Abstract and Keywords
Bereavement, which is the circumstance of having experienced the death of a significant other, is associated with significant emotional, cognitive, spiritual, physical, and social disruption. Given its ubiquitous nature, nearly everyone is affected by bereavement at some point, and opportunities for social work intervention with the bereaved are many and varied. This entry provides a brief summary of our extant knowledge about bereavement including its theoretical underpinnings, psychosocial sequelae, and empirical evidence of related interventions.
By its very nature, life for most of us includes bereavement, which is the circumstance of having experienced the death of a significant other. Whether expected or sudden, self-inflicted, or the result of an accident, violent crime, disease, or disaster, death comes to everyone (some 50 million people globally each year) and leaves many more survivors in its aftermath. Notwithstanding its frequency and universality, bereavement is typically accompanied by grief, a complex and often distressing condition that affects people emotionally, cognitively, spiritually, socially, and physically. Furthermore, although grief is also experienced with other losses (for example, divorce, health, a job, a home), it is generally understood to be especially challenging when connected with the death of a loved one and can be accompanied by significant physical and psychological morbidity. For all of these reasons, opportunities for social work intervention with the bereaved are many and varied. This entry provides a brief summary of our extant knowledge about bereavement including its theoretical underpinnings, psychosocial sequelae, and empirical evidence of related interventions.
Most bereaved individuals adapt (that is, mourn) successfully, albeit in different ways and in different time frames depending upon individual and loss-specific factors (for example, type or emotional intensity of relationship with the deceased, meaning ascribed to the death), and do not experience psychopathology. This normative adjustment to bereavement, referred to variously as “normal,” “simple,” and “uncomplicated,” has been described extensively in the literature and is commonly depicted as a series of stages or tasks proposed most notably by John Bowlby, Colin Murray Parkes, Elizabeth Kubler-Ross, and William Worden. Stage theories suggest that individuals experience disbelief or denial of the loss, yearning, anger, depression, and acceptance after being bereaved and must face these feelings actively in order to mourn successfully.
This sizeable literature purports that as the bereaved successfully negotiate these distressing psychological conditions and tasks, the death becomes more integrated into their lives and the suffering of grief is simultaneously ameliorated. The time required for this process is a topic of considerable interest in the popular literature and is often of great concern to the bereaved. Professionals tend to agree that while grief is permanently transformative, its intensity begins to shift within months to several years after a death and thus becomes less preoccupying. Although the predominantly conceptual bereavement literature has been widely accepted despite limited empirical examination, there is some new evidence to support a stage theory of grief in which individuals experience disbelief, yearning, anger, depression, and acceptance over the first 2 years of bereavement. (Maciejewski, Zhang, Block, & Prigerson, 2007).
Recent research, however, suggests that many of the long-held assumptions about the bereaved and their grief do not have empirical support. Some, such as the assertions that “letting go” of emotional attachments to the deceased and repeated confrontation of events related to the death (that is, “grief work”) are essential to healthy resolution of bereavement, have been challenged. In their place, newer paradigms including the “Continuing Bonds” framework popularized by Klass, Silverman, and Nickman (1996) and the Dual Process Model proposed by Stroebe and Schut (1999) have further examined and specified the multiple processes that comprise bereavement. This contemporary work and that of other scholars have brought increased attention to the wide range of thoughts and feelings experienced by the bereaved and to the myriad ways cultural and sociopolitical forces shape the experience. This scholarship, in turn, has broadened our perceptions of “normal” bereavement and has stimulated exciting research that pushes our conceptualizations from the more simplistic and categorical into the more complex and interrelated spheres in which bereavement most likely belongs (for examples of recent research see issues 8 and 9 of Death Studies, 30, November 2006).
Because bereavement is generally viewed as a distressing but normative experience it is listed as a V code in the DSM-IV-TR (APA, 2000). Accordingly, clinicians must use existing criteria for other disorders to diagnose people with noted psychopathology thought to be grief related. While the psychological symptoms of grief may be similar to those for depression and anxiety, generally speaking when they occur within the first 3 months after the death of a loved one and are not accompanied by other signs of possible pathology (for example, a morbid preoccupation with worthlessness, thoughts of death other than the survivor feeling that she/he would be better off dead, nothing brings even momentary relief from distress) an Axis I diagnosis is not made.
Research does suggest that most bereaved individuals experience uncomplicated grief. However, a clinically significant subset does undergo difficulties extending beyond those viewed as normal. For example, when deaths are sudden, violent, or perceived as unjust, such as those within the context of disasters and other potentially traumatic events, survivors may experience an overlap of trauma and grief that leads to complications. This response process, referred to most recently as “complicated grief,” is thought by some to manifest in a set of core symptoms that resemble those associated with major depressive disorder and posttraumatic stress disorder but reflects a distinct psychiatric syndrome with additional characteristics such as intense pining for the deceased (for detailed information about complicated grief and its evolution as a construct see Horowitz et al., 1997; Jacobs, Mazure, & Prigerson, 2000; Lichtenthal, Cruess, & Prigerson, 2004). A related proposal to include complicated grief as a diagnostic entity is the next iteration of the DSM and is currently being evaluated by an international group of experts. However, concerns about its validity as a unique disorder, its applicability to all groups of bereaved individuals (for example, those with intellectual disabilities), and potential negative ramifications of the medicalization of grief have been raised and must be given serious consideration.
Given the lack of expert consensus surrounding the conceptualizations of normal and pathological grief, it is no surprise that extant knowledge about interventions for the bereaved is similarly provisional. Although survivor and death-specific support groups (for example, for bereaved parents, survivors of homicide victims, partners of those who died of cancer) are increasingly common and have strong anecdotal support from both participants and social work facilitators, they and other types of grief interventions have little empirical support of effectiveness. Research reveals that interventions for uncomplicated bereavement are at best minimally effective and in some cases may even be harmful. There is some evidence that interventions for certain subgroups of the bereaved including those who are self-referred or at high risk for complications (for example, widowers, survivors of sudden or violent deaths, those who exhibit intense anger, depression, or rumination early after the death) may lead to improved client outcomes. Similarly, interventions that are delivered to individuals, incorporate more sessions, occur closer to the date of death, and are provided by highly trained practitioners have also shown greater promise of effectiveness (for a detailed examination of the research literature see Jordan & Neimeyer, 2003). Finally, an intervention developed specifically for individuals exhibiting symptoms of complicated grief has recently demonstrated effectiveness for that group (Shear, Frank, Houck, & Reynolds, 2005).
In conclusion, bereavement is a universal experience accompanied by a range of challenging emotional and relational sequelae. Overall, extant empirical data suggests that most bereaved people will not need professional counseling to cope with their grief but rather will draw upon their preexisting internal and external resources to heal from this most painful experience. Nevertheless, given the vast numbers of people affected by bereavement, there undoubtedly will be many among them who seek additional support and guidance from social workers or who will benefit from it because their grief becomes atypically problematic. In each of the varied settings that social workers are based, we are likely to work with an individual or family who is grieving the death of a loved one. Whether that grief is the present issue or an important contextual factor shaping it, social workers in generalist practice as well as in specialty areas, such as end-of-life care or trauma, must be knowledgeable about bereavement and related interventions. Given the expansion of research in this field, it is essential for clinicians to keep abreast of new empirical findings. Ideally, social workers will contribute to this knowledge not only through active participation in intervention development and evaluation but also through collaborations with researchers who will benefit greatly from their practice wisdom.
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Worden, J. W. (2002). Grief counseling and grief therapy: A handbook for the mental health professional (3rd ed.). New York: Springer Publishing Company.Find this resource: