The Anatomy of Bereavement

A Handbook for the Caring Professions

Beverley Raphael

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9780415094542
• eBook ISBN: 9781134868735
• Topic: Medicine
• Subtopic: Health Care Delivery

Bereavement is a painful and inevitable experience. This book shares the experience of many bereavements, how they are dealt with, understood, and eventually adapted to in the ongoing framework of human life.

CHAPTER 1.
Human Bonds and Death: The Background to Bereavement

“When I met Pete it was as if the whole world changed—as if everything would never be the same again. It was as if I’d been waiting for him…waiting for him all of my life.”

Annie, age 22

“Our baby, our baby, that little growing part of Pete and me… our baby is coming…. He’d put his ear against my womb and smile secretly. ‘I’m sure it’s Melissa,’ he would say.”

Annie, age 24

“My days are filled with our life as a family—our children, our friends…. Our family is now.”

Annie, age 28

In human society the loss of one who is dearly loved brings great emotional pain and grief. Some suggest that this pain has significance for the species—that it serves the function of binding the social group, the group essential for survival.

The bonds of human societies take many different forms. There are the intimate, intense, interwoven bonds of the nuclear family. There are the attenuated, yet still powerful bonds of the extended family; bonds of blood, relatedness, shared background, shared experience. There are also the bonds of great friendships—valued, enduring, built upon mutualities of personality and not of blood. There are the complex social bonds of neighborhood and workplace, of acquaintance and community, that go to make the social milieu in which the individual lives. From birth to death, this fabric of family and social relationships will provide the interpersonal context that is the essence of human existence.

Death is also an inevitable part of human experience. The awareness of death grows slowly through childhood, tingeing its latter years with fears and denial, games of magic and ghosts. The specter of personal death is the antithesis of the thrust and joy of adolescence: death seems impossible when all is growth and love; yet in the darkness of death lies mystery and romance as well. Man sets the thought of his own death aside in the years of his young adult life. He makes his family and embarks upon his achievements. Yet death will not be denied: in his middle years he glimpses it again, reminding him that his time is not infinite. In the latter half of his life, its reminders become more constant, more persistent. And, at last he meets it, fearfully or as a friend, his own, his personal death.

Death has other powers as well. It may come when it is neither expected nor wanted. Its time is its own. It is always unknown and unknowable, mystery and uncertainty. It may be peaceful or violent, anticipated or sudden, and it may be accompanied by stigma, shame, pain, or pride. And it has the awesome power to rob one of those one loves—to bring the greatest of human pain, grief. To understand bereavement it is necessary to have a conceptual framework in which to view two key elements: the human relationships that may be lost; the human deaths that may bring these losses.

Human Bonds

Human bonds take many different forms. There are many ways of conceptualizing them and many different ways to view the key components of such bonds. The most intimate and intense relationships are those that are associated with the greatest grief when they are lost, though less intense relationships may also be a source of grief. Relationships are characterized by many different feeling stages, many different interactional patterns, and many needs that they meet.

Weiss (1974b) outlines a series of “provisions” or needs that are normally met in relationships. These include attachment, providing a sense of security and place; social integration and friendship, providing for shared concerns; nurturing, providing a sense of being needed; reassurance of worth, attesting to a person’s competence; a sense of reliable alliance, providing dependable assistance; and guidance, so important in stressful situations.

Hinde (1979) attempts to provide a framework that summarizes the scientific understanding of human relationships and their dynamics, providing dimensions wherein they are described. His work has been extremely important in delineating some of the components of relationships in operational terms. Thus, he suggests that to describe a relationship, the content, qualities, and patterning of its component interactions must first be understood. Relationships have both affective and cognitive aspects. They exist over time. The experiences of relationships are stored as symbols that can be manipulated. It is probably his own perception of the relationship that seems most important to the individual, even though it may not always reflect its true characteristics.

