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Patterns of Complicated Grief among Bereaved Parents

Article  in  OMEGA--Journal of Death and Dying · July 2002

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OMEGA, Vol. 45(2) 119-132, 2002

PATTERNS OF COMPLICATED GRIEF

AMONG BEREAVED PARENTS*

KARNI GINZBURG, PH.D.

YAEL GERON, PH.D.

ZAHAVA SOLOMON, PH.D.

Tel Aviv University, Isreal

ABSTRACT
This study assessed patterns of grief reactions and their adaptiveness, among
bereaved parents, who had lost an adult child during military service. The
prevalence of the various reactions and their associations with psychosocial
adjustment and risk-related factors were examined. Eighty-five bereaved
parents filled out a battery of questionnaires 2.5 years after their loss. Type of
grief reaction (absence, delayed, prolonged, and resolved) was identified
utilizing the Texas Revised Inventory of Grief (TIG). In addition, psychiatric
symptomatology, psychosocial functioning, and sociodemographic back-
ground were examined. Results indicated that prolonged grief reactions
and absence of grief were the most prevalent variants. Absent and delayed
grief reactions were associated with lower levels of psychosocial adjustment
compared with prolonged grief reaction. Level of education, religious
attitudes, and the circumstances of the loss were associated with the type
of grief reaction. The findings of this study demonstrate the complexity
of defining certain reactions as complicated. The identification of absence
of grief and delayed grief reactions as being complicated is supported, but the
inclusion of prolonged grief reaction as a complicated maladaptive reaction
should be reconsidered.

*This research was supported by the Israeli Ministry of Defense. The authors thank Tamar Granot,
Ester Ben Dor, Tamar Bilu, Hannah Fishbein, Ahuva Goldman, Ofra Laor, and Anat Sadovski from the
Rehabilitation Department of the Israeli Ministry of Defense for their support and advice throughout
the various phases of the research.

119
Ó 2002, Baywood Publishing Co., Inc.
120 / GINZBURG, GERON AND SOLOMON

Although death is an integral part of life, losing a loved one is a difficult

experience that entails a painful adaptation process. This adjustment process is
often described as shift between three main phases that, while not necessarily
linear and sometimes overlapping, represent a process of gradual separation from
the deceased, acceptance of the loss, and adaptation to the new reality (Jacobs,
1993; Shuchter & Zisook, 1993).
The first phase is characterized by shock and denial of the loss, often accom-
panied by sense of emotional numbness (Jacobs, 1993). The second phase begins
with the cognitive and emotional acknowledgment of the reality of the loss. It is
characterized by intensive preoccupation with the loss along with elevated levels
of cognitive, behavioral, somatic, and social manifestations of distress (Horowitz,
1990; Lindemann, 1944; Raphael & Middleton, 1987; Shuchter & Zisook, 1993;
Stroebe & Stroebe, 1987).
During the final phase of the grief process, the bereaved gradually integrates
the meaning of the loss. While many manifestations of the grief work, such as
yearning for the deceased may be experienced, the high levels of distress are
decreased. The bereaved can invest himself in daily life and regain his or her sense
of satisfaction and optimism (Weiss, 1993).
While many of the bereaved go through this adjustment process and resume
their previous levels of functioning (Weiss, 1993), some experience considerable
difficulties in adaptation to the new reality. These bereaved are considered as
manifesting a complicated grief reaction.1 In the absence of accepted diagnostic
criteria for complicated grief reaction, most theoreticians use a normative defini-
tion: a particular grief process that seems as deviant from the expected in a given
society or culture, is defined as complicated grief (Middleton, Raphael, Martinek,
& Misso, 1993).
Three major types of complicated grief reactions that diverge from the norma-
tive, either by intensity or temporal parameters were identified. Absent grief is
defined as the inhibition of typical expressions of grief, denial of the loss or
feelings related to the loss (Faschingbaner, Zisook, & DeVaul, 1987; Middleton
et al., 1993; Rando, 1992-93). Delayed grief is determined when there is a signifi-
cant interval between the loss and the onset of grief reaction. The length of the
interval may vary from weeks to years (Faschingbaner, Zisook, & DeVaul,
1987; Lindemann, 1944; Middleton et al., 1993; Rando, 1992-93). Lindemann
(1944) suggested that delayed grief reactions are the most common form of
complicated grief in clinical populations. This impression was supported in a
survey conducted among professionals (Middleton et al., 1993). Jacobs’ (1993)
impression was that delayed grief occurs in 10-15 percent and absent grief in
5 percent of the cases of complicated grief reaction. On the other hand, in a

