WORKING WITH THE BEREAVED Although bereavement is one of the most

stressful experiences that occur in our lives, we should not conclude that most bereaved persons will need help with their adjustment process.

Research has shown that many bereaved persons do not want or need intervention services (Levy, Derby, & Martinkowski, 1993;

Lund et al., 1985). Most researchers estimate that between 15 and 25% of the bereaved will experience considerable long-term difficulty and may require major forms of assistance from others (Lund, 1993). This point is important to recognize because many clinicians and other service providers assume that most older bereaved persons are depressed, socially isolated, and incapacitated by their loss. In fact, gerontologists have reminded us that the majority of older adults do not fit the general stereotypes of being dependent, frail, poor, lonely, and in poor health (Hooyman & Kiyak, 1996). The research evidence does not support these and other assumptions, although certainly

some bereaved persons are depressed, isolated, and incapacitated (Wortman & Silver, 1989). In fact, as mentioned previously, older adults are quite resilient and find ways to manage the many losses that they experience throughout their lives (Cleiren, 1993; Lund, 1993; Murrell et al., 1988; Worden, 1991).

The tasks for those developing intervention services are many, and among their first should be an attempt to reach those who are at greatest riskÐto seek them out rather than simply announcing the existence of the serviceÐand encourage their participation by explaining how and why the service will be helpful. It is absolutely critical to recognize that many, perhaps most, of the potential population of bereaved persons will not want to participate (Caserta & Lund, 1993; Lund et al., 1985). This can be discouraging to those who are committed to the value of their services, but their motivation to continue their efforts will prob-ably be less adversely affected if they anticipate the lack of enthusiasm among many potential clients. For example, only 44% of the bereaved spouses who completed a study by the author said that they would have liked the opportunity of attending self-help groups (Lund et al., 1985).

Later in another study only 27% of those assigned to self-help groups actually agreed to participate (Lund, Redburn, Juretich, & Case-rta, 1989). For those who need assistance but are reluctant, it is often beneficial to obtain encouragement from others in the bereaved person's network, particularly physicians and important family members and friends.

Interventions need to be available early in the bereavement process and continue over rela-tively long periods of time (Horacek, 1995;

Schuster & Butler, 1989; Trunnell et al., 1992).

As discussed previously, there is a good deal of research evidence suggesting that the first few months are the most difficult and that early adjustments will influence outcomes much later (Caserta & Lund, 1993; Wortman et al., 1993).

Also, because bereavement may last for many years and some people may not be ready for early interventions, it would be most helpful to have services available over long periods of time so that they may obtain the appropriate help when they are most ready to receive and benefit from it (Faletti et al., 1989). Others may require intervention or assistance for long periods of time but dependency on any particular form of help is not desired (Silverman, 1986).

Because the impact of bereavement is multi-dimensional, it is imperative that interventions offer comprehensive and diverse sets of services.

It is unlikely that any one intervention will be capable of providing all that is needed, but each intervention should clearly identify which needs

are being targeted in relation to the overall multidimensional process so that there is an awareness of what help is not being provided.

For example, the death of a spouse in later life can impact emotions, psychosocial functioning, health, family life, interpersonal relationships, work, recreation, and financial situations.

Therefore, those designing interventions which provide primarily an opportunity for self-expression (such as self-help groups) should recognize that some dimensions are not likely to be addressed (Shuchter, 1986; Shuchter &

Zisook, 1993). Clinicians need to be aware of the full range of services that are available in their communities so their clients can obtain a unique set of diverse services to meet their unique needs. Ideally, all communities would have available a variety of interventions or services so that each person's unique skills, resources, and circumstances could be matched to the most appropriate set of services. While this is unlikely, we can at least strive to offer interventions with the broadest scope of impact.

Therefore, whenever possible, it would be worthwhile to impact several dimensions si-multaneously (Shuchter, 1986) by providing opportunities for self-expression and the en-hancement of self-esteem; by teaching new skills to complete the tasks of daily living; by enhancing and mobilizing already existing social support networks; by providing educa-tion and assistance regarding health, nutrieduca-tion, and exercise; and by encouraging social parti-cipation. Each of the predictor variables reviewed in this chapter can be integrated within nearly every type of intervention.

