Rawe leet CHAPTER 1 Introduction For the third time at a particular conference, yet another participant ‘wondered whatresources would help her intervene with someone whose mourning had been resistant to typical grief facilitation techniques. As Thad for the previous two participants who had inquired, Isuggested a {few works I deemed helpful for her particular problem but told her that theliterature was widespread and that she would havetto synthesizeitfor herself. For the third time, [wondered why no comprehensive clinical sesouzce on the topic was available. For the first time, I decided to try to create one. Treatment of Complicated Mourning isthe culmination of that attempt. Ithas been written forall clinicians and caregivers who work with individuals whose geief and mourning does not respond to mere thera peutic facilitation. ‘Because uncomplicated bereavement has been documented fo pre- ipitate a host of negative psychological, behavioral, social, physical, and ‘economic sequelae (Osterweis, Solomon, & Green, 1984), bereavement ‘that exceeds the normcan be expected to create additional problems. For ‘whatever reasons, individuals experiencing such complications require rmoreextensive, more iniensive, or different interventions. In these situa tions, primary prevention and secondary level intervention (Caplan, 1968) 1have failed, and tertiary intervention is mandated. This bookis directed toward this level of intervention. GROWING INTEREST IN THE TOPIC Inrecent years, there has been a plethora of writings and investigations pertaining to loss and the reactions stimulated by it. Loss, grief, and ‘mourning relating to both death and nondeath situations—have been ‘@amined throughout the entire life cycle, and the field has burgeoned ex: ‘penentially, For example, in Siopson’s (1979) frst critical bibliography in Ue field of thanatology, a total of 763 titles were listed as being available4 carne up to that year. His subsequent bibliography (Simpson, 1967) noted that ‘well over 1,700 books had been published tothat point, mostin theinterim 8 years, Working with the inherently oxymoronic aspects of uncomplicated sriefand mourning (ie., its “normal abnormality") is sulficient for many caregivers. However, others are extremely interested in the prediction, evelopment, description, assessment, diagnosis, classification, and treat- ‘ment of the more complicated varieties ofthese processes, AsThavenoted previously (Rando, 1986d), such interest has shifted gradually from be- reavementin general to different types oflossesand how they are experi- enced. Much early research centered on the loss experience in the first year of white, middle-class widows whose husbands had died of cancer, inaccidenis, orfrom heart attacks. An understanding of three pointshas hhelped clinicians and researchers move beyond description of such "typi- cal’ reactions to death: Firs, because of the complex interaction of factors known to influence response to loss, no two bereavements are exactly alike. Second, different types of bereavement experiences will require different types oftreatmentinterventions. And third, although itis always dangerous to compare different losses (e.g., “My loss is worse than yours’), itis equally dangerous not to lookat ie unique dilemmas posed by specific types of losses and to ignore the distinct needs of mourners experiencing different types of bereavement (Rando, 19864). As a result of these new understandings, research now generates better data about uncomplicated grief and mourning. Thanks to the work of such researchers as John Bowlby, Colin Murray Parkes, Beverley Raphael, Sidney Zisook, and others, a more accurate comprehension of the variations in loss response is being achieved. Investigations now con- tinually yield information that extends the Limits of ¢o-called normal responses to loss. must be noted that previous literature has not omitted complicated. ‘mourning entirely; however, the topic has been severely neglected. ‘Usually, discussion is relegated o afew paragraphs at the end of a given article or book. Despite this relative lack of consideration, it does not appear that authors are uninterested in complicated mourning, On the contrary, many are quite interested but simply do not know what to say ‘on the topic. Most describe the phenomenon asa variation of uncompli- cated grief and mourning, pick a pazticular term to label it, cite some predisposing characteristics, offer a few classic references, and leave it at that, With relatively few exceptions, when complicated mourning hasbeen addressed, the literature has not been synthesized. IF the work focuses ‘on complicated mourning, discussion generally centers on its character- istics but not its treatment. Ifthe discussion is about both complicated ‘mourning and its treatment, focus may be directed toward only some of the grief aspects or certain ofthe treatments. In view ofthis, itseems that Intrduction 5 the time has arrived for an in-depth examination ofthe theoretical, practi- cal, and clinical aspects of complicated mourning. The purpose of the present book isto provide just that, then to identify the specificcaregiver perspectives, clinical strategies, assessments, teatment approaches, and interventions known to promote healthy accommodation of loss. PREVALENCE AND COSTS OF COMPLICATED MOURNING A significant proportion ofthe bereaved experience complications. There are approximately 2million deaths per year in the United States, with each individual death affecting from 8 to 10 family members (Hocker, 1989; Redman, 1988), for a total of 16 to 20 million new mourners each year. After exhaustively studying the literature, Raphael (1983) estimates that ‘as many asonein three bereaverents resultin “morbid outcomeor patho- logical patterns of grief” (p. 68). Raphael’ statisticis applied, the poten. tialexistsfor5 to million new cases of complicated mourning each year. In fac, these figures may be misleadingly low because they fail to ‘account for other individuals affected by the death, such as neighbors, friends, coworkers, students, former in-laws, or others outside ofthe family system who aze vulnerable to complications. Although the number of indi- viduals experiencing complicated mourning cannot be ascertained pre- ‘cisely, one can presume that these other affected persons certainly increase the ranks, ‘The costs of complicated mourning not only relate to personal suffer- ing, they also extend economically, socially politically, and philosophically into the family, cocial network, workplace, community, and society as 8 ‘whole, Persons who believe thatthe losses suffered by others donotcon- cem them should probably not examine too closely the realities of in creased health insurance premiums; the financial and social costs of ‘worker drug abuse, absenteeism, accidents, and lowered productivity and product quality; the offects of escalating social violence; and so fort all of which are among the many sequelae of complicated mourning, FACTORS CONTRIBUTING TO INCREASED ‘COMPLICATED MOURNING. Seven high-risk factors, falling generally into two categories, predispose any individual to complicated mourning. Thefirst category includes factors associated withthe specific death: sudden, unexpected death (especially when traumatic, violent, mutilating, or random); death from an overly lengthy illness; loss of child: and the mourner’s perception ofthe death as preventable. The second category includes antecedent and subsequent variables: a premorbid zelationship withthe deceased that was markedly6 CHAPTER? angry arambivalent, or markedly dependent; prior orconcurrentmourer liabilities—specifically, unaccommodated losses andior stresses and ‘mental health problems; and the mourner’s perceived lack of social sap- port. All of these factors appear to be on the rise, resulting in greater numbers of people experiencing complicated mourning. Sociocultural and Technological Trends A number of sociocultural and technological trends in Western society hhave complicated healthy griefand mourning, First the phenomenon of social change, occurring at an increasingly rapidirate, has exerted a signifi- ‘cant impact. A number of processes have been especialy influential in ‘this regard. These include urbanization; industrialization; technicaliza- tion; secularization and deritualization; increasing social mobility; social reorganization (specifically, breaksiown of the nuiclear family, increases {nsingle parent and blended families, andthe relative eclusion of theaged and dying); rising societal, interpersonal, and institutional violence (physical, sexual, and psychological); and unemployment, poverty, and ‘economic problems. Relevant social consequences include increases in social alienation, personal helplessness and hopelessness, parental ab- sence and neglect ofchildzen, discrepancy between the “haves” and “have- nots’ rug and alcohol abuse, physical and sexual abuse of children and others without power (e.g., women, the elderly, minorities), and avail- ability of guns. These sequelae all havetended to sever or weaken the link between children and adults, increase violence, and expose individvals to more traumatic and unnatural deaths. Second, medical advanceshave resulted in an increased lifespan, altered mortality ates lengthier chronic illnesses, and intensified bioethical dilemmas. Finally, these trends are accompanied by the realities of increasing political tecrovism, assassina- ton, torture, and genocide, played out against the ever-present possibility of ecological disaster, nuclear holocaust, and megedeath. All of these factors have a dramatic and undeniable impact on today’s mourner (see Feifel, 1971; Krupp, 1972; Rando, 1984, 1987a; Volkazt, 1957). Unfortunately, contemporary trends have resulted in death's being, away oflife Previously, thanatologists observed that urbanization, result= ng in less contact with nature and the extended faraily, caused a lack of ‘exposure to death in a natural context. They pointed out that this lack of exposure contributed to an array of problematicresponses, particularly increased death arvdety and denial of death. Today, aa a result of current sociocultural and technological tends, many persons are exposed to death allthe time. But the deaths they are exposed to are often unnatural, violent, and frequent. Such exposure—often sensationalized and exploitative, not personally traumatizing —fosters desensitization and repression. To these trends must beadded problems caused either by the stil significant lack ofopen communication about loss, dying, and death orby inappropriate Iboduction 7 romanticization of these phenomena. These problems impede mental ‘health, fosterpathology, and further compromise the individual's ability tocope with death when it does occur (Rando, 19873). In partculay, violence in contemporary sacety contributes signi cantly tothe increasing prevalence of complicated mourning, As reported by the Federal Bureau of Investigation (1990), one crime index ofense cceurs every 2secondsin the United States, with one violent rime occur ting every 19 seconds (a murder every 4 minutes, a forcible rape every minutes, arobbery every 55 seconds, and an aggravated assault every 38 seconds) ‘Three social trends are often associated with this increase in violent csime: breakdown ofthe family avalability of weapons, and increased alcohol and drug abuse. Violent crime in this country increased by 10 percent in 1950, according to the FBL, such that Attorney General Dick ‘Thomburgh stated that “a cizen of this country is today crore likely to be the victim of a violent crime than of an automobile acident (‘FBI Reports,” 1991) The United States Department of justice estimates that five outofsixof today’s 12-year-old willbecome victins of violent crime uring their lifetimes (National Victim Center 1991), with estimates for the lifetime chance of becoming a victim of homicide ranging froin Lin 18310 Lin 153, depending upon the source of the statistics (US, Depart ‘ment offustice, 1985). righteninly impressive statistics document signi cant increases in murder by juveniles, wife beating, abuse of senior citizens, hate-motivated crimes, sexual assault, and child abuse and neglect, Thereaderis referred to Rando (in press-b)for delineation ofthe statistics and discussion of media violence believed to perpetuate such ‘Type of Death ‘Today, deaths are more frequentiy of atype known to contribute to compli- cated mourning, In particular, these include sudden, unexpected death, especially when traumatic, violent, mutilating, orzandom; death resulting from an overly lengthy illness; death ofa child; and death the mourner perceives as preventable, ‘Sudden, unexpected death associated with traumatic circumstances ‘Technological advances have decreased the proportion of natural death and increased the proportion of sudden, unexpected deaths asso- ciated with trauma, The decrease in natural death hinges upon the sub- stantial improvements in biomedical technology. Very simply, people are capable now of surviving linesses that previously would have killed them, ‘This eaves them alivelonger to be susceptible to unnatural death. Inaddi- ‘tion, the inerease in unnatural death results from greater exposure to8 charreey machinery, molor vehicle, azplanes, chemicals, rears, and other potentially dangerous technology. Toalof ths mustbe added increased ks oftunnatua death consequent the developmentol nen weapons ana yeapone syteme, capable of filing ever restr numbers. These Iypesof deaths eqn ae troumatic i ature andincorportc