1
Various terms have been used to describe the “abnormal” grief process, among them are atypical,
morbid, pathologic, unresolved, and complicated grief. We prefer to use the term of “complicated grief
reaction.”
 PATTERNS OF COMPLICATED GRIEF / 121

community-based study Middleton, Burnett, Raphael, and Martinek (1996) did

not find support for the pattern of either absent or delayed grief reactions.
Prolonged, chronic, or unresolved grief is manifested in prolonged per-
sistent depression, preoccupation with the loss, overidentification and intense
yearning for the deceased, and social inhibition, that do not decline over time
(Faschingbaner, Zisook, & DeVaul, 1987; Jacobs, 1993; Middleton et al., 1993;
Rando, 1992-93). Jacobs (1993) suggests that this is the most common form
observed in clinical practice. Other reports ranged between 9 (Middleton et al.,
1996) to 14 percent (Zisook & DeVaul, 1983) in community-based samples and
17 percent (Zisook, Schuchter, & Schuclit, 1985) in clinical populations. When
the sample was comprised of bereaved parents, the rates of prolonged reaction
were raised to 63 percent of the sample (Zisook & Lyons, 1988).
As can be seen, the distinction between normative and complicated grief
reactions is not dichotomous, but rather a matter of degree. The theoreticians
disagree regarding the duration of the time criterion. Some authors suggest that
the normative grief process lasts for about a year (Jacobs, 1993; Horowitz et al.,
1997), others imply a longer period (Zisook, DeVaul, & Click, 1982), while
some claim that the time limit is not adequate (Lister, 1998). The parameter
of intensity is even more problematic, since the mouming process is highly
idiosyncratic by nature (Rando, 1992-93). Therefore, it is not surprising that the
reports on the prevalence of the variants of complicated grief reactions are not
consistent.

CRITERION-BASED VALIDITY

To validate the concept of a certain reaction as complicated, it is crucial to

demonstrate that it is complicated with emotional and psychosocial maladjust-
ment (Prigerson et al., 1995). Some studies, that examined the phenomenon
of complicated grief reaction without distinguishing between the variants, in
non-clinical populations, indicated that it is associated with high levels of
depression, anxiety, sleep disturbances, suicidal ideation, and impairment in
psychosocial functioning (Horowitz et al., 1997; Jacobs, 1993; Kim & Jacobs,
1991; Prigerson et al., 1996; Szanto, Prigerson, Houck, Ehrenpreis, & Reynolds,
1997).
The literature on the association between the specific forms of complicated grief
and adjustment is limited. Parkes and Weiss (1983), report high levels of anxiety,
depression, and difficulties in social functioning among subjects classified as
having prolonged grief. Zisook and his colleagues found that this pattern of
complicated grief is associated with depression, both in clinical (Zisook et al.,
1985) and general samples (Zisook & DeVaul, 1983). To the best of our knowl-
edge there are no studies that investigated the emotional and psychosocial adjust-
ment of the other types of complicated grief reaction.
122 / GINZBURG, GERON AND SOLOMON

