der Wal 1986, 1987; Van der Wal & Cleiren 1988; Van der Wal, Cleiren & Diekstra 1988a, b). Van der Wal (1988) made a thorough analysis of the reactions of bereaved from suicide and the bereaved from a traffic accident, four months after the loss. His work is part of the basis of this publication.

In this book, these data are elaborated with a third mode of death: long-term disease, and the data of a follow up interview with the bereaved at fourteen months will be added. The focus of the present publication will be, on the one hand, on describing the characteristics of loss-reactions, health and social functioning after the loss, and, on the other hand on factors that may influence functioning, such as characteristics of the loss-situation, the relationship with the deceased, and sociodemographic factors. Throughout the study, we will systematically examine the role of the mode of death and the kinship relationship to the deceased.

Before giving a more detailed review of the literature and the design, method and results of our study, it is desirable to give a rough indication of our subject and to position it in its context. We also have to define the terminology we will use to discuss our subject. In the remaining sections of this chapter, we will first give a brief outline of the field under study. In the subsequent sections, a definition of the concepts involved will be given.

1.2 The context of bereavement

In our culture, the death of someone close is being regarded as one of the most pervasive events in human life. Although, as regards frequency, death has a less important place than in earlier times and in many other (third world) countries, it is still a common event in our society. The death of a family member, in particular, may constitute an important change of our world as compared to how it was before the loss. In order to be able to function in this new life-situation, we in turn need to adapt ourselves to this change.

The human reaction to bereavement seems to be characterized by a remarkable variety of feelings, thoughts and behavior. Grief or sadness is commonly regarded as the most generally experienced emotion, but it is by no means the only one. Yearning and pining for the deceased, symptoms of shock, numbness, hallucinatory experiences, feelings of anger, guilt, depression, meaninglessness, health problems, irritability, hyperactivity, but also relief and hope, may all be experienced in often rapid succession and alternation. The bereaved not seldom find themselves for a shorter or longer period of time ‘out of control,’ being swept from one state of mind to another. This process is often an exhausting experience, draining energy and attention away from the demands of daily life.

Although death and dying are universal phenomena in human beings, the experience of these events and the reactions they elicit are by no means universal. Not every bereaved person experiences all, or even the majority of the phenomena mentioned above.

Cultural influences

Death, and the experience of its consequences, takes place in a context. This context is, in its widest sense defined by one’s culture. The cultural aspect of bereavement that draws most attention in this respect are the rituals and stories associated with death and dying. They are an important reflection of a society’s attitude towards death, and can tell us about the social context of the loss. A culture, however, is more than its rituals.

In today’s world, differences between cultures are increasingly associated with differences in well-being, poverty and death rate of the population. The extent to which death is a frequent, and relatively ‘normal’ phenomenon thus also differs widely from culture to culture, and may profoundly shape the social and personal context of a loss. People living in a country where children at an early age run a high risk of dying (e.g. from diseases or hunger) may have less trouble finding recognition and models for coping with the loss of their child than parents in our culture. They also may feel less ‘abnormal’ as a result of the death. Also within a culture there may be relevant differences in this sense between social classes.

In the present study we will limit ourselves to the consequences of bereavement as they can be found in our own culture, broadly defined as the modern Western culture. The literature which was consulted and referred to in this publication originates primarily from the Anglo-saxon tradition, with most of the studies being conducted in Great Britain and the United States. To a much lesser extent, literature from the Latin tradition was available and consulted. Of course further subdivisions on different levels are possible in terms of cultural traditions and nationalities. To the extent that we are aware of them, these differences will be mentioned and, where relevant, discussed. The limitation to these origins implies that no assertion is made about the possibilities of extending the findings to other cultures.

Situational and individual differences

Within our society, the reactions to a death differ widely according to the persons concerned. The situation (or the smaller context) in which the loss takes place also defines the subsequent processes.

Some reactions may be expected to be more pronounced with specific causes of death: survivors of suicide may be more prone to experience feelings of guilt. Bereaved who lose someone after a prolonged period of illness may show severe signs of exhaustion due to intensive caregiving, and in the case of homicide, feelings of anger towards the murderer(s) may be all-absorbing. If in addition to the loss, a person has or has had to cope with other problems, such as poverty, additional stressful events, or impaired physical health, this may increase the tension and impair adaptation.

The character and intensity of bereavement reactions are also determined by the relationship to the deceased. Here, not only the degree of emotional and social closeness to the deceased (e.g. a close friend versus a far-off acquaintance) may play a role, but also the nature of the relationship. The loss of ones young child is obviously different in nature from the death of a spouse.

Still, the impact of death seems to be not always determined by relationship, kinship or distance. People may react intensely to the death of an admired statesman, or a cherished pop-musician, who may have been an idol or considered as a far-off personal friend or supporter.

Individual reactions to death also differ considerably in seemingly identical situations. The reason for this is, first of all, that everyone carries with him a personal history of events. More or less stable personal characteristics or coping patterns that existed before the loss define, to a large extent, the way one deals with it.

In understanding the reactions to the death of a family member, it is thus imperative to take the context of the loss into account. This context is defined by cultural, situational and individual characteristics. In Chapter 3, empirical knowledge on these aspects will be discussed in more detail.

