Grief, Loss, and Bereavement

Almost every person in the world, at one time or another, experiences events that can be considered major losses (Harvey and Weber 1998). A loss occurs when an event is perceived to be negative by individuals involved, and it results in long-term changes in one's social situations, relationships, or way of viewing the world and oneself. Death is the event most often thought of as a loss, but there are many others. Tangible losses can be personal (i.e., loss of one's vision, hearing, sexual activity, or mental capacity; infertility; chronic pain or illness; rape, domestic violence and abuse; or political torture), interpersonal (i.e., divorce, ending a friendship, or death of a loved one), material (i.e., losing a job, leaving one's country, war-time trauma, changing residence, or becoming homeless), or symbolic (i.e., losses related to racism, role redefinition, or reentry adjustment to home culture). Intangible psychological losses include changes in self-worth due to harassment at work or job demotion; changes in sense of control and safety due to crime, terrorism, or victimization; changes in identity related to widowhood; or changes in worldview related to experiencing a natural disaster or chemical accident.

Dominant cultures in Western countries tend to define loss dichotomously: an object is either present or absent, a person is either dead or alive. However, coexisting cultural groups in the West and other parts of the world may categorize losses by many levels of gradations—thus, someone from whom we are recently separated (through death or physical separation) may be seen as still communicating and with an active presence, different from someone who has been physically absent for many years (Rosenblatt 1993). There may be a series of stages of transition into nothingness, or to another state. In addition, losses have different meaning between cultures and among individuals within a culture, depending on their life circumstances. For example, in impoverished cultures where infant and child deaths are viewed as inevitable, seriously ill children may be categorized as dead, and their later deaths may not be mourned for more than a few days. Such responses may seem puzzling to outsiders when they learn that those dead children still are considered a part of the nuclear family and are expected to be reunited with the mother in an afterlife (Scheper-Hughes 1985).

Each traumatic or stressful event may cause several losses; and each loss can have multiple consequences. Therefore, when individuals have a severe chronic illness, they and their partners experience multiple losses, including losses each of them experience related to physical or mental deterioration. There can be related losses involving careers, finances, sexual interaction and love life, inability to do normal chores together or participate in activities previously enjoyed. They may experience losses in self-esteem related to having the disease, or the stigma of being with a chronically ill person; and losses related to being ignored by medical personnel discussing one's own condition, or (in the case of unmarried partners) being ignored in medical decision-making because one is not an "official relative."

There are several imprecise terms used to discuss reactions to loss, and it is important to clarify their intent. The usual reaction to a loss of someone or something that was valued is termed grief. It consists of emotional, psychological, and physical dimensions (Stroebe et al. 2001) and there has been debate as to whether grief occurs only for individuals, or whether there is such a thing as family grief (Gilbert 1996; Moos 1995). In Western cultures grief is typically discussed as a psychological phenomenon—largely as a cognitive challenge, an emotional reaction to loss. In many other cultures, however, grief is viewed as a somatization, where "personal and interpersonal distress [is manifested as] physical complaints [and people have learned to respond to their losses] through the medium of the body" (Kleinman 1986, p. 51).

The term mourning is often used to describe the varied and diverse social expressions of grief. Affects can range from pain and sadness to humor, pleasure, and joy. Actions, rituals, and emotions observed during mourning are shaped and controlled by the beliefs and values of a society or cultural group and are intended to be for the benefit of grievers and/or the community. In countries in which hundreds of cultures are represented (such as the United States and Canada) one might expect that cultural expectations for mourning would evolve in a manner that represents the many cocultures. However, Paul Rosenblatt and his colleagues (Rosenblatt, Walsh, and Jackson 1976) found that overt expressions of crying, fear, and anger were common, acceptable, and encouraged in most parts of the world, except for some Western cultural groups. This suggests that the United States and Canada have never truly been "melting pots" beyond some of the early European nationalities in terms of cultural, ethnic, and religious attitudes toward grief, loss, and mourning (Irish 1993).

