Bereavement and Grief

by

Kathrin Boerner

• LAST REVIEWED: 26 August 2022
• LAST MODIFIED: 29 November 2011
• DOI: 10.1093/obo/9780199828340-0011

Introduction

The field of bereavement and grief focuses on the human experience of loss in response to the death of a loved one. The term bereavement refers to the objective status of a person who has suffered the loss of someone significant. Grief, on the other hand, refers to the emotional experience of the psychological, behavioral, social, and physical reactions to one’s loss (see the first chapter of Stroebe, et al. 2008, cited in General Overviews). Early writings on bereavement and grief were guided heavily by the psychoanalytic traditions. They were based on clinical observation and a very limited empirical database. The focus was on the intense distress people are thought to experience following the death of a loved one, and on the need to work through this distress in order to recover from the loss and be able to move on with one’s life. For a long time, popular and professional ways of thinking about bereavement were strongly influenced by this literature, without having been put to any serious empirical test. Over the past few decades, however, the field has developed into a scientific discipline with high methodological standards and an accumulating number of sound empirical studies, which have greatly contributed to our current understanding of grief. One of the most groundbreaking findings from this research is probably the pervasive insight that there is extraordinary variability in how people react to the death of a loved one. While some people are devastated and never again seem to regain their emotional equilibrium, others emerge from the loss relatively unscathed and perhaps even strengthened. An important focus of current bereavement research is to better understand this variability in response to bereavement, to find ways of identifying those who are at risk for developing long-term difficulties following the death of a loved one, and to provide them with the appropriate support or treatment. The first section of this bibliography introduces general overviews of the field of bereavement, including three influential handbooks of bereavement research that appeared in the literature between 1993 and 2008. This is followed by a section on journals that primarily focus on bereavement issues. The remaining sections examine specific areas and perspectives in the field of bereavement in more detail. This selective review highlights works pertaining to what are to date considered traditional views on grief, followed by a description of current theoretical models and thinking. Next, research areas in which a striking increase in knowledge has occurred (i.e., grief trajectories, caregiving and bereavement, continuing bonds, risk factors, and complicated grief) receive particular attention. This is followed by a selective review of literature with a focus on specific relationship perspectives in terms of who died (i.e., loss of spouse, child, parent, or sibling), as well as sections dedicated to often unacknowledged bereavement situations, referred to as “disenfranchised grief,” and different cultural perspectives on grief. The bibliography concludes with coverage of discussions about supportive interventions in the context of bereavement.

General Overviews

The field of bereavement has grown tremendously over the past three decades. The three handbooks of bereavement research published between 1993 and 2008—Strobe, et al. 1993, Strobe, et al. 2001, and Stroebe, et al. 2008—provide a comprehensive account of past and new developments in the literature. Although each of these handbooks offers a general overview of the field in a particular time period, it is worthwhile to consider them separately, because the selection of chapters and focus areas in each is unique. Much of the research and conceptual discussions reported in the handbooks were influenced by Wortman and Silver 1989, which can be considered a classic in the field. Wortman and Boerner 2011 gives a comprehensive account of research evidence on coping with loss that has been accumulated since the original identification of the “myths.” Bonanno 2009 targets a broader audience and offers not only an up-to-date summary of available research evidence but also uniquely new perspectives on life after loss. Finally, addressing yet another type of audience with interest in grief and bereavement, the Handbook of Thanatology (Balk, et al. 2007) provides a useful introductory resource for professionals in thanatology research and practice as well as in death education.

• Balk, David E., Carol Wogrin, Gordon Thornton, and David K. Meagher, eds. 2007. Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement. London: Routledge.

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  This handbook, copublished by the Association for Death Education and Counseling (ADEC), is a helpful resource for professionals in thanatology research and practice and death education. It provides good introductions into core areas of the field, and points the reader to additional useful resources.

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• Bonanno, George A. 2009. The other side of sadness: What the new science of bereavement tells us about life after loss. New York: Basic Books.

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  This excellent book uses a combination of rigorous research and compelling cases examples to share the most up-to-date insights about the grieving process with a broader audience.

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• Stroebe, Margaret S., Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, eds. 2001. Handbook of bereavement research: Consequences, coping, and care. Washington, DC: American Psychological Association Press.

  DOI: 10.1037/10436-000Save Citation »Export Citation » Share Citation »

  This handbook provides an updated overview of the literature up to early 2000. In addition, there are extensive sections on methodological and ethical issues, consequences of bereavement over the life span, and the role of coping in adaptation to loss.

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• Stroebe, Margaret S., Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, eds. 2008. Handbook of bereavement research and practice: Advances in theory and intervention. Washington, DC: American Psychological Association Press.

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  This handbook provides the most up-to-date overview, reflecting primary domains of growth and discussion in the field over the previous decade, such as issues involved in including a complicated grief diagnosis into the DSM-V, as well as aspects related to variability in patterns and consequences of grief.

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• Stroebe, Margaret S., Wolfgang Stroebe, and Robert O. Hansson, eds. 1993. Handbook of bereavement: Theory, research, and intervention. New York: Cambridge Univ. Press.

  DOI: 10.1017/CBO9780511664076Save Citation »Export Citation » Share Citation »

  This first of a series of handbooks not only gives a general overview of the bereavement literature up to the early 1990s, it also includes particular focus areas that are unique to this edition, such as several chapters dedicated to physiological changes following bereavement.

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• Wortman, Camille B., and Kathrin Boerner. 2011. Reactions to the death of a loved one: Myths of coping versus scientific evidence. In The Oxford handbook of health psychology. Edited by Howard S. Friedman, 414–479. New York: Oxford Univ. Press.

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  This comprehensive book chapter reviews the literature on bereavement with particular attention to major paradigm shifts that have occurred over the past few decades.

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• Wortman, Camille B., and Roxane C. Silver. 1989. The myths of coping with loss. Journal of Consulting and Clinical Psychology 57.3: 349–357.