on or ior of he follwing fers scenes and lac of ation, ‘lene, mutton, and destruction, randomness andor : Snipe dest or he mouse’ pesona encour wih death and, inprest), Cone assodnted with accident, homicides and oui, dent of eis sort transite ico higher protabltis of complicated ourning Frequently associated with trauma, accidents are the single most common ype feud, unexpected death or persons of any age Incl ingmou deaths inolving motor vehices fats, potonng, owning fe suffocation, and fran accidents are thea cane ot death anorg, All persons ages 18037 and represent the fourth ending case of death Ang persons ofa age National Safety Counc 199). On the average there are Tl acdenal dest and about 1050 disabling injuries every hour dzng the yea (National Safety Counc, 191). Clonee 1N)000 «ident flies oct ench yearn the United States wt death by ace ran ing iat in term of ves los prematurely (Dion & Clearwater, 19), Homie‘ the second scenaioin which udden, amexpecte deaths associated with eauma commonly ocur The increase in the incidence ofhomiid the sising number seal Kile, andthe nature of hei Jencspespenatedbefore during and afer te Sinalhomidal oc suggest that, today ska ndvidnlsae ding sche things. More than ever before, home mate the form of clo ital ing, tv ing random ling or drive shooting. Moe than ever blog it maybe sccompanied by predesth torture an pordeat deflement. Telnet. ing pathology of tote who commit murder may be seen asa rebut of detensing sol prohibitions increasing socal violence, exealatng socal dlaconnection and senses personal powerlessness and, pechape mest import, increasing inpalment of peyhologicl development, ten characteried by an snes conslnce, low frstation tolerant, poor Impulse conta inailty to delay gratification or modulate aggression, ‘sense of deprivation and entiemnent, and ntally poor ctachanené bonds and pagel pater cfvelating, Once spun, ase eiishave beenhypothesioe ot various tinesas due ta nunber of sal enon ene all of which enable violence. Among these phenomena ae deine of the nce fay increased parental tbsence or esl increased physi and senalebuse of chldren (who, once vince can go on fo become vietimizers themselves) exposure to violence on eletsion andin he ervioneent the avolabliy of guns, drugs, and akohol-and poverty, anemployment, and other rcesion ca sale, Introduction 9 The third scenario in which sudden, unexpected deaths oceur is suicide. Higher suicide rates currently found in Western society appear to derive from the same sociocultural trends that generally contribute to complicated mourning, Death associated with an overly lengthy illness Another increasingly frequent type of death results from long-term, chronicillness. Because of biomedical and technological advances, today many illnesses are longer than ever before. Depending on the cizcum stances, deaths associated with long-term chronic illness can bring a host ‘ofunique stresses, including previously unheard of bioethical dilemmas. ‘These stresses generate the types of experiences that can come back to ‘haunt the survivor and interfere with healthy adaptation toloss (see Rando, 1986a, 1986e, 1986h for a complete discussion of these experiences). Tthas been well documented that survivors are at risk for significant problemsin mourning when aloved one's terminalillness persists for #00 long (e-g-, Rando, 1983; Sanders, 1982-1983). AIDS and other ilinesses, associated with the Hunan Immunodeficiency Virus, or HIV, pose per- ‘haps the most striking contemporary example of tissituation, Inthe case of HIV infection, the multidimensional stresses that accompany other long,term illnesses are compounded by anger, ambivalence, guilt stigma- tization, social disenfranchisement, problems obtaining health cre, and parental bereavernent. Indeed, the fac that an individual may test positive for the HIV virus long before developing any clinical manifestation of ilness—coupled with a particularly unpredictable and difficult disease course—gives new meaning to the notion of stress in both the individual with the infection and in survivors. Death of a chi Inthe past, parents commonly predeceased their adult children. How- ‘ever, advances in medical technology and resulting increases in the life- span have permitted parents to survivelong enough to witness the deaths ‘of theiz adult children, The problems associated with death of any child are extrome; frequently, death of an adult child poses additional compli- cations (Rando, 19860). Death the mourner perceives as preventable ‘When 2 death is perceived as having been preventable, the individual ‘experiences additional complications in mourning. This was adeath that did not have to happen—it could have been avoided. Carelessness,negli- gence, or maliciousness perceived to have caused the death brings anges, Feelings of victimization and unfairness, the need to assigh blame and30 HAPTERL responsibility and mete out punishment, obsession and mamination, attempts to regain control, lack of closure, significant violations of the assumptive warld, and the search for reasons and meaning. All ofthese sequelae complicate mourning and interfere with coping, Antecedent and Subsequent Factors Associated With the Individual Mourner Complicating factors associated with the individual include a markedly angry or ambivalent, or markedly dependent, premorbid relationship ‘with the deceased; mourner liabilities associated with prior or concurrent (@) unaccommodated losses and/or stresses or (b) mental health problems; and the mourners perceived lack of social support. Each ofthese factors is on the rise in our society. “Asacconsequence ofthe aforementioned socal trends, there hasbeen, an increase in conflicted (e., markedly angry or ambivalent) and depen- dent relationships in our society. Specifically, these have escalated secon- dary tothe exclusivity and limited ange of interaction within the American ‘family (Volkart, 1957); the overall increase in physical and sexual abuse and victimization of children and adults; and the developmental conse~ quences of being raised in families headed by parents who are peychologi- cally impaired, substance abusing, absent, or neglectful. "A growing liability for today’s moumeris the existence of increased prior or concurrent unaccommodated losses or stresses. There is no ques- tion that current sociocultural trends bring additional losses and stresses into an individual’ life, both priortoagiven death (eg. parental divorce) and concomitant withit (eg., unemployment). Because such losses and stresses may contribute to complicated mourning, the contemporary mourner is relatively more disadvantaged. ‘The mourney’s personality and mental health also critically influence the ability to mourn aloss successfully. The sociocultural trends previously outlined may negatively affect psychosocial development, resulting in increases in both individual deficiency and conflicted or dependent rela- tionships with others. In particular, clinical cbservation suggests that im- ‘pairments subsequent to poor attachment bonds with one’s parents can bbe transmitted intergenerationally and result in psychosocial deficits in one’s own offspring. In addition, itappears appropriate tohave increased concern about the long-term impact of family destabilization (eg. divorce, ‘multiple caretakers for children, decreased quality and quantity offamily. time) on ability to cope with loss and stress. Difficulties related to thetypes of early developmental defects and poor psychosocial experiences known to ensue from such situations are reflected in rising rates of anxiety dis- orders, as well asin the dramatically increased frequency of borderline, narcissistic, and antisocial personality disorders and the notable esc ton of impaired superego development and poor impulse control. The Intmduction 18 {increased incidence of such disorders implies that a greater proportion of individuals will experience complicated mourning, given that such diagnoses predispose toward negative outcomes. "Another reason for increased complications in mourning concerns the ccampromise af the mourner’s resources and the mourner’s subsequent ‘perception ofa ack of social support. It is quite clear that conditions in society today promote disenfranchisement in the three areas in which it ‘may occur ((e,, invalidation ofthe loss, the zelationship, or the moumer; ‘Doka, 1989). Examples of invalidated losses that areon the increase include akortions, adoption placements, the death of pets, and losses associated with Alzheimer's disease. Invalidations of the lost relationship include scenarios in which the mourner does not share a kin tie, a socially sanc- tioned relationship (eg.,.gay orlesbian relationship, extramarital affais), ora current relationship with the deceased (e.., former spouse or in- laws). Situations where the mourmer is iwvalidated occur frequenly when, the mourner is an elder cra child, or has a mental disability. PROBLEMS IN THE FIELD ‘Two main problemsin the field exit with zegard to complicated mourning. ‘The rst concerns dificulty defining the phenomenon. Thesecond relates {failures on the par of the mental health profession to recognize andor understand the phenomenon, Difficulty Defining Complicated Mourning Anadequate definition of complicsted mourning has been elusive, mainly ‘because imprecise and inconsistent terminology is used and because objec- tire cxiteria to determine when mourning becomes complicated arelacking. ‘Acvatious times and by various authors the phenomenon of complicated mourning has been described as morbi, atypical, pathological, neurotic, uunresoloed, complicated, distorted, abnormal, deviant, or dysfunctional. All of these terms and more have been employed to indicate that a mourners response to loss is somehow failing to progress as the person evaluating itchinksit should. Each of these terms has its ovm qualifications andlimpli- cations, yet with little orno definition their usefulness is imited. The fact that the terminology used to denote complicated mourning is vague and inconsistent impedes consensus on what the phenomenon entails and Interferes with communication between mourners and caregivers, 2s well as among caregivers. In addition to imprecise and inconsistent terminology, objective cciteria to determine just when grief and mourning become complicated. ate absent, primarily because what may constitute pathology in one set ofcixcamstances may not in another. Several physicians will likely agree2 carry that bone isbroken. However, mourning phenomena tend notto beso inarguable.Forinstance, a womar(s hearing her deceased husband's voice in some circumstances is quite appropriate but in others reflects gross, pathology. In brief, the demarcation between uncomplicated and complicated mourning is hazy at best and constantly changing. Such change is due rot only toadvancementsin data collection inthis area but alsoto the fact that no determination of abnormality can be made without taking into con- sideration the various sets of factors known to influence any response to Joss (Rando, 1984). Reactions to loss can only be interpreted within the content of those factors that circumsctibe the particidarloss forthe particular ‘mourmer in the particular circumstances in which the loss took place. ‘The idiopathic perspective required by such a situation prohibits a rigid definition of complicated mourning. Unfortunately, the lack of specificand objective eriteria interferes with the development of a valid, reliable, and precise definition, which in turn impairs operationalization, ofthe phenomenon and ultimately the generalizability of findings about 51 Fora these reasons, it's more useful tolookat complicationsin mourn ing processes than to focus on particular symptoms of complicated mourn: ing, Although these processes—identified in the present volume’as the six "R” processes of mourning—certainly are influenced by idiosyncratic factors, they do provide an objective bench mark against which to evaluate ‘mouming. Because subjective pain cannot be compared among mourners, these processes also serve asthe areas in which (o compare andl contrast impediments and complications. Therefore, as defined in this book, complicated mourning is a generic term indicating that, given the amount of time since the death, there is some compromise, distortion, or failure ‘of one or more of the “R” processes of mourning. Issues in the Mental Health Profession ‘The mental health profession sustains three specific problems when it ‘comes to bereavement. (Forthe purpose of discussion, the mental health profession is construed as including all those who provide care tothe be- reaved, whether or not they are formally considered mental health ‘workers.) These problems are lack of adiagnosticcategory for complicated mourning, insufficient understanding of bereavement, and limitationson ‘weatment. Lack ofa diagnostic category for complicated mourning First among the problems in the mental health profession is the lack of a diagnostic category for anything but the most basic uncomplicated ariel. Al present, the Diagnostic aud Statistical Manual of Mental Disorders (DSMILR; American Psychiatric Association, 1987) contains only the diagnostic category for uncomplicated bereavement (V62.82). The criteria Introduction 13 {forthis diagnosis typically are seen as quite unealisticin light of contem- porary information about uncomplicated mourning, Thus, caregivers are forced to assign other diagnoses that have clinicalimplications unaccept- able to many bereaved individuals. Common