RISK-RELATED FACTORS
Various risk-related factors were studied as associated with difficulties in
adjustment following loss. The kinship to the deceased and the nature of the loss
are considered as significant factors. Bereaved parents were identified as more
prone to develop adjustment difficulties following the loss on an offspring,
than adults who lost a parent or a spouse (Middleton et al., 1996; Sanders,
1979-80). Among the bereaved parents, mothers exhibit more distress than
fathers (Cleiren, 1992).
Sudden and unanticipated death is considered as risk factor to complicated
grief reactions (Jacobs, 1993; Parkes & Weiss, 1983; Rando, 1992-93). There are
some studies, however, that did not find differences in adjustment between
bereaved who lost their loved ones in an accident, following chronic disease, or
suicidal act (Cleiren, 1992).
Low level of education is associated with adjustment difficulties among
bereaved (Roskin, 1984). Religious belief and behaviors, on the other hand, are
associated with less adjustment difficulties (Sprang & McNeil, 1998). These
factors, however, were not found by others as related to level of distress among
the bereaved (Vachon et al., 1982).
As can be seen, there is a considerable gap between the prevalent use of the
notion of complicated grief and its variants and the limited empirical findings in
this domain. In addition, most of the studies addressing this issue suffer from
various methodological limitations, the most relevant being those that relate to the
sample such as including mixed population with respect to the kinship with the
deceased (e.g., Sprang & McNeil, 1998) and the nature of the loss (e.g., Middleton
et al., 1996).
This study attempts to explore systematically the different variants of com-
plicated grief among bereaved parents who lost an adult child. More specifically, it
has three aims: 1) to assess the prevalence of the variants of complicated grief
reactions; 2) to validate these reactions as reflecting complicated reaction, by
utilizing the criterion of psychosocial adjustment; and 3) to study risk-related
factors that are differentially associated with the various grief reactions.

METHOD

Subjects and Procedure

The participants in the study were bereaved parents who lost a child during
military service in the Israel Defense Forces and participated in support groups
that were administered by the Rehabilitation Department of the Israeli Ministry
of Defense. This intervention is part of the integrative treatment offered by the
Rehabilitation Department to bereaved families, and defined as a supportive
intervention for normative population who experience a loss.
 PATTERNS OF COMPLICATED GRIEF / 123

The questionnaires were administered during one of the regular group

sessions. After complete description of the subject, written informed consent
was obtained.
Of the 174 bereaved who participated in the 16 groups conducted during
the period of data collection, 138 agreed to participate in the study. Eighty-five
subjects completed the battery of questionnaire presented in this article.
Most of the subjects (82 percent) lost a son, and 18 percent lost a daughter.
Nearly half of the subjects (45 percent) lost their child in military operation,
15 percent in military accidents, and 28 percent in road accidents. Twelve percent
of the deceased committed suicide and 2 percent died following a disease. During
the data collection the subjects were 31.2 months on average after the loss
(SD = 11.7).
Forty-six percent of the subjects were males. Mean age of the sample was 5l
(SD = 4.97). Most of the subjects (95 percent) were married, and the rest
(5 percent) were divorced. Six percent of the participants in the study had
elementary school education, 68 percent had partial or complete high school
education, and 34 percent had academic education. Fifty-five percent of the
subjects defined themselves as secular, 27 percent as traditional, and 18 percent
as orthodox.

Measures

Texas Revised Inventory of Grief (TIG)

This self-report scale (Faschingbaner, Zisook, & DeVaul, 1987) consists of two
parts, relating to two points of time: past (immediate or shortly after the loss) and
present (the time of data collection). It is comprised of 21 items. Subjects are asked
to indicate, on a 5-point scale, the extent to which each item describes their
reactions.
Following Faschingbaner, Zisook, and DeVaul (1987), based on the median
scores of both parts of the questionnaires (2.50 for the past, and 1.69 for the
present; in the current sample), a typology of four types of grief reactions was
formed: Absence of grief included bereaved whose scores were under the
median both in the past and in the present; delayed grief included bereaved
whose scores were under the median in the past and below the median in
the present; prolonged grief included bereaved with scores below the median
both in the past and in the present; and resolved grief included bereaved
whose scores were below the median in the past and under the median in
the present.
The TIG is used in studies of various bereaved populations. It was found to be
valid and reliable (Faschingbaner, Zisook, & DeVaul, 1987). Internal consistency
in the current study was high in both parts (Cronbach alpha = 0.88 in the past;
0.95 in the present), indicating high reliability.
124 / GINZBURG, GERON AND SOLOMON

Symptom Checklist 90 (SCL-90)

