Robert A Neimeyer & Louis A Gamino. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 2. Thousand Oaks, CA: Sage Reference, 2003.
In a sense, the history of humanity can be understood as the history of grief. Indeed, long before written accounts chronicled human events, prehistoric burial rituals gave evidence of the enduring concern of early Homo sapiens with members of their families or tribes who had died. Likewise, as cultures evolved, so too did these rituals of remembrance, giving rise to elaborate practices of collective mourning as described in the 8th-century Beowulf epic and often prescribed within the classic texts of the world’s great religions. Not surprisingly, with the emergence of the medical and social sciences, the phenomenon of bereavement again became a topic of central concern, yielding a growing body of theory and research that achieved increasing scientific credibility over the course of the 20th century. We survey this evolving understanding of grief as a biological and psychological response to loss, concentrating on the changing conceptualization of grieving as successive models have borrowed from and extended those that preceded them.
In the Beginning: The Seminal Contribution of Sigmund Freud
The scientific attempt to understand the responses of bereaved people dates to Sigmund Freud’s ([1917] 1957) frequently cited paper, Mourning and Melancholia. In keeping with the objectives of psychoanalytic theory to provide a comprehensive interpretation of human behavior, Freud posited that, just as death was a universal if unconsciously threatening fact of life, there were also universal dynamics involved in grieving the death of a loved one. His explication of these dynamics provided the accepted point of departure for the majority of influential grief theories to follow and in many respects came to shape and inform common lay conceptualizations of the psychology of bereavement, especially in Western countries.
Freud defined mourning as the nonpathological response to the death of a loved one (or the loss of some abstraction such as one’s country, one’s liberty, or an ideal). Its distinguishing features include painful dejection, withdrawal of interest in the outside world, loss of the capacity to love, and inhibition of all activity. The work of mourning is accomplished gradually as the mourner’s psychic energy or libido once invested in the attachment to the lost “object” is systematically recalled, reexperienced, and then released, resulting in detachment from the lost object. Freud’s concept of emotional detachment or decathexis as the natural end point of mourning has had an enduring impact on both professional and public understandings of bereavement.
Freud’s second major contribution was his effort to delineate how processes of mourning can go awry and become unhealthy. Melancholia was defined as a pathological outcome marked by an insistent narcissistic identification with the lost object, in effect, a refusal to “let go.” Instead, the mourner’s self or ego incorporates the lost object into itself as a way of warding off the loss. Particularly when the premorbid attachment to the deceased was characterized by ambivalence, such identification is inherently conflictual as love and hate impulses struggle against each other. As will be seen later, this suspicion about the pathological implications of identification and “holding on” to the lost love object was carried over by many subsequent theories, as was the presumably problematic consequences of relational ambivalence prior to the loss.
Psychiatric Extensions
Viewing bereavement as a medical syndrome with specific symptoms was formalized in Lindemann’s (1944) article on acute grief, stimulated largely by his interviews with people traumatically bereaved by a fire in a popular nightclub. Lindemann enumerated five consistent clinical features of their response: somatic distress, preoccupation with the image of the deceased, guilt, hostile reactions, and loss of customary patterns of conduct. A sixth characteristic sometimes observed was the appearance of traits of the deceased in the behavior of the bereaved, which he called identification, thereby broadening Freud’s intrapsychic use of the term to include observable behaviors once associated with the deceased. Lindemann was one of the first theorists to define the process of grief work in three stages: (a) emancipation from (emotional) bondage to the deceased, (b) readjustment to the environment in which the deceased is missing, and (c) the formation of new relationships. Later, Engel (1961) extended these arguments by asserting that grief was a “disease” with a consistent etiologic factor (i.e., loss), predictable symptomatology, and a known clinical course. After a prolonged phase of restitution and recovery during which the work of mourning is carried out, the loss is overcome, and a state of health and well-being is reestablished.
One of the contributions of this and subsequent psychiatric extensions of grief theory was a clearer specification of the biology of bereavement, in keeping with its conceptualization in symptomatic terms. Existing research documents predictable clusters of symptoms associated with intense grief, including shortness of breath, tachycardia, dry mouth, sweating, frequent urination, digestive disturbance, and choking sensations (Rando 1993). Taken together with other symptoms such as restlessness and increased muscular tension, these responses can be understood as part of a broader pattern of sympathetic arousal in response to the stress of separation (Parkes 1996).
