Worden, J. W. (2009). The mourning process: Mediators of mourning. In Grief counseling and grief therapy: A handbook for the mental health practitioner (pp. 57-76). Springer Publishing.
It is not sufficient to know only about the tasks of mourning. It is also important for the counselor to understand the second part of the mourning process—the mediators of mourning. If you assess a large number of grieving people, you will see a wide range of behaviors, and although these behaviors may reflect those on the list of normal grief reactions, there are major individual differences. For some, grief is a very intense experience, whereas for others it is rather mild. For some, grief begins at the time they hear of the loss, while for others it is a delayed experience. In some cases grief goes on for a relatively brief period of time, while in others it seems to go on forever. In order to understand why individuals handle the tasks of mourning in different ways, one must understand how these tasks are mediated by various factors. This is especially important when one is working with complicated mourning (described in chapter 5).
To begin with the most obvious: if you want to understand how someone will respond to a loss, you need to know something about the deceased. Kinship identifies the dead person’s relationship to the survivor. Such a relationship could be that of a spouse, child, parent, sibling, other relative, friend, or lover. A grandparent who dies of natural causes will probably be grieved differently than a sibling killed in a car accident. The loss of a distant cousin will be grieved differently than the loss of a child. The loss of a spouse may be grieved differently than the loss of a parent. In the case of two children whose father has died, there can be significant individual differences in grief responses. Who the father was to the 13-year-old daughter can be quite different from who the father was to the 9-year-old son. Each child lost a father, but each had a different relationship with him and different hopes and expectations about him.
The tasks of mourning are mediated not only by who the deceased was, but also by the nature of the survivor’s attachment to the person. You need to know something about:
- The strength of the attachment. It is almost axiomatic that the intensity of grief is determined by the intensity of love. The grief reaction often increases in severity proportionately to the intensity of the love relationship.
- The security of the attachment. How necessary was the deceased to the sense of well-being of the survivor? If the survivor needed the lost person for his or her own sense of self-esteem—to feel okay about him- or herself—this will portend a more difficult grief reaction. For many individuals, security and esteem needs are met by their spouse, and after their spouse dies, the needs remain the same, but the resources are missing.
- The ambivalence in the relationship. In any close relationship there is always a certain degree of ambivalence. Basically, the person is loved, but there also coexist negative feelings. Usually the positive feelings far exceed the negative feelings, but in the case of a highly ambivalent relationship in which the negative feelings coexist in almost equal proportion to the positive ones, there is going to be a more difficult grief reaction. Often in a highly ambivalent relationship, the death leads to a tremendous amount of guilt, often expressed as “Did I do enough for him?” along with intense anger at being left alone.
- Conflicts with the deceased. This refers not just to conflicts around the time of death, but also to a history of conflicts. Of special note are conflicts stemming from earlier physical and/or sexual abuse (Krupp, Genovese, & Krupp, 1986). In conflicted relationships there is the possibility of unfinished business that never gets resolved before the death. This is especially true in the case of sudden death. Sarah, her husband, and her mother lived together in the same house. One morning Sarah and her mother had a big fight before the mother left for work. On her way to work, the mother’s car was hit by an 18-wheeler truck and the mother was killed. Sarah carried a lot of guilt with regard to her interactions with her mother on the day of the death, as well as guilt about their long-standing conflicts with each other. She sought out counseling to help herself resolve this guilt and her unfinished business with her mother.
- Dependent relationships. Such relationships can affect the person’s adaptation to the death, especially task III issues. The external adjustments will be greater for a person who was dependent on the deceased for the fulfillment of various daily activities such as bill paying, driving, and meal preparation than for the person who had less dependency on the deceased for these activities of daily living.
How the person died has an impact on how the survivor deals with the various tasks of mourning. Traditionally, deaths are cataloged under the NASH categories: natural, accidental, suicidal, and homicidal. The accidental death of a child may be grieved differently than the natural death of an older person, whose death would be seen as occurring at a more appropriate time. The suicidal death of a father may be grieved differently than the expected death of a young mother leaving small children. There is evidence that survivors of suicidal deaths have unique and very difficult problems handling their grief (see chapter 7). Other dimensions associated with the death that can affect bereavement are the following.