This questionnaire is a widely used measure that assesses the level of emotional
distress (Derogatis, 1977). The SCL-90 consists of 90 psychiatric symptoms, and
respondents are asked to indicate, on a 5-point scale, the extent to which they
endorsed each symptom during the two weeks preceding the assessment.
A global measure (GSI) assesses the severity of general psychiatric symp-
tomatology endorsed by the respondent. In addition, the specific pattern of psychi-
atric symptomatology is examined by nine sub-scales: Somatization, obsession-
compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation, and psychoticism.
The SCL-90 is widely used among various populations, including bereaved
subjects (Piper, McCallum, & Azim, 1992), and has proven psychometric proper-
ties (Derogatis & Clearly, 1977).

Psychosocial Functioning

This questionnaire, based on the Psychosocial Adjustment to Illness Scale

(PAIS, Derogatis & Lopez, 1983), was modified for the current study. It assesses
psychosocial functioning in five major areas: occupational functioning, sexual
functioning, relations in the close family, relations in the extended family, and
social functioning.
The scale includes 11 items. The subjects are asked to respond, on a 4-point
scale, to the extent of change experienced in the above areas, following the loss.
Internal consistency indicated considerable reliability (Cronbach alpha = 0.59
for occupational functioning, 0.92 for sexual functioning, 0.68 for relations in
the close family, 0.45 for relations with the extended family, and 0.56 for social
functioning).

RESULTS

Grief Reactions
According to the TIG (Faschingbaner, Zisook, & DeVaul, 1987), subjects were
classified into four groups of grief reaction: absence of grief, delayed grief,
prolonged grief, and resolved grief. Examination of the distribution of the subjects
in the four groups of grief reactions revealed that about one third were classified
as having prolonged grief reaction (N = 31; 36 percent), a similar rate was
identified as absence of grief reaction (N = 28; 33 percent), and the rest were
divided into delayed (N = 14; 17 percent), and resolved grief reaction groups
(N = l2; 14 percent).
To examine whether the grief reaction is related to subjects’ background
variables, a series of P2 tests were conducted. Table 1 presents the distribution of
grief reactions according to sociodemographic variables. First, a relation between
 PATTERNS OF COMPLICATED GRIEF / 125

Table 1. Distribution of Grief Reactions According to

Sociodemographic Background

Absence of Delayed Prolonged Resolved

grief grief grief grief

N % N % N % N %

Circumstances
Military operation 7 18 7 18 16 42 8 21
Accident 18 51 5 14 9 26 3 9
Suicide 2 20 2 20 5 50 1 10

Time since event

–12 months 2 40 0 0 1 20 2 40
12-26 months 12 34 6 17 12 34 5 14
24-36 months 12 31 6 15 16 41 5 13
36+ months 2 33 2 33 2 33 0 5

Gender
Male 12 31 7 18 15 38 5 13
Female 15 33 7 16 16 36 7 16

Education
8-11 years 12 75 2 12 1 6 1 6
12 years 5 23 3 16 5 26 6 32
Professional 7 35 3 15 8 40 4 10
Academic 4 14 5 18 16 57 6 11

Religious attitudes
Secular 14 30 9 20 17 37 6 13
Traditional 13 56 1 4 5 22 4 17
Orthodox 1 7 4 27 8 53 2 13

the type of grief reaction and the circumstances of the event was found, approxi-
mating the level of statistical significance (P2 = 10.98, DF = 6, p < 0.10). Fifty-one
percent of the subjects who lost their child in an accident were classified as
the absence of grief reaction group, compared to 18 percent of those who lost
their child during military operation, and 20 percent of those whose child com-
mitted suicide. Only 26 percent of the subjects who lost their child in an acci-
dent were classified as having prolonged grief reaction, compared to 42 percent of
those who lost their child in military operation, and 50 percent of those whose
offspring committed suicide. Finally, 21 percent of the subjects who lost their
child in a military operation were classified as manifesting resolved grief reaction,
126 / GINZBURG, GERON AND SOLOMON

compared to 9 percent of those who lost their child in an accident, and 10 percent
of those whose child committed suicide.
Secondly, level of education was related to the type of grief reaction (P2 = 24.84,
DF = 9, p < 0.01). Seventy-five percent of the subjects with low level of educa-
tion were classified in the absence of grief reaction group, compared to 14
percent of subjects with academic education. Fifty-seven percent of the subjects
with academic education were classified as the prolonged grief reaction group,
compared to 6 percent of the subjects with 12 years of education.
Finally, type of grief was related to religious attitudes (P2 = 13.05, DF = 6,
p < 0.05). Fifty-six percent of the subjects who defined themselves as tradi-
tionals were classified as the absence of grief reaction group, compared to
7 percent of orthodox subjects. Twenty percent of secular subjects and 27 percent
of orthodox were classified as having a delayed grief reaction, compared to
4 percent of the traditionals. Finally, 53 percent of the orthodox subjects were
classified as having a prolonged grief reaction, compared to 22 percent of the
traditional subjects.
Gender and time since the event were not related to the type of grief reaction
(P2 = 0.27, DF = 3; P2 = 5.97, DF = 9, respectively).

Grief Reaction, Psychiatric Symptomatology,

and Psychosocial Functioning

First, to examine the associations between the type of grief reaction and level
of distress a series of Analyses of Variance was conducted. Table 2 presents
means and standard deviations of the distress measures, according to the types of
grief reaction.
As can be seen in Table 2, GSI that reflects the severity of the general
psychiatric symptomatology was related to the type of grief reaction. Scheffe
contrasts revealed that subjects who were classified as having a prolonged grief
reaction reported lower level of general psychiatric symptomatology than subjects
in the absent or delayed grief reactions groups.
Analyses of Variance, followed by Scheffe contrasts, indicated that in most
of the SCL-90 sub-scales, subjects who were classified as having a prolonged
grief reaction received lower scores than those who were classified as absent of
grief. More specifically, the subjects who were classified as having a prolonged
grief reaction reported on lower levels of somatization, obsession compulsion,
depression, anxiety, interpersonal sensitivity, and hostility than those who were
classified as absent of grief. In addition, subjects who were classified as delayed
grief reaction, manifested higher levels of somatization than the prolonged grief
reaction group.
Finally, to examine whether the type of grief reaction is related to psychosocial
functioning, a series of Analyses of Variance was conducted. As can be seen
in Table 2, subjects who were classified into the absent of grief reaction group
 PATTERNS OF COMPLICATED GRIEF / 127