More seriously, prolonged grief also has been associated with neuroendocrine disturbance and sleep disruption (Hall and Irwin 2001), as well as evidence of generalized anxiety or panic syndromes in over 40% of spouses some time during the first year of bereavement (Jacobs 1993). Perhaps most worrisome is the accumulating evidence that the stress of bereavement is associated with a 40% to 70% increase in mortality among surviving spouses in the first 6 months following loss (Parkes 1996). Numerous investigators, for example, have linked bereavement with cardiovascular disease, including heightened risk of myocardial infarction and congestive heart failure (Osterweis, Solomon, and Green 1984). Evidence is also accumulating that loss undermines the functioning of the immune system (Hall and Irwin 2001), providing an instigating context for the onset of infectious diseases and cancer. Although evidence suggests that most people ultimately adapt well to the stressors of bereavement, the health consequences for a significant minority of mourners has given impetus to the ongoing study of complicated grief, as discussed later.
Stage Theory
If contemporary audiences have read any scholarly work on death and grief, it is likely to have been Elisabeth Kübler-Ross’s (1969) On Death and Dying. The popularity of her book among college students, health care workers, and the general public renders it one of the most recognizable sources on the subject in the English language, even more than 30 years after its publication. From consultation interviews with patients hospitalized for terminal illnesses, Kübler-Ross derived her framework featuring five stages in the dying process (i.e., denial, anger, bargaining, depression, and acceptance). Her concepts have attained near axiomatic status among readers because they seem to reveal a fundamental truth about how human beings approach the end of life. Kübler-Ross delineated how the reality of death is assimilated gradually, in stages, rather than all at once, and then only after a series of psychological protests, delaying tactics, and mourning. Moreover, although her focus was initially on the experience of terminal patients facing their own deaths, Kübler-Ross’s stages have been generalized to the bereaved grieving the death of a loved one, making it the epitome of several similar stage theories of bereavement. As such, stage theory captures some of the ambivalence of accepting one’s own death or that of another while at the same time providing a simple framework for organizing the complex of emotional responses that can be experienced in the process.
The intuitive appeal of stage theory notwithstanding, serious criticisms of Kübler-Ross’s work have been lodged from several quarters, especially from death professionals who see her model as too simplistic, invariant, and lacking empirical support (Corr 1993). Critics argue that its “one-size-fits-all” approach constitutes too narrow a formula to explain individual differences in death experiences, particularly the fact that not everyone achieves a level of “acceptance” before death. Moreover, critics have argued that it suffers from a number of other limitations, including its focus on emotions to the virtual exclusion of cognitive and behavioral adaptations to loss, its inattention to the social processes of grieving, and its questionable application to all grieving persons, regardless of age, gender, ethnicity, or culture (Neimeyer 1998). For all these reasons, most scholars question its validity, although it continues to be influential among lay readers and some helping professionals.
Attachment Theories
Studying the distress shown by children temporarily separated from their families or orphaned during World War II, John Bowlby (1969) developed attachment theory to account for a child’s disposition to seek proximity to and contact with the individual who is his or her security source—typically, the mother. The attachment bond results from a socioemotional drive for caregiving and protection that is distinct from other motivations (e.g., hunger, sex) and of no less importance for survival. In this sense, attachment behavior in humans is part of an evolutionary heritage shared with other social animals, thereby predisposing the bereaved to predictable symptoms of separation when the attachment is broken. Bowlby postulated that attachment behavior in humans persists throughout the life cycle and may be maintained by inner working models of the self and of attachment figures, which can vary as a function of the level of security provided by the caregiving relationship. Ideally, responsive and consistent caregiving helps the developing child form a secure attachment in subsequent close relationships, although experiences with overprotective, neglectful, or unpredictable caregivers can lead to dependent, avoidant, or disorganized/ambivalent attachment patterns that can complicate later relationships.