Behavioral competency interventions (Ben-Sira, 1983; Hill, Lund, & Packard, 1996) that identify and provide specialized training in daily survival skills can be of great value for several reasons. First, such training equips bereaved individuals with the special expertise they need to manage the tasks that had been performed by their deceased loved one. Second, successful mastery of new skills builds self-esteem and reinforces beliefs about personal competence.

Finally, the process of training provides informal opportunities for the individual to socialize and interact with others while learning important life skills. Skill training interventions offer an innovative approach with promise for helping bereaved older adults cope with issues of grief and mourning and prepare for healthy independent living.

Various intervention formats and profes-sionals are needed to ensure that appropriate services are available. Not all people experience bereavement in the same way; similarly, not all people will use or benefit from the same interventions. In terms of format, some people

will only want to have a one-on-one type of intervention. This might be because they feel the uniqueness of their situation can be dealt with more effectively one-to-one, because they are reluctant to express personal and sensitive feelings in group situations (Silverman, 1986).

Others have reported that they particularly enjoyed being in a self-help group because they learned from others, recognized some common-alities in their situations, and enjoyed the socializing and friendships which developed (Lund & Caserta, 1992; Caserta & Lund, 1996).

Self-help support groups are a commonly used intervention with older adults (Lund, Redburn et al., 1989). Such groups generally consist of bereaved individuals who voluntarily meet to discuss issues and problems associated with their situation (Lieberman, 1993; Lieber-man & Videka-SherLieber-man, 1986). Participants can experience hope, learn new ideas and problem-solving strategies, improve skills for developing social relationships, become less lonely, explore new role definitions, discover that others have similar difficulties, and receive additional social support and encouragement.

Belonging to a group and sharing feelings of fellowship and solidarity have been helpful to many older adults. Many of the general benefits of various self-help groups are especially relevant to bereaved older adults. Group members often discuss ways to alleviate the feelings of loneliness, social isolation, and hopelessness that accompany widowhood.

Members also have opportunities to meet new people, participate in social activities, and form new friendships (Caserta & Lund, 1993). In addition, many bereaved spouses experience difficulties managing tasks of daily living such as meal preparation, house cleaning, yard maintenance, and transportation that were performed previously by the deceased spouse.

Group members regularly share information, advice, and resources about these common problems. Finally, self-help groups are less expensive than most alternative services and are often attractive to individuals who are reluctant to use the services of mental health professionals and agencies. Support groups are not without their share of problems because they require clear goals, well trained leaders, and realistic expectations. Poorly run groups can become overly depressing and ineffective. Good out-comes do not often happen by chance but are the result of careful planning and good leader-ship (Lund, Redburn et al., 1989).

Many people have skills and expertise which are well suited for helping the bereaved. Silver-man (1986), who developed the widow-to-widow program, has shown that widow-to-widows are quite capable of assisting each other. An

Working with the Bereaved 109

experienced widow can reveal to the new widow that she has been there and knows how it feels to grieve. Also, there are important contributions that can be made by researchers, gerontologists, psychologists, psychiatrists, physicians, social workers, nurses, occupational therapists, coun-selors, clergy, and many other professionals, including social scientists, lawyers, accountants, educators, and direct service providers. Again, because bereavement has a multidimensional impact, interventions can be developed by many different professional and trained team mem-bers. Other bereaved persons can provide a sharing of experiences while trained persons assist with legal, financial, health, spiritual, and educational issues. A multidimensional team approach is highly recommended because it will increase the likelihood of developing interven-tions which address the diversity of needs and lead to greater success.

7.05.9 SUMMARY

Bereavement is a common and natural experience that we all share. Unfortunately, many people are not well prepared for the pain, threats, and challenges that it presents. Because bereavement occurs in broader contexts, we do not all have the same personal and social resources available (Caserta & Lund, 1993), or have the same experiences and needs. What appears to help one person may have an entirely different impact on someone else. The best way to be prepared to help bereaved persons is to be educated about the process, assess the context in which it occurs, become familiar with a wide range of helping resources, and be patient, a good listener and nonjudgmental.