diagnoses inchide one ofthe depressive, anxiety or adjustment disorders; brief reactive psychosis; or ‘one of the other V-code diagnoses. Annumber of authors argue persuasively for delineating diagnostic “cteria for bereavement reactions and including these in subsequent revie sions of the Diagnostic and Statistical Manual. Several proposals for new diagnostic criteria for mourning have been offered in recent years. After ‘examining adult grief and its interface with mood disorder, Hartz (1586) [proposes preliminary diagnostic criteria for the syndromes of complicated bereavement and uncomplicated bereavement, He finds the diagnostic criteria forthe later especially unsatisfactory in the DSM-IR becuse 2 time frame for determining when bereavement becomes complicated is lacking, Noting that there is little doubt that symptoms other than de- _pression are present in mouming but that no evidence exists that any of ‘these symptoms point dearly to abnormality, Hartz suggest using symnp- toms of depression and a period ofa year as beginning criteria, However, |herecognizes the limitations of using symptoms of depression exciusively ‘and recommends further research in order to determine which symptoms should be used to formulate diagnoses. In addition, he urges more research to develop the most appropriate criteria for different populations of bereaved individuals (eg, hereaved patents; adults los nts, siblings, and close friends). i ae ‘Farkes and Weiss (1983) agree that more emphasis must be placed on, grief as a condition that stands by itself. They note that a mumber of de- tailed studies of bereaved psychiatric patients reveal that most suffer from atypical forms of grief and that the symptoms bringing them into psychiatric care are part of an overall clinical picture having the form of Sistorted or abnormally persistent and severe forms of grief. Yet because sriefis not, and has not been, a recognized clinical diagnosis, such indi viduals tend to be diagnosed as suffering from reactive depression or a similar condition, depending upon the symptoms predominating at the initial request for help. Parkes and Weiss propose a method they feel is Detter than diagnosing grieving psychiatric patients as having some forin of depression—advocating the recognition of pathological forms of grief «8 separate conditions in their own right, each having a distinct etiology, psychopathology, symptomatology, and prognosis. In articulating the problem of iting grief and mourning into tract ‘ional medical diagnostic categories, Parkes (1987) observes hat most cini- cians dassify « bereavement reaction as aeactive depression and overlook the fact that, although depression is a prominent feature, separation aruciety is more characteristic ofthe pang of grief. However, because sepa ration arvety is not always the symptom causing a bereaved individualMo ciarmeR: toseekhelp, Parkes does not see putting mourning under a subgroup of anxiety states asthe ansiver. Parkes and Weiss (1983) suggest a tripartite classification of unanticipated, conflicted, and chronic grief, each of which hhas the two features evident in all forms of atypical grief: intense separa- tion anxiety and strong but only partially successful attempts to avoid grieving. Parkes (1987) concludes as follows: know of only one functional psychiatric disorder whose ‘cause is known, whose features are distinctive, and whose ‘course is usually predictable, and this is grief, the reaction to Joss. Yet this condition has been so neglected by psychiatrists ‘that until recently it was not even mentioned in the indexes of ‘most ofthe best-known general textbooks of psychiatry. (p. 26) Also sensitive to problems in diagnosis, Beverley Raphael and her colleagues in Australia have reviewed th cioniicand clinical literature and surveyed the opinions of experts inthe field in an efor to devise Research Diagnostic Criteria for normal and pathological grief. These have ‘been developed and now are being proposed for adoption by researchers and clinicians in order that reliability and validity can be farther estab lished Raphael, Middleton, Dune, Mactnek, & Saith, 19%) Itappeass from the literature, as wellas from general complaint among clinicians thatthe near fature must ring improved diagnosticcategories for uncomplicated and complicated bereavement in the psychiatric nomenclature and subsequent revisions of the Diagnastic ad Statistical ‘Manual. Inclusion ofthese diagnoses willindieatean appropriate arare- 1ess ofthe need tofocusnesearch andintervention on gue and mourning, row that its serious consequences have been impressively documented (eg. Osterweis etal., 1984). Inaddition, such recognition willzepresent yet another step inthe continued evolution of the conceptualization of the ‘mourning experiences complex, widezanging, and deeply influential. Insufficient understanding of bereavement ‘The second problem in the mental health profession sthat most prac- titioners have an insufficient understanding of bereavement. Like the general public, they tend to have inappropriate expectations and unzeal- istic attitudes about grief and mourning, and to believe in and promote the stereotypes pervasivein society at large (see Rando, 1988). Caregiver misinformation is probably the major cause of iatrogeresis in the treat- -ment of grief and mourning. Inpaticulay insufficient understanding ofthe concurrence ofbereave- ‘ment with psychiatric complications causes much difficulty. Jacobs and ‘Kim (1990) have made it clear that, in the past 20 years, attention to the Introduction 15 paychiatric complications of bereavement has diminished. Thesesulthas been two serious conceptual problems that conteibute to the prevailing professional uncertainty regarding the nature and clinical significance st the “paychopathologic syndromes observed during acute bereavement” Oscobs & Kim, 1990) p. 34). The frst conceptual problem concerns the {Ghestion of whether pathological syndromes occur and how to distinguish them, given that no DSM-IER category for them exists, Along with any others, Jacobs and Kim are frustrated by the DSM-IILRs lack ofan appro piste formal category for complicated mourning, They note thats nueaber ofDSMIILR symptoms of major depression e.g, morbid preoccupation ‘with worthlessness, prolonged or marked functional impairment. searked psychomotor retardation, and suicidal gestures) are absent for many of the unremitting depressions of bereavement, If such symptoms are required criteria for diagnosing major depression among the bereaved, the result will bea significant underestimation ofthe rate of depression: asacomplication of bereavement (iacobs & Lieberman, 1987). Inaddition, anxiety disorders have been found to complicate bereavement (jacobs, Hanson, Kasl, Ostfeld, Berkman, & Kim, 1990) but are not included as potential complications in the DSM-UT-R. Consequently, they too may go ‘unrecognized, increasing both their underestimation and the litelixood that they will go untreated ‘The second conceptual problem identified by Jacobs and Kim (1990) concerns the problem of understanding the psychiatric complications of bereavement, given the two competing models and nosologies in psy- chiatry. On the one hand, in psychoanalytic psychiatry, complications are characterized as symptoms of pathological mourning. On the other, inthe SAGER nosology of American psychiatry (he, the aeortcl mol lying. (ITER), pathological mourning is not considered to bea psychiatric syndrome despite clinical evidence tothe contrary Jacobs and Kim find that depression and anxiety have significant overlap inure complicated and complicated mourning and report on statistics for the ‘prevalence, duration, comorbidity, andisomoxphy of these two responses, Arguing that this information must become common knowledge forall ‘mental health professionals, they conclude as follows: eth causative nature ofthe loss were ignored, clinical undetsanding othe prychopathologc andro asa ‘aladaptation and inplicatons fx poychothenpentc intervention would be missed. On ha other han the slationship berween pathologie grief and arsety or depres: sive disorders were ignored there would bean undeeaies fon of peehstc eomplcatons a wel ase porsnna tht psjchopharmacloginterentions would be ied integrated concept combines an etlote perspective with standardized enter andes in undantending16 Harmer nature of the psychopathologic process and the objectives of ‘treatment. Neither approach to treatment is sufficient, and an integrated model holds more promise forboth the diagnosis and the treatment of the patient. Jacobs & Kim, 1990, pp. 316-317) Limitations on treatment ‘The third problem inherent in the profession concerns decisions by third-party payers to decrease funds and increase restrictions on mental health services. Unfortunately, these changes do not take into account the findings that uncomplicated grief and mourning are more significant]y associated with peychiatrc distress (e.g, Jacobs & Kim, 1990) and persist or a longer duration (eg, Zisook & Shuchter, 1985) than previously be- lieved. Such policies also coincide with the reality that the incidence of ‘complicated mourning is increasing and that higher proportions of the bereaved will require more extensive treatment, Inather words, atthe exact point when the mental health community will have more bereaved indi- ‘viduals, with more complicated mourning, requiring treatment forlonger periods of time, mental health services will be subjected to imitations, preapprovals, third-party reviews (often by persons ignorantabout the ‘area), the application of short-term models, and inappropriate diagnosis {forcediby an inadequate classification system). Plainly, thecurrentsystem ‘willbe unable to respond tothe coming onslaught of individuals experienc- {ng complications in mourning, As caregivers, we must find models, approaches, and treatinents appropriate to these grim realities, CONTENT AND ORGANIZATION OF THIS BOOK ‘This ook focuses on adult bereavement. Theinterventions described are ‘rimaily pertinent to individual weatmen, although certainly mos infor talon canbe readily ecrapoatedofitcterreatnent medaitios Part provides an overview of the fundamentals required to place complicated -mourningin he proper context. Specifically, chapter? offersa perspective onloss gif, and mourning, reviewing the information about ancompl- cated pref anc mourning that underpins the remainder ofthe discussion. This chapter briefly identifies the six “R” processes of mourning, or the processes whereby the mouzner moves from an inital recognition of the Joss through eventual ceinvestment in other sources of gratification. As noted, itis the compromise, distortion, oF failure of one or moreof these processes that by definition constitutes complicated mouring. This teview is relatively bret the presumption is that the reader is well acquainted ‘with the iteraturein this area. I this is no the eave, the reader is urged to consult Grif, Dying, and Death: Clinical Interventions for Caregivers (Rando, 1984) forthe necessary background, Intreduction 17 Chapter’ reviews the work of 19 individuals whom Ifeel have made ‘the most significant contributions tothe literature on complicated mourn- ing. The workof many fine contributors to other azeas of thanatology has been omitted solely because of a strict focus on complicated grief and mourning. The chapter is exceptionally long for a review of this sort because, unfortunately, too many professionals are unfamiliar with the lassicliterature in the field. An understanding ofthe precise development ofthis literature is essential to comprehension of much of the subsequent discussion in the book. In addition, important information about treat- mentcan be extrapolated from these sources, This is not aceitical review Duta surnmary of available writings: When reporting the work ofa particu larauthor, Ihave used his orher own terminology and have assumed that ‘the underlying philosophy and treatment approaches are valid. Thereader is urged to be open-minded when considering the work of an author ‘whose language, philosophical approach, theoretical biss, or empirical data might be personally unacceptable. ‘Chapters 4 and 5 detail four complicated outcomes that may result fromloss: (a) complicated grief and mourning symptoms~psychological, behavioral, socal, or physical manifestations that are of insufficient number, intensity, or duration to qualify as acomplicated mourning syndrome cra iagnosable mental ox physical disorder; (b) one of seven complicated mourning syndromes; (c) diagnosable mental or physical disorder; oF (d) death. Specifically, chapter 4 synthesizes information on the symptoms ‘ofcomplicated mouzning and the clinical syndromes ofcmplicated moum- ‘nginto which they may coalesce. Treatment issues are described for each syndrome. Chapter 5 follows the classification system of the DSM-UFR sm@amining the associations between complicated mowing and recog nized mental and physical disorders. The discussion also briefly eamines ‘he potential for death in extreme cases, noting that this outcome may result rom suicide, acute consequences of complicated mourning symptoms (e.g, fast driving), or the long-term sequelae of complicated mourning (eg, cardiac problems secondary to increased smoking and drinking). Fart Il addresses concems relating to assessment and treatment of ‘complicated mourning. In particular, chapter 6 outlines issues in assess- ment and describes the proper use of a new clinical tool, the Grief and ‘Mourning Status Interview and inventory (GAMSM). (The GAMSTitself is presented in an appendix to this volume.) Chapter 7 discusses seven specific treatment approaches to complicated mourning, offering anexten- sive review of primary sources. Chapter gives a brief overview of research ‘concerning the efficacy ofintervention in mourning and discusses philo- sophical perspectives on treatment and generic treatment guidelines pert- nent fo all work with complicated mourning. Finally, chapter 9 identifies specific interventions for working through the se “R” processes of mourn ing, which by definition are incomplete if mourning has become complicated18 cHAPTERL Specie clinical problems are the topic of Par IL. The first three ‘chapters in this section deal with risks and therapeutic implications associated with various factors implictin the loss. Chapter 10 focuses on individual, relationship, and system factors such as mourner liabilities, anges, ambivalence, guilt, dependency and codependency, and social support. Chapter 11 concerns potential problems associated with the various modes of death (ie., natural desth; accidental death, including disaster and war death; suicide; and homicide). The high-risk factor ofthe ‘mouror’s perception of the death as preventabeis discussed under the topicofhomicie.losues relating to sudden, unexpected death; multiple death; and traumatic death are the topie of chapter 12, and concerns associated with death ofa child and AIDS-related death ae the focus of chapter 13. Chapter M4 identifies various caregiver concems in the teat iment of complicated mourning, specifically discussing common thera- peutic erors, counterttansference, and stress-related issues. ‘Except where the work of particular theorists discussed, the generic term cinigiver has been chosen in order to help readers fromm all profes sions identify with the person attempting to intervene therapeutical. Likewise, the term compliaatd mourning has been chosen over other Yar ants unless another term is characteristic ofa particular author's work. Finally, throughout the book, masculine and feminine pronouns have been used alternately to designate the mourner. CHAPTER 2 A Perspective on Loss, Grief, and Mourning In order to be able to understand and treat complicated mourning, one ‘must comprehend the uncomplicated mourning processes from which it departs. This chapter offers an overview of uncomplicated grief and ‘mourning. First, the terms loss, grief, and mourning are defined as used ‘throughout this book. The inevitability ofloss and myths and realities of mourning are next discussed, followed by an outline of factors influencing individual response toloss, Next described are three phases of grief and ‘mourning and the six R” processes of mourning that take place within these three phases, Finally, perspectives on the duration and course of ‘mourning aze presented, and the phenomenon of subsequent temporary ‘upsuges of griefSTUG reactions—is discussed. As will benoted repeatedly in subsequent chapters, the tréatment of complicated mourning involves ts conversion to uncomplicated mourn- ing. Therefore, it is imperative thatthe caregiver be totally familiar and comfortable with the content of this chapter. For more detailed discussion ofuncomplicated mourning, the reader s referred to Rando (1984, 1988) Other recommended resources for further analysis ofthese topics include Bowlby (1980); Freud (1917/1957e); Glick, Weiss, and Parkes (1974); Lindemann (1944); Osterwels etal. (1964); Parkes (1987); Parkes and Weiss (1983); and Raphael (1983), DEFINITIONS Definitions of oss, grief, and mourning are important because the care- siver’sinabilty to appreciate the implications oftheir differences may con- tribute to the devolution of loss reactions into complicated mourning.2 cHarreR2 Loss Two general categories oss ext physical loss and psychosocial oss al este lou of something tangle. Eeomples inlude act that olen, abousethet bums down, abreast thatissurgealy removed, oramemeno thats misplaced. Often, others recognize physical esses auch; usually thereat leas inital evacenes that he ini ‘have feelings about the loss and ay have deal with them. Tneon- trast apes Ine—sometines called sya ose ithe oss of somethingintangble, payhosoc in nature, framnpes include geting, 2 divorce retiring developing chroniciiness, ot heving «eam shat tere. Such events ar seldom recognized by overs aslosses generating felings that require processing. "Achat minis one orth sat of hang steed sea his intresting tonote thatthe words errand rb dese om he ame oot ‘whichizples an uniling deprivatonty orc, having something th eldunjundyandinucouslyastealing aay feomettingvluable—all of which lev the inva victized, Any type of change necesraiy involves oes. tthe very leat loss ofthe statis quo envotved. Unpleasant changes or depriveons eg theta ofealaed jewel the development of seriousness) ae usualy leary recognized by both the moter and her soc group, However, change thet is not unpleasant alobringsloss, andthe usualy goes ur, recognizedby the moumer socal grou and atten by the movener r= sel Thee types of change tha automaticaly constitute lose het defined asouch orn ate dereopnental lay lose resulting om nonral charge and growth, and competency-based lee. Developmental los crs as aatzlencequenceo thehutan development an aging te cess (eg. eyesight deteorates stengt dzadse, thinking poveses Slow), Losszemaing from nora change and groth follows rom usted development and maturation inlfee., acouple goesfrombeinge dyad fa tad wth the birth of tei ist cil, an adolescent relingushes dependency on his parents) Finally, competency-based oss stems rom theattainment ofcerain ables, capcties or functioning (eg, gradu, son‘zom college achidsleavinghome, even theachievenente desired al). has “A secondary loss is a physical or psychosocial loss that coincides with cx developsasacorsequenceoftieintalloes Focexample withthe ceath ef soved one the mourmer experiences the secondary pysclloss of theloved one’s presence the mournerhastorelocte due economic hardship after the death this creates another secondary phyoia loss “The mouse typically sustains much more than pia los afer death. Loved ones lay many roles an individuals, or instance aspouse may be ones lover bet rend helpmate, confidant, coparent, Social partner housemate tel comparion, busines associ cree? Lass, Grief end Mourning 21 supporter, auto repair person, housekeeper, and “other half,” among myriad other soles. With the death, the mournerloses someone toil these roles and to gratify the needs and sustain the feelings associated with them in the particular way the deceased did. In addition, the mournerloses 2 view ofthe world and the countiessfeelings, thoughts, behavior and inter- action patterns, hopes, wishes, fantasies, dreams, assumptions, erpec- tations, and beliefs that required the loved one's presence. The deprivation cof the gratification the loved one once provided, the unfulfilled needs, the _unreinforced behavior patterns, the unmet expectations, the emotional Privation, the violated views ofthe world, the dashed hopes, the frustrated ‘wishes, and the roleelationshipsleft empty azeall examples of secondary psychosocial losses associated with the death, Each of these secondary losses initiates its own grief and mourning reactions, which ultimately may be greater orlesserin intensity and scope ‘than those following the precipitating loss. At the proper time, each of ‘these secondary losses must be identified and mourned justas the actual death precipitating it must be mourned. The following case example ‘lustrates this point, John was 20 winen is father died. Fle was in college studying engineering at the time. Atter the death John was forced to abandon his dream of becoming an engineerin order to fake ‘over the family grocery store his father had ovmed and ‘operated. Without this there would Ihave been insuticient income for John’s mother and three siblings. Toh not only lost his father; heals lost his vocation, his independence (he had to move back home), his glsiend (after John’s withdrawal from the university she found some- ‘one eise who was near enough to spend more time with het), and his role as & happy-go-lucky young adult (be now assumed his fathers sole in the family as eldest male and chief provider) Until John could identify end grieve over these secondary losses, his grief could not be resolved Ironically he could cope better with the loss of his father, which he had been gradually preparing for than with the ‘other losses that his fathers death brought about. (Rando, 1984, pp. 53-59 A mourner may sustain a psychosocial loss without an accompany ing or consequent physical loss. Itis impossible, however, o experience aphysicalloss without an accompanying or consequent paychosocial oss. At the very least, the significance the mourner assigned to the tangible object is lost when the object is lost. Therefore, every physical loss will engender psychosocial loss,22 CHAPTER? Insummary, in mourning the death of any loved one, amixture of both, physical and psychosocial losses, as well as anumber of secondary losses, accrues. These secondary losses can be physicalor psychosocial nature and generate their own grief and mourning reactions. Because the death of a loved one brings many losses, what one perceives as a given in- Aividual’s grief and mourning fora specific death is actualy the Sura total of all the grief and mourning for each of the losses experienced in con- nection with this death, ot CO) “2 psychological, behavioral, social and physical reactions othe perception ‘of loss. Five important clinical implications derive from this definition sls expres maje ways: prchelogialy oe ee ee ae ene eat utbeopby! Uist behenoly (eough peor selon conduc ,, demeanén), socially (through reactions to and interactions with \ trey and pata reugh body symptom and ied sa 2. Gling cotoning derlppor. Iya nota ates / ~ rather itinwolves many changes over 2 Gein open tn ag Den warranted by the factors circumscribing Toss, is abnormal eee nae a eee vies ou aaa oct: {validated by others for the individual to grieve, although itis J amost helpful when this can occur \ / ~ cular grief response expresses one or a combination of four Thing a the ourner feelings bout he los and the depron causes (@g,, sozrow, depression, guilt); (b) the mourner’s protest atthe Joss and wish to undo itand have itnot be true (e.g, anger, searching, preoccupation withthe deceased); (9) the effects caused by the assault on themourner as azesut of he loss e disorganizaton an confusion, fear and arvéety, physical symptoms); and (A) the mourners persci tctons sawlete dy theve ft ee og. eying, soda with ne creased use of medication and/or psychoactive substances), Toe (eats oss, Grief, aad Mourning — 23, Any specific grief response is a reaction to the loss. However, the ultimate goal of grief and mourning is to take the mourer beyond these reactions to the oss. Mourning requires more than the passive reactions of grief; it demands working actively to adapt tothe loss. Failure to accom- amodate or respond appropriately tothe changes following a major loss Ge. notadapting but persisting asifthe worlds the same when itis not) constitutes an unhealthy response to anew reality. For this reason, more than griefis required. Mere expression ofreaction tothe loss too passive, ‘There must be active movement and change if a major loss is to be pro- cessed, worked through, reconciled, and integrated intoa mourners fe, and if that individwal is tobe able to continue on in a healthy fashion in ‘thenew life without theloved one. Thus, griefis anecessary but not suff. ‘ent condition to come to success(ul accoramodation af loss. The active processes of mourning aze required as well Mourning. ‘Traditionally, mourning has been defined as the cultural and/or public clsplay of grief through one's behaviors. Ths definition focuses on mourn- ing as 2 vehicle for social communication. However, as defined in this ‘book, the term follows the psychoanalytic tradition of focusing on intra psychic work, expanding on itby including adaptive behaviors necess tated by the loss of the loved one (or whatever has been lost physically oF sychosocially). For purposes of clarity, the following discussion focuses ‘exclusively on the loss of a loved one. Specifically, then, mourningrefers to theconscious and unconscious [processes and courses of action that promote three operations, each with, its own particular focus. The first operation promoted by mourning isthe "undoing of the psychosocial ties Linding the mourner to the loved one, “with the eventual facilitation ofthe development of new ties. Inthis opera ‘on, an internal focus on the deceased helps stimulate the acute grief resulting from the separation, the recollection and reexperience of the deceased and the relationship, and the ultimate changing of emotional investment the deceased and developmentof anew relationship In the second operation, mourning processes help the survivor adapt othe loss Here there is an internal focus on the mourer as he undertakes the necessary revision ofthe assumptive world; adoption or modification of ‘oles, skills, and behaviors; and development ofa new identity. The third ‘and inal operation promoted by mourning helps the mourerlearn how {olive in a healthy way in the new world without the deceased. There is ‘anextemal focus as the mournerattempts tomave adaptively into thenew ‘world without the presence ofthe loved one through the adoption of new ‘ways of being in that world and reinvestment in