  DOI: 10.1037/0022-006X.57.3.349Save Citation »Export Citation » Share Citation »

  This article was the first to question widely held basic assumptions about grief, to show that available research evidence does not necessarily support them, and to demand that these assumptions be more systematically investigated.

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Journals

There are only a few journals that specifically focus on issues of death and bereavement. The most notable ones are Omega: Journal of Death and Dying, Death Studies, and Bereavement Care. They are all dedicated to disseminating work on death and bereavement, and they target an interdisciplinary audience. Although these journals are a useful source for tracking developments in the field, many influential articles on bereavement have been published in other journals, including psychological (e.g., Journal of Personal and Social Psychology, Journal of Clinical Psychology) and medical journals (e.g., JAMA). Aging journals are also a common outlet for articles on bereavement (e.g., Journal of Gerontology: Psychological Sciences, or Psychology and Aging).

• Bereavement Care.

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  This is the United Kingdom’s leading bereavement journal, but it is internationally recognized and disseminates international work. The journal is intended for all who have an interest in bereavement care.

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• Death Studies.

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  This journal disseminates research, scholarship, and practical approaches in the areas of bereavement, grief therapy, death attitudes, suicide, and death education. Out of the existing journals that focus on death and bereavement, this one is a little more research-oriented.

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• Omega: Journal of Death and Dying.

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  This journal is dedicated to the topic of death and dying, including papers on terminal illness, the process of dying, bereavement, mourning, funeral customs, and suicide. It primarily targets clinicians, social workers, and other health professionals who are faced with problems in crisis management.

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Traditional Views on Grief

Early writings on bereavement were heavily shaped by psychoanalytic thinking. They were also primarily based on clinical observation and a rather limited empirical database. However, they have strongly influenced professional and popular ways of thinking about grief for a long time. Thus, to be able to understand how the literature on grief has evolved, with its major controversies and research efforts aiming at clarifying the questions raised in these debates, it is imperative to be aware of these early works. The first major conceptual contribution to the field of bereavement was Freud seminal paper “Mourning and Melancholia” (Freud 1957). While Freud’s thinking on grief was based in his clinical experience, one of the earliest well-known empirical studies on grief was published in Lindemann 1944. However, one of the most widely read works dealing with grief is Kübler-Ross 1969. Although the focus was on how dying persons react to their own impending death, by going through five sequential stages, this book was instrumental in popularizing stage theories of bereavement. (It should be noted, however, that the empirical evidence available today is largely inconsistent with the notion of stages.) Another author who proposed stages of grieving was Bowlby, who integrated ideas of psychoanalysis and the literature on separation distress (see Bowlby 1980). Raphael 1983 also discussed stages of mourning, and then analyzes how the effects of loss may differ by stage of life. Finally, Maciejewski, et al. 2007 presents findings from a study examining several grief indicators for consistency with the stage theory of grief. The conclusion that the findings represent evidence in support of stage theory was questioned in several critical letters to the editor (e.g., Silver and Wortman, 2007).

• Bowlby, John. 1980. Attachment and loss. Vol. 3, Loss: Sadness and depression. New York: Basic Books.

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  In this influential book, the author integrated ideas from psychodynamic thought, from the developmental literature on young children’s reaction to separation, and from work on the mourning behavior of primates.

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• Freud, Sigmund. 1957. Mourning and melancholia. In The standard edition of the complete works of Sigmund Freud. Vol. 14. By Sigmund Freud. Edited by J. Strachey, 152–170. London: Hogarth.

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  This seminal work was the first major contribution to the field of bereavement. Freud’s view of the grieving process has dominated the bereavement literature over much of the past century, and only more recently has it been called into question. Originally published in 1917.

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• Kübler-Ross, Elisabeth. 1969. On death and dying. New York: Macmillan.

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  This widely read book focuses how dying persons react to their own impending death, and posits that people go through stages of denial, anger, bargaining, depression, and ultimately acceptance. Although it was not developed for the case of bereavement, it was Kübler-Ross’s stage model that popularized stage theories of bereavement.

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• Lindemann, Erich. 1944. Symptomatology and management of acute grief. American Journal of Psychiatry 101:141–148.

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  This article presents findings on grief symptomatology from the earliest well-known empirical study on spousal loss, the “Coconut Grove” study. Findings suggested that sudden, unexpected deaths tend to be more distressing than anticipated deaths.

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• Maciejewski, Paul K., Baohui Zhang, Susan D. Block, and Holly G. Prigerson. 2007. An empirical examination of the stage theory of grief. JAMA: Journal of the American Medical Association 297.7: 716–723.

  DOI: 10.1001/jama.297.7.716Save Citation »Export Citation » Share Citation »

  This article examines five grief indicators for consistency with the stage theory of grief, and interprets the presented findings as in line with basic tenets of this theory.

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• Raphael, Beverly. 1983. The anatomy of bereavement: A handbook for the caring professions. New York: Basic Books.

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  This book takes an interesting perspective by going beyond the description of stages of mourning, analyzing how the effects of loss differ at each stage of life.

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• Silver, Roxane C., and Camille. B. Wortman. 2007. The stage theory of grief (Letter to the Editor). JAMA: Journal of the American Medical Association 297.24: 2693–2694.

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  This letter to the editor was written as a criticism of Maciejewski, et al., 2007. Major points made pertain to gaps in the literature review, problematic methodological issues, and issues with conclusions drawn from the data.

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Current Understanding of Grief

Current theorizing on grief has moved away from the assumption of universal stages, and it has become clear that popular long-standing notions, such as the need to “work through” grief as part of healthy adjustment to loss, do not necessarily hold up under every circumstance. Both Archer 2008 and Bonanno and Kaltman 1999 provide a discussion of past and present theories of grief and highlight ways in which the theoretical thinking in the field has changed. Bonanno and Kaltman 1999 then draws on several more general social and developmental theories to develop a new integrative theoretical framework for understanding bereavement. Neimeyer 2001 takes another unique perspective in thinking about bereavement by focusing of the reconstruction of meaning following loss. To date, the only existing coping process theory in the field, the dual-process model of coping with bereavement, has been advanced by Stroebe and Schut 1999. In Stroebe and Schut 2001, the authors integrate the notion of meaning-making as an essential part of the grieving process into this model. Finally, further expanding the authors’ own theoretical framework, Stroebe, et al. 2006 proposes a more comprehensive model that integrates the elements stressors, risk and protective factors, as well as coping processes.