Loss of an attachment figure constitutes a major disruption of the bond and results in a multiphasic bereavement response: numbing, yearning and searching (in an attempt to recover the lost figure), disorganization and despair, and reorganization (Bowlby 1980). Both children and adults are thought to display corresponding behaviors in response to the loss of a loved one, and progression through these behaviors is regarded as “healthy mourning.” Such adaptation can be complicated, however, when the bereaved person is disadvantaged by insecure attachment models, as discussed later. Bowlby’s model is bolstered by animal research as well as research on young children placed in unfamiliar situations, giving it stronger empirical grounding than other models that focus on stages or phases of adaptation to bereavement.
The work of Colin Murray Parkes and Robert Weiss (1983) on the bereavement reactions of widows and widowers extended many of Bowlby’s ideas about the nature of grieving. They formulated the recovery process as consisting of three basic cognitive and emotional tasks, foreshadowing subsequent models of bereavement adaptation. First, the mourner has to accept the loss intellectually by developing an account of what happened that settles the question of “why” the loss occurred. Second, achieving emotional acceptance implies that the mourner no longer needs to avoid reminders of the loss because the intensity of distress has diminished to the point where it becomes tolerable and the pleasure of recollection begins to outweigh the pain. Third, the individual’s model of self and the outer world must change to match the new reality. In other words, under favorable circumstances, the bereaved modify their working models to reflect their changed lives. Parkes and Weiss (1983), however, argued that good outcomes are less likely if the death occurred with no forewarning, if the marital relationship had been conflicted (and therefore ambivalent), or if the relationship had been characterized by excessive dependency. In the opinion of these authors, these conditions make the work of mourning more difficult to accomplish.
One major elaboration of attachment models has concentrated on a further specification of complicated grief, with a particular emphasis on its diagnosis, measurement, and associated outcomes. Prigerson and Jacobs (2001) argue that an identifiable syndrome of bereavement complications can arise either when the loss is itself traumatic, shattering the mourner’s assumptions of the world as just, predictable, and trustworthy (as in homicide, disaster, or the death of a child), or even when the death is normative, if the survivor is vulnerable as a function of an insecure attachment style. Under either circumstance, a significant minority of bereaved persons will experience substantial impairment in their social and occupational functioning for many months following the loss, accompanied by marked symptoms of emotional numbness, disbelief, purposelessness, futility, insecurity, and a sense that a part of the self has died (Jacobs, Mazure, and Prigerson 2000). Persistence of this specific complicated grief symptomatology, distinguishable from both ordinary depression and anxiety, has been found to predict a variety of negative outcomes, ranging from increased susceptibility to high blood pressure and stroke to elevated risk of substance abuse and suicide (Prigerson and Jacobs 2001). Further specification of the links between the attachment bond and postbereavement adaptation therefore seems to be a promising area for future research, one already yielding new insights into postloss coping styles (Stroebe 2002).
Task-Based Theories
Just as Kübler-Ross’s (1969) book On Death and Dying heralded the modern death awareness movement, the publication of William Worden’s (1982) text Grief Counseling and Grief Therapy provided one of the first systematic manuals for how professionals could assist the bereft. Now in its third edition, Worden’s (2001) work represents a “second generation” of bereavement models that conceptualize the tasks of mourning in active terms rather than viewing the impact of bereavement in terms of the dominant negative emotional states engendered. In a sense, it provides a useful descriptive elaboration of the “work” of mourning.
Worden’s (2001) model of mourning involves four basic tasks. Task I is to accept the reality of the loss—that is, to acknowledge that the person is gone forever and that reunion, at least in this life, is impossible. Task II is to work through the pain of grief, an unavoidable consequence of losing someone to whom the mourner was deeply attached. This includes experiencing the pain of grief in its multiple forms: physical, emotional, and behavioral. Task III is defined as adjusting to an environment in which the deceased is missing, a task that varies depending on what the relationship was with the deceased and the various roles the deceased played. Originally, Worden (1982) described Task IV as withdrawing emotional energy from the deceased and reinvesting it in another relationship, akin to Freud’s ([1917] 1957) notion of detachment from the lost object. In later revisions, however, he refined Task IV as emotionally relocating the deceased and moving on with life. In part, this reflected a growing acceptance in the field that “continuing bonds” with the deceased are possible and potentially healthy (Attig 2000; Klass, Silverman, and Nickman 1996).