people, objects, roles, hopes, belies, causes, ideals, goals, or pursuits,Py ) CHAPTER? ( Z Hane \.77” scTherefore;tidirning involves processes elated tothe deceased, the self, and the external world-Basically- after the death of a loved one the ‘mourer must reorient himselfin relation tothe deceased, the self, and the external world. These processes all occur within the lager context of the six “R” processes of mourning, to be discussed later in the chapter. Specifically, mourning processes related to the deceased include the following, 1. Coming to grips with the reality ofthe loss by gradually acknowl: edging and understanding the death and its implications and. ultimately relinquishing hope thatthe loss can be zeversed 2. Reacting to separation from the loved one (Le., acute grief) and finding ways fo experience, express, and channel all the pain and other psychological reactions 3. Reviewing and reexperiencing psychosocial ties with the deceased (eg, memories, thoughts, feelings, hopes, needs), modifying them, and reacting to changes in them 4. Doing something with the unfinished business with the. deceased that presses for completion 5. Transforming the attachment to the deceased from one anchored in physical presence to one of symbolic interaction; changing ‘he relationship to recognize the death and develop appropriate new ways to relate to the deceased -——Mourning processesrelated to the self involve the following pheno: 1. Altering the needs, feelings, thoughts, behavior and interaction patterns, hopes, wishes, fantasies, dreams, assumptions, expecta tions, and beliefs that had been predicated on the presence of the loved one 2. Coping with the defenses and behaviors used to mitigate the pain of the loss, minimizing and ultimately relinquishing those that Interfere with the necessary completion of the six “R” processes of mourning Finding ways to incorporate the loss into the philosophical frame- ‘work of one's life and integrate the loss with other meanings and systems of belief in the assumptive wold; finding ways to elimi- \ nate, reduce, or accommodate cognitive dissonance \4. Sustaining meaning in the face of major loss—which can destabi- |, lize meaning—and creating some sense out of the “non-sense” of the loss Lass, Grief and Mourning 25 5, Developing a new sense of identity to eflect and incorporate the many changes and readjustments that occur as a consequence of the death 6, Deciding what can and cannot be controlled in terms of the loss; ‘making choices about what can be controlled 7. Deciding whether the loss will be survived and, ifthe decision isto survive, choosing how to do so. Mourning processes elated othe extemal world inch the following 1. Readjusting to the loss by taking on healthy new ways of being in the new world without the loved one (Le., adopting or modifying specific roles, skills, and behaviors in response to the losses sustained and to compensate for the absence of the loved one) Accommodating the loss by integrating its psychosocial and ‘physical wealities, demands, and implications into ongoing Life Finding new people, objects, roles, hopes, beliefs, causes, ideals, ‘goals, or pursuits in which to put the emotional investment that formerly had been placed in the relationship with the deceased In order to offer appropriate interventions, caregivers must under. ‘and the relationship of grief to mourning, The purpose ofthe active work of grief and mourning's to assist the mournerin recognizing that theloved ‘one truly s gone and then in making the necessary internal (psychological) ‘and external (behavioral and social) changes to accommodate this realty ‘Grief helps the individual recognize the loss and prepare for the processes ‘of mourning. Without the experiences and learning provided by acute grief, mourning cannot take piace. (For more on this issue, see the subse- ‘quent discussion of the Confrontation Phase of mourning.) Griefis actualy the beginning part of mourning. Uncomplicated reac- tions of acute grief may last a number of months and, in some specific ‘cases, even longer. In contrast, uncomplicated mourning can last for a number of years if not forever under some circumstances. This does not ‘mean that the individual is in acute grief all ofthis time. Onecan mourn, but not bein acute grief (i.e,, not manifesting psychological, behavioral, social, orpiysical reactions tothe perception of loss). Even though grief reactions may be spent, the mournerstillmay have to achieve much adap- tation and integration before the loss is successfully accommodated in ongoing and future life Also there willbe times when the mourner experi- ences subsequent temporary upsurges of grief, as discussed later in this chapter. Hence, just as infancy is a part of childhood bist childhood is composed of moze than that one phase (e.g, toddlerhood, latency stage,25 CHAPTER? easly adclencence), git i a part of mourning but mourning isnot rly apart of ge. By dedeon, mourn encompasses ich thor than gk a his Gassic atte “Symptomatology and Management of Acute Grief Lindemann (154) coined the tex ri ork Is an apt expres Sion, expicly recognizing the labor requed in coming to gripe sith tndladaping othe om ofslonedone, However, the pene mote appro Ditely might be grifand mourning work because te aks Lindeninn {tneaes( entnpation from tebondage the deease,rngjus- tentothe environmen white deceased missing andthe forma ton fnew relationships) do notresdeexusvely within te dauain but are ls a prt of mowing errne dlintnetion between grief avd mousning is crucial to treatment ‘Many caregivers asset the Bereaved sith the Fegan process expressing the reactions to the los) but not with the niportnt ater processes ce, reorienting in elation to the dacease, the el nd the {Steal word). Asaesul mowers sre requertl leon he own 9 reshape self and wold ater the les of loved one. INEVITABILITY OF LOSS Repeately, human beings re mourners in if. There fano escaping he inevitability of continvedcontrontton with oe, whether that os i teeocnted with death of pe, rection bya particular cslege orc, development ofachonicHineas,orsome ale event. Therein seeh. ster these experiences (eg loneliness after the os ofthe pet depres tion after being ected b te college, dysfunction ding the divorce, Soda wither concting uronic nes) are ut and parcel cfarouringasocated wth oe They may neverench th ames ts reactions afr the death of beloved person, but they ace variations on the ame theme~ psychological, behwionl socal or pyc enc fons to the perception lose "The mow afc experiences ine always inveive some meatureo lose~physcl, peychovod, cacti of hee wo. Caregivers must helpindiviatis undergoing thse experincesto comprehend them ab losses and fo perceive thelr eactions we gel end mourning response, This fords them beter understanding. increased meting, reduced Helpletsness anda rete senseclconol-allof whch inprewe coping thy, Nes ing el nacontfanevndates “neacing to ths divorce you are mounng the death of our manage tcthe los of your érema forthe utr wi this perso allows man beings to mantge move eect. nthe eld of mental health intervention day, anuaber of eatment areas rereeving well deserved atenton, Thee areas indude, rong ass, Grief and Mourning 2 others, plysic and soxal abuse, rape, problems experienced by adult ehildren of alcoholic and by members of other dystunctonalfealen divorce, suicide, sual dsteretion, fat of iniacy and posttest stress Although the literature may adaess these enconin He loeston special fous los, grit, andmotming ae tujor inherent stpenechondy These cure vsleareasol eoncen ave heirowmjacpens nove, lee all ate loss experiences. Such terization inna ay dns their importance; rather it highight their shared dynamics Althongs the caregiver ast of course be mare ofthe unique conten, desenc States techniques end issues spect trestnen ef these patel groblems placing them on continuum offosscan paride neaghtney thelrcomeronaiy and offer anew perspective on iervenion caer, to een haa iver can erty the apes oes aman experience and respond and fcitate rie ant mourning, set nah sidulpsseiesknowidge andl ndamenltinerventonncrey mas condition MYTHS AND REALITIES OF MOURNING” ‘Work associated with grief " ‘and mourning demands ergy. Unfortunately, this need is sadly misperceived by society, which maintains a host of ‘unrealistic assumptions about and inappropriate expectations for such work and those who undertake it (Rando, 1988). Some notable myths include the following, 1. Griefand mourning dectine in a steadily decreasing fashion over time, 2. All losses prompt the same type of mourning. 3. Bereaved individuals need only express thei feelings in order ‘to resolve their mourning, ‘4. Tobe healthy after the death of a loved one, the mourner must put that person out of mind, 5. Grief will fect the mourner psychologically but will not interfere in other ways, 6, Intensity and length of mourning are a testimony to love for the deceased. 7. When one mourns a death, one mourns only the loss of that person and nothing else. 8 Losing someone to a sudden, unexpected death isthe same 4s losing someone to an anticipated death. 9. Mourning is over in a year,2 coaPrER2 iy egregious myth concerns the presumed role of ime asheflet aa inthe familiar phrases “Time heals all wounds” “Just give ‘tsene? anid “Time will ease the pain” However ime does nothealin and tenor does it necessary affect mourning though i does have {ninifluence onthe amount of support evaable othe mournerand thus canbe constned toatfet indirect Rather whatis done during that time males the diference| Time can lend perspective, and tis can ’be quite helpful. However its the mourner who must develop this per spective and used What ie alone can dois serve as an objective marker” ‘indicating thatthe perio left efi has continued to survive for an extended petiod.Incases ofmajorlos,inwhich the mourner might have {questioned her abiityo endure without the deceased, the passagecoftime can be most validating Myths about grief and mourning notonlyfailtobelp mourners they actually make the experience worse than it necessarily has tobe. This is because mourners evaluate themselves by the mytis incorrect informa. tion; caragivers treat mourners according tit, an family, frends, and society determine the type and extent of suppor offered based upon it. Consequently proper knowledge about grietand mourning is essential foralliwolved to minimize such potentially deleterious consequences as mourners’ personal assumption of failure and caregivers’ insaficient provision of support or inappropriate diagnosis of pathology. Tin adaltion to the negative impact of society's erroneous information and expectations about mowrningin general andits course and duration inparticular, several other often unsecognized issues beat brief mention. ‘Atmajoriseue, already discussed, pertains o the need tomourn notonly ‘he oss ofthe person bat the secondary physical and poychooocal losses that accrue to that loss. "Another issue concerns the fact that aloss reaction sometimes entals age and mourning not only for what one had that now slot but also forvhat one never had and nov never wil have. This situation would exis, for eample, when the death of an individuals mother call forth smouring forthe fac that thee had never been a postive relationship with that parent and now, with ber death, all hope is lost of ever establishing one, Arotheresample would concer theindividual mouming the exper fence of traumaization by child abuse. Aithough that person tay never havehad an appropzate culdhood, thelackofitis st deeply mourned, Morimers an howe who sek to asist them often fl torecgnize thatthe loss of potential (oth for what stil could have been up unt the death ar for what once could have been in the past is alos ike any other Be- cause ofmisunderstanding about thisisste, mourners can beleft without necessary leptimization and support. This only serves to vctaize them farther Afinal important points that majorloss ends to resurrect od issues and unresolved confit (eg, early childhood experiences of anvety and ns, Gris and Mourning 28 belplesoness ol eonfcs about sepaton dependency, ambivlence, ot fnsecusity). Als the experience ofa major loss not uncommonly tage at the roots f ol, incompletely mouaned loses losses that arene sco but are sil partally unmoured; or even opses that although mowed seinain quite ensive Inother word, the destablatoncxcaionedlty tajorlos often pus one in ouch with pat pa and previo ties ck chaos stress and anton, andean summon uals ina oy the pastall of which can add tothe ites ofthe curent experience, Bowiby (2980) oes th sdtional notion that when ons seca peson tovwhom he currently iatached tis pata for hm oun force toan atic attachanen figure i this person also decesoee, the pone of the ener loss may be fl afesh—perhaps eve forthe et re, ‘Thisphenomenon,thereaurecion of previous losses, explain shy smouoners canbe surprised find themselves atthe tanec scare ose ‘eecngon ener oe manatee’ aren (ea, “Twvonder why Tkeep thinking about my divorce as Tn yng deal with my bet edt eat’). I ilustuetes wy careguers nee ee ‘hooughie ter asesment ofa oumer anno ane thal cue renlyexerencedreacions pertain othe deathathand. Quite Requentiy and often unfortanately the mourne hast struggle not ony with contemporary los bt also withthe vestiges of previous losses aswell Sometimes this isthe sole condition under which delayed or inhted ‘eourning fora previous loss expessed (ve chaper Tone inst viewed a woman who ostenasy sought teatment for tne deat of ht husband? month prio However during the