Proximity
Where did the death occur geographically—did it happen near the survivors or far away? Deaths occurring at a distance may give the loved one a sense of unreality regarding the death. One can assume that the person is still there, which affects task I of mourning. There have been different findings as to whether home deaths help or increase distress in bereavement. Addington-Hall and Karlsen (2000) studied home deaths in Britain and found that bereaved individuals who cared for a patient dying at home had more psychological distress, missed the deceased more, and had a more difficult time coming to terms with the death after it occurred. As part of Project Omega at Massachusetts General Hospital, Avery Weisman and I interviewed caregivers whose loved ones had died at home.
We asked if they would do this again. The results were split 50/50. Half would do it again. They felt that they could give their dying loved one special attention and that their children could see death as a part of life. The other half said, “No way.” They found it difficult to manage some of the medical procedures and always felt like they could be doing more for the dying person (Weisman & Worden, 1980). Hospice home care has developed since we did that study, so the latter attitude may be less of a problem now.
Suddenness or Unexpectedness
Was there some advance warning or was the death unexpected? A number of studies suggest that survivors of those who die sudden deaths, especially young survivors, have a more difficult time than people with advance warning a year or 2 years later (Parkes & Weiss, 1983). In the Harvard Child Bereavement Study, sudden death (40%) as opposed to expected death (60%) affected both the adjustment of the children as well as the adjustment of the family. This was most apparent during the first year of bereavement. As the family moved into the second year, other mediators were more prominent in affecting their adjustment. Although half of the children remained fearful of their surviving parent’s safety 2 years after the death, it was not the suddenness of the death that created this fear but rather the poor functioning of the surviving parent. Sudden deaths overlap with violent deaths, and it may be the latter that is the most impactful. When it came to natural deaths, the longer the survivor had to anticipate the death, the better his or her adjustment. However, it was not necessarily objective time (i.e., weeks and months) but rather their perceptions of expectation that made the difference in adaptation in the Harvard study. However, Donnelly, Field, and Horowitz (2000) found that objective expectancy was a stronger predictor of symptoms than was subjective expectancy, so more investigation is needed.
Violent/Traumatic Deaths
The impact of violent and traumatic deaths can be long lasting and often leads to complicated mourning (the sequelae of homicides and suicides will be discussed in chapter 7). This type of death does several things to challenge the tasks of mourning. First, it challenges a person’s sense of self-efficacy and the internal adjustments of task III—”What could I have done to have prevented this from happening?” is often a major preoccupation. Second, violent deaths are highly likely to shatter a person’s worldview and pose a challenge to meaning making that is part of task III. Third, the circumstances surrounding the death may make it difficult for survivors to express their anger and blame (task II). This is particularly true in cases in which the survivor killed the person in an accident or a homicide; guilt will obviously be a key factor in coping with the loss. A fourth sequela following traumatic deaths is a possible posttraumatic stress disorder (PTSD).
Multiple Losses
Some people lose a number of loved ones in a single tragic event or in a relatively short period of time. One man I know saw his whole family killed in front of him when a construction crane collapsed on his car, killing his wife and two children. When such multiple losses occur there is the possibility of “bereavement overload” (Kastenbaum, 1969). There is too much grief and pain, and the person is unable to manage feelings associated with the second task of mourning. Intervention requires exploring each loss individually, beginning with the least complicated, looking at what has been lost, and gradually jump- starting the grieving process. For the man who lost both children in the accident exploring his relationship with each child separately was important, as his relationship with and expectations for each child were different.
Preventable Deaths
When the death is seen as preventable, issues of guilt, blame, and culpability come to the surface. These issues need to be worked through as a part of task II. Prolonged litigation is often a correlate of preventable deaths and can prolong the mourning process for those involved with it (Gamino, Sewell, & Easterling, 2000). Bugen (1977) brought this dimension to our attention and shows how it has an impact on the overall adaptation to a death, along with the dimension of emotional closeness. More recently, Guarnaccia, Hayslip, and Landry (1999) tested Bugen’s model on a large group of adults and found that perceived preventability of the death was a very strong mediator affecting grief measures.