Another influential exemplar of task-based theories is that of Therese Rando (1993). Combining the nomenclature of stage (or phase) models with the notion of tasks (or processes), Rando juxtaposed six fundamental “R” processes of mourning—recognizing the loss, reacting to the separation, recollecting and reexperiencing the deceased, relinquishing the old attachment, readjusting to the new world, and reinvesting—with three major phases of grief. In the avoidance phase, the mourner needs to recognize the loss by acknowledging and understanding the death. In the confrontation phase, the mourner reacts to the separation by experiencing and expressing the pain of the loss, recollects and reexperiences the deceased and their relationship, and relinquishes the “old” attachments to the deceased and the now outdated assumptions about the world. Finally, in the accommodation phase, the mourner readjusts into the new world by developing a new relationship with the deceased and adopting new ways of being in the world. Reinvestment of emotional energy in relationships, roles, or activities in which the mourner can realize some satisfaction in return is seen as the final process of accommodation.
An important aspect of Rando’s (1993) work for clinicians is identifying factors believed to complicate the processes of mourning. She cited four high-risk factors involving the circumstances in which the death occurred: sudden, unexpected death associated with traumatic circumstances; death associated with an overly lengthy illness; death of a child; and death the mourner perceives as preventable. Three additional complicating factors were characteristics of the mourner: a problematic premorbid relationship between mourner and decedent (e.g., conflictual, ambivalent, or markedly dependent); mourner “liabilities” such as other unaccommodated losses, stress, or mental health problems; and the mourner’s perceived lack of social support. Research has provided general support for these risk factors (e.g., Gamino, Sewell, and Easterling 1998).
Task-based models enjoy popularity among counselors and clinicians. Assessing to what degree a mourner has accomplished, or failed to accomplish, specific tasks provides a vehicle for understanding where a mourner is in his or her grief trajectory and also serves as a roadmap for where therapeutic intervention may be needed. Like stage theories, however, task-based models have been criticized for emphasizing a single pathway from the loss of a loved one to some ephemeral point of “recovery” in the future (see Rubin 1999). Perhaps in response to this limitation, recent innovations have been more pluralistic, driving our understanding of the phenomenology of grieving in diverse directions. The result has been the emergence of models that attempt to detail the diversity of grief responses, as well as increased attention to positive outcomes of bereavement that tend to be neglected by traditional approaches.
Dual Process Model
The dual process model put forward by Stroebe and Schut (1999) subsumes the traditional notion of “grief work” within a broader conceptualization of how people adapt to bereavement. Rather than emphasizing universal stages or tasks, it proposes that people deal with loss dialectically, engaging in the dual processes of loss-oriented coping and restoration-oriented coping. The former process entails experiencing and managing the negative emotions of grieving triggered by the loss of the loved one, missing and longing for the lost person, and reorganizing the attachment relationship with the deceased. Significantly, coping in this way entails temporarily denying or distracting oneself from the demands of the external world that has been changed by the loss. Restoration-oriented coping, on the other hand, entails attending to the many life changes required to adjust to one’s world after the loss of a close person. This can include learning new skills, assuming new roles, and forming new relationships. Importantly, this sort of outwardly focused coping involves denying or distancing from the pain of grief in order to “learn to live again.”
Perhaps the most distinctive aspect of Stroebe and Schut’s (1999) model is their assertion that successful coping with loss entails a dynamic of oscillation, an “alternation between loss- and restoration-oriented coping, the process of juxtaposition of confrontation and avoidance of different stressors associated with bereavement” (p. 215). That is, individuals normally self-regulate their bereavement (through a “dosing” mechanism) by confronting their loss at times and, alternately, avoiding the emotional pain of grieving. Rather than proposing a phasic progression through grief, this model posits waxing and waning, an ongoing flexibility over time with loss-oriented coping dominant early on in bereavement and restoration-oriented coping more prevalent later. Recent research supports the assertion that grievers oscillate between dealing with intrusions of feelings and images associated with the loss and avoidance of them as a means of coping with grief (Hogan and Schmidt 2002).