• Archer, John. 2008. Theories of grief: Past, present, and future perspectives. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, 45–65. Washington, DC: American Psychological Association Press.

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  This chapter provides a concise discussion of past and present theories of grief.

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• Bonanno, George A., and Stacey Kaltman. 1999. Toward an integrative perspective on bereavement. Psychological Bulletin 125.6:760–786.

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  In this article, the authors draw on cognitive stress theory, attachment theory, the social-functional account of emotion, and trauma theory to develop an integrative theoretical framework consisting of four fundamental components of the grieving process: context, meaning, representations of the lost relationship, and coping and emotion-regulation processes.

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• Neimeyer, Robert A. 2001. Meaning reconstruction and the experience of loss. Washington, DC: American Psychological Association Press.

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  This interesting book fills a gap in the literature by focusing on an often-overlooked aspect of grief, the reconstruction of meaning following loss. Grief is portrayed as an idiosyncratic process in which people strive to make sense of what has happened.

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• Stroebe, Margaret. S., Susan Folkman, Robert O. Hansson, and Henk Schut. 2006. The prediction of bereavement outcome: Development of an integrative risk factor framework. Social Science and Medicine 63.9: 2440–2451.

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  This article proposes an integrative risk-factor framework, which incorporates an analysis of stressors, risk and protective factors, as well as appraisal and coping processes that are thought to affect adjustment to bereavement. The model is meant to encourage more systematic analysis of individual differences in response to bereavement.

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• Stroebe, Margaret, and Henk Schut. 1999. The dual process model of coping with bereavement: Rationale and description. Death Studies 23.3: 197–224.

  DOI: 10.1080/074811899201046Save Citation »Export Citation » Share Citation »

  The dual-process model of coping with bereavement indicates that following a loved one’s death, bereaved people alternate between two different kinds of coping: loss-oriented coping and restoration-oriented coping. The authors propose that the oscillation between the two coping modes is necessary for adaptive coping.

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• Stroebe, Margaret. S., and Henk Schut. 2001. Meaning making in the dual process model of coping with bereavement. In Meaning reconstruction and the experience of loss. Edited by Robert A. Neimeyer, 55–73. Washington, DC: American Psychological Association Press.

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  In this chapter, the authors integrate the notion of meaning making as an essential part of the grieving process into their dual-process model.

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Grief Trajectories

Our understanding of grief has increased tremendously following large-scale studies with prospective longitudinal data that include data from before the death to years after the loss, allowing the full range of possible grief patterns to emerge. This section includes citations of articles that delineate different pathways of grieving. Bonanno, et al. 2002 and Bonanno, et al. 2004 were the first to identify core bereavement trajectories based on prospective longitudinal data. Mancini, et al. 2011 confirms these trajectory patterns with a larger than usual longitudinal sample, employing latent growth mixture modeling, an approach that allows trajectory patterns to emerge in a non-arbitrary and purely empirical manner, overcoming some of the critical limitations of prior approaches. Whereas the focus of Bonanno’s and Mancini’s work was conjugal bereavement in the general aging population, several other prospective, longitudinal studies have addressed grief trajectories in caregiver samples. Aneshensel, et al. 2004; Haley, et al. 2008; and Zhang, et al. 2008 identify different depression trajectories, as well as risk factors for developing each of the trajectories. Li 2005 investigates depression trajectories in a general caregiving sample, but is focused on the individual trajectories of mother and daughter caregivers.

• Aneshensel, Carol S., Amanda L. Botticello, and Noriko Yamamoto-Mitani. 2004. When caregiving ends: The course of depressive symptoms after bereavement. Journal of Health and Social Behavior 45.4: 422–440.

  DOI: 10.1177/002214650404500405Save Citation »Export Citation » Share Citation »

  This article focuses on response to loss following a time of caregiving for a chronically ill loved one. The study describes depressive symptoms among caregivers following bereavement and connects these trajectories to earlier features of caregiving using life course and stress process theory.

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• Bonanno, George A., Camille B. Wortman, Darrin R. Lehman, Roger G. Tweed, Michelle Haring, John Sonnega, Deborah Carr, and Randolph M. Neese. 2002. Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Journal of Personality and Social Psychology 83.5: 1150–1164.

  DOI: 10.1037/0022-3514.83.5.1150Save Citation »Export Citation » Share Citation »

  This study was the first to identify core bereavement trajectories (common grief, chronic grief, chronic depression, improvement during bereavement, and resilience) based on prospective longitudinal data that include data from before the death to years after the loss, allowing the full range of possible grief patterns to emerge.

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• Bonanno, George. A., Camille B. Wortman, and Randolph M. Nesse. 2004. Prospective patterns of resilience and maladjustment during widowhood. Psychology and Aging 19.2: 260–271.

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  Presents findings from additional analyses conducted by Bonanno, et al., to examine differences in how respondents in each trajectory group reacted to and processed the loss.

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• Haley, William E., Elizabeth J. Bergman, David L. Roth, Theresa McVie, Joseph E. Gaugler, and Mary S. Mittelman. 2008. Long-term effects of bereavement and caregiver intervention on dementia caregiver depressive symptoms. The Gerontologist 48.6: 732–740.

  DOI: 10.1093/geront/48.6.732Save Citation »Export Citation » Share Citation »

  Investigates the joint effects of bereavement and caregiver intervention on trajectories of caregiver depressive symptoms. Findings suggest that supportive caregiver interventions have the potential to benefit caregivers both pre- and postbereavement.