Ambiguous Deaths
There are some situations when the survivors are not sure whether their loved one is alive or dead. We saw this during the Vietnam War when military personnel were listed as missing in action. Families were not sure whether the person was dead or alive. This puts the mourner in an awkward position not knowing whether to hold out hope or to give into grief. Similar ambiguity can exist after an airplane crash into the ocean. I worked with some families after the KAL plane was shot out of the sky in 1983. No bodies from that flight were retrieved. Although these families knew their loved ones were dead, some held out hope. It was helpful to get closure when the South Korean government erected a monument with the names of the passengers on it. After the September 11, 2001, tragedy some bodies were not recovered leaving family members with the hope their loved one would show up at some point. We need more understanding of this type of loss, and this can be done by documenting the narratives of families who manage to change and move on in spite of an ambiguous loss (Tubbs & Boss, 2000).
Stigmatized Deaths
Doka and others have written about disenfranchised grief (Attig, 2004; Doka, 1989, 2002). Deaths such as suicide and death by AIDS are often seen as stigmatized deaths. When such stigma exists, social support for the mourner may be less than sufficient (Doka, 1989). Stigmatized deaths are related to socially unspeakable losses and socially negated losses, which are discussed in chapter 7.
In order to understand how someone is going to grieve, you need to know if he or she has had previous losses and how these were grieved. Were they grieved adequately, or does the person bring to the new loss a lack of resolution from a previous one?
A person’s mental health history may be important here. One historical focus has been on those who come to a loss with a history of depressive illness. Zisook, Paulus, Shuchter, and Judd (1997) believe that a major depression prior to the death can create an increased risk for major depression following spousal bereavement. On the other hand, Byrne and Raphael (1999) did not find that a major depressive episode was predicted by a past history of dysphoria in widowed older men. Such differences in findings can be explained, in part, by differences in populations, time frames, and measures used.
Another historical mediator has to do with family issues. Unresolved loss and grief can transcend several generations and affect the current mourning process (Paul & Grosser, 1965; Walsh & McGoldrick, 1991).
Bowlby (1980) makes a strong plea for therapists and other counselors to take the mourner’s personality structure into account when trying to understand an individual’s response to loss. Such personality variables include the following.
Age and Gender
There has been considerable recent interest in gender differences and the ability to grieve, especially men’s ways of grieving (Martin & Doka, 1996). It is true that boys and girls are socialized differently, and many of the differences in how men and women approach the tasks of mourning may be more a part of this socialization than in some intrinsic genetic differences. One speculation has been that women may grieve differently and have different bereavement outcomes because they receive more social support than men. A well done study by Stroebe, Stroebe, and Abakoumkin (1999) shows that such is not the case. Schut, Stroebe, de Keijser, and van den Bout (1997), however, found that there were strong gender differences in the type of intervention found to be efficacious. Men responded better to affect-stimulating interventions, and women to problem-solving interventions. The interventions appear to be the opposite of typical gender styles. Looking at men who had lost spouses, Lund (2001) found men in their 50s were the most effective in coping with their grief.
Coping Style
Distress is mediated by one’s coping choices—how inhibited one is with feelings, how well one handles anxiety, and how one copes with stressful situations. Lazarus and Folkman (1984) define coping as the changing thoughts and acts that an individual uses to manage the external or internal demands of stressful situations. The death of a loved one certainly makes such demands. Coping styles vary from person to person. Coping research—whether coping with cancer, bereavement, or trauma—has been a major part of my professional life. There are different paradigms for understanding coping, but here is one that I find particularly useful both in research and clinical intervention. It is a problem-solving model in which coping can be seen as what one does with a problem to bring about relief and resolution. Both relief and resolution are interval measures and may vary as to the degree of relief and resolve. There are three main groups of coping functions.
Problem-Solving Coping
People vary in their ability to solve problems. Those with the poorest skills overuse ineffective strategies, or they try one thing to solve the problem and then give up when that doesn’t work. There are ways to teach problem solving to people lacking these skills. One is a cognitive behavioral intervention that Sobel and I developed (Sobel & Worden, 1982).
Active Emotional Coping
Active emotional coping is the most effective strategy for handling problems and managing stress. Redefinition is at the top of the list for effectiveness. This is the ability to find something positive or redemptive in a bad situation. The whole notion of growth through grief is predicated on the effective use of these strategies. In studies of both cancer patients and the bereaved, those with the lowest emotional distress were those who could reframe problems and find something positive in the difficult situation. Humor is another coping strategy that can be effective. To use humor requires a certain distancing from the problem that can be helpful in the short haul. Venting of emotions rather than bottling up feelings can be useful. However, venting is best when it involves positive as well as negative feelings and isn’t the kind of affect display that blows others out the door. The ability to accept support is another dimension of an active emotional approach to coping. Accepting the support of others does not necessarily make one feel less efficacious. On the contrary, accepting support is a choice of the mourner that may enhance efficacy as well as esteem.