interview itbecnme ont {at notwithstanding genuine gee ver er husband lon, the mone dynamic catalyst focher cate rie waste fact that recent cath orcad her o contend withthe dent of her only cd 20 year eaten, What appeared onthe surface as acs grief recent death was actly nee ‘loci of delayed mourning for loss decade before FACTORS INFLUENCING GRIEF AND MOURNING. No person(s grief or mourning response occurs in a vacuum. Rather itis influenced, shaped, and determined by a constellation of factors that combine to rendera mourners response unique—asindividualasa finger. print. In order to correctly diagnose and treat, caregivers must possess ‘complete knowiedge ofthe factors circumscribing the particular loss of 4 particular mourner at a particular point in time. A response perfectly appropriate and healthy for one person under one set of circumstances ‘may be pathological for another in different cizcumstances. This is why sm accurate assessment for each mourner is so important and why each assessment must consider the various sets of factors that can influence individual response,30 CHAPTER? ‘Three broad categories of factors influence grief and mourning: psychological factors, socal factors, and physiological factors. These are listedin Table21, along with pertinent subcategories Fora mare compre- hensive discussion of most ofthese sts of factors and the different impact of variables within each set, the reader is referred to Rando (1984). Oil THREE PHASES OF GRIEFAND MouRNING © L Profesional have ben bombard by stage heriek ong and be reavementinthelast several decades. However mosthavebeenceutioned about the dangers ofzigidly applying such theories and wamed against pigeonholing mourners by inappropritely emoleyingmodelsto ‘explain’ persons instead of ascertaining their particular needs, experiences, or realities. Without question, commonalities exist within the human ‘experience; equally without question, idiosyncratic variations occur. The astute caregiver identifies and responds to both, recognizing that even ‘universal are experienced distnely and individually. Thus, datapather- {ng and intervention must occur at both general and specific levels, ‘To say that grief and mourning follow a progression is not imply san invariable sequence, for human beings are not so unigorm or predic able that individuaityispreciaded in any response. However, the schema described in the following pages elucidates common zesponses to major loss over time. This schema, condensed from a valety of sources and discussed in greater depth in Rando (1984), divides responses into three time periods ox phases, each characterized by aimajor response set toward the loss: Avoidance, Confrontation, and Accomunodation. These thuee phases house af the dfferentloss reactions, regardless of number, type or source (¢.,conceptualizations describing dying patents, divoring individual, persons coping with chroniciliness, survivors of disasters) Although various theories may have different names and examine diverse populations, they all acknowledge these same basic reaction. Ttisimportantto keepin mind that these three phases are not discrete. ‘Themourner probably will move backand forth among them depending ‘upon (a) the precise issue at hand (come issues are easier to cope with than others) (b) how that issue stands with regard nother pertinent issues with which tte mourner must contend, (e) where the individualisin the rmousning process, and (d) the interaction of factors circumscribing this particular loss for ths specific mourner. Not all mourners willexperience all ofthe reactions described. Which ones are experienced depends on the specific factors associated with the mourner’ loss Tor the purpose ofilustration, the following discussion will describe thethree phases as they would apply to asudden, unexpected death. To the edent that circumstances differ responses will differ. For eample, Jn the situation of an anticipated death from a terminal illness, the Table 2.1. Factors Influencing Grief and Mourning PSYCHOLOGICAL FACTORS (Characteristics Pertaining to the Nature and Meaning of the Specific Loss ‘The unique nature and meaning ofthe loss sustained or relationship severed Qualities of the relationship lost (psychological character, stength, and security of the attachment) Roles the deceased occupied in the mourners family or social sytem. (number of roles, functions served, their centrality and importance) Characteristics ofthe deceased ‘Amount of unfinished business between the moumer and the deceased Mourners perception ofthe deceased's fulillment in life Number type, and quality of secondary losses [Nature of any ongoing relationship withthe deceased Characteristics of the Mourner Coping behaviors, personality, and mental health Level of maturity and intelligence Assumptive world Previous lf experiences, especialy past experiences with loss and death Expectations about grief and mourning Social cultura, emi, generational, andreigtousphiosophicalptua background is Sec-role conditioning Age Developmental sage of i, este and sonseof mean and fulfillment : Presence of concurrent stresses or crises 3Table 2.1 (cont'd) (Characteristics of the Death The death surround (location, type of death, reasons for it, moumer's presence ait, degree of confirmation of it, mourners degree of preparation and participation) Timeliness Psychosocial context within which the death occurs Amount of mourner’s anticipation ofthe death Degree of suddenness ‘Mouner’s perception of preventability Length of ilness prior to the death ‘Amount, type, and quality of anticipatory grief andl involvement with the dying person SOCIAL FACTORS ‘Moumer’s social support system and the recognition, validation, acceptance, and assistance provided by is members Mourmer’s social, cultural, ethnic, generational, and religious/philosophicalspiritual background Mourners educational, economic, and occupational status Funerary or memorial ites Involvement in the legal systern Amount of time since the death PHYSIOLOGICAL FACTORS Drugs (including alcohol, caffeine, and nicotine) Nutrition Rest and sleep Bercise Physical health oss, Grif and Mourning 33 ‘Avoidance Phase may not be as dramatic as portrayed here. Many of the reactions witnessed in the Avoidance Phase aftera sudden, unexpected death are present at the time of diagnosis in cases of terminal illness ‘because, for mourners dealing with such situations, this is the time when ‘hey initially contend with the loss and therefore ty to avoiit (See Rando, 1986 for a full discussion of losses inherent in terminal illness) Itisim- portant to qualify this statement by saying, however, that anticipating and actually encountering a death are two different things, and avoidance of ‘the realty ofthe death certainly may be evident in those who lose loved. ‘ones to terminal illness. ~~ ‘Avoidance Phase ‘The Avoidance Phase covers the time period in which the news ofthe death isinitially received and briefly thereatter Ibis marked by the understand. able desire to avoid the terble acknowledgment that the loved one is lost. ‘The world is shaken, and the mowmer may be overwhelmed. Like the physical shock that occurs with trauma tothe body, the human psyche goes {nto shock with the traumatic assault of the death ofthe loved one. Emo- tionally, the mourner may become numb. Itisnet uncommon for theindi- vidual to feel confused, dazed, bewildered, and unable to comprehend what has happened. There may be disorganization of thought, emotion, andior behavior. In brief, the mourner is reeling from the news. As recognition of what has happened starts to seep in and shockand ‘numbness slowly start to wear off, denial immediately takes its place. Denial is natural and therapeutic at this juncture, It functions as abuffes, allowing the mourner to absorb the reality ofthe loss gradually over time and serving as emotional anesthesia while the mourner begins to experi= ence the painful awareness ofthe loss. Possible reactions that may be mani- {ested at this pointare disbelief and aneed to knovr why. From some, there _may be outbursts of emotion—anger, intense sorrow and sadiness, hysteria, tears, ragefal protest, screaming. From others, there may be quiet with- drawal or mechanical action without feeling. Some report feeling de- personalized, as if they were witnessing the experience happening to someone else. ‘Some survivors appear intially to accept the death and begin immed ately o comfort others and make arrangements. They recognize thelossiut consciously put ade their emotions as they try to be strong or carry out particular roles. This tendency is especially prevalent in our society with ‘males, with those expected to car for others (e.g., adult children of older parents), and sometimes with parents when younger surviving children, are present. This temporary delay of mourning need not be harmful fit isreversed relatively soon. Inother cases, mourners may respond this way. ‘in anattemapt to deny the fact of death, its implications, or feelings about it. When this denial continues for too long, tis quite pathological.34 CHAPTER? Confrontation Phase ‘The Confrontation Phase is a time when grief is experienced most in tensely and reactions tothe loss are most acute, Separation from the loved cone generates alarm in the mourner, which zesults in heightened autonomicarousal, anger and protest, and calls forth biologically based searching behavior The mourner reacts to the strong urge fo ind, recover, and reunite with thelost one (see Boviby, 1980, and Parcs, 19 oryearning (Le, the persistent and obtrusive wishing and longing forthe “ceased the cubjective and emotional component of the biological urge to search. This pining or yearning constitutes separation arty ands the characteristic feature ofthe pang of grefindicatve ofthis time (Parkes, 1987. ‘his phase sa painful interval when the mourner confronts the reality ofthe loss and gradually absorbs what it means. [tis a tinw in which a most excruciating leatning process takes place—one that is ecessary for themourner ultimately to come to see that changes must be made. How- ever even though this critical function moves the mournerever closer healthy accommodation ofthe loss it does not take away the pain Each time the mourner is frustrated in his desire tobe withthe de- ceaced, he “learns” again thatthe loved one is dead. Each pang of gel, ‘each stab of pain whenever the mourners expectation, desize, or need for ‘the loved one is unfulfilled “teaches” the mourner that the loved one is nolonger there. When the mourner heats hilariousjoke and reaches for the phone to pass it onto his brother, only to remember that his brother Isburied across town, that painfulrealization teaches the moumer. When the bereaved mother hears the school bus but does not see her daughter step of ot, the searing agony she experiences teaches the mother When the widow reaches out inthe middle of the night to touch her husband, but herhand touches only ais, her overwhelming loneliness teaches hex All such hurtful incidents teach the mourner the lesson he wants to resis'—that the lowed one s dead, Thus, the Confrontation Phase involves coming to grips cognitively with the loss—lesmning about it—as well as reacting psychologically, behaviorally, socially, and physically tos. “Itwiltake a long time and hundreds, pechaps thousands, ofthese painful experiences of unfulfilled longing for the deceased before the “znourner will be abe to transfer to his gut what he knows in his head — thet theloved onesrealy truly imevocably gone. Yearning and searching continue forsometime, despite being unxewarded. Repeated frustration of desires for the deceased and the unsuccessful conscious and un- conscious attempts to recover the loved one ultimately lead toa gradual ~ diminution of disbelief and denial and then othe depression, disorgani zation, and despair thit signal the mourners elinguishment of hope fot reversing the los and avoiding his reactions to it reality Disbelief and denial conte to occu intermittently fora whileand, inthe most positive Lass, Gre and Mowing Some individuals want to express” feelings but being unable to do so. Frequently, needs and extons eas ‘conflict with each other. So, too, are thoughts about how tohandle this Situation, Itis an overwhelming, confusing, and frightening time ae te ‘mourer experiences types, intensities, and vacillatons af entlons thet ‘aks him unrecognizable to himselt, afraid of who and what he willbe, Most ofthe phenomena of gia ‘traditional psychological defenses, pr rit co tet atetive release, coping eharon andspec, Follies, sna ofthe ec fone andilusons inking objets and messages, ean ey reminder selective orgeting Parkes 108) acrvean ee ee Sonat this point. Accorainge Pskes they ep regatta a of novel, unonpnize, orn other respece desis oe ete person handles at given ime. Parkes cts that he oer see ‘etweertvinopposing tendencies, Oneisaninhon tener y epresion, avoidance, postponement andsoiothfolaesene ee A previously, any grief response expresses nat acombination ofthe mourners feelings about theless andi dep, Teg, Drolet atthe loss and wish to reverse it effect caused by the assault on the moumner as a result of the oss, and any personal accone stated by these reaction. Pe #4 Bry personal actionsTable 2.2 Common Psychological, Behavioral, Social, and Physical Responses to Loss PSYCHOLOGICAL RESPONSES Affects Separation pan, sadness, sorrow, anguish ‘Anxiety, panic, fear, vulnerability, insecurity Yeaming, pining longing Helplessness; powerlessness; feelings of being out of contr, vitimized, overwhelmed ‘Ange, hosility,itabilty, intolerance, impatience Guilt, sel-reprosch, regret 1 Depression, hopelessness, despair ‘Anhedonia, apathy, restricted range of affect Frustration Fear of going erazy “Emotional lability, hypersensitivity Deprivation, mutilation, violation Loneliness ‘Abandonment Ambivalence Relief Cognitions Disbeliet Bewilderment Disorganization, confusion, distractibility Preoccupation with the deceased, absession, rumination Impaired concentration, comprehansion, mental functioning, memory, decision making Cognitive dissonance, meaninglessness,senselessness, asilusionment, aimlessoess Spiritual cofusion, alienation, rejection; increased spirituality Lowored seitesteem, felings of inadequacy Pessimisen Diminished sel-concem Decreased interest, motivation, Initlaive, direction 36 Perceptions Feelings of unreality,depersonalizaton, derealization, dissoclation Development of a perceptual cet forthe deceased Paranormal experiences pertaining to the deceased (eg, visual ‘or auditory hallucinations, sense of presence) Fesling asi something Is abou to happen Defenses and/or Attempts at Coping Shock, numbness, absence of emotions ‘Avoidance or repression of thoughts, feelings, or memories associated with the deceased or painful reactions to the loss Denial ‘Searching behavior (forthe deceased) Protest Regression Search for meaning ‘dentiication with the deceased Dreams ofthe decease! Feelings of unreality, depersonalization, derealization, dissoclation BEHAVIORAL RESPONSES Searching behavior (or the deceased) Restless hyperactivity, searching for something to do, heightened arousal, agita ‘on, exaggerate startle response, hypervigilence, kypomanic behavior Social withdrawal Disorganized activity absent minded behavior Increased intake of medicine andor psychoactive substances 4015 of pattems of social iteacton (eg, dependency, clingines, -woidance of being alone) Crying and tearfulness Anorexia or appetite disturbance leading o weightloss or gin Sleep disturbance (00 litle, too much, intercupted) Tendency to sigh Decreased interest, motivation, intitive, direction, and energy ‘or relationships and organized pattems of activity ‘Decreased effectiveness and productivity in functioning (personal, social, work) ‘Avoidance of or adherence to people situations, and sul Feminiscent ofthe deceasedTable 2.2 (cont'd) Selfdestructve behavloss (eg, accidentprone behavior, high-risk behavior such a fast delving) [ Acting-out behaviors, impulsive behaviors Hyposexuality or hypersexualty ‘Change in le-style Hiding grief fr fear of driving others away Clinging behavior Grief spasms SOCIAL RESPONSES | lack of interest in other people and in usual activities due ‘e preoccupation withthe deceased . Social withdrawal Decreased interest, motivation, initiative, direction, and energy for relationships and organized patterns of activity Boredom : Criticalty toward others and other manifestations of anger ‘retain with others Loss of pattems of social interaction ‘ Feeling alienated, detached, or estranged from others Jeslousy of athers without loss Dependency on others, clinginess, and avoidance of being alone | PHYSICAL RESPONSES 4 ‘Symptoms Indicative of Biological Signs of Depression ‘Anorexia or appetite disturbance leading to welght loss or gain Decreased interest, mtivation, Initiative, direction, and energy Depressed mood Anhedonia, apathy, restricted range of affect Impaired concentration, mental functioning, memory, decision making, : Decreased sexual interest; hyposexualiy or hypersexuality a Sleep disturbance (too litle, too much, interupted) Crying and tearulness 7. Tendency to sigh a Fatigue, lethargy 4 Lack of strength : Prasical exhaustion 4 Feelings of emptiness andlor heaviness Psychomotor retardation or agitation 4 Feeudonieuralogie symptoms ‘Symptoms indicative of Anxiety and Hyperarousal ‘Motor tension Trembling, shaking, twitching ‘Muscle tension, aches, soreness Easy fatigabiliy Headache Restlesness and searching for something to do Autonomic hyperactivity | fansite, nousnese : Hear palpation tcc Soret of beth umes cnglng sensations Sinotneringsensatone, Oieinesunstany lng, ainness Dry mouth ee os Sweating or ol, cammy hands Hotter or ci Ghest pain, prs dsconon Choking Nausea, dares oter abdominal dress Frequent ration ehesin ethos rouble swallowing felingofsonethingsickintedoat Digestive disturbance fee eer eee Vigilance and scanning 4 Heightened arousal Agitation 4 Sense of being “geared up” i Exaggerated state response \ letability, outbursts of anger \ Ditficuly falling or staying asleep f Impaired concentration Hypervigilance Phystologic reactivity upon exposure to evans that symbolize or resemble ‘an aspect ofthe death or events associated with It Other Symptoms I clive of Physiological Response to In aon oth other hil symptoms ready manoneds Haicos | Constellation of vague, diffuse somatic complaints, sometimes ‘ ‘experienced in waves lasting minutes to hours | Gastonia smptons | Cariopuimonary symptoms | i40 HAPTER? ‘The psychological responses ofthe acutely bereaved mourerilus- trate that the mourners emotional, cognitive, perceptual, atitudinal, and religiousiphilosophical/spiritual domains are all seriously affected. The ‘behavioral responses reveal the myriad actions and demeanor that can be stimulated by the loss and the reactions toi. The social responses of the acutely bereaved mourer indicate that the person is interested only in reuniting with theloved one and thatallelseis somewhat devalued, Acute sgriefalso involves a state of great stain and physical risk (Osterweiset al., 1984), with significantly lowered zesistance, Physical zesponses associated ‘with heightened arousal and increased vulnerability have been well docu- mented by both scientific studies and clinical observation to occur even ‘with appropriate grieving as aconcomitant of the uncomplicated mourn- ing process. (See chapter for more on physical liness secondary toloss.) ‘Accommodation Phase In the Accommodation Phase, formerly called the resstaishment phase (Rando; 1984), there is a gradual decline ofthe symptoms of acute griel and the beginning ofsocal and emotional reentry into the everyday world, “However, the worldisbeing reconstructed, as seen inthe transformation “ofthe felationship with the deceased and the mourners revision of her assumptive world and establishment of a new identity. The mourner it learning to go on without the deceased, making necessary internal and ‘eternal changesto accommodate the absence ofthat person yet finding "ways to keep thenew relationship with the deceased appropriately alive ‘The deceasedisnot forgoten,noristheloss; however, the mourn learns tolivewith cognizance ofthe death andits implications ina way that does rot preclude healthy, lifeafirming grovth Other theorists have used the term resolution to refer to this phase, However the type ofonce-and-foralllosureimplied by thisterm doesnot actually occur after the death of amuch-loved person. Certain aspect of theloss willremain until themoumers own death, and, as discussed ater inthis chapter the mourner willikely experience subsequent temporary “upsurge offre. The term azconmadation connotes an adaptation of one- selfto make oom fora particularcircumstance. As such, teaptures more accurately the reality that theloss can beintegrated appzopriaey nto the zest of life bu that a trly final closure usually cannot be obtained, nor isit even desirable. It has been rightly pointed out that adaptation could mean in some cases making the best ofbad situation, not changing, or not recovering lst functions (Osterweis etal, 1984). perceive its syno- sym, accommodation, to be the single best tem cursently available. Re- cevoeryand completion carry the same accurate connotations as salon. In contest, accommodation implies making onesel it or congruous, or reconciling the loss. The crucial action-oriented emphasis of mourning is relained in this term. Loss, Grif and Mourning 1 Accommodation of te loss waxes and wanes dusing the latter part ofthe Confrontation Phase and continues slowly thereafter Many ofthe reactions from the Confrontation Phase coeds far some time with the initial aspects of thisnevrone. One notable sample is guilt- which often isa stumbling block. The mourne struggles to work through such issues as the mistaken belief that the intensity and duration of acute grief fs @ testimony tolovefor the deceased or thatitisonly by experiencing signii- cant pain thata link can be maintained with the eved one. Isisiesportant tha these conflicts be worked thuough. Ifnot addressed, they may con- tribute tothe development of complicated mourning The goal ofaccommodationistoleam tolive with the loss and readjust conos new life accordingly. Adjustments must occur in the relationship withthe deceased (developing anew relationship), in onesel revising the assumptive word and forming a new identity), and in the external ‘world (eadjusting roles, skis, andl behaviors and, a the appropriate time, reinvesting emotional energy in new people, objects, roles, hopes, belief, ‘causes, ideals, goals, anc other puss). Accommodation docs not mean that the mourner would have chasen or wanted theloss,Itmerely means that she no longer has ofghtit, But acceptsitin the sense of earning £0 live with it as an inescapable fact of le. ‘Accommodation also means that the mourner can integrate the past ‘ith the present and the new person that exists, The mourner will never forget, but she will not always be acutely bereaved. Accommodating the loss willeave a psychic scar similar ta sca that remains after aphysical injury. This scar does not necessarily interfere with the mourners overall functioning, but on certain days and under particular conditions it may ache or throb. It ill remind the mourer of whet she has been through and that she must tend to her feelings unt the pain passes ‘Mourning brings many changes. The mourner can expect tohave an altered identity and redefined roles relationships skils, and behaviors. ‘These changes canbe ether positive or negative. As someone who has loved and ost, the mourner can be rcher or poorer because ofthe pasts offherself that are iretrievably gone. Like physical sass, paychic scars can giveone character orbe sources of vulnerability. Although she may have had no contol or choice over herloved one’s ying, the mourner doeshave a choice over how she wile theloss affecther. This choice does not per- tain to the acute period of grief, in which the mournerisinevtebly sub- jectto psychological, behavioral, soil, and physical effects in all realms ‘of her life. Rather, it pertains to the perspective or atitude che wil take toward the rest of her lifes her mourning brings er to a changed site Wil she make the most out ofthe rest ofherlf, or will she becomebitter? Will she incorporate herloss and useitas acatalyst for growth, orwill she never take rsis again? Will the death cause her to make sure she never has any unfinished business with others she cares about, or wil t give heer the sense that the world oves er?2 qHarTeR? Cones bereaved nviduals desire positive benefits rm mejor los. Ths fc estates thet one can choose to recover tom los and capilize on whatever good can come trom the ba This View does nol deny the pain of gif end price of he lose of «loved one. Rather it recognizes tit, efen in undenging the pain of seperation, a mourner Gan dei hat ows il ave some posive meting forthe reminder off, Postive eoponees canbe many and varied (eg, new pores, inerenied commitment to ving ie more flly and meaningily, new wares flies precowsness and apy reduced unis business ‘th oved ones, tnased communication and comatment fo fami, {pene senstvity and fle exreasonotfecngs incensed egiousnes tnd spl) Many ave Catermined tas socal food should come fromiwirlossesandhave chareled heir puinanragetntomeaningél endeavors asiting both themselves and soy, Bereavement support ayovps have been exablshed tel ofhem Some, enc as Forno of Murdered Children or Motere Agunst Bronk Dring ge poll Changes oensce that thers do nt slfer the saw brent "Many bererved individuals have discovered and developed agpect of the identty that previously were unknown They have elzed new Interest found new relationship, or started ving in way that ren som cases ore satisfactory and fling thanbeore This doesnot ean tht they nen nt priered by thelesoeeved one, on te they responded to hat lowest period o grit and mourning way tat tnviched hem Indee there are many who contend tht beeateneats indispensable for growth (e.g., Cassem, 1975). ust ar one can deci whet heathy ccominodation wllmen, one candesdewhet itll sotanean,eneednotneen ha one isunfouched tyreminders, suchas acerainsong parctlarsmell or pecal location. {enecd normean thet one does ot eparene te bitersveet combina fonoffeingsthathelidaycan bingo nesses vith hose who are sillpresentand mourns for those nolonger there it does not mean that inceraineventsinife one illo painflly wish or the loved one tobe ive to hare one's oy ore pou of one doesnot mean tha one no longo tony meat that one len tov withering a that do notinterfere with ongoing healt funcioningin theese ‘without the loved one Indice ofusestul accommodation do not sup gest tht one must iced connection with the decease loved Oncor {eget tht psson Rather hey soges tat acvommdatoncrers on tearing olive withthe fac of the ove one's sbeance and moving for srardinthe ser word dope the at hat the pyc careused the toss wil rerain and on occasion, bring pan Caregivers can share with nouners fe fnalperopecve on breve sent And, in the end, this moving