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• Li, Lydia W. 2005. From caregiving to bereavement: Trajectories of depressive symptoms among wife and daughter caregivers. Journal of Gerontology: Psychological Sciences 60.4: 190–198.

  DOI: 10.1093/geronb/60.4.P190Save Citation »Export Citation » Share Citation »

  Investigates the trajectory of depressive symptoms for wife and daughter caregivers during the transition from caregiving to bereavement, looking at whether the trajectory varies depending on caregiving stress, social support, and background characteristics.

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• Mancini, Anthony D., George. A. Bonanno, and Andrew E. Clark. 2011. Stepping off the hedonic treadmill: Individual differences in response to major life events. Journal of Individual Differences 32.3: 144–152.

  DOI: 10.1027/1614-0001/a000047Save Citation »Export Citation » Share Citation »

  Examines divergent trajectories of response to significant life events (widowhood, divorce, and marriage), using latent growth mixture modeling. This approach allowed trajectory patterns to emerge in a non-arbitrary and purely empirical manner, addressing critical limitations of prior approaches. These analyses offered important confirmatory support for previously found trajectories.

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• Zhang, Baohui, Susan L. Mitchell, Kara Z. Bambauer, Rich Jones, and Holly G. Prigerson. 2008. Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers. American Journal of Geriatric Psychiatry 16.2: 145–155.

  DOI: 10.1097/JGP.0b013e318157caecSave Citation »Export Citation » Share Citation »

  Identifies three subgroups of depressive symptom trajectories among bereaved AD caregivers (persistently syndromal, syndromal-becoming-threshold, and persistently absent depression), as well as determined risk factors for syndromal and syndromal-becoming-threshold level depression after loss.

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Caregiving and Bereavement

Since a majority of deaths now occur as a result of chronic health conditions that require an extended period of caregiving, the topic of caregiving and bereavement has received increasing attention over the past decade. Investigators have begun to examine the impact of caregiving on adjustment to the loss following the loved one’s death. This research demonstrates that the relationship between caregiving and adjustment to bereavement is complex. Although stressful caregiving is associated with poor psychological adjustment when the spouse is alive, many overly taxed caregivers seem to rebound to relatively high levels of functioning after the death. However, a minority of strained caregivers demonstrates intense and prolonged grief, and investigators are attempting to uncover the determinants of this reaction. Schulz, et al. 2008 offers a comprehensive overview of the available literature on caregiving and bereavement. Boerner and Schulz 2009 focuses on the relationship between challenging caregiving situations and difficult grieving processes, and gives practical suggestions for professionals who work with caregivers. Schulz, et al. 2003 demonstrates that when death is preceded by an extended and stressful period of caregiving, many caregivers experience relief after the death. However, as one potential predictor of adjustment difficulties following loss, Hebert, et al. 2006 and Hebert, et al. 2009 address the important but thus far understudied issue of caregiver preparedness for the death of a loved one. Carr 2003 draws attention to another aspect that may have implications for the grief experienced by surviving family members: whether the death was perceived as a “good death.”

• Boerner, Kathrin, and Richard Schulz. 2009. Caregiving, bereavement, and complicated grief. Bereavement Care 28.3: 10–13.

  DOI: 10.1080/02682620903355382Save Citation »Export Citation » Share Citation »

  This article describes how the caregiving experience affects bereavement, with an emphasis on the relationship between challenging caregiving situations and difficult grieving processes. It offers practical suggestions for what professionals can do to help caregivers both before and after the death has occurred.

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• Carr, Deborah 2003. A “good death” for whom? Quality of spouse’s death and psychological distress among older widowed persons. Journal of Health and Social Behavior 44.2: 215–232.

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  This article characterizes good death by physical comfort, support from one’s loved ones, acceptance, and appropriate medical care. Carr is one of the first bereavement researchers to suggest that whether a loved one dies a “good death” may have implications for the grief experienced by surviving family members.

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• Hebert, Randy S., Holly G. Prigerson, Richard Schulz, and Robert M. Arnold. 2006. Preparing caregivers for the death of a loved one: A theoretical framework and suggestions for future research. Journal of Palliative Medicine 9.5: 1164–1171.

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  This thought-provoking article presents the first theoretical model outlining the relationships between preparedness, caregiver–health-care provider communication, and caregiver well-being, and provides recommendations for future research from this model.

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• Hebert, Randy S., Richard Schulz, V. C. Copeland, and R. M. Arnold. 2009. Preparing family caregivers for death and bereavement: Insights from caregivers of terminally ill patients. Journal of Pain Symptom Management 37.1: 3–12.

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  Presents data suggesting that preparedness has emotional, pragmatic, and informational components. Findings indicate that a person could feel prepared with respect to the informational and pragmatic components, but yet, feel entirely unprepared emotionally.

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• Schulz, Richard, Kathrin Boerner, and Randy S. Hebert. 2008. Caregiving and bereavement. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, 265–285. Washington, DC: American Psychological Association Press.

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  This chapter gives a comprehensive review of the literature on caregiving and bereavement.

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• Schulz, Richard, Aaron B. Mendelsohn, William E. Haley, Diane Mahoney, Rebecca S. Allen, Song Zhang, Larry Thompson, and Steven H. Belle. 2003. End-of-life care and the effects of bereavement on family caregivers of persons with dementia. New England Journal of Medicine 349.20: 1936–1942.

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  This study, by the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) investigators, found that depressive symptoms among caregivers decline on average from before to after the Alzheimer’s patient’s death, and that when death was preceded by an extended and stressful period of caregiving, caregivers reported considerable relief at the death itself.