Interactions may occur on many levels. They may be verbal or nonverbal. There may be overt communications with metacommunications that are different. Interactions may be intense in their frequency, affect, and duration; or they may be diffuse. Such interactions may also be frustrating or rewarding, depriving or gratifying. Hinde notes two key categories of reciprocity and complementarity. Relationships that are reciprocal have symmetrical, similar patterns of interaction which may occur simultaneously or alternately. Reciprocity tends to characterize relationships between peers, equals, and colleagues. Some marital intimacy may also involve such interactions. Complementarity in relationships involves different but complementary interactions, such as the mother-infant behaviors of that dyad. Some marital relationships may be predominantly complementary in terms of roles where role definition is very clear—for example, the provider and the provided for. This may set the total pattern of the relationship, or it may represent only one facet with other aspects being much more reciprocal. Relationships that are flexible may change their patterns in terms of situation and need. Power and dominance are also important in relationships, as are issues of permissiveness and control.

Relationships may be reinforced by similarity, or the complementarity of difference may be valued. Not only may those who are similar have more opportunities for relationships, but also social pressures and norms as well as attitudinal similarities may reinforce the shared world even further. For others, however, the stimulus of difference may be much more valued and arousing. It may also be that, as people spend more time in interaction, in relating they become more similar. Kreitman et al. (1970) found from their study of sixty married couples that wives of neurotic husbands grew more neurotic than did those in a control population. This fits well with psychodynamic concepts such as those of Dicks (1967) that conceptualize such dyads in terms of mutual interlocking psychopathology.

Out of these many factors some key elements emerge. Relationships are made up of interactions that operate on many different levels. Relationships also occur over time. The past of the relationship experience and other related relationship experiences are stored as symbols, which may be conceptualized as the “inner image” that is held of the relatioship at any one time. That image is composed of the present symbols and the many other symbols that can be called from past memory stores. Symbols will be experienced not as affectless memories, but rather in association with the inevitable human feeling and emotion that are attached to them. Such images will influence interactions as well as the individual’s perceptions of the relationship and will in turn be influenced by them.

The most intimate of human relationships, those of attachment, require primary consideration. The seminal work of John Bowlby (1969) defines attachment in the human species, building from a variety of sources, including the ethological. He defines clearly the attachment behaviors of the infant to its mother and their vital role in the mother-infant bond.

Close human relationships are often spoken of as attachments, and the person with whom an individual is involved in the most important of these relationships is said to be the primary attachment figure. Although there has been some argument against such a broad definition, perhaps it is useful when attempting to define close relationships and differentiate them from the wider group of social relationships. The value of this distinction is shown in a study of the dimensions of relationships conducted by Henderson, Byrne, and Duncan-Jones (1981). Henderson’s group developed an instrument that attempts to quantify and qualify human relationships. They devise an interview schedule that clearly differentiates, at least in terms of the individual’s perceptions of them, the differences between primary attachments and other social relationships and their relative importance.

MODELS OF PRIMARY BONDS

Because grief and bereavement are so much more clear-cut and intense with the loss of primary attachments, it is worth elaborating further a conceptual model of these attachments to help explain the effects of their loss.

Annie is fifteen. She has straight hair, dark eyes. Her life is full and joyful. Her mother is warm, friendly and rather disarrayed. Her father is strong, caring, but tends to be impatient. Her brothers and sister form part of the rich fabric of family life. Annie likes life. She dates a pleasant young man called Joe. She enjoys school. She is filled with excitement as she feels her womanhood within her—the woman she is to become, the dreams of the husband she will marry, the babies she will bear. Some of these fantasies she shares with her best friend, Mary. Others she nourishes privately, feeding them, watching them grow. Joe is nice: a good friend, a step to adult life, but not her man. She knows she is not ready yet for him. She has so many things to do, so much to be, such a lot of the great world she wishes to sample and explore.

Annie is twenty-two. Her hair is straight, her fine dark eyes, warm and full of life. She enjoys her work as a teacher.

“When I met Pete it was as if the whole world changed—as if everything would never be the same again. It was as if I’d been waiting for him—waiting for him all of my life. It was at a party. He caught my eye—half a smile, that was all. Then later that evening, he came and sat beside me. We started to talk. I felt this thrill, this excitement. I like him. I liked everything about him. I felt so good inside—warm, happy, excited. He was so attractive—strong, caring, good looking. I could feel he liked me, too—we just knew it was something special between us. I felt as though he was like someone I’d known before, but of course, I hadn’t.

“We talked for hours. There were so many things we shared, so many thoughts and feelings, so many things we both liked. There were new, exciting things, too—his work, the world he knew.

“Those weeks were magic. We saw one another every moment we could. When we were apart, we missed one another dreadfully. He was in my thoughts all the time. I would see his face—think I heard him, dream I was with him. I was so much in love, I did not know if I could bear it. When he wasn’t there, it was as though there was a pain inside me waiting for him, longing for him. And when he came, I felt right and whole. He was like another part of myself. He made me feel complete. When we made love, there were whole new worlds we found in each other. They were really happy times for us both.

“I suppose it could not last in such an intense way. Perhaps no relationship can. I was so disappointed—so hurt that day. How could he feel so differently to me; how could he value something like that? I was sad and cross. I hated him for a minute, for he’d broken my perfection, my ideal. Then he grinned his friendly old grin and it was all right again.

“There were more times like that, but really they weren’t much. They were the differences between us, the other sides of the coin. Some things about him really frustrated me. There were things in me that disappointed him too. Sometimes we would have a dreadful row. How could I love this man, I would think. How could I? And for a moment, just a moment, I might hate him again. They were only moments. I suppose he changed a little for me, too, and I knew I changed a little for him. In a way, we grew closer. Perhaps most important of all, we were ourselves—and as time went on I knew, knew in my heart that he loved me and accepted me as I was, and that I, too, loved him in that way as well.”

ADULT-TO-ADULT PAIR BONDS

To adult pair bonds, each partner brings an inner image of such relationships and how they should be—a constellation of cognitive symbols with memories and affects attached. It is composed of all the earlier experiences and perceptions that the individual has known. It may include internalizations of his parents’ relationship at its various stages and in its positive and negative aspects. There may be internalizations of dyadic components from his own relationship with the opposite-sex parent, and also, but perhaps to a lesser degree, with the same-sex parent. There will be fantasies of dyads from the individual’s society and culture. There will be all the earlier dyadic experiences as they have been internalized.

The influence of the quality of previous relationships is evidenced by an interesting study carried out by Uddenberg, Englesson, and Nettelbladt (1979). They found that women’s relationships with their opposite-sex partners and their sons, but not their daughters, were related to their perceived relationships with their fathers. It semed that the father-daughter relationship influenced the daughter’s way of relating to significant males. This fits closely with psychodynamic theories that would hypothesize the importance of family relationships and oedipal constellations in such adult object choice.

Not only may these factors influence the choice of partner, but similarities in attitude, behavior, and personality may also be important. A study by Hendrick and Brown (1971), using the Maudsley Personality Inventory, shows that in choosing a reliable friend, extroverts tended to choose extroverts while introverts preferred introverts. Similarities may operate through inherited predispositions, the opportunities that people have to meet, and the propinquity that similar involvements may bring. Differences may also attract, perhaps because, as the psychodynamic view might suggest, the individual looks for the absent or denied parts of himself to give him the sense of wholeness, oneness, that the adult pair-bond seems to offer.

Hinde (1979, p. 305) suggests that the stages in the development of a relationship may be progressively influenced by various factors: at first external factors such as the opportunity to meet and discover common interests may be important. Physical attributes may also be very important in the early stage and, what is considered attractive physically will vary with culture, subculture, individual, and historical time. As a relationship develops, complementarity of attitudes and needs becomes more important and may then determine the progress or consolidation of the relationship as it moves toward intimacy and commitment. Needs may change as the relationship progresses. Compatibility of values seems to become more important too as the relationship grows, although this may vary with the type of relationship.

The kind of framework in which a relationship commences and develops may depend on social and cultural factors. Thus, young adults may refer to their relationship as one of “being in love” if their culture or subculture idealizes such romantic love. Certainly the “falling in love,” the passionate love of romantic novels, is not universal to all cultures. Some cultures may expect adult pair-bonding to be based on a prearranged pattern, or on good sense, or on exchanges such as those of services or property. The image each partner brings to the relationship will thus be strongly influenced by such social and cultural value systems. Then the inner image brought to an adult pair bond will be more of the role and its values for that culture than the personal characteristics of the potential partner.

