A Conceptual Understanding of the Multiple Dimensions of Loss

Bereavement is widely regarded as one of life’s greatest stressors, having wide-reaching effects across emotional, cognitive, behavioural, physical, spiritual/existential, financial, and social domains (Love, 2007). Grief and mourning are both healthy and adaptive reactions to the loss of a close attachment (Shear, Simon, et al., 2011); as portrayed by Parkes (2011),

“grief, it seems, is the price we pay for love” (p. 36). Despite its universality, grief is recognised as one of the most highly individualised human phenomena, with no two people grieving or mourning the same (Allan & Harms, 2010). As such, grief may involve the expression of intense feelings of sadness, fear, anger, shame, jealously, or relief, disbelief that the death has occurred (sometimes labelled ‘denial’), helplessness and hopelessness, intrusive

thoughts and/or feelings, avoidance of reminders of the death, hallucinatory-like experiences (including seeing or having conversations with the deceased), sleep and appetite disturbance, and other somatic experiences (Granek, 2016). Equally impactful secondary losses associated with bereavement may include housing rearrangements (Nihtilä & Martikainen, 2008), financial instability (Biro, 2013), changes to roles and responsibilities (Barlé, Wortman, &

Latack, 2017; Dent & Stewart, 2004), familial conflict and relationship breakdown (Albuquerque, Pereira, & Narciso, 2016; Barlé et al., 2017), and social stigma and isolation (Breen & O’Connor, 2011; Dyregrov, 2005-2006). Although grief is often most intense in the first year, many bereaved individuals report the continual or intermittent experiencing of these symptoms for years or even decades following the loss (Carnelley, Wortman, Bolger, & Burke, 2006).

As highlighted in Chapter One, a minority of bereaved individuals will experience a prolonged and complicated grief reaction associated with considerable impairment to daily function, rarely diminishing without therapeutic intervention (Aoun et al., 2015; Kersting et al., 2011). Such complications of grief have been found to be associated with an increased risk of suicidality, substance use, self-neglect (nutrition and personal care), poorer quality of life, and comorbid depressive, anxiety, and adjustment disorders (Ajdacic-Gross et al., 2008; J. Y.

Allen et al., 2013; Boelen & Prigerson, 2007; Latham & Prigerson, 2004; D. Lund, Caserta, Utz, & De Vries, 2010; Pilling, Konkolÿ Thege, Demetrovics, & Kopp, 2012; Prigerson, Vanderwerker, & Maciejewski, 2008). These individuals are also at higher risk of a range of adverse physical health outcomes including insomnia, overproduction of cortisol, high blood pressure, cardiovascular problems, and cancer (M. S. Stroebe et al., 2007).

2.2.1 Risk and protective factors

The question of how to protect bereaved individuals from developing grief complications has long been contested in bereavement research. Research has identified an extensive list of factors prior to (e.g., attachment style), associated with (e.g., anticipation of the death), and following the death (e.g., perceived social support) as key predictors of psychosocial outcomes following bereavement (L. A. Burke & Neimeyer, 2013; Lobb et al., 2010). It is important to note that the research summarised throughout this section is limited by its predominate focus on cancer/palliative care settings (where some type of formal support might be assumed), limited diversity in cultural contexts, low diversity samples (e.g., by gender and age), differences in outcome measures for complicated or prolonged grief, and failure to explore interactive effects of predictors. Though not exhaustive, this summary does highlight the idiosyncratic nature and complexity of individual grieving experiences.

2.2.1.1 Factors prior to or fixed at death

Personal factors prior to the death, including attachment, psychological comorbidity, gender, and caregiving role, have received the most attention in bereavement literature, yet are least amenable to change in therapy (L. A. Burke & Neimeyer, 2013). Attachment theorists posit that an individual’s attachment style (including internal working models) and attachment relationship with the deceased person (prior to death) are highly predictive of psychosocial outcomes following bereavement, with grief representing a form of separation distress (Parkes, 2011). An individual’s attachment system is activated by perceived psychological threat and serves to re-establish proximity to the attachment figure, always assuming a separation to be temporary and reversible (Field & Filanosky, 2010). According to Bowlby (1980), integration of loss, therefore, entails an individual accepting “both that a change has occurred in his external world and that he is required to make corresponding changes in his internal, representational world and to reorganize, and perhaps reorient, his attachment behaviour accordingly” (p. 18). As expected, secure attachment has been found to correlate with more positive adjustment to bereavement (Fraley & Bonanno, 2004; Shaver & Tancredy, 2001).