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Continuing Bonds

What happens with the relationship to a loved one after this person dies? This question has received considerable attention in the field of bereavement over the past two decades. Freud’s classic paper “Mourning and Melancholia” (Freud 1957) expressed the view that the major task to be accomplished in the grieving process is to relinquish the tie to the deceased in order to be able to reinvest in new relationships. This position remained fairly unquestioned until it was challenged by the influential Klass, et al. 1996, causing an initial paradigm shift away from the necessity of disengagement from the loved one, and toward the belief that continuing bonds are common and typically comforting and helpful. This was followed by a thrust of research studies examining all aspects of continuing bonds, including what kind of continuing connections people may have, and which type of connections might be more or less adaptive for whom. For example, Field, et al. 2003 assesses the frequency of a wide variety of attachment behaviors, including attempting to carry out the deceased’s wishes and having inner conversations with the deceased. Boehlen, et al. 2006 is one of several studies showing that some of these attachment behaviors are adaptive whereas others are not. Stroebe and Schut 2005 and Field 2008 offer helpful summaries of this body of empirical evidence, as well as the conceptual conclusions that have grown out of this work. Finally, Stroebe, et al. 2010 outlines an integrative theoretical model for predicting the (mal)adaptiveness of continuing or relinquishing bonds to a deceased loved one, drawing on attachment and coping theory.

• Boelen, Paul A., Margaret S. Stroebe, Henk A. Schut, and Annemieke M. Zijerveld. 2006. Continuing bonds and grief: A prospective analysis. Death Studies 30.8: 767–776.

  DOI: 10.1080/07481180600852936Save Citation »Export Citation » Share Citation »

  This study found that maintaining bonds through comforting memories, but not cherishing possessions of the deceased, continued to predict later grief symptoms severity. Findings demonstrate that continuing bonds should not be regarded as exclusively adaptive.

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• Field, Nigel P. 2008. Whether to relinquish or maintain a bond with the deceased. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, 113−132. Washington, DC: American Psychological Association Press.

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  Provides a comprehensive review of the literature on continuing bonds, detailing under which conditions and for whom maintaining a continuing connection with the deceased may have adaptive or maladaptive implications.

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• Field, Nigel P., Eval Gal-Oz, and George A. Bonanno. 2003. Continuing bonds and adjustment at 5 years after the death of a spouse. Journal of Consulting and Clinical Psychology 71.1: 110−117.

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  This study found evidence for a wide variety of common attachment behaviors even five years following the death of a spouse, including attempting to carry out the deceased’s wishes, having inner conversations with the deceased, and using the spouse as a guide in making decisions.

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• Freud, Sigmund. 1957. Mourning and melancholia. In Standard edition of the complete psychological works of Sigmund Freud. Vol. 14. By Sigmund Freud. Edited by J. Strachey, 152−170. London: Hogarth.

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  In this classic paper, Freud argued that the psychological function of grief is to withdraw emotional energy (cathexis), and become detached from the loved one (decathexis). Originally published in 1917.

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• Klass, Dennis, Phyllis R. Silverman, and Steven Nickman, eds. 1996. Continuing bonds: New understandings of grief. Washington, DC: Taylor & Francis.

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  This influential book caused a paradigm change away from the long-standing belief that healthy grieving can only occur if the bereaved disengages from the deceased, positing instead the notion that maintaining a continuing connection to the deceased is not only common but also adaptive.

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• Stroebe, Margaret S., and Henk. Schut. 2005. To continue or relinquish bonds? A review of consequences for the bereaved. Death Studies 29.6: 477−494.

  DOI: 10.1080/07481180590962659Save Citation »Export Citation » Share Citation »

  Offers a thorough review of both theoretical discussions and empirical evidence on the (mal)adaptive value of retaining versus relinquishing bonds. The authors conclude that neither continuing nor relinquishing bonds is necessarily helpful, and that further research is needed to clarify this issue.

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• Stroebe, Margaret S., Henk Schut, and Kathrin Boerner. 2010. Continuing bonds in adaptation to bereavement: Toward theoretical integration. Clinical Psychology Review 30.2: 259–268.

  DOI: 10.1016/j.cpr.2009.11.007Save Citation »Export Citation » Share Citation »

  Outlines a theoretical model for predicting the (mal)adaptiveness of continuing or relinquishing bonds, drawing on both attachment and coping theory. The purpose of this model is to help explain patterns of individual differences in the impact of continuing bonds.

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Risk Factors for Complications in Grief Response

Mounting research evidence has made it increasingly clear that reactions to loss vary considerably from person to person, but that a significant minority of bereaved individuals show enduring effects. Therefore, researchers have become particularly interested in identifying factors that may promote or hinder people’s adjustment to bereavement. Knowledge about risk factors can not only help recognize those who may be more likely to develop long-term difficulties, it can also aid in the identification of people who may benefit the most from bereavement interventions. The three works described in this section all provide useful summaries of the literature on risk factors. Stroebe and Schut 2001 is helpful from a research standpoint because it also discusses conceptual and methodological issues that should be considered when interpreting findings from or planning a study of risk factors in the context of bereavement. Stroebe, et al. 2007 offers the most comprehensive review of risk factors for health outcomes of bereavement. Wortman and Boerner 2007 includes a detailed section on risk factors for bereavement outcomes that does not focus on particular types of outcomes.

• Stroebe, Wolfgang, and Henk Schut. 2001. Risk factors in bereavement outcome: A methodological and empirical review. In Handbook of bereavement research: Consequences, coping, and care. Edited by Margaret S. Stroebe, Robert O. Hansson, Wolfgang Stroebe, and Henk Schut, 349–371. Washington, DC: American Psychological Association Press.

  DOI: 10.1037/10436-015Save Citation »Export Citation » Share Citation »

  Provides a useful perspective on risk factors, because it not only reviews the available research findings but also discusses conceptual and methodological issues that should be taken into account in the investigation of risk factors in the context of bereavement.

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• Stroebe, Margaret S., Henk Schut, and Wolfgang Stroebe. 2007. Health outcomes of bereavement. Lancet 370.9603: 1960–1973.

  DOI: 10.1016/S0140-6736(07)61816-9Save Citation »Export Citation » Share Citation »

  Provides the most comprehensive review of health outcomes of bereavement, with a detailed discussion of risk factors that increase vulnerability of some bereaved individuals. The types of risk factors addressed are circumstances of death, intrapersonal and interpersonal factors, and ways of coping.

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• Wortman, Camille B., and Kathrin Boerner. 2007. Beyond the myths of coping with loss: Prevailing assumptions versus scientific evidence. In Foundations of health psychology. Edited by Howard S. Friedman and Roxane Cohen Silver, 285–324. New York: Oxford Univ. Press.

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  This chapter has a separate section on risk factors, which summarizes the available research on a variety of factors, including demographic factors, factors describing the type and nature of the relationship, personal and social resources, and the context in which the loss occurs.

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Complicated Grief

Most theorists understand complicated grief as a form of grief characterized by persistent, intense longing and yearning for the deceased, intrusive thoughts or images, emotional numbness, anger or guilt related to the loss, a sense of emptiness, and reactivity in response to cues. There is a general consensus that these are typical features of complicated grief. Prigerson, et al. 1999 and Prigerson, et al. 2008 offer a summary of these consensus criteria. However, scholars in the field have disagreed on some criteria, such as the role of avoidance in complicated grieving. The diverging views have resulted in two existing diagnostic systems for complicated grief. Forstmeier and Maercker 2007 provides a comparison of these two systems. The perspective stressing the importance of avoidance in complicated grief is presented in Horowitz, et al. 1997. In a similar vein, Shear, et al. 2007 presents an attachment-based model of complicated grief, including empirical evidence in support of the assumption that avoidance is a key element of complicated grief. The assessment tool for complicated grief most commonly used in research studies was first presented in Prigerson, et al. 1995. Simon, et al. 2010 and Prigerson, et al. 2009 both provide empirical evidence on which assessment criteria might be the most informative for the purpose of diagnosing complicated grief, but they come to slightly different conclusions. To understand the ongoing controversies, it is therefore helpful to read both of these articles.

• Forstmeier, Simon, and Andreas Maercker. 2007. Comparison of two diagnostic systems for complicated grief. Journal of Affective Disorders 99:203–211.

  DOI: 10.1016/j.jad.2006.09.013Save Citation »Export Citation » Share Citation »

  This article makes an important contribution by discussing and testing the two main diagnostic systems for complicated grief that exist in the literature. Also, the study was conducted in Switzerland, whereas the bulk of research on complicated grief has been done in the United States.

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• Horowitz, Mardi J., Bryna Siegel, Are Holen, George A. Bonanno, Constance Milbrath, and Charles Stinson. 1997. Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry 154:904–910.

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  The diagnostic system proposed by these authors differentiates between the categories of intrusion, avoidance, and failure to adapt. The main difference between this view and that of Prigerson, et al. 1999 is that avoidance symptoms are considered an important criterion.

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• Prigerson, Holly G., Mardi J. Horowitz, Selby C. Jacobs, et al. 2009. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine 6.8: e1000121.

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  Empirical evidence from a longitudinal study supporting the psychometric validity of criteria for prolonged grief disorder (PGD) that the authors propose for inclusion in the DSM-V and ICD-11. Criteria considered most informative in this study differ slightly from Simon, et al. 2010.

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• Prigerson, Holly G., Paul K. Maciejewski, Charles F. Reynolds III. 1995. Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research 59.1–2: 65–79.

  DOI: 10.1016/0165-1781(95)02757-2Save Citation »Export Citation » Share Citation »

  This was the original article to present the newly developed Inventory of Complicated Grief (ICG). This well-designed scale has since been widely used in research studies to assess complicated reactions to bereavement.

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• Prigerson, Holly G., M. K. Shear, S. C. Jacobs, et al. 1999. Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry 174:67–73.

  DOI: 10.1192/bjp.174.1.67Save Citation »Export Citation » Share Citation »

  Presents consensus criteria that reflect two categories of symptoms, separation distress and traumatic distress; symptoms should be present for at least six months. To date, most studies on complicated grief have applied these criteria.

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• Prigerson, Holly G., Lauren C. Vanderwerker, and Paul K. Maciejewski. 2008. Prolonged grief disorder: A case for inclusion in DSM-V. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, 165–186. Washington, DC: American Psychological Association Press.

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  This chapter provides a summary of complicated grief research and introduces the new term “prolonged grief disorder.” However, it is noted that this term has not been adopted by all experts, and “complicated grief” is still the more common term.

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• Shear, Katherine M., Timothy Monk, Patricia Houck, et al. 2007. An attachment-based model of complicated grief including the role of avoidance. European Archives of Psychiatry and Clinical Neuroscience 257.8: 453–461.

  DOI: 10.1007/s00406-007-0745-zSave Citation »Export Citation » Share Citation »

  Presents an attachment-based model of complicated grief and tests the assumption that avoidance is a key element of complicated grief. Findings support this notion and counter the perspective of Prigerson and colleagues, who have removed avoidance from their diagnostic system for complicated grief.

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• Simon, Naomi M., Melanie M. Wall, Aparna Keshavia, M. Taylor Dryman, Nicole J. LeBlanc, and Katherine M. Shear. 2010. Informing the symptom profile of complicated grief. Depression and Anxiety 28.2: 118–126.

  DOI: 10.1002/da.20775Save Citation »Export Citation » Share Citation »

  Empirical evidence from cross-sectional study with a large sample, providing helpful guidance about the most informative items from the Inventory of Complicated Grief and their relationship with complicated grief severity. Also includes support for the notion that behavioral avoidance is an important element of complicated grief.

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Relationship Perspectives

One important aspect to consider when thinking about what a particular loss might mean for a person is who was lost. Regardless of relationship aspects such as closeness or quality of the relationship, the loss of a spouse, for example, will always have different implications than the loss of a child. This section includes literature on the major relationship types that have received research attention: the loss of a spouse, child, parent, and sibling.

Disenfranchised Grief

The term “disenfranchised grief,” coined by Kenneth Doka (see Doka 1989), refers to any type of loss experience that is not acknowledged by society. This can be the case in any scenario where the relationship between the mourner and the deceased is not recognized as one that can legitimately trigger grief (e.g., the death of an unborn child, or the death of a mentor or colleague in a professional setting). The more recent volume on disenfranchised grief edited by Doka (Doka 2002) gives an overview of the literature, delineating basic definitions, and the nature of unacknowledged losses in a variety of contexts. Moss and Moss 2002 draws attention to the experience of long-term care staff after the death of a patient they have cared for. Rickerson, et al. 2005 reports findings from one of the few available empirical studies on the prevalence of grief among long-term care staff. Disenfranchisement of grief can occur when the circumstances of the loss are ambiguous (e.g., when a person has gone missing). Boss 1999 outlines different scenarios in which this might be the case, and discusses how it might cause complications in a person’s adjustment to the loss. The lack of recognition for one’s loss can also result from a death that comes with societal stigma, such as suicide. Cvinar 2005 provides an insightful review of the literature on suicide bereavement. Finally, Elison and McGonigle 2003 takes the opposite perspective on the issue of acknowledging loss experiences by discussing loss situations that constitute a positive development for the bereaved, with feelings of liberation and relief, rather than the appropriate distress expected from someone who would otherwise be considered a legitimate mourner.

• Boss, Pauline. 1999. Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard Univ. Press.

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  This thoughtful book discusses various types of losses involving ambiguity, either because the “lost person” is merely physically present, as in case of severe dementia, or because the person is physically no longer there, so that it is unclear where the person is or is not still alive.

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• Cvinar, Jacqueline G. 2005. Do suicide survivors suffer social stigma: A review of the literature. Perspectives in Psychiatric Care 41.1: 14–21.

  DOI: 10.1111/j.0031-5990.2005.00004.xSave Citation »Export Citation » Share Citation »

  Examines the literature to determine whether or not, and in which way, stigma plays a role in suicide bereavement. The stigma elements highlighted include the societal perception that the survivors must carry some responsibility for the death, and that there must have been a failure on their part in terms of dealing with emotional issues experienced by the deceased.

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• Doka, Kenneth. J., ed. 1989. Disenfranchised grief: Recognizing hidden sorrow. Lexington, MA: Lexington.

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  This book introduced the term and topic of “disenfranchised grief” into the literature. The author defined disenfranchised grief “as grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported.”

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• Doka, Kenneth. J., ed. 2002. Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press.

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  Gives an excellent overview over the topic of disenfranchised grief, with a helpful introduction outlining basic definitions of the phenomenon used in the literature and individual contributions that examine the nature of unacknowledged losses in various contexts.

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• Elison, Jennifer, and Chris McGonigle. 2003. Liberating losses: When death brings relief. Cambridge, MA: Perseus.

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  This compelling book gives voice to bereavement responses that are not uncommon but seldom talked about. Feeling liberated by a loss could involve being relieved that a loved one’s death finally put an end to period of intense suffering, or of being free of a troubled relationship.

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• Moss, Miriam S., and Sidney Z. Moss. 2002. Nursing home staff reactions to resident deaths. In Disenfranchised grief: New directions, challenges, and strategies for practice. Edited by Kenneth. J. Doka, 197–216. Champaign, IL: Research Press.

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  This insightful chapter draws attention to the largely overlooked issue of how long-term care staff respond to patient death. The authors note that long-term care facilities typically provide little support to help staff through this time.

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• Rickerson, Elizabeth M., Carole Somers, Christine M. Allen, Beth Lewis, Neville Strumpf, and David J. Casarett. 2005. How well are we caring for caregivers? Prevalence of grief-related symptoms and need for bereavement support among long-term care staff. Journal of Pain Symptom Management 30.3: 227–233.

  DOI: 10.1016/j.jpainsymman.2005.04.005Save Citation »Export Citation » Share Citation »

  Most reports of grief among staff have been anecdotal. This article reports on one of the few studies that have systematically assessed prevalence of grief in nursing home staff. Self-reported grief symptoms varied depending on number of patient deaths and closeness of relationship with the patient.

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Cultural Perspectives on Grief

Although the experience of grief over the death of a loved one is likely one that can be found in all cultures, there are many aspects surrounding death and bereavement that can differ by culture. Among these are interpretations of the meaning of death or what happens after death and how different expressions of grief are understood. Most importantly, there is considerable variability across cultures when it comes to mourning rituals. Rosenblatt 2008 provides a comprehensive review of the literature on all these issues. Klass 1999 proposes a theoretical model in which Klass distinguishes between the universal nature of core emotions of grief and culturally based perceptions and expressions of grief. This mode is further discussed in Parkes 2000 and Klass 2000. Finally, mourning rituals of major world religions are described by Parkes, et al. 2000, the third edition of a popular book targeting the readership of both professionals and lay persons who are involved in the care of the dying and bereaved.

• Klass, Dennis. 1999. Developing a cross-cultural model of grief: The state of the field. Omega: Journal of Death and Dying 39:153–176.

  DOI: 10.2190/BDTX-CYE0-HL3U-NQQWSave Citation »Export Citation » Share Citation »

  Klass distinguishes between cross-cultural and multicultural perspectives and then proposes a model that assumes core similarities in grief across cultures, with interpretive schemes such as how death is perceived and the acceptability of emotional expression that are thought to differ by culture.

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• Klass, Dennis. 2000. Response to Colin Murray Parkes’ comments on my article “Developing a cross-cultural model of grief.” Omega: Journal of Death and Dying 41.4: 327–330.

  DOI: 10.2190/BFGT-0JKU-3MJK-GVK0Save Citation »Export Citation » Share Citation »

  Klass contests Parkes’s proposal of an alternative perspective to the cross-cultural model of grief previously proposed in Klass 1999.

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• Parkes, Colin Murray. 2000. Comments on Dennis Klass’ article “Developing a cross-cultural model of grief.” Omega: Journal of Death and Dying 41.4: 323–326.