Bereavement is used to describe the objective situation of someone who has experienced deprivation through the loss of a person or thing that was valued (Corr, Nabe, and Corr 2000). Although bereavement is a factual situation of loss, how individuals respond to loss can be highly varied. The extent to which one grieves, and overt expressions of mourning, will differ from culture to culture, from person to person, and from situation to situation for any one person. For example, the extent to which one grieves for the loss of her parent, colleague, stepchild, pet, partner, homeland, or unfulfilled dream may differ. Level of display of mourning may also differ depending on the societal messages received about one's position in the hierarchy of grievers—that is, how entitled one is to mourn a particular loss. In the United States a bereaved mother is considered more entitled to a high level of grief than are surviving siblings or classmates; and a current spouse is more entitled to grieve than a former spouse. However, the effect of culture on style of grieving may not be "visible" to those within the culture. It is important to remember that there is no one way that an individual "should" react to loss, and that our discomfort with the reactions of others often occurs when their reaction contradicts values and beliefs we have developed in response to our own culture and experiences.

Consequences of Grief

Although loss is a normal event, there can be physical, psychological, and social consequences for survivors, as well as a reduction of individual and family resources, whether personal, material, or symbolic. Over the lifespan, one experiences a buildup of memories associated with losses—some of which may be painful and sad, and some of which may be positive in that we feel we have grown or reacted to situations in ways consistent with our values. These memories are triggered by cues we encounter in daily life, rituals on holidays or anniversaries, familiar places, hearing someone use a word in the same way, or wind blowing the way it did just before the storm that took our home.

Despite attempts by scholars like John Harvey (1998, 2000) to develop an inclusive field called the social psychology of loss, most literature on outcomes of loss still comes from research on survivors of the death of a family member, probably because death is viewed as the only type of loss that can never be recovered. Grief related to bereavement can result in negative consequences for physical health, including susceptibility to illness and disease, new symptoms (often similar to those the deceased had endured), aggravation of existing medical conditions, anorexia or loss of appetite, energy loss, sleep disturbances, a drop in the number and function of natural killer cells, and long-lasting changes in both the brain and gene expression (c.f. Murray 2000, 122).

Reported changes in mental health include affective changes (i.e., depression, guilt, anxiety, anger, and loneliness), cognitive manifestations (preoccupation with thoughts of the deceased, helplessness, hopelessness, lower self-esteem, and self-reproach), and behavioral changes (i.e., crying, fatigue, agitation, and social withdrawal) (Stroebe et al. 2001). However, it is not clear to what extent mental and physical health changes occur because of grief and how much change is related to other life changes (i.e., increased consumption of drugs, alcohol, and tobacco, and/or poor nutrition). Individuals with prior personality disorders are more likely to experience complications during grief (Rando 1993). However, neither researchers nor clinicians have done a good job of distinguishing grief from depression, nor of examining traumatic grief separately from "normal" grief.

Dealing with social ramifications of loss can also be problematic. Grieving individuals often report there is a lack of clarity as to their role, and a lack of social or family support. Loss may have resulted in changes in their social status, identity, or income; there may be family or community conflicts related to inheritance or lawsuits—all contributing to a sense of social isolation.

Despite the emphasis on problematic outcomes, literature is emerging that emphasizes growth as an outcome of many types of major losses. Post-traumatic growth is said to occur when, at some point following a loss, growth occurs "beyond" one's previous level of functioning (Tedischi, Park, and Calhoun 1998). This growth can include changes in perception of self (i.e., as survivor rather than victim, or as self-reliant while recognizing heightened vulnerability), interpersonal relationships (i.e., increased ability to be compassionate or express emotions), and philosophy of life (i.e., spiritual change or sense of wisdom, gaining a new meaning and purpose in life, or reorganized priorities). However, the experience of trauma alone does not "heal" problematic family relationships; there are other cognitive, motivational, and behavioral changes required as well.