Avoidant Emotional Coping
Perhaps the least effective strategies are avoidant emotional coping. They may make the person feel better for the moment, but they are not particularly useful in solving a problem. Avoidant coping includes blame, both of self and others; distraction, which can be useful in the short haul, but not if it persists; denial, which like distraction can have short-term benefits as a buffer against difficult reality but is not effective over the long term; and social withdrawal, again helpful over the short term but not the most effective coping. Substance use and abuse may make the person feel better but do not solve the problems and may have their own iatrogenic effects.
In the Harvard Child Bereavement Study, the best outcomes both for the parents and for their children came from the use of active emotional coping strategies, especially the ability to redefine and reframe. Passive strategies (e.g., “There is nothing that I can do about it”) are among the least effective (Worden, 1996). Schnider, Elhai, and Gray (2007) found that active coping was associated with best outcomes after a traumatic loss and that avoidant emotional coping was associated with the development of PTSD and/or complicated grief.
The question arises whether coping styles are stable in an individual or if they are modifiable. Folkman (2001) believes that some strategies like reframing and cognitive avoidance tend to be more stable types of coping, while others such as problem-solving skills and the use of social support are more modifiable. From my research I would agree with this. We had real success using a cognitive- behavioral approach to teach problem-solving skills to a group of poor problem solvers (Sobel & Worden, 1982). Also, through the use of bereavement groups, mourners can learn more effective ways to use social support.
Attachment Style
Another important mediator that affects how one handles the various tasks of mourning is one’s attachment style. Attachment styles are set up early in life as the result of early parent-child bonding. The goal of these behaviors is to maintain or reestablish proximity to an attachment figure, usually the mother. The attachment figure’s responsiveness to the child’s emotional needs, especially under stress, determines these patterns. Attachment styles are seen by some as traits, traits that are somewhat malleable under situations like traumatic events and psychotherapy but basically firmly established (Fraley, 2002). The appraised availability or psychological proximity of the attachment figure is the important factor determining whether the person feels secure or distressed in the absence of the attachment figure. Generally, attachment styles evolve as a result of experiences or relationships with important others early in life. Attachment bonds exist between adults but are considered to differ in important ways from the child-parent bond, because both partners can serve as an attachment figure to each other.
When the relationship to an attachment figure is severed through death, the survivor is under threat to maintain or reestablish proximity to the figure. Separation distress leads to searching behavior in order to reestablish the lost relationship, but gradually the bereaved comes to appreciate the permanence of the loss. A healthy adaptation to this new reality is for the mourner to internalize the deceased into him- or herself and his or her schema of life so that psychological proximity substitutes for the previous physical proximity. The bereaved can be emotionally sustained by the mental representation of the deceased, with less need for the physical presence no longer available. Internal models or representations have been described in terms of styles of attachment (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990; Mikulincer & Shaver, 2003).
Secure Attachment Style
Through good parenting and other healthy early relationships, many people develop what is called a secure attachment style. Those with secure attachments have positive mental models of being valued and of being worthy of support, concern, and affection. After experiencing the loss of an important attachment figure through death, individuals with a secure attachment style experience the pain of sorrow but are able to process this pain and move on to develop healthy continuing bonds with the lost loved one. Early intense grief (searching and pining) do not overwhelm their acceptance of the reality of the loss—task I.
Insecure Attachment Styles
There are four types of insecure attachment styles that people may have when parenting and early relationships have not gone well. These are anxious/preoccupied attachments, anxious/ambivalent attachments, avoidant/ dismissing attachments, and avoidant/fearful attachments. (Some researchers may use other terms for the same phenomena.) These various attachment styles affect one’s rela-tionships throughout life and are important mediators for the grieving process when the attachment figure dies. These insecure attachment styles are particularly important mediators because they can make adaptation to the tasks difficult and contribute to the development of complicated mourning (Stroebe, Schut, & Stroebe, 2006). Let’s look at these insecure attachment styles in some detail.
- Anxious/Preoccupied Attachment. These are relationships that give a person a sense of uneasiness and in which the person is often supersensitive to slights and other perceived neglect in the relationship. These are individuals who keep extra boyfriends (or girlfriends) in the wings in case the current one does not work out. These people do not feel good about themselves and are likely to have their self-esteem needs determined by the significant other. When death takes the loved one, individuals with this attachment style often show high levels of distress that goes on for some time and may lead to the complication of chronic or prolonged grief. Their ability to regulate affect, as well as their ability to handle stress, may be deficient. Rumination over the loss may be high, and excessive pain may be handled by avoidant behavior—avoiding reminders of the loss to buffer the pain. Low self-efficacy is often apparent when the person sees him- or herself as helpless and unable to cope without the loved one. Clinging and help-seeking behavior are behavioral features of this style. The therapy goal for people with this style is to help them stop trying to regain physical proximity to the deceased and through internalization to feel secure through psychological proximity (Field, Gao, & Paderna, 2005).
- Anxious/Ambivalent Attachment. In ambi-valent relationships, love and hate coexist on almost equal levels. Individuals who form this kind of attachment see the other as undependable. Relationships can be stormy, and anger can be observed when the relationship is threatened. In my clinical work, I sometimes call these angry attach-ments. I have treated a number of couples over the years in which one partner has to leave for several days or weeks for legitimate business purposes and the other partner goes crazy with angry responses. On some level of awareness, the anger may be perceived as a way of keeping the person from leaving so that the anxiety that underlies this style does not have to be experienced. This is similar to the protest of the child to reestablish the physical proximity of the attachment figure. When the loved one dies, the intensity of anger and anxiety is excessive, so in order to keep stability, the mourner may focus on positive feelings—the polar opposite feelings from the anger. These are the mourners who make their loved ones bigger than life so as not to confront the depths of anger on the other side of their experience. When they talk about their loved one, the counselor gets the feeling that no one can be that great. Intervention should be directed toward the acknowledgment and expression of both types of feelings, positive and negative. If the anger cannot be expressed and integrated into the loving feelings, the person may experience high levels of depression or prolonged grief, along with extensive rumination.
- Avoidant/Dismissing Attachment. Here the individual may have had an unresponsive parent and developed a pseudo self-sufficient style. Behavior is organized around the goal of self-reliance and independence. Some of these individuals are seen as unreliable. Autonomy and self-reliance are of para-mount importance to them. After a death, these people may show few symptoms and minimal emotional reactions, basically because they are minimally attached. These individuals have an excessively positive view of themselves and often a negative opinion of others, to whom they are less likely to turn under stress. There is some controversy in the field as to whether individuals with this style, who initially show minimal emotional reactions to a loss, go on to develop a delayed grief reaction. Some, like Fraley and Bonanno (2004), do not think so. However, there is some likelihood that those with this style go on to experience somatic reactions after a loss, either immediately following the death or later, due to unconscious longings for detachment (Stroebe et al., 2006). Because of defensive exclusion, they cannot process the implications of the loss and task III issues may be a struggle.
- Avoidant/Fearful Attachment. People with this style of attachment are very likely to make the poorest adaptation to the loss. Unlike the avoidant/ dismissing person, who values self-sufficiency, they want relation-ships but have long histories of tentative attachments due to the fear that these attachments might be broken. When death takes away any attachments they have developed, they are very susceptible to developing high levels of depression. This depression often protects them against anger that they may be feeling. Social withdrawal is the behavior most frequently seen in bereavement situations and serves as a protection of the self.
Healthy attachments, when broken, lead to feelings of grief. Less healthy attachments lead to feelings of anger and guilt when the attachment is broken through death (Winnicott, 1953). Attachment problems are also of importance for the highly dependent person and the person who has difficulty forming relationships. Individuals diagnosed with certain personality disorders may also have a difficult time handling a loss. This is especially true of those classified with borderline personality disorders or narcis-sistic personality disorders (see American Psychiatric Association, 2000). Less healthy attachments can lead to separation disorders, which are the current focus of traumatic grief (Jacobs, 1999).
Cognitive Style
Different people have different cognitive styles. Some are more optimistic than others and are likely to report the glass half full rather than half empty. Associated with such an optimistic style is the ability to find something positive or redemptive in a bad situation. One cancer patient said, “I am not happy this happened to me, but it did give me the opportunity to reconcile with my mother.” In the Harvard Child Bereavement Study, we found that optimism and the ability to redefine were associated with lower levels of depression in the surviving parents during the first 2 years following the loss (Worden, 1996). Likewise, Boelen and van den Bout (2002) found that positive thinking was inversely related to measures of anxiety and traumatic grief symptomatology but especially to depression. This should not be surprising since Beck et al. (1979) and other depression researchers find that depressed individuals have negative views of life, themselves, the world, and the future. This pessimistic attitude of the depressed often leads to a cognitive style that involves the use of overgeneralization. “I will never get over this” and “No one will ever love me again” are examples of this type of thinking.
Another important cognitive style is rumination. People who ruminate persistently and repetitively focus on their negative emotions without taking action to relieve these emotions. In the context of bereavement, this involves chronically and passively focusing on grief-related symptoms. This cognitive style lengthens the time that negative emotions are experienced, which does not lead to an effective handling of task II and may lead the depressed mood to become a depressive disorder (Nolen-Hoeksema, 2001; Nolen-Hoeksema, McBride, & Larson, 1997). Ruminators focus on their loss presumably to find meaning and understanding, but research shows that they are less likely to find it than are non-ruminators. One possible explanation for the perdurance of this cognitive style, despite the pain it brings, is that such pain represents the individual’s last and perhaps final tie to the deceased. However, there are two main negative sequelae to this style: first, the mourner does not engage in good problem-solving behavior, and second, it can drive people away, people who might offer social support. There are several interventions that can be useful in work with bereaved people who ruminate a lot. Help them with their problem-solving focus and teach them skills for the same; help them to increase their social contacts in a way that doesn’t drive people away; and help them find more appropriate ways to handle task IV issues, to stay connected without making the pain their point of connection, and to go on with their lives without the deceased.
Ego Strength: Self-Esteem and Self-Efficacy
All people come to a death event with attitudes about their own worth and attitudes about their ability to affect what happens to them in life. Some deaths can challenge a person’s self-esteem and self-efficacy, thus making the internal adjustments of task III more of a challenge (Reich & Zautra, 1991). This is especially true when long-standing negative self-images have been compensated for by one’s spouse. If the spouse dies, such a profound loss can reactivate previously held latent negative self-images (Horowitz, Wilner, Marmar, & Krupnick, 1980). Self-efficacy is another component of ego strength. It is similar to Rotter’s locus of control and involves how much a person believes that he or she has control over what happens to him or her in life. The death mediator of preventability becomes a major focus for some when the death makes one feel impotent and out of control. Benight, Flores, and Tashiro (2001) found that older widows who had a stronger sense of coping self-efficacy had a better sense of emotional and spiritual well-being and were also in better physical health. In the Harvard Child Bereavement Study, self- esteem and self-efficacy were important strengths in the experience of children who made the best adjustments to the death of a parent (Worden, 1996). Haine’s team (2003) also found locus of control and self- esteem to be important stress mediators in their study of bereaved children in Arizona (esteem more so than efficacy). Bauer and Bonanno (2001) found a strong link between self-efficacy and psychological health and found it predicted less grief over time in a group of midlife bereaved spouses. Efficacy was particularly useful in helping mourners with task III issues of finding meaning for the loss and establishing new identity constructions.
Assumptive World: Beliefs and Values
Each of us carries assumptions about the benevolence and the meaningfulness of the world (Schwartzberg & Janoff-Bulman, 1991). Some deaths can challenge a person’s assumptive world more than others, causing a spiritual crisis for the individual who is uncertain of what is true and what is good. When this happens, the spiritual adjustments of task III are made more difficult. I have worked with several mothers whose young children were in the yard playing when they were shot and killed by drive-by shooters, often gang members. This senseless loss of their children presents a crisis of faith to these mothers, challenging their belief in the predictability of the world and God’s place in it. However, certain worldviews can serve a protective function by allowing individuals to incorporate a major tragedy into their belief system. A person who holds a firm belief that all things are part of God’s larger plan may show less distress following the loss of a spouse than a person who does not hold this view (Wortman & Silver, 2001). The belief that one will be reunited for all eternity with the deceased may also serve a protective function (Smith, Range, & Ulmer, 1991-1992).
Grieving is a social phenomenon, and the need to grieve with others can be important. The degree of perceived emotional and social support from others, both inside and outside the family, is significant in the mourning process. Several studies have shown that perceived social support alleviates the adverse effects of stress, including the stress of bereavement (Schwartzberg & Janoff-Bulman, 1991; Sherkat & Reed, 1992; Stroebe et al., 1999). Even pet owners showed fewer symptoms than those without companion animals (Akiyama, Holtzman, & Britz, 1986). Most studies find that those who do less well with bereavement have inadequate or conflicted social support. One difficulty with social support is that although it may be present around the time of death and shortly thereafter, 6 months to a year later, when the mourner is realizing all that he or she lost when the loved one died, people who were there at the funeral may no longer be there, and if they are there, they are encouraging the person to get over it and move on with life.
Stroebe, Schut, and Stroebe (2005) looked at four longitudinal studies that examined the relationship between social support and depression over a 2-year period. These studies were the Tubingen Longitudinal Study of Bereavement (Stroebe, Stroebe, Abakoumkin, & Schut, 1996), the Changing Lives of Older Couples Study (Carr, House, Kessler, Nesse, Sonnega, & Wortman, 2000), a study of parents who had lost children to violence (Murphy, 2000), and a study of ruminative coping (Nolen-Hoeksema & Morrow, 1991). In all four studies, those with more social support had lower depression scores at each assessed time point. However, in none of the studies did social support accelerate adjustment to the loss or make adjustment easier. Although knowing that one can call upon the support of friends and family members may help to soften the blow of loss, it does not necessarily accelerate the grief process. The following are important social mediators.
- Support satisfaction. More important than the mere availability of support is the mourner’s perception of social support and satisfaction with it. Research has shown numerous examples where support was available but the person defined it as less than satisfactory. Social integration—the time spent with others and utilization of social support (con-fiding in others)—are two dimensions that go into support satisfaction (Sherkat & Reed, 1992).
- Social role involvements. Involvement in multiple roles has been found to affect adjustment to a loss by death. Persons who participate in more and varied social roles seem to adjust better to loss than those who don’t. Some roles measured in the research include those of parent, employee, friend, and relative, as well as involvement in community, religions, and political groups (Hershberger & Walsh, 1990).
- Religious resources and ethnic expectations. Each of us belongs to various social subcultures—including both ethnic and religious subcultures. They provide us with guidelines and rituals for behavior. The Irish, for example, grieve differently than the Italians, and the Old Yankees grieve still differently. In the Jewish faith, Shiva—a period of 7 days when the family stays home and friends and family come to help them and help facilitate their grief—is often observed. This is followed by other rituals such as going to the synagogue and unveiling the headstone a year later. Catholics have their own rituals, as do some Protestants. In order to adequately predict how a person is going to grieve, you have to know something about his or her social, ethnic, and religious background. The extent to which participation in ritual affects adjustment to bereavement is still unknown. It stands to reason that it should be useful, but more research is needed here.
A final dimension that should be mentioned under social mediators is the secondary gain that the survivor may find in grieving. A survivor might get a lot of mileage in his or her social network out of grieving, and this would have an effect on how long it goes on. However, extended grieving can have the opposite effect and alienate the social network.
Other factors that affect bereavement are the concurrent changes and crises that arise following a death. Some change is inevitable, but there are those individuals and families who experience high levels of disruption (secondary losses) following a death, including serious economic reversals. In the Harvard Child Bereavement Study, surviving parents who experienced the largest number of life-change events following the death of their spouse (as measured by the Family Inventory of Life Events) had the highest levels of depression, and their children were also functioning less well over the 2 years of follow-up (Worden, 1996).
CAUTION
Let me suggest a caution at this point. There is a tendency toward simplistic thinking about determinants of grief and mediators of mourning, especially in research. For example, one might look at the impact of sudden violent death on the survivor’s depression and perhaps examine perceived and received social support as comediators. However, such research overlooks other important relationship mediators such as the subtleties of the attachment, a person’s coping skills, the ability to make meaning out of a tragedy, and many other mediators of mourning. Mourning behavior is multi-determined, and the clinician and researcher would do well to keep this constantly in mind.