  DOI: 10.2190/QH8N-9RNY-7V0G-4EJGSave Citation »Export Citation » Share Citation »

  In this commentary, the author offers an alternative perspective to the cross-cultural model of grief proposed by Klass 1999.

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• Parkes, Colin Murray., Pittu Laungani, and Bill Young, eds. 2000. Death and bereavement across cultures. 3d ed. New York: Routledge.

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  Describes mourning rituals of major world religions and explains their psychological and historical context. Written for doctors, social workers, nurses, counselors, and others involved in the care of the dying and bereaved.

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• Rosenblatt, Paul C. 2008. Grief across cultures: A review and research agenda. In Handbook of bereavement research and practice: Advances in theory and intervention. Edited by Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, 207–222. Washington, DC: American Psychological Association Press.

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  This chapter provides a thorough review of fundamental issues in understanding grief across cultures, including different perspectives on the meaning of death, the spirit of the deceased, and the nature of grief. Cultural variations in mourning, and aspects of grief that might be universal, are also discussed.

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Treatment

The most widely read book on grief counseling and therapy, Worden 2008, was first published in 1982 and is now in its fourth edition. This book, which bases its principles and guidelines on the contested notion of tasks of mourning, is considered the bible of bereavement counseling by many professionals in the field of grief counseling. Its reputation comes from the fact that it represents a helpful and straightforward guide for those who work with the bereaved. Unfortunately, the author has not integrated new advances of bereavement research into its more recent editions. During the past decade, several reviews of grief and mourning treatment studies that examined the efficacy of treatment have appeared in the literature. Neimeyer 2000 provides a summary of meta-analytic reviews that were conducted on grief and mourning treatment studies in the 1990s. Jordan and Neimeyer 2003 and Stroebe, et al. 2005 are comprehensive narrative reviews of the literature on treatment. Currier, et al. 2008 reports on findings from a more recent meta-analysis of treatment studies with children. Taken together, these different reviews suggest that, in many cases, people may not need therapy following a loved one’s death, but that some subgroups are likely to benefit substantially from treatment. Shear, et al. 2005 developed and tested an intervention designed specifically to address the problems of mourners in high-risk categories, such as those who have already developed complicated grief. Zhang, et al. 2006 provides a general review of evidence-based treatments, with particular attention given to the diagnosis and treatment of complicated grief. Finally, Zisook and Shear 2009 offers concrete recommendations for clinicians on how to recognize and identify complicated grief, and on treatment choices.

• Currier, Joseph M., Jason M. Hollan, and Robert A. Neimeyer. 2008. The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research. Journal of Clinical Child and Adolescent Psychology 36.2: 253–259.

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  Offers a meta-analysis of grief treatment studies that is far more comprehensive than previous efforts. The key finding is that when interventions target respondents who experience significant distress as a result of the loss, effect sizes compared favorably with the positive outcomes shown for psychotherapy in general.

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• Jordan, John R., and Robert A. Neimeyer. 2003. Does grief counseling work? Death Studies 27.9: 765–786.

  DOI: 10.1080/713842360Save Citation »Export Citation » Share Citation »

  Authors identify factors that may influence findings from grief treatment studies, including that treatment may not show beneficial results if the treatment offered did not include enough sessions, or if the intervention was not offered at the most appropriate time.

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• Neimeyer, Robert A. 2000. Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies 24.6: 541–558.

  DOI: 10.1080/07481180050121480Save Citation »Export Citation » Share Citation »

  In this article, the author provides a summary of meta-analytic reviews conducted of grief treatment studies. The major conclusion is that interventions are often ineffective and perhaps even harmful, at least in the case of normal bereavement, and that benefits of treatment have been found for interventions targeting complicated grief.

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• Shear, Katherine, Ellen Frank, Patrocoa R. Houck, and Charles F. Reynolds III. 2005. Treatment of complicated grief: A randomized controlled trial. JAMA: Journal of the American Medical Association 293.21: 2601–2608.

  DOI: 10.1001/jama.293.21.2601Save Citation »Export Citation » Share Citation »

  Reports on a randomized, clinical trial comparing an intervention designed for people with complicated grief to a more standard treatment for depression. Although both treatments produced improvement in grief symptoms, there was a higher response rate and a faster time to response in the complicated grief treatment.

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• Stroebe, Wolfgang, Henk Schut, and Margaret S. Stroebe. 2005. Grief work, disclosure, and counseling: Do they help the bereaved? Clinical Psychology Review 25.4: 395–414.

  DOI: 10.1016/j.cpr.2005.01.004Save Citation »Export Citation » Share Citation »

  This article reviews the grief treatment literature with an eye for who might benefit from treatment. One consistent finding emerging from the evaluated intervention studies is that those who seek treatment are likely to show better results from grief therapy than those who are recruited into treatment.

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• Worden, J. William. 2008. Grief counseling and grief therapy: A handbook for the mental health practitioner. 4th ed. New York: Springer.

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  This book, first published in 1982, is perhaps the most widely used book on grief counseling written for clinicians and other mental health professionals. The outlined recommendations for treatment are based on the (contested) assumption that individuals must “work through” their feelings to accommodate the loss.

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• Zhang, Baohui, Areej El-Jawahri, and Holly G. Prigerson. 2006. Update on bereavement research: Evidence-based guidelines for the diagnosis and treatment of complicated bereavement. Palliative Medicine 9.5: 1188–1203.

  DOI: 10.1089/jpm.2006.9.1188Save Citation »Export Citation » Share Citation »

  Provides a general review of evidence-based diagnosis and treatment but pays particular attention to the differential diagnosis of complicated grief compared to other mental disorders, with a discussion of specific treatment options for complicated grief.

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• Zisook, Sidney, and Katherine Shear. 2009. Grief and bereavement: What psychiatrists need to know. World Psychiatry 8.2: 67–74.

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  This is one of few articles written directly for clinicians to help them identify complicated grief and provide guidance for treatment choices. Also discussed are the implications of patient suicide for clinicians themselves.

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