Coping with Loss

Much of what has been written about how people grieve has focused on individual survivors. The Victorian belief that grief was a sign of a "broken heart" resulting from the loss of a love was replaced by the psychodynamic view that grief was painful because it involved letting go of attachment to the deceased. This "letting go" was viewed as essential for "moving on" with one's life, eventual recovery from depression, and a return to "normal" (Neimeyer 2001). Theories of grieving later included an emphasis on differences between pathological (complicated) and normal (uncomplicated) grief reactions (e.g., Lindemann 1944), and an emphasis on phases, stages, or trajectories of the grieving process. The best-known stage model was presented in Elisabeth Kubler-Ross's (1969) book On Death and Dying. In discussing anticipatory grief of terminally ill persons she outlines five stages: shock and denial, anger, bargaining, depression, and acceptance. These stages were viewed by many lay people and professionals as "the" way successful grief is experienced. Many still gravitate to this model for its simple linear approach, using it as a prescription to measure how grief is progressing. Since its publication, this stage model has been applied to other losses including divorce, chronic illness, and infertility.

Although these models have been prominent in the popular media, many scholars have been critical of them (Attig 1991). Studies have failed to find any discernible sequence of emotional phases of adaptation to loss, or any clear endpoint to grieving. Rather than a passive climb up a linear staircase, characteristics of grieving may more closely resemble unsteady twisting and turning paths requiring adaptation and change, but with no specific end. In addition, there is no evidence that someone who deviates from those stages is experiencing pathological grief, so authors have called for a de-emphasis on universal grief syndromes and a recognition of varied practices of subcultural groups.

There also have been many challenges to the concept of grief work that underlies these theories— an assumption that one must do cognitive work to confront the loss and that failure to undergo or complete grief work results in pathological grief. The idea that one must "work" at dealing with grief is not a universal concept, and probably is reflective of the broader emphasis in the United States that anything worth having requires hard work.

Newer models of grief tend to focus on context and circumstances of a loss, variability in individuals' grief experiences, meaning of the loss to individual survivors and their families, recognition that rather than a withdrawal of attachment from the deceased (or lost object) there is a continued symbolic bond, and adjusting to the new world that exists after the loss (including new interpretations one has of the environment, and new elements in one's identity). The emphasis appears to have shifted from identifying symptoms to the process of grieving. For example, the Dual Process Model of Coping developed by Margaret Stroebe and Henk Schut (1999), suggests that active confrontation with loss may not be necessary for a positive outcome. There may be times when denial and avoidance of reminders are essential. Most individuals can expect to experience ongoing oscillation between a loss orientation (coping with loss through grief work, dealing with denial, and avoiding changes) and a restoration orientation (adjusting to the many changes triggered by loss, changing routines, and taking time off from grief). This reflects a movement between coping with loss and moving forward, but the extent to which one needs either of these dimensions differs for each individual.

Theories about families have been slower to develop elements that address loss and grief. Family systems theory (with its emphasis on viewing reactions to loss by the family group as a disruption in the family system's equilibrium and structure requiring reorganization of roles and functions; and the impact of reactions of one family member on another) appears well suited for examining loss. However, its emphasis on the present and current interactions appears to have slowed development along this line. There are a few notable exceptions, including Monica McGoldrick's (1991) elaboration of Murray Bowen's work on the legacy of loss. Bowen (1976) suggested that a family's history and experiences with loss influences how the family adapts to subsequent losses as well as the legacy of viewing themselves as either "survivors" or "cursed" (i.e., unable to rise above the losses) that they pass on to future generations.

Another notable work is that of Ester Shapiro (1994), who integrated individual and family life-cycle development with systems theory to discuss loss as a crisis of identity and attachment, in which grief disrupts the family's equilibrium but makes possible development of new "growth-enhancing stability" (p. 17). In addressing losses related to chronic illness, John Rolland (1994) developed the Family Systems-Illness Model to examine the interface of the individual, family, illness, and health-care team. Rather than focusing on the individual, Rolland views the family or caregiving system as the central resource affected by and influencing the course of the illness.

Differences in Grieving

There are many factors that appear related to differences in nature and intensity of the grief one experiences following a loss. Those who experience losses that are stigmatized by others (e.g., losses that are assumed to have been caused by an individual's disturbed or immoral behavior, or ones where there is a fear of contagion or fear for one's own safety) often feel isolated and pressured to show no grief in public. Grief of someone who recently has experienced an "unusually" high number of losses, as well as that related to the death of a loved one who was a drunk driver, a partner with AIDS, or a son in prison, are not well-acknowledged. Suicide, which is both violent and stigmatized, can provoke feelings of anger and guilt and result in secrecy and blame within the family.