Table 2. Means and Standard Deviations of SCL-90 and

Functioning Scores According to Grief Reaction

Absence of Delayed Prolonged Resolved

grief grief grief grief

N % N % N % N %

GSI 1.33 0.57 1.37 0.75 0.82 0.50 1.01 0.49 F(3,81) = 5.13**

Somatization 1.26 0.81 1.47 1.17 0.60 0.67 1.00 0.73 F(3,70) = 4.38**

ODa 1.76 0.71 1.66 1.17 0.95 0.59 1.09 0.60 F(3,68) = 6.23***

ISb 1.16 0.65 1.22 0.74 0.69 0.68 0.80 0.35 F(3,70) = 3.29*

Depression 1.90 0.80 1.58 1.00 1.21 0.66 1.65 0.78 F(3,69) = 3.49*

Anxiety 1.36 0.82 1.39 0.83 0.77 0.65 1.17 0.79 F(3,75) = 3.49*

Hostility 1.07 0.64 1.06 0.75 0.61 0.56 0.64 0.42 F(3,78) = 4.82*

Phobic anxiety 0.51 0.55 0.50 0.54 0.29 0.41 0.35 0.40 F(3,71) = 1.12

PIc 0.87 0.73 0.82 0.46 0.53 0.64 0.87 0.71 F(3,72) = 1.43

Psychoticism 0.85 0.73 0.76 0.68 0.55 0.47 0.61 0.51 F(3,71) = 1.20

Occupational 2.21 0.80 1.77 0.47 2.45 0.71 2.46 0.66 F(3,78) = 2.79+
functioning

Extended 2.18 0.61 2.18 0.64 2.38 0.61 2.00 0.48 F(3,80) = 1.34
family

Social 1.71 0.46 2.00 0.77 2.27 0.69 1.95 0.42 F(3,79) = 4.12**
functioning

Sexual 2.16 0.69 2.18 0.64 2.43 0.55 2.32 0.64 F(3,76) = 0.91
functioning

Close family 2.95 0.56 2.76 0.52 3.11 0.40 2.92 0.61 F(3,79) = 1.29
a b c
Obsession-compulsion. Interpersonal sensitivity. Paranoid ideation.
+
*p < 0.05. **p < 0.01. ***p = 0.001. p = 0.07.
128 / GINZBURG, GERON AND SOLOMON

reported on more impaired social functioning than those who were classified as
having a prolonged grief reaction.
Occupational functioning was also associated with the type of grief reaction on
a level that approximates to statistical significance (p < 0.07). Scheffe contrasts
revealed that subjects who were classified as having a delayed grief reaction
reported on more impaired occupational functioning than those that were classi-
fied as prolonged grief.
Since the subjects in the four grief reaction categories differed in level of
education, religious attitudes and the circumstances of the event, a series of
Multi-Variate Analyses for parallelism was conducted, to examine whether the
association between type of grief reaction and general psychiatric symptoma-
tology (GSI) can be explained by the sociodemographic variables. The inter-
actions between grief reaction and each of the sociodemographic variables
(level of education, religious attitudes, the circumstances of the event) were not
significant (F(6,83) = 1.20; F(6,84) = 1.67; F(6,83) = 1.03, respectively). These
results indicate that the association between GSI and type of grief reaction can not
be explained by the sociodemographic background.
Similarly, another series of Multi-Variate Analyses for parallelism was con-
ducted with social functioning as dependent variable. The interactions of grief
reaction with either level of education, religious attitudes, or circumstances of the
event were not significant (F(6,78) = 2.00; F(6,78) = 0.25; F(6,77) = 0.65,
respectively). When occupational functioning was the dependent variable, the
interactions of grief reaction with level of education, religious attitudes, or circum-
stances of the event were not significant (F(5,79) = 1.56; F(6,79) = 0.65; F(6,78) =
l.66, respectively). These findings indicate that the association between both
occupational and social functioning and type of grief reaction can not be explained
by the sociodemographic background.

DISCUSSION

The findings of the study revealed that patterns of grief reactions, that are
considered as complicated, are more prevalent among bereaved parents who lost
an adult child, than the resolved reaction. Prolonged grief reaction and absence of
grief were the two most prevalent types of reactions among the subjects, each
comprising a third of the sample. Additional 17 percent of the participants in the
study were classified as having a delayed reaction, and only 14 percent were
categorized as displaying resolved grief reaction.
The high rate of bereaved parents that were classified as absence of grief
reaction is inconsistent with the literature. This rate goes far beyond Jacobs’
(1993) estimation of 5 percent of the cases of pathological grief reactions, and the
report of Middleton et al. (l996) who did not find support for this pattern of grief
reaction in a community-based sample.
 PATTERNS OF COMPLICATED GRIEF / 129