Although initially distressed by repeated frustrated attempts at reunification, an individual with a secure attachment style will eventually revise their working model of the relationship to represent an internal, rather than external attachment (Bowlby, 1980). In contrast, insecure attachment styles (anxious, avoidant, or disorganised) are associated with complications of grief (Field & Filanosky, 2010; Mikulincer & Shaver, 2008; van der Houwen, Stroebe, Stroebe, et al., 2010; Vanderwerker, Jacobs, Parkes, & Prigerson, 2006; Wijngaards-de Meij et al., 2007). These individuals are more likely to demonstrate ongoing oscillation between avoidance of reminders of the loss and excessive rumination about the deceased, with the death representing a form of intolerable abandonment that cannot be reconciled with the individual’s rigid internal working model of the relationship (Parkes, 2011).

Many studies have also explored the impact of caregiving at the end-of-life on bereavement outcomes (Breen, 2012). In a study of 127 bereaved former cancer caregivers, Abbott, Prigerson, and Maciejewski (2014) found that perceptions of lower quality of life in cancer patients (by their carers) at end-of-life was associated with higher rates of suicidal ideation in the initial months following the death. Additionally grief complications are predicted by greater dependency in the caregiving relationship, caring for a spouse, and a more intensive caregiving role (Thomas, Hudson, Trauer, Remedios, & Clarke, 2014). Caregiving factors associated with better bereavement outcomes include having a do-not-resuscitate order and perception of a better quality death (Garrido & Prigerson, 2014).

Research on gender has produced mixed findings, with some studies finding women to be more susceptible to grief complications (Chiu et al., 2010; Keesee, Currier, & Neimeyer, 2008; Kersting et al., 2011), whilst other studies have suggested that gender is not predictive (J. Y. Allen et al., 2013; L. A. Burke, Neimeyer, Bottomley, & Smigelsky, 2017). Empirically-supported theories suggest that gender in itself may not have a direct association with bereavement outcomes, but rather may mediate risk for complications of grief through preferred grieving styles and practices, which may be associated with, but not tied to gender (Doka & Martin, 2010). Supporting this argument, research has identified that women are more likely than men to confront and express their grief (M. S. Stroebe, 2001) and it is these symptoms that are more often the focus of measurement instruments (Doka & Martin, 2010).

Other important factors associated with complications of grief include experiences of early trauma or childhood adversity (Vanderwerker et al., 2006), psychological comorbidities such as depression and anxiety (J. Y. Allen et al., 2013; Bruinsma, Tiemeier, Verkroost-van Heemst, van der Heide, & Rietjens, 2015), neurotic personality structure (Boogar &

Talepasand, 2015; van der Houwen, Stroebe, Stroebe, et al., 2010), avoidant coping style (Smith, Tarakeshwar, Hansen, Kochman, & Sikkema, 2009), and a lack of religion or spirituality (Brown, Nesse, House, & Utz, 2004; Chiu et al., 2010).

2.2.1.2 Factors associated with death

Circumstances of the death have received considerable attention in the literature, with factors such as anticipation of death and cause of death identified as influencing bereavement outcomes. The expression of grief may be intensified when a death is unexpected, often even more so when the death is also perceived as non-normative (untimely), for example, occurring in childhood or early adulthood (J. Y. Allen et al., 2013). Studies have found associations between unexpected deaths and major depressive disorder (Barry, 2002; Burton, Haley, &

Small, 2006) and complications of grief (Barry, 2002; Fujisawa et al., 2010). However, as recognised by Zisook and Shuchter (1985), it is the meaning the individual attributes to the death, and not the timing of death per se, that has the potential to complicate the grieving process. Thus a sudden death may incite more distress related to the guilt of not being present at the time of death or having the opportunity to say goodbye, than distress relating to the premature ending of a life.