Finally, Stroebe and Schut (1999) argue that their model provides a means of understanding gender differences in bereavement, because women tend to be more emotion focused and hence more loss oriented, whereas men tend to be more problem focused and hence more restoration oriented in their coping behaviors. This broad characterization of male and female styles of grieving has received increasing attention, although grief theorists caution that many men grieve in predominantly “feminine” ways, just as many women deal with loss in classically instrumental, “masculine” fashion (Martin and Doka 2000). Most important, the dual process model suggests that people of both genders characteristically oscillate between a loss and restoration focus in the course of coping with bereavement, even if they tend to “specialize” in one orientation or the other.
Meaning Reconstruction and the Narrative Turn
Another recent innovation in bereavement theory represents less an alternative theory than a metatheory, an integrative framework that emphasizes some of the common themes of traditional and recent models of mourning. This perspective draws inspiration from psychological constructivism (Neimeyer and Mahoney 1995) and social constructionism (Burr 1995), both of which emphasize the interpretive activity of human beings as they impose order, pattern, and significance on life experiences at individual and collective levels. As applied to bereavement, such an approach proposes that the central process of grieving is the attempt to reaffirm or reconstruct a world of meaning that has been challenged by loss (Neimeyer 1998). In this respect, a meaning reconstruction perspective extends themes articulated in phase and attachment models concerned with the effort to find an explanation for the death and to realign one’s models of self and world in light of the loss. Meaning making, in this view, is much more than simply an exercise in cognitive or intellectual “reframing” of a bereavement experience. Instead, the struggle to find a viable meaning in both the loss one has suffered and the life one must now lead is a predominantly tacit, passionate process that unfolds in a social field (Neimeyer 2000b). Therefore, meaning reconstruction is really a quest for a new orientation in the world at both practical and existential levels, one that can be acutely anguishing as well as cognitively confusing. Attig (1996) has called this adaptation process “relearning the world,” because the mourner’s customary patterns of functioning are shattered or eroded with the death of a loved one and a new way of living and being must be developed.
A distinctive feature of a meaning reconstruction approach is its use of narrative as an organizing concept for understanding the bereavement experience. If human beings are viewed as striving to construct self-narratives or life stories that make sense of who they have been, what they are experiencing, and who they are becoming, then significant experiences of loss can be viewed as challenging the narrative coherence of their lives, introducing dramatic and often unanticipated discontinuities in their sense of identity over time (Neimeyer and Levitt 2001). Because identities are constructed always in relationship to others who affirm or validate one’s sense of self, the loss of relational anchoring that occurs with the death of a loved one can be profoundly disorienting. Especially when death occurs traumatically, the decimation of one’s sense of autobiographical continuity and undermining of one’s assumptive world can result in the persistent symptoms of loss of self and meaninglessness observed in studies of complicated grief (Neimeyer, Prigerson, and Davies 2002). But importantly, the ways in which people respond to these narrative disruptions in the construction of self are as richly diverse as the life stories into which the losses intrude, affording opportunities for progressive or growth-producing revisions in the self-narrative, as well as regressive or self-limiting outcomes (Neimeyer 2000a).
The strong focus on personal paths through grief that characterizes a meaning reconstruction approach is complemented by its equally strong emphasis on the social construction of bereavement. Thus local cultures (familial, ethnic, and historical) and discourses (professional, lay, and religious) all offer rituals and resources for making sense of death and bereavement, sometimes competing with each other for the allegiance of a given mourner negotiating a loss (Neimeyer et al. 2002). In this sense, bereaved people do not seek to give meaning to their loss and changed lives in isolation but instead do so by drawing selectively on a fund of interpretations, rules, and practices that jointly constitute the grief system in which they live (Walter 1999). Ultimately, then, a meaning reconstruction approach could contribute to the integration of molar/sociological, and molecular/psychological models of mourning, something that receives too little attention in a field that is often balkanized along disciplinary lines.