One final suggestion concerning future re-search and clinical practice is the need to be creative and work in interdisciplinary teams whenever possible. Being creative means that while looking at the same thing you are able to see something different, perhaps many different things. Good quality research and interventions are not always the result of following a ªcookbookº approach where we simply look up the issue or problem and find the recipe to resolve it. In order to ask the most interesting and important research questions, decide on the best methodology, or develop and offer the most effective intervention, we need to be very creative. We need to be willing to take a risk and modify the way we mechanically make research and treatment decisions. One of the best ways to be more creative is to work in interdisciplinary teams.

Researchers and clinicians are trained within specific disciplines and learn to favor specific

research designs and intervention strategies.

Over time, each professional's training becomes his or her area of expertise and there is a natural tendency to define questions and issues in a way that leads to using the same methodologies and practices. Abraham Kaplan, a philosopher of science, refers to this rigidity as ªthe law of the instrumentº (1964, p. 28). He states that if you give a young boy a hammer, everything he encounters will need pounding. If a researcher or clinician exclusively uses only one theory, one methodology, or one counseling strategy then other techniques and strategies are ignored. If they cannot become skilled with more than just a single approach to their work (the hammer) it is even more important for them to work collaboratively in interdisciplinary teams so that other tools, strategies, perspectives, and meth-odologies are used. One of the best ways to be creative is to assemble a team of investigators who represent diverse and needed areas of expertise. When clinicians and researchers from medicine, pharmacy, nursing, social work, social and behavioral sciences, and other disciplines work collaboratively the end results are much greater than just the sum of the parts.

New methodologies, techniques, and strategies will result from the creativity that is enhanced by working in multidisciplinary teams.

Death and other bereavement-related losses will continue to surround our daily lives, offering us choices to learn from these experi-ences or to use them to be better prepared for our personal losses and our professional work.

Although we have learned much from research and clinical practice there are substantial gaps in our knowledge. Much creative and pioneering work remains for those who have the interest, expertise and enthusiasm to learn more about grief and bereavement and to apply this knowledge to make a difference in people's lives.

7.05.10 REFERENCES

Aiken, L. R. (1994). Dying, death and bereavement (3rd ed.) Boston: Allyn & Bacon.

Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ:

Prentice-Hall.

Atchley, R. C. (1989). A continuity theory of normal aging.

The Gerontologist, 29, 183±190.

Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122±147.

Ben-Sira, Z. (1983). Loss, stress, and readjustment: The structure of coping with bereavement and disability.

Social Science Medicine, 17, 1619±1632.

Bowlby, J. (1969). Attachment and loss. Vol.1: Attachment.

New York: Basic Books.

Caine, L. (1974). Widow. New York: Bantam.

Caserta, M. A., & Lund, D. A. (1992a). Bereaved older adults who seek early professional help. Death Studies, 16(1), 17±30.

Caserta, M. S., & Lund, D. A. (1992b). Bereavement stress and coping among older adults: Expectations versus the actual experience. Omega, 25, 33±45.

Caserta, M. S., & Lund, D. A. (1993). Intrapersonal resources and the effectiveness of self-help groups for bereaved older adults. The Gerontologist, 33, 619±629.

Caserta, M. S., & Lund, D. A. (1996). Beyond bereavement support group meetings: Exploring outside social contacts among the members. Death Studies, 20, 537±556.

Caserta, M. S., Lund, D. A., & Dimond, M. F. (1989).

Older widows' early bereavement adjustments. Journal of Women and Aging, 1(4), 5±27.

Caserta, M. S., Van Pelt, J., & Lund, D. A. (1989). Advice on the adjustment to loss from bereaved older adults: An examination of resources and outcomes. In D. A. Lund (Ed.), Older bereaved spouses: Research with practical applications. New York: Hemisphere.

Chigier, E. (1988). Grief and bereavement in contemporary society. London: Freund.