Violent or traumatic losses, for example through suicide, homicide, or accident, may also complicate the grieving process (Barlé et al., 2017). Studies have revealed an association between violent deaths and major depressive disorder (Barry, 2002) as well as complications of grief (L. A. Burke & Neimeyer, 2014; Field & Filanosky, 2010; Keesee et al., 2008). This

impact may be further intensified if the bereaved person discovers or witnesses the body after death (Feigelman, Gorman, & Jordan, 2009). However, Currier, Holland, and Neimeyer (2006) found the relationship between traumatic death and grief complications to be mediated by greater inability to make sense of the loss, indicating that similar to expectation of death, it is more about the meaning attributed to the death than the cause. Such losses challenge the bereaved person’s assumptive world, calling into question fundamental beliefs about themselves, other people, and the justice and safety of the world in which they live (Neimeyer, 2006a). Deaths that are more incongruent with an individual’s assumptive world often contribute to greater difficulty accepting or finding meaning in the death, inducing patterns of rumination relating to the fear of guilt and suffering (Barlé et al., 2017).

2.2.1.3 Factors following death

In the weeks, months, and years following a death, concurrent stressors, such as financial burden, relationships and parenting difficulties, and work strain, may increase the likelihood of grief complications (Ott, 2003; M. S. Stroebe et al., 2007; Worden, 2009). Other research has identified that meaning reconstruction—comprising sense making, benefit finding, and identity reconstruction—may mediate grief reactions through informing the bereaved person’s subjective interpretation of the death which, in turn, enables or inhibits the assimilation of the loss into his or her life narrative (Currier et al., 2006; Holland, Currier, & Neimeyer, 2006;

Keesee et al., 2008). Contributing to meaning reconstruction, engagement in funeral and mourning rituals (e.g., candle ceremonies and story circles) have also been recognised as protective against complications of grief, offering opportunities to internalise the relationship with the deceased and re-narrate the life and death stories (Cacciatore & Flint, 2011; Neimeyer, 2006b; Vale-Taylor, 2009). In individuals experiencing a more intense grief reaction, the timely introduction of psychotherapeutic interventions, delivered by trained psychologists, psychiatrists, or counsellors, may also buffer against ongoing grief complications (Currier, Neimeyer, & Berman, 2008).

Above all others, social support has received the most widespread attention for moderating or mediating the grief trajectory after the death has occurred (Bath, 2009).

Following bereavement, an abundance of research has found an association between poor social support and posttraumatic stress disorder (PTSD; Bottomley, Burke, & Neimeyer, 2017), depressive and anxiety symptoms (Bottomley et al., 2017; Spino, Kameg, Cline, Terhorst, & Mitchell, 2016; van der Houwen, Stroebe, Stroebe, et al., 2010), and grief complications (J. Y. Allen et al., 2013; L. A. Burke et al., 2017; Chiu et al., 2010). This effect may be further pronounced if the deceased person formed an integral part of the bereaved person’s primary support network (Barlé et al., 2017). However, a meta-analysis was unable

to identify the specific mechanism through which social support may serve as a risk or protective factor for complications of grief (Stroebe, Zech, Stroebe, & Abakoumkin, 2005). It is, therefore, likely that protective effects of social support are more complex than initially assumed and may even be mediated by previously uncontrolled for factors such as emotional loneliness (W. Stroebe, 2008), the bereavement experience of the supporter (Benkel, Wijk, &

Molander, 2009a, 2009b), the level of congruence between support expected/required and support received (Ha & Ingersoll-Dayton, 2011), and perceptions of the actual helpfulness of the support received (Wågø, Byrkjedal, Sinnes, Hystad, & Dyregrov, 2017).