Sometimes what one views as a loss is unrecognized by others, particularly if the loss has been stigmatized. Disenfranchised grief occurs when society does not recognize one's "need, right, role, or capacity to grieve" (Doka 1989, 3). Examples of these unacknowledged losses can include divorce after years of being abused; immigration to a "better" place; death of a former spouse, foster parent, stepchild, coworker, companion animal, professional caretaker; or death related to pregnancy. Individuals who may be seen as incapable of, or without a need for, grief include young children, older adults, mentally disabled persons, those who are deaf, masculine grievers, military, police and firefighters, or those in cultures who do not grieve or mourn according to societal norms.

Families may have additional difficulties with loss if they are experiencing other stressful situations at the same time. They may have difficulty if dealing with the stress of typical life-cycle events (e.g., a new marriage, birth of child, changes during adolescence, beginning employment) concurrent with major losses (e.g., illness, death, trauma, loss of employment or homeland). Dealing with life-cycle events and additional losses may tax resources (e.g., money, health, friendship, self-esteem, or sense of mastery).

Vulnerability also is related to centrality of the role and function of the lost item or person, such as items with significant meaning, those that can never be replaced, or losses that are critical to everyday functioning. Complications can also arise with the loss of individuals who played central roles in our lives, or when we lose someone for whom we feel ambivalence, estrangement, or intense continuous conflict. Differences in adjustment often attributed to gender may actually be related to other intertwined cultural factors (Wisocki and Skowron 2000).

To understand how a family perceives a loss, one needs to understand its view of the world. One common family paradigm is known as the Belief in a Just World (Lerner 1971). This perspective values control and mastery and assumes there is a fit between one's efforts and outcomes; therefore, one gets what one deserves. This view is only functional when something can be done to change a loss-situation. Otherwise, it results in blaming the griever for the loss. Chronically ill persons are blamed for their condition or lack of recovery, and it is assumed that adolescent deaths are caused by their own reckless behavior or drug use.

Another factor that can influence coping with grief is boundary ambiguity—confusion that arises when it is not clear who is in and who is out of the family (Boss 1999). Such a situation can exist in cases where someone is physically absent, but psychologically present in the family (e.g., a soldier missing in action, a missing child, an absent non-custodial parent, or yearning for one's family who remained in the homeland rather than immigrating). It can also exist when someone is psychologically absent but physically present (e.g., a family member with dementia or a brain injury, a parent who spends all her time with work or hobbies, or a depressed adult who has difficulty connecting to his partner). In the case of a sudden traumatic loss, denial and boundary ambiguity may initially be functional, giving the family time to regroup before dealing with the loss, but a high degree of ambiguity over time poses difficulties for coping. Reports that continuing bonds often occur following death (Klass, Silverman and Nickman 1996), with conversations with the dead replacing rituals as the normative way bonds are maintained (Klass and Walter 2001), may challenge the notion of boundary ambiguity, suggesting that conflicting images can coexist within the psychological domain—that one can cognitively recognize the loss and still maintain psychological, emotional, and spiritual connections.

Although the study of what facilitates coping with grief originally tried to classify factors that facilitated grief versus those that inhibited grieving, it appears that some elements may simultaneously complicate and facilitate grieving (Doka 1998). For example, it appears that no single length of time between the first hint of the inevitability of a loss and its actual occurrence is most problematic. Losses that are sudden or unanticipated do not allow one the opportunity to engage in anticipatory grieving; losses that are long and drawn-out result in depleted resources, including wearing out one's network of social support. In light of modern technological and medical advances, protracted losses (e.g., chronic illness) can involve a series of improvements and relapses that occur so often that family members begin to expect that with each relapse there will be another recovery. Thus, when death finally occurs, family members may experience it as a sudden unanticipated loss.