This is even more striking, considering the finding that in respect to the other
variants of grief reactions, absence of grief is most strongly associated with
emotional and psychosocial adjustment difficulties. This can be explained by the
traditional psychoanalytic thinking, that suggests that repression or denial of
painful event often result in emotional or somatic manifestations, as the psychic
energy that was isolated from the causing event, is channeled to other indirect
routes (Freud, 1896). Therefore, the pattern of absence of grief reaction may be
considered as reflecting a pattern of displacement in which the emotional reactions
from the loss find other channels.
Zisook and Lyons (1988) report that 63 percent of bereaved parents in their
study were classified as unresolved grief. In our study the rates were lower,
however, this was the most prevalent grief reaction. The literature identifies this
reaction as a form of complicated grief work which is associated with high levels
of emotional distress (Parkes & Weiss, 1983; Zisook & DeVaul, 1983). According
to our findings, this group manifested the lowest levels of emotional and psycho-
social distress. This questions the definition of this pattern of reaction as a variant
of complicated grief. It seems that being invested emotionally in the grief work
does not hinder the process of adjustment and resuming a sense of well-being.
These findings support the concept of “continuing bonds,” recently offered by
some authors (e.g., Klass, Silverman, & Nickman, 1996; Malkinson & Bar-Tur,
2000). This concept challenges the traditional thanatological approach, that views
“breaking the bonds” with the deceased as the major task of the bereaved, and
the persistent occupation with the loss as an indicator of complicated reaction.
According to the “continuing bonds” perspective, many bereaved remain involved
with their relationships with the deceased, preoccupied and interact with his or her
inner representation, and these reactions should not be labeled as abnormal
(Rubin, 1996).
Findings suggest that the circumstances of the loss tend to be associated with
the type of grief reaction. Bereaved parents who lost their child in accident differed
from those whose offspring died in military operation. These findings can be
explained by the meaning attached by the Israeli society to the soldier’s death.
While accidents are often perceived as a “senseless” event that bear no meaning,
should and could be avoided, being involved in a military operation is one of the
main combatant’s tasks.
Malkinson and Bar-Tur (2000) suggest that the Israeli society may encourage
the persisting mourning among bereaved parents who lost their child during his
military service. During its 50 years of existence, Israeli society has developed a
“bereavement culture” that views the death of a soldier in a military action as a
symbol of heroism, and his bereaved parents as a symbol of sacrifice in the battle
of defending the People and Homeland. Official commemorating ceremonies and
rituals represent the society’s obligation to the dead heroes and mourning family.
This approach attaches social and national meaning to the death but also may
encourage a never-ending, eternal grief.
130 / GINZBURG, GERON AND SOLOMON

Recent writers had criticized the manner the DSM treats the issue of bereave-
ment (e.g., Rando, 1992-93). In its fourth edition, the DSM (APA, 1994) recog-
nizes the phenomenon of complicated grief reaction, but its reference is some-
what obscure. That is, in the category that specifies “conditions that may be a
focus of clinical attention,” bereavement is included. In addition, complicated
grief reactions are addressed both under the diagnoses of Major Depression
Episode and Adjustment Disorder. Major depression disorder is diagnosed when
the depressive symptoms persist for more than two months after the loss. The
diagnosis of adjustment disorder “may be appropriate when the reaction is in
excess of, or more prolonged than, what would be expected” (APA, 1994; p. 626).
While the temporal parameter of two months seems to be inadequately short,
the “expectation” criterion for diagnosing adjustment disorder is too vague.
This inconclusive approach may reflect the dispute regarding the issue of
establishing a distinctive diagnostic criteria for complicated grief reaction.
Various authors call for this effort and some suggested criteria (Horowitz et al.,
1997; Prigerson et al., 1995). Others, however, claim that due to the idiosyncratic
nature of grief work, the establishment of such a criteria is problematic, and may
lead to stigmatizing and pathologization of individual reactions (Lister, 1998).
The findings of the current study demonstrate the complexity in defining certain
reaction as complicated. On the one hand, it support the identification of absence
of grief and delayed grief reactions as complicated grief reactions, and points to
the need to pay clinical attention to these groups of bereaved parents. On the other
hand, the inclusion of prolonged grief reaction as a complicated maladaptive
reaction, at least for individuals who lost an adult child, should be reconsidered.
These findings should be considered, however, in the light of the study’s
limitations. We should bear in mind the special characteristics of our sample. First,
the social context is unique. The loss of a child during military service may define
the loss somewhat differently than other types of losses of a child. In addition,
although the sample was not identified as a clinical population, all the subjects
participated in support groups. Even more significant is the point that the data
collection was made in the course of this intervention. That is, all the bereaved
parents who participated in the study were during a phase that the issues of loss
and grief were brought into the awareness, discussed, and processed regularly
during the group meetings. The confounding effect of the intervention should
be considered. Therefore, the generalization of the findings to other populations
should be made cautiously. Further research that will examine these issues among
other bereaved populations, following other circumstances of loss, and in other
social climates is needed.

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