1.3 Definition of concepts

Like in many areas of daily life, a variety of terms is used to describe the processes associated with death and bereavement. In the literature we find terms like loss, bereavement, grief, grieving, griefwork, bereavement process, mourning process, mourning, and the like. Many of them are overlapping, or are used interchangeably. This conceptual overlap poses itself as a problem to the researcher. In order to be able to adequately describe the field from an empirical point of view, a clear definition of terms is necessary.

The concepts involved can be separated into a number of categories: those referring to the situation before the death occurred, those referring to the event of death itself, expressions referring to the adaptive processes following the death, and those referring to the situation that is considered to be the result of these processes. Each of these categories will be discussed hereafter.

Anticipation of the loss

If the death can in some way be expected or anticipated, the period before the death can be regarded as of influence on adaptation afterwards. The post-loss situation may be formed and influenced to a substantial degree by this knowledge or anticipation. The most generally used term for the processes during the time before the death is ‘anticipatory grief’. The definition of anticipatory grief differs, however, considerably with the author and may comprise many different feelings (like anxiety, fear, or also relief) cognitive processes (like avoidance, hope, or role rehearsal) and behavior (like information seeking, intensified contact with the dying person). To what extent the stress in this period can be considered as valuable for adaptation to the death remains to be seen (see Cleiren et al. 1987). For this reason, we will make no assertions about the contents of this process, and henceforth prefer to speak of anticipation of the loss or anticipation of the death.

The loss event

A second category of terms refers to the objective situation. Words such as death, loss and bereavement all directly refer to the event that took place.

Bereavement will be seen as the action of having something or someone go permanently out of one’s control, possession or environment. In the context of this publication, bereavement will always pertain to death of a person.

The term loss will be used here as a synonym to bereavement. Thus, unless mentioned otherwise, ‘loss’ will be used here with the connotation of ‘loss from death’. In this case, like bereavement, it also implies the irrevocable and definitive cessation of contact with a person.

The difference between the terms ‘bereavement’ and ‘loss’ on the one hand, and the term ‘death’ on the other, is that ‘loss’ and ‘bereavement’ are referring to the person who loses the object or person, while ‘death’ pertains to the person that was lost (the object of the loss). On the basis of this definition we can also define the term ‘bereaved’.

The term bereaved as applied here, pertains to the person who has sustained a loss by death of another person.

It must be added that there has to be a meaningful relationship to the deceased person, at least in the ideation of the bereaved.

Processes after the loss

Next to terms referring to the loss situation per se, there are words that refer to the experience of this situation.

To grieve can be seen as experiencing sorrow, pain, distress and sadness about a loss. The noun grief has, however, gained a more elaborate meaning in the bereavement literature (e.g. Parkes & Weiss, 1983), comprising a variety of emotions as well as thoughts and behavior that occur after a loss. The term grief as employed here, also refers to the complex of feelings, cognitions and behavior of an individual in reaction to a loss.

The processes in the individual after the loss are often indicated by adding extensions like ‘-work’ or ‘-process’ to the terms ‘grief’ and ‘bereavement’. These extensions indicate that the situation after the loss is seen as characterized by changes, rather than stability.

Another term to indicate bereavement processes is ‘mourning’. Freud (orig.1917) saw this as the process in which a person unwillingly has to withdraw libido from a loved object. Later authors employ ‘mourning’ for the visible aspects of the reaction to a loss, rather than for the intrapersonal aspects of the process. Averill (1968) described it as the overt reaction to the loss prescribed by the community. Ramsay (1979) conceived mourning as the behavior that occurs after bereavement. Parkes & Weiss (1983) defined mourning as ‘the observable expression of grief’.

Since we do not want to limit the study of the process neither to internal nor behavioral processes, we will not use this terminology in the context of the present study, and will prefer the more neutral term bereavement process, which will be used in the same sense as grief.

Bereavement process will refer here to the cognitive, affective and behavioral changes in the bereaved individual after the loss.

It must be noted that in this definition no specific direction of this process is assumed. The term ‘bereavement process’ will thus mainly be used in a descriptive sense. Although in the literature phases or steps in this process are often presumed, no assumptions will be made here about its phasing or resolution.

Adaptation after the loss

In many studies of bereavement an attempt is made to assess the situation of the bereaved in terms of emotionality, physical and psychological health, or acceptation of the loss. Other indicators of functioning, like social integration are also considered.

Many different formulations are employed to describe virtually the same aspect. Psychological and physical ill-health after a loss are alternately indicated as ‘poor recovery’, ‘bad outcome’, ‘unresolved grief’, or ‘poor functioning’. It is necessary to take a closer look at these concepts, since each of them can have a specific (theoretical) connotation.

The term recovery implies a return to the state as it was before bereavement in certain areas of functioning (Weiss, 1988). St...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgments
• 1 Introduction
• 2 Theories on adaptation after bereavement
• 3 Empirical research on bereavement
• 4 The Leiden Bereavement Study: objectives, method and response
• 5 Mode of death, kinship, and functioning after bereavement: empirical results
• 6 The structure of functioning
• 7 A prospective study on functioning
• 8 Discussion
• References
• Appendix 1
• Appendix 2