Cleiren, M. (1993). Bereavement and adaptation: A comparative study of the aftermath of death. Washington, DC: Hemisphere.

Cumming, E., & Henry, W. E. (1961) Growing old. New York: Basic.

Dimond, M.F., Lund, D. A., & Caserta, M. S. (1987). The role of social support in the first two years of bereave-ment in an elderly sample. The Gerontologist, 27, 599±604.

Faletti, M. V., Gibbs, J. M., Clark, M. C., Pruchno, R. A.,

& Berman, E. A., (1989). Longitudinal course of bereavement in older adults. In D. A. Lund (Ed.), Older bereaved spouses: Research with practical applications (pp. 37±51). New York: Hemisphere.

Farnsworth, J., Pett, M., & Lund, D. A. (1989). Predictors of loss management and well-being in later life widow-hood and divorce. Journal of Family Issues, 10, 102±121.

Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., De Longis, A., & Gruen, R. J. (1986). Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology, 50, 992±1003.

Freud, S. (1957). The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Ho-garth.

Gallagher, D., Lovett, S., Hanley-Dunn, P., & Thompson, L. W. (1989). Use of select coping strategies during late-life spousal bereavement. In D. A. Lund (Ed.), Older bereaved spouses: Research with practical applications (pp. 111±121). New York: Hemisphere.

Gass, K. A. (1989a). Appraisal, coping, and resources:

Markers associated with the health of aged widows and widowers. In D. A. Lund (Ed.), Older bereaved spouses:

Research with practical applications (pp. 79±94). New York: Hemisphere.

Gass, K. A. (1989b). Health of older widowers: Role of appraisal, coping, resources, and type of spouse's death.

In D. A. Lund (Ed.), Older bereaved spouses: Research with practical applications (pp. 95±110). New York:

Hemisphere.

Goldfried, M. R., & Robins, C. (1982). On the facilitation of self-efficacy. Cognitive Therapy and Research, 6, 361±380.

Grollman, E. A., (1977). Living when a loved one has died.

Boston: Beacon.

Hardt, D. V. (1978). An investigation of the stages of bereavement. Omega, 9, 279±285.

Havighurst, R. J. (1968). Personality and patterns of aging.

The Gerontologist, 8, 20±23.

Hess, B., Markson, E., & Stein, P. (1996). Sociology.

Needham Heights, MA: Allyn & Bacon.

Hill, C. D., Thompson, L. W., & Gallagher, D. (1988). The role of anticipatory bereavment in older women's

adjustment to widowhood. The Gerontologist, 28, 792±796.

Hill, R. D., Lund, D. A., & Packard, T. (1996). Bereave-ment. In J. I. Sheikh (Ed.), Treating the elderly (pp.

45±74). San Francisco: Jossey Bass.

Hooyman, N., & Kiyak, H. A. (1996). Social gerontology:

A multidisciplinary perspective. Needham Heights, MA:

Simon & Schuster.

Horacek, B. J. (1995). A heuristic model of grieving after high-grief deaths. Death Studies, 19, 21±31.

Irish, D. P., Lundquist, K. F., & Nelsen, V. J. (1993).

Ethnic variations in dying, death, and grief. Washington, DC: Taylor & Francis.

Kaplan, A. (1964). The conduct of inquiry. San Francisco:

Chandler.

Kubler-Ross, E. (1969). On death and dying. New York:

Macmillan.

Kushner, H. S. (1982). When bad things happen to good people. New York: Avon.

Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill.

Leming, M. R., & Dickinson, G. E. (1990). Understanding dying, death and bereavment. New York: Holt, Rinehart

& Winston.

Levy, L. H., Derby, J. F., & Martinkowski, K. S. (1993).

Effects of membership in bereavement support groups on adaptation to conjugal bereavement. American Journal of Community Psychology, 21, 361±381.

Levy, L. H., Martinkowski, K.S., & Derby, J. F. (1994).

Differences in patterns of adaptation in conjugal bereavement: Their sources and potential significance.

Omega, 29, 71±87.