forward with that scar isthe very best that we could hope for, You would not want to Loss, Gre and Mowing 43 forget your loved one, as if she never existed or [had] not been an important past of your life. Those things that are important to you in your life are remembered and kept in the very special places of your heart and mind. This is no lass true with regard to the loss of a beloved person, Keep this Joss, treasure what you have learned from it, take the ‘memories that you have from the person and the relation- ship and, in a healthy fashion, remember what should be remembered, hold on to what should be retained, and let go of that which must be relinquished. And then, as you cons ‘tinue on to invest emotionzlly in other people, goals, and Pursuits, appropriately take your loved one with you, along, ‘with your new sense of self and new way of relating fo the ‘World, to ensich your present and future life without forget ‘ing your important past. (Rando, 1988, p. 287) THE SIK“R” PROCESSES OF MOURNING Coinciing with these three phases, the mourner experiences sc major stoming procese. This schema consti arenensent oft proces necessary inorder to resolv grief and mourning, orgy presencia Rando (1088). Chapter9 discusses these si processes fatherand deals ‘eestment suggestions for complcaed mourn resuleng fede them ‘Theseader may wonder why mourning is discussed Fase in ero rocstesrather than sks, apt for example in Werde1982) walk Fecsived schema, although the seflness af Werden’ ppuoachs uns squstioned, operationalizing mosmingintermsel procter is peerablo forthiee main reasons Fast, knowledge of whether atak (he aspectc desired outcome) has been successuly completes genes oly st the enol the processes involved in completing the tsk. Athat olny tanay betoolatfo promote those processes easy. Themoumeraheaty haves *asnotaccomplishedthetarkand int mustbe urged to readdeers the requisite proceses. Incontac viewing mousningin terme ci process rather than otzomes allows the caregiver to focus on wha the mocrser curentyis doing ths providing more irumedatefecdbk ard the jpounds orinerventon. Seeand,processescan be evetated. monered fd influenced throughout te mowing experience. Aas the cts ot other developmental sequences keeping the spolighton processes salle, than outcomes enhances the chanc that ny becesnry intstestion vil be timely and effective. The processes themdelves ae the ery agels of thatietervention. Thzd, processes provide uefa cect foreleg thepece at ames and mesg ant muing esample focus on where the mune sine mourning ext evel where hes stuck before he has fied athe task werd Wait he Woe Progressing, In sununary, proceses beter operationalize motsning3 HAPTER? ‘because, as compared to tasks, they offer the caregiver moze immediate ‘feedback, the ability to intervene more quickly and appropriately, the spe- “fic targets for intervention, and improved assessment of the mourner’s curtent experience. In addition, they provide aconceptual and experien- ‘ial base from which to understand mourning, Table2.3liss the six’R” processes of mourning, which mustbe under- taken fora loss to be accommnodated in a healthy fashion, and indicates their relationship to the three phases of grief and mourning. Although these processes are interrelated and tend to build upon one another, a number of them may occur simultaneously (eg., the second, third, and fourth “R’ processes, which occur in the Confrontation Phase, and the {fifth and sixth “R” processes, which cocurin the Accommodation Phase), Inaddition, some elements or subprocesses may occur in more than one phase. The sequences not invariant, although the order does reflect the {typical course fora majority of mourners, Mourners may move back and forthamong the processes, with such movement illustrating the nonlinear and fluctuating course of mourning. ‘ Recognize the Loss Ifthe mourner is to commence active mourning, she needs to acknowl- ‘edge thatthe death has occurred. Initially, this acceptance ison an intellec- tual level, involving only recognition and concession of the fact of the death. It will take much longer to internalize this fact and accept itemo- tionally. This can occur only afterrepeated and painful conicontations with the loved one's absence, which begin with the mourners cognitive admis- sion that the death has occurred. I the world isto continue to maintain some order forthe mourner, she will also have to attain some understand ‘ng of the reasons for that death. Acknowledge the death If the mourner does not acknowledge the reality ofthe death or ts implications, then there is no need to grieve. By not admitting the death orits reversibility, the moumeris able to construc the loss asa temporary absence which, although causing sadness due to separation, does not demand the same typeof reorientation and readaptaion as does death Ttis only natural for the mourner to resist acknowledgment thatthe loved one has died. No one wants to ada that someone she has loved Js gone forever. The natural urge sto deny deaths reality and avoid con- fronting. Thsis why confirmation ofthe deat so important and why somuch time, money, and effort are spent attempting to recover bodies alter airplane crashes, boating accidents, earthquakes, and 30 forth. In the absence of sufficient evidence to confront mourners with the eath—which in most cases ia the body ofthe loved one—they can postpone thelr mourning or rationalize it vay. A high percentage of Table 2.3 The Six “R” Processes of Mourning in Relation to the Three Phases of Grief and Mourning AVOIDANCE PHASE 1. Recognize the loss *+ Acknowledge the death * Understand the death CONFRONTATION PHASE 2, React to the separation + Experience the pain * Feel, identity, accept, and give some form of expression toall the psychological reactions tothe loss * Identify and mourn secondary losses 3. Recollect and reexperience the deceased and the relationship, * Review and remember realistically ‘+ Revive and reexperience the feelings 4. Relinquish the old attachments to the deceased and the old assumptive world ACCOMMODATION PHASE 5 Readjust to move adaptively into the new work without forgetting the old + Revise the assumptve world + Develop a new relationship with the deceased + Adoptnew ways of being in the world *+ Form a new identity 6 Reinvest4% CHAPTER? mourners who experience complications either havenot viewed the body. Orhave failed to partcipatein faneral uals. Nothing opposes their need todeny and avoid. Especially in situations of sudden, unexpected death, the substantiation of the loss through the viewing ofthe body (or some part of isan important peychological requirement for bringing home Ahetruth, confronting understandable urges to deny, challenging disbeie, and commencing healthy mourning. ithe status of theloved oneis unknown, themournerisleftin sort of limbo. In tis situation, the folowing types of questions may plague the mourmer: Is my loved one alive or dead? Is he out there somewhere ‘but unable to come home? Did the accident leave him with amnesiasohe cannot fina his way back to us? Does he need ray help? and, Shovld Tbe ooking for hi? This manner of questioning and other difiultis are ‘witnesced in families of missing childzen, as wellasin those whoseloved tones are missing in action in the military or presumed dead but whose bodies have not been recovered, ‘Sometimes just a small piece of confirmatory evidence can help a person go on about the business of mourning. One woman felt that her husband “most probably” had died on a canoeing expedition when his raft overturmed. However, for many months she could not fhake any changes inherself, her house, orherlife-style. Athough she “sort ofknew” inkerhead, she couldnotallow herself to mourn. Sheieltit wouldbe tanta- :mourt to giving upon herhusband, The following spring, aset of dentures found on the riverbank was identified as her husband's. Once she knew this, she could plana memorial service, stat to grieveactively,and begin tomuake changes in herlife, Prior to this, the absence of any physical confi- sation ofthe death had kept her mourning on hold, Understand the death Inaddition to acknowledging thatthe death has occurred, the mourmer will have to come to some understanding of the reasons for it, These are not philosophical religious reasons; rather, they concern the facts con- ‘tibuting tothe death and the circumstances surroundingit. The explana tion needs to make sense intellectually, but it does not necessarily have tobe acceptable tothe survivor. Itmerely means that the mourner under- stands the reasons for the events leading tothe deeth and hasan account that explains how, why, and under what conditions the death happened asitdid, makes no difference whether orrot this explanationisin accord ‘with anyone else's—only that satisfy the mourner. Foreample, the man ‘who refuses to believe his son died by suicide, insisting the death was an accident, has achieved a personally satisfactory understanding of his ort’s death, even though his refusal to believe the truth may haveimplications in other areas. Withouta context for understanding loved one’s death orsomesort of rationale forit,amournertends to become arvdous and confused, wonder oss, Grif and Mourning 47 ing about hat happened to he loved one and what poten ‘pence Te det of be ea peso ates srs sense of the world’s meaning, orderliness, and predictability, making it cl ferhertorecover fom the loss Parents havea hice ee Suldeninfant Death Synaiome in whichnorpecticcuncaldcahnn determined, offer have pacar problem inthis sepa React to the Separation Ones the reality ofthe ath has ben ecogize, the moumermste toandcope with that reality Responses tothe recognition efthe deer theloved one aremyriad andthey wil oceuronallcrelsorarenenes To the etent thatthe mourner grants Mmoet permission to wpe andesresethece reaons appropriately halk nacang ore Experience the pain 2 the lve isto be accommodated succesfully the mouraer mn ‘vps the pain of att and the se te non roots Like acute, plnimay be expenenced see, Uicnneal then corrcanme a social and physical. The type inenay an area walle diferent foreach individual determined by theanioue create son faces nce wh he ener ue os at heal mourning the survivor makes neous tem torevere the realty of the death to awid pun eg by chine teas fora recover the deceased), Such temper atid ormnamise ah tre understandable and natu Thy ae inpovant cae taney inate fue to reverse these thathepsthe noumertomete ees it Thee frustated atempis ring mucha an does tecepenter thelovedone Mitigatonsare employed eg, avollanceofeemiciees Besceivingcertain events messager foie dese) Reopeseoa versions peoit distance and allow fr replenishment weesereeton wath other parts fife andarenewed sense contol llohace acy epee deamumeis cay on ah muring woes bee oss a titan of constant venting pln, Howesee Pain eventually must be felt, aes Se ere toal the poychologlrasclon ts these or eae eee neta ee inmate eras Tau ht erie enone Docent afore ie cmanetge eset lens erry uote ou O aap cre acon48 CHAPTER? ‘unfamiliar emotional responses associated with theloss; (b) identify, label, and differentiate among these responses (to make painful stimuli more ‘manageble); promote source identification, psychological processing, and problemsolving torender greater control; and(c) find personally com- fortable and appropriate avenues of verbal and nonverbal expression, ‘Identity and mourn secondary losses nour nite lof here or bt Scrondan ones ccsonedy the deth Ths meato ropa Fae antes fap tnpeint herp ommaarehd tion valdafon renoceeent, and geatican once roviced yer are i er ete Se ions eset and bela tharsowentin be absence Be ea ete neeeonnaar en vealed wither, andthe uy oer poyocaland pysallsses thscawe tote dea Some of hese secondary osses willbe immediatly apparent (ea, the 1oss ofthe loved one's companionship), whereas others will become ‘optableony over tinea he urea toeinthe wee tui be deceased (egy the oss ofthe ved ones unique upon wen tre mourrer expres confetti uperey a wor Excl hese ned end oses poms ioewa mocrng end dd he sure foal mowing epeerce Recollect and Reexperience the Deceased and the Relationship nner oedema he Sere ge eager Spice Gee aaa detec sit etre tenis Worse en tie the mine sales her ebosonal tached ve ments inthe loved one in order to make way psychologically for these sub- “FS atten dd opt aun anche ee ‘Scone gia emia eames coe ein enablers Ech ccna etae ih cel ‘SR alan ene a at ‘ee mea ta ted esa st ose mayen mA a so ti Sata eats Sghaayani rege ono ox, Grif and Mourning 49 addressed. At some point, the mourner will need to find appropriate vehicles for achieving closure on this unfinished business Review and remember realistically Inbealthy mourning, the deceased must be remembered cealistically ‘This means thatall aspects ofthe person and the mutual relationship must Derecalled—allof the positives, negatives, and neutrals The mournes must zepeatedly review the entire relationship, the expectations anc needs thet initially formed it, its ups and downs, its course and development, its «rises and joys—all elements of it throughout the years. As these events and features of the relationship unfold, the mouzner can exemnine associated feelings and thoughts: negative ones, suchas anaiety, ambiva, ence, and guilt, as wellas more postive ones, suchas satisiaction, happic ness, and mesning. Only by repeatedly reviewing the unique relationship Iniss totality (ie.,allofits component parts with all of the emotional and

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