A meaning-oriented perspective on grieving is clearly not the work of any single theorist, and accordingly, it receives support from a host of qualitative and quantitative research programs that map the delicate individual and social processes by which people negotiate their bereavement. Thus researchers have documented the ways in which bereaved parents assimilate the death of a child into their existing belief systems (Milo 1997) or, alternatively, renegotiate these systems interactively as couples (Rosenblatt 2000). Similar conversational reconstruction of meaning has been traced within broader family systems (Nadeau 1998) with parallel meaning-making concepts found to emerge from diverse groups of mourners (Frantz, Farrell, and Trolley 2001; Gamino, Hogan, and Sewell 2002; Hogan and DeSantis 1992). Successful attempts at making sense of the death and finding a longer-term existential benefit in the loss also have been linked to better symptomatic outcomes (Davis, Nolen-Hoeksema, and Larson 1998). When considered as a converging body of work exploring the role of meaning in mourning (Neimeyer 2001), a meaning reconstruction approach seems poised to make further theoretical, empirical, and applied contributions to the field of grief and bereavement.
Continuing Bonds
One topic brought to the fore by newer theories of bereavement is that of a continuing bond with the person who has died, the centrality of an ongoing relationship with the deceased (Klass et al. 1996). Long regarded as a pathological manifestation of an inability to “let go” and “move on,” attention has turned recently to the possibility that retaining or restoring a psychological attachment to the lost loved one can be adaptive rather than a sign of incomplete “decathexis” (Attig 2000). In fact, even psychodynamic writers have begun to question this once taken-for-granted Freudian tenet, noting that vividly accessing the mourners’ memories of the deceased seems to vitalize, rather than vitiate, their investment in other living relationships (Hagman 2001). Accordingly, renegotiation rather than relinquishment of the continuing bond to the deceased is emphasized by most contemporary task, attachment, dual process, and meaning reconstruction formulations of bereavement, just as data suggest that continued attachment, even to the point of hallucinating the presence of the lost loved one, is a normal phenomenon, long after the death has occurred (Shuchter and Zisook 1993).
Still, complex questions of what kind of continuing bond with the deceased is adaptive or whether an ongoing relationship should sometimes be relinquished remain open. For example, although the “hallucinatory” sense of “contact” with the deceased (e.g., through sensing their presence or hearing their voice) is apparently comforting for the majority of mourners, those who experience it also score higher on “neuroticism” than those who do not (Datson and Marwit 1997). Likewise, efforts to preserve more concrete connections with a lost loved one (e.g., by holding onto his or her belongings) have been associated with more intensified grief, whereas more abstract bonds (such as having recourse to positive memories or identifying with the loved one’s values) have not (Field et al. 1999). Although intriguing, such results are not definitive; they leave unresolved the question of whether those grievers who are more distressed seek solace in more concrete connections or whether these more concrete connections predispose to more problematic bereavement adjustment.
What seems called for here are more sophisticated theories of the function of bonding phenomena for different mourners, facing different kinds of losses, at different points in their adaptation to bereavement. One promising beginning is offered by the “two-track” model of bereavement (Rubin 1999), which argues that postloss adaptation entails adjustments not only on the “biopsychosocial track” emphasized by most bereavement research, theory, and practice (e.g., symptoms of physical, psychological, and social disruption) but also along a second track specifically having to do with the relationship to the deceased (e.g., one’s access to memories, flashbacks to the death scene, and rituals of remembrance). From this perspective, it becomes as important to trace and foster healthy adaptation in one domain as in the other. It is also probable that refinements in attachment theory (Shaver and Tancredy 2001) will shed light on the form and function of continuing bonds. For example, it is possible that mourners who enjoy secure attachment histories benefit from such bonds, retaining comforting access to memories regarding the deceased while also alternately attending to the demands and opportunities of ongoing life. On the other hand, those with anxious/ambivalent or dismissive/avoidant attachment styles could tend preemptively to either cling to or avoid reminders of the deceased, respectively, prolonging or inhibiting their grief as a result (Stroebe 2002). Likewise, future research should be conducted in full awareness of the immense diversity of continuing bonds expressions in different world cultures and religions (Irish, Lundquist, and Nelsen 1993; Klass 1999), raising the possibility that the same form of ongoing attachment might be adaptive in one social context but maladaptive in another. Ultimately, this form of theory-guided and contextually sensitive research should enable investigators to address more incisive questions that could be of practical relevance to the bereaved.
Trauma and Transformation
One of the most recent developments in contemporary understandings of grief and bereavement is a new emphasis on personal growth following loss of a loved one, supplementing the traditional focus on the pathogenesis of grief. Although these approaches do not discount the painladen aspects of grieving a loved one, they highlight what “disease” models may otherwise neglect in the adaptation process—demonstrable changes for the better (e.g., greater self-efficacy, enhanced spirituality) in the aggrieved individual as a result of bereavement. Their focus is how the poignant experience of bereavement may be a catalyst to positive personal transformation.
Actually, some of the first work in transformative aspects of adaptation to loss arose in research on the impact of psychological trauma. Tedeschi and Calhoun (1995) reported on posttraumatic growth among those who had experienced traumas as diverse as death of a loved one, illness, combat, accidents, fires, floods, divorce, sexual assault, and job loss. Growth following trauma was observed in three broad domains: changed sense of self, changed relationships, and changed philosophy of life. One’s sense of self changes by virtue of surviving such a life hardship, typically yielding perceptions of the self as stronger, more capable, more independent, and self-reliant. In tandem with these shifts in identity, survivors of loss often report that their experience led to an increased connectedness and intimacy with others as well as a deepened sense of empathy with and compassion for others. Finally, many survivors report a changed philosophy of life, which entails an increased appreciation for one’s existence, not taking life for granted, and living each day to the fullest.
Others have reported similar increases in personal growth following loss or trauma (Hogan, Morse, and Tason 1996; Lieberman 1996; Yalom and Lieberman 1991). A recent study extended this concept by correlating key aspects of the bereavement situation with the degree of personal growth observed among grievers (Gamino, Sewell, and Easterling 2000). The ability to see some good resulting from the death, having a chance to say “goodbye” to the decedent, possessing an intrinsic sense of spirituality, and spontaneously activating positive memories of the decedent were mourner characteristics correlated with higher levels of postbereavement personal growth. Such findings buttress and clarify more recent perspectives on bereavement, such as those concerned with meaning reconstruction and the place of continuing bonds.
Although it has been shown that intrinsic spirituality (i.e., conviction about the existence of God or a higher power and the perception of an internalized relationship to that higher power) rather than mere church attendance is associated with better bereavement adjustment and higher levels of postbereavement personal growth (Easterling et al. 2000), research also has indicated that the experience of bereavement can lead to a salutary enhancement of the mourner’s spirituality. In a series of reports on the spiritual aspects of loss among partners of men with AIDS (Richards, Acree, and Folkman 1999; Richards and Folkman 1997), spirituality functioned as an organizing principle that helped bereaved partners in multiple ways, such as interpreting the events of the dying process, defining the location of the deceased partner, providing a sense of connection to the whole of life, and establishing solidarity among living family and friends. Yet even more impressive was the fact that at follow-up 3 to 4 years postbereavement, partners felt a deepening of their spirituality, with it becoming more of a source of personal purpose, direction, and meaning. Finding that a mourner’s spirituality can grow and develop as a result of a loss experience is a key aspect of transformative approaches to the bereavement process.
Conclusion
Although the human attempt to understand death and loss may be as old as the human species, explicit scientific theories of grief and bereavement date back only 100 years. Yet over this century of theoretical and empirical developments, a good deal has been learned about loss and its accommodation by survivors. Beginning with insightful attempts to delineate the dynamics of grieving as an intrapsychic process, theories evolved to specify the symptomatology of maladaptive mourning and to map its biological bases. At the same time, efforts to understand the experience of bereavement have grown from intuitively appealing but empirically questionable stage models to more active conceptualizations of grieving as a series of psychosocial tasks or transitions that confront the mourner. Most recently, theories that elucidate the consequences of sundered attachments have been complemented by a range of new perspectives: (a) exploring the dynamic and sometimes opponent processes of coping with bereavement, (b) reorganizing the ongoing relationship with the deceased, (c) reconstructing life narratives challenged by loss, and (d) realizing the possibility of posttraumatic growth as well as complicated grief in the aftermath of devastating loss. Given this developing conceptual sophistication, there is reason to believe that our understanding of bereavement will grow in both scientific credibility and practical relevance in the years to come.