Lewis, C. S. (1961). A grief observed. Minneapolis, MN:

Winston.

Lieberman, M. A. (1993). Bereavement self-help groups: A review of conceptual and methodological issues. In M. S.

Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement: Theory, research, and intervention (pp.

411±426). New York: Cambridge University Press.

Lieberman, M. A., & Videka-Sherman, L. (1986). The impact of self-help groups on the mental health of widows and widowers. American Journal of Orthopsy-chiatry, 56, 435±449.

Lindemann, E. (1944). The symptomatology and manage-ment of acute grief. American Journal of Psychiatry, 101, 141±48.

Lopata, H. Z. (1973). Widowhood in an American city.

Cambridge, MA: Schenkman.

Lund, D. A. (1989a). Conclusions about bereavement in later life and implications for interventions and future research. In D. A. Lund (Ed.), Older bereaved spouses:

Research with practical applications (pp. 217±231). New York: Hemisphere.

Lund, D. A. (1989b). Older bereaved spouses: Research with practical applications. New York: Hemisphere.

Lund, D. A. (1993). Widowhood: The coping response. In R. Kastenbaum (Ed.), The encyclopedia of adult devel-opment (pp. 537±541).Phoenix, AZ: Oryx.

Lund, D. A. (1996). Coping in later life. In K. J. Doka (Ed.), Journeys (pp. 1,3). Washington, DC: Hospice Foundation of America.

Lund, D. A., & Caserta, M. S. (1992). Older bereaved spouses' participation in self-help groups. Omega, 25, 47±61

Lund, D. A., Caserta, M. S., & Dimond, M. F. (1986).

Gender differences through two years of bereavement among the elderly. The Gerontologist, 26(3), 314±320.

Lund, D. A., Caserta, M. S., & Dimond, M. F. (1988). A comparison of bereavement adjustments between Mor-mon and non-MorMor-mon older adults. Journal of Religion and Aging, 5(1/2), 75±92.

Lund, D. A., Caserta, M. S., & Dimond, M. F. (1993). The course of spousal bereavement in later life. In M. S.

References 111

Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement (pp. 240±254). New York: Cambridge University Press.

Lund, D. A., Caserta, M. S., Dimond, M. F., & Gray, R.

M. (1986). Impact of bereavement on the self-concep-tions of older surviving spouses: An application of the interactionist perspective. Symbolic Interaction, 9(2), 235±244.

Lund, D. A., Caserta, M. S., Dimond, M. F., & Shaffer, S.

K. (1989). Competencies, tasks of daily living, and adjustments to spousal bereavement in later life. In D. A.

Lund (Ed.), Older bereaved spouses: Research with practical applications (pp. 135±152). New York: Hemi-sphere.

Lund, D. A., Caserta, M. S., Van Pelt, J., & Gass, K. A.

(1990). Stability of social support networks after later-life spousal bereavement. Death Studies, 14, 53±73.

Lund, D. A., Dimond, M. F., Caserta, M. S., Poulton, J.

L., Johnson, R. J., & Connelly, R. J. (1986). Identifying elderly with coping difficulties after two years of bereavement. Omega: Journal of Death & Dying, 16(3), 213±224.

Lund, D. A., Dimond, M. F., & Juretich, M. (1985).

Bereavement support groups for the elderly: Char-acteristics of potential participants. Death Studies, 9, 309±321.

Lund, D. A., Redburn, D. E., Juretich, M. S., & Caserta, M. S. (1989). Resolving problems implementing bereave-ment self-help groups. In D. A. Lund (Ed.), Older bereaved spouses: Research with practical applications (pp. 213±216). New York: Hemisphere.

Marris, P. (1958). Widows and their families. London:

Routledge & Kegan Paul.

McCrae, R. R., & Costa, P. T. (1993). Psychological resilience among widowed men and women: A 10-year follow-up of a national sample. In M. S. Stroebe, W.

Stroebe, & R. O. Hansson (Eds.), Handbook of Bereave-ment: Theory, research and intervention (pp. 196±202).

New York: Cambridge University Press.

New York: Cambridge University Press.

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