Other factors that can simultaneously complicate and facilitate the grieving process include the belief that a loss is "God's will" and the availability of a social support network (Doka 1998). A belief in God's plan can help one in finding meaning in the loss. It can also create anger toward God for being unfair and allowing such an act to happen, leading to guilt and isolation from one's spiritual connection or religious community. A social support network can lend assistance and be there to listen, but it may also place unrealistic expectations on the griever.

Adaptation or Resolution

Questions often arise as to how long grief lasts and how it is resolved. It is a mistaken assumption that grief has an ending point and that one will return to a prior state of "normal." Media-orchestrated virtual grief experienced by consumers who go through the rituals of mourning in front of their televisions or computer screens provides an illusion of intimacy and produces an emotional response without the depth of pain experienced in actual grief. Because recovery from virtual grief is quick, individuals may become less sensitive to the extent of time actually required for grieving.

Actual grief can occur as "emotional shock waves" (Bowen 1976) that ebb and flow for years after a loss, and even be transmitted across the generations in a family. Children and adults can experience regrief as a revisiting of a significant loss at each new developmental stage (Oltjenbruns 2001) or as reverberating losses in the form of recurrent memories triggered by new major life events. Studies have failed to identify any discernible sequence of emotional phases that lead to adaptation to loss, nor can they identify any clear endpoint to grieving that would constitute a state of recovery (Neimeyer 2001). Rather than a return to a prior state of "normal," one experiences a new normal based on one's new situation, altered identity, and reconstructed meanings of life and loss.

With increased awareness that bonds continue after a loss and that one does not recover from grief, the focus of grief therapy is also shifting away from relinquishing attachments and toward meaning-making and meaning-finding in the loss. There is a growing recognition that grieving is nearly always complicated (Attig 2001), and that some behaviors or thoughts that would be described as pathological at other times may be normal reactions to the abnormal situation of loss. An emphasis on universal syndromes of grieving has been replaced with a recognition of cultural relativity, focus on family patterns and processes by which loss is negotiated, implications of loss for one's sense of identity, and potential for post-traumatic growth.

Conclusion

Although there are some commonalities in response to loss, there is no universally predictable emotional trajectory, and the range of effects, thoughts, and behaviors experienced is quite malleable (Rosenblatt 2001). To understand processes following loss, the dialectic of loss and growth, and meanings one gives to loss-experiences, it is important to consider the individual embedded within the family, family embedded within community, and community embedded within social and cultural systems.

See also:Boundary Ambiguity; Chronic Illness; Death and Dying; Depression: Adults; Depression: Children and Adolescents; Disabilities; Divorce: Effects on Children; Divorce: Effects on Couples; Divorce: Effects on Parents; Elders; Euthanasia; Health and Families; Hospice; Immigration; Later Life Families; Loneliness; Missing Children; Rape; Runaway Youths; Sudden Infant Death Syndrome (SIDS); Suicide; Widowhood

Bibliography

attig, t. (1991). "the importance of conceiving of grief as an active process." death studies 15:385–393.

attig, t. (2001). "relearning the world: making and finding meanings." in meaning reconstruction and the experience of loss, ed. r. a. neimeyer. washington dc: american psychological association.

boss, p. (1999). ambiguous loss: learning to live with unresolved grief. cambridge, ma: harvard university press.

bowen, m. (1976). "family reaction to death." in familytherapy: theory and practice, ed. p. j. guerin. new york: gardner.

corr, c. a.; nabe, c. m.; and corr, d. m. (2000). death and dying, life and living, 3rd edition. belmont, ca: wadsworth.

doka, k. j., ed. (1989). disenfranchised grief. lexington,ma: lexington books.

doka, k. j. (1998). introduction to living with grief: who we are, how we grieve, ed. k. j. doka and j. d. davidson. philadelphia: brunner/mazel.

gilbert, k. r. (1996). "'we've had the same loss, whydon't we have the same grief?' loss and differential grief in families." death studies 20:269–283.

harvey, j. h. (1998). perspectives on loss: a sourcebook.philadelphia: brunner/mazel.