Nevertheless, the falling-in-love pattern provides a useful model for considering the processes involved in the formation and consolidation of the adult pair bond. Like the mother’s falling-in-love bonding with her infant, the adult pair bond is initially very intense but later settles into a more regular interactional pattern with mutual adjustments of expectations and needs. Like the mother-child relationship, it too goes through phases of development and adaptation.

When the adult (or adolescent) falls in love he brings to this dyadic encounter the complex inner amalgam of memories and feelings, conscious and unconscious, that forms the image of his “ideal” mate. This ideal may consciously represent personally or culturally valued attributes of man or woman, parent, lover, friend. At a deeper level it may represent desired psychodynamic constellations that fit and meld with the unconscious dynamic processes of the individual. In most instances these psychodynamic images are considerably weighted toward gratifying adult needs, even producing further maturation and growth in the individual should he find the partner to fit. There will always be some residues of the more infantile and neurotic parts of the self seeking some complementarity to these in the partner, but this is usually outweighed by the healthy components. For some, of course, it is not. The infantile neurotic parts of the self covertly and unconsciously demand a complementarity and matched pathology in the partner.

The person who is the “object” with whom the man or woman fall in love seems, initially at least, to fit in every way the “subject’s” inner image. In the glowing and idealized beginnings of such a relationship there are intense positive feelings, an ebullient joy and passion, as each partner seems to find the fit between the other and his own wish fulfillment. Sexual attraction may initiate or reinforce such feelings. The interactions build. They are intense and gratifying and tend to operate on many interpersonal levels at one time. The inner image becomes enriched by these glowing and positive attributes. The primitive dyadic processes involved in this intense attachment phase are not dissimilar from those of that phase of the mother-infant relationship. There is an intense preoccupation with the face of the beloved. It is touched and cherished. Touch has a magnetic and gratifying quality. Long mutual gazing, filled with intense and personal exploration of each other, is common.

Like the mother-infant relationship this interactional pattern of the adult bond, too must be increasingly adapted to the real qualities and real interactions of the individuals in it. While initially each partner notices only the similarities between them and the degree to which the other person approaches the idealized image, as time progresses, they begin to recognize differences. These differences may be either accepted and incorporated into each partner’s image or they may lead to frustration and negative affects. In the latter case, this produces a strand of ambivalence that will become part of the relationship. This ambivalence may trigger links with buried ambivalences in a partner’s internalized image, reawakening reverberations of negativity from earlier relationships. These may be significant, leading to an increased expectation of such painful affects in the present relationship. Old repetition-compulsion patterns may thus be set in train.

If the disillusionment with the relationship is great, the relationship may be relinquished: it cannot continue because the realities of each partner make it untenable for the other. Or the disillusionment may be one-sided, leaving the other partner his intense and unrequited love. Sometimes, instead of the relationship breaking down, one partner may try to force the other to behave as the idealized fantasy. This may be temporarily successful if the partner forcing change wields great power over the other. When such behavior meets mutual needs a distorted relationship of false ideal-selves may result. Another, possible consequence, so elegantly outlined by Henry Dicks (1967) is that partners may switch to mutual negative projections. In this pattern of relating, each partner starts to interpret characteristic behaviors and interactions of the other from an increasingly negative viewpoint, selecting especially for condemnation those aspects of the other partner that unconsciously represent the aspects of himself he hates and denies. The bonds in such a relationship may be very strong, yet filled with negative affects of hate and anger. One, or both partners, may not...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• PREFACE
• CHAPTER 1. HUMAN BONDS AND DEATH: THE BACKGROUND TO BEREAVEMENT
• CHAPTER 2. THE EXPERIENCE OF BEREAVEMENT: SEPARATION AND MOURNING
• CHAPTER 3. THE BEREAVED CHILD
• CHAPTER 4. THE ADOLESCENT’S GRIEF AND MOURNING
• CHAPTER 5. LOSS IN ADULT LIFE: THE DEATH OF A SPOUSE
• CHAPTER 6. LOSS IN ADULT LIFE: THE DEATH OF A CHILD
• CHAPTER 7. THE GRIEFS OF GROWING OLD
• CHAPTER 8. DEATH AND DISASTER
• CHAPTER 9. CARING FOR THE BEREAVED
• CHAPTER 10. LIVING WITH LOSS: PASSION, COMPASSION, AND DEFENSE
• REFERENCES