harvey, j. h. (2000). give sorrow words: perspectives on loss and trauma. philadelphia: brunner/mazel.

harvey, j. h., and weber, a. l. (1998). "why there mustbe a psychology of loss." in perspectives on loss:a sourcebook, ed. j. h. harvey. philadelphia: brunner/mazel.

irish, d. p. (1993). "introduction—multiculturalism and themajority population." in ethnic variations in dying, death, and grief: diversity in universality, ed. d. p. irish, k. f. lundquist, and v. j. nelsen. washington, dc: taylor and francis.

klass, d., silverman, p. r., and nickman, s. l., eds. (1996). continuing bonds: new understandings of grief. bristol, pa: taylor and francis.

klass, d., and walter, t. (2001). "processes of grieving:how bonds are continued." in handbook of bereavement research: consequences, coping, and care, ed. m. s. stroebe, r. o. hansson, w. stroebe, and h. schut. washington, dc: american psychological association.

kleinman, a. (1986). social origins of distress and disease: depression, neurasthenia, and pain in modern china. new haven, ct: yale university press.

kubler-ross, e. (1969). on death and dying. new york:macmillan.

lerner, m. (1971). "justice, guilt, and veridical perception." journal of personality and social psychology 20:127–135.

lindemann, e. (1944). "symptomatology and management of acute grief." american journal of psychiatry 101:141–148.

mcgoldrick, m. (1991). "echoes from the past: helpingfamilies mourn their losses." in living beyond loss, ed. f. walsh and m. mcgoldrick. new york: norton.

moos, n. l. (1995). "an interactive model of grief." deathstudies 19:337–364.

murray, c. i. (2000). "coping with death, dying, and grief in families." in families and change: coping with stressful events and transitions, 2nd edition, ed. p. c. mckenry and s. j. price. thousand oaks, ca: sage.

neimeyer, r. a. (2001). "introduction: meaning reconstruction and loss." in meaning reconstruction and the experience of loss, ed. r. a. neimeyer. washington, dc: american psychological association.

oltjenbruns, k. a. (2001). "developmental context ofchildhood: grief and regrief phenomena." in handbook of bereavement research: consequences, coping, and care, ed. m. s. stroebe, r. o. hansson, w. stroebe, and h. schut. washington, dc: american psychological association.

rando, t. a. (1993). treatment of complicated mourning.champaign, il: research press.

rolland, j. s. (1994). families, illness, and disability: anintegrated treatment model. new york: basic books.

rosenblatt, p. c. (1993). "cross-cultural variation in theexperience, expression, and understanding of grief." in ethnic variations in dying, death, and grief: diversity in universality, ed. d. p. irish, k. f. lundquist, and v. j. nelsen. washington, dc: taylor and francis.

rosenblatt, p. c.; walsh, r. p.; and jackson, d. a. (1976).grief and mourning in cross-cultural perspective. new haven, ct: human relations area files press.

scheper-hughes, n. (1985). "culture, scarcity, and maternal thinking: maternal detachment and infant survival in brazilian shantytown." ethos 13:291–317.

shapiro, e. r. (1994). grief as a family process: a developmental approach to clinical practice. new york: guilford.

stroebe, m. s.; hansson, r. o.; stroebe, w.; and schut, h.(2001). "introduction: concepts and issues in contemporary research on bereavement." in handbook of bereavement research: consequences, coping, and care, ed. m. s. stroebe, r. o. hansson, w. stroebe, and h. schut. washington, dc: american psychological association.

stroebe, m., and schut, h. (1999). "the dual processmodel of coping with bereavement: rationale and description." death studies 23:197–224.

tedischi, r. g.; park, c. l.; and calhoun, l. g. (1998)."posttraumatic growth: conceptual issues." in post-traumatic growth: positive changes in the aftermath of crisis. mahwah, nj: lawrence erlbaum.

wisocki, p. a., and skowron, j. (2000). "the effects ofgender and culture on adjustment to widowhood." in handbook of gender, culture, and health, ed.r. m. eisler and m. hersen. mahwah, nj: lawrence erlbaum associates.

colleen i. murray