Changes in Emotions and Thought Processes

There is general agreement that forewarning of death permits the soon-to-be-bereaved to structure the event cognitively and to reconcile differences with the dying person in a way that can serve to alleviate some of the feelings of anger and guilt that commonly appear after bereavement. There is disagreement, however, about whether the emotional responses to an impending death, which may resemble postdeath reactions in many ways, are comparable to grief following loss and about whether these reactions soften the blow of the actual death. Some observers of the bereaved (e.g., Bowlby, ⁴ Brown and Stoudemire, ⁵ and Bugen ⁶) have found that grieving begins when a person learns of a terminal diagnosis. In their experience, anticipatory grieving allows people to begin to let go of the relationship. The clinical observations of Parkes and Weiss ³³ and Vachon et al., ⁴⁴ however, have led them to conclude that persons threatened with loss typically intensify, rather than give up, attachment behaviors.

The most frequent immediate response following death, regardless of whether or not the loss was anticipated, is shock, numbness, and a sense of disbelief. Subjectively, survivors may feel like they are wrapped in a cocoon or blanket; to others, they may look as though they are holding up well. Because the reality of the death has not yet penetrated awareness, survivors can appear to be quite accepting of the loss.

Usually this numbness turns to intense feelings of separation and pain in the months after the funeral. Based on her review of the literature as well as her own years of clinical experience with the bereaved, the Australian psychiatrist, Beverly Raphael, ⁴⁰ describes this phase in the following way:

The absence of the dead person is everywhere palpable. The home and familiar environs seem full of painful reminders. Grief breaks over the bereaved in waves of distress. There is intense yearning, pining, and longing for the one who has died. The bereaved feels empty inside, as though torn apart or as if the dead person had been torn out of his body.

According to clinical researchers, "searching" behaviors—including hallucinations, dreams in which the deceased is still alive, ''seeing" the deceased person in the street, and other illusions and misperceptions—are frequently reported during this phase. When the lost person fails to return, however, these behaviors decrease and despair sets in. ¹ Symptoms such as depressed moods, difficulties in concentrating, anger, guilt, irritability, anxiety, restlessness, and extreme sadness then become common. Offers of comfort and support are often rejected because of the bereaved person's focus on the deceased.

The bereaved may swing dramatically and swiftly from one feeling state to another, and avoidance of reminders of the deceased may alternate with deliberate cultivation of memories for some period of time. People generally move from a state of disbelief to a gradual acceptance of the reality of the loss, although, as already noted, the progression is by no means linear. The bereaved may be intellectually aware of the finality of the loss long before their emotions let them accept the new information as true. Although no two bereaved persons are exactly alike, depression and emotional swings are characteristic of most people for at least several months, and often for more than a year following bereavement.

As old, internalized roles that included the deceased begin to be given up and as new ones are tried out, the bereaved person enters the final phase of "resolution" ⁵ or "reorganization. ^4,23 Eventually, the survivor is able to recall memories of the deceased without being overwhelmed by sadness or other emotions and is ready to reinvest in the world.

Behavioral Changes

Feeling slowed down, with accompanying postural changes, may alternate with agitation, restlessness, and increased motor activity in the early stages of bereavement. Crying and general tearfulness also are common. During the period of despair, the bereaved may lack interest in the outside world and often give up activities they used to enjoy, such as eating, watching television, or socializing.

As noted in Chapter 2, potentially health-compromising behaviors, such as smoking and drinking, may become excessive following bereavement, especially in people who tended to use these substances before experiencing loss. Such behaviors may be considered normal in the bereaved because they occur with considerable frequency. Nevertheless, they are also psychologically and physically self-destructive, potentially leading to such illnesses as lung cancer and cirrhosis of the liver. Substance abuse and other dangerous activities, such as reckless driving, may not appear to be obviously suicidal, but they can serve the same purpose as more overt efforts. Risk-taking behavior may not appear to be directly associated with bereavement; such behavior is not readily expressive of grief but may instead be part of a defensive operation. ³³ So although they are endangering their lives and, in reality, struggling with grief, survivors may appear to be coping reasonably well.

Interpersonal and Social Changes

Although bereavement precipitates changes within people, it also alters their interpersonal and social experiences. Although the bereaved person may have begun to resolve the loss emotionally, shifts in social status may lead to changes not only in self-perception but also in the ways a person is perceived by others, and the changes may continue for some time. Suddenly thinking of another as a ''widow" or "bereaved person" may also instigate particular stereotypes or expectations, resulting in different qualities being ascribed to the person. The nature of these interpersonal changes is largely dependent on the relationship that was lost and sometimes on the nature of the death (see Chapter 4). These changes also are influenced by the broad sociocultural context in which the person lives (see Chapter 8) and by the bereaved person's age. For example, a middle-aged widow or widower may find social life greatly curtailed because people tend to socialize in couples. An elderly person may find that most of his or her friends and relatives have died, leaving few familiar people to be with. Making new friends may be difficult. Thus, social isolation and feelings of loneliness are common, often long after the bereavement.

Physical Complaints

Because of the defense mechanisms used by a particular person, as well as cultural norms that influence the way psychologic pain is expressed, grief may be expressed more in terms of physical symptoms than psychologic complaints. ^2,29,41 As noted in Chapters 2 and 8, numerous clinical observers and social scientists have found that acute grief is associated with a variety of physical complaints, including pain, gastrointestinal disturbances, and the very "vegetative" symptoms that, at another time, might signal the presence of a depressive disorder (e.g., sleep disturbance, appetite disturbance, loss of energy). Especially in the elderly, this grief-related depression may be misdiagnosed as organic dysfunction if health professionals are not aware of the nature of bereavement reactions and the history of the particular patient.

Some bereaved persons, identifying with the deceased, may take on symptoms of the illness that killed the person for whom they are grieving. In a prospective exploration of identification phenomena in the bereaved, Zisook et al. ⁴⁶ found that 14 percent of their sample admitted to feeling physically ill since their loss, 15 percent felt "just like the person who died," 8 percent had acquired habits of the deceased, 12 percent felt they had the same illness, and 9 percent had pains in the same area of their bodies as the person who died.

Physical symptoms may not necessarily disguise the personal pain associated with grief, but they may divert the attention of physicians, other health professionals, friends, family, and even the afflicted person from the psychologic aspects of loss. These symptoms normally abate as the loss is resolved.

Favorable Outcomes

Although the bereavement process involves the completion of certain tasks and the resumption of others, all the feelings and symptoms triggered by bereavement do not simply disappear or return to exactly the same state as before. People do adapt and stabilize, yet clinical observers of the bereaved have found that some of the pain of loss may remain for a lifetime. Reactions to the loss may recur around birthdays, holidays, or other circumstances that are particularly poignant reminders of the deceased. Clinical observations of psychiatric patients show that anniversaries can trigger serious pathology in vulnerable persons, ³⁵ but usually such responses are transitory; recurrent waves of grief are normal and usually limited both in intensity and duration. An examination of bereavement outcomes should consider not only the presence or absence of various signs and symptoms, but also the quality and personal meaning of different behaviors.

For example, readiness to invest in new relationships does not invariably indicate completion of or recovery from grief. As with many types of behavior, a given action may mean different things to different people. A seemingly quick remarriage or a decision to have another child may reflect a sense of hope or strength in one case, whereas in another such actions may stem mainly from a wish to avoid grief. Many clinical and nonclinical observers have found wide variation in the ways people grieve and adapt. A healthy outcome for one person may be different from adequate resolution for another.

It has also been found that bereavement can have positive, growthproducing effects. Pollock, ³⁶ having studied the lives and works of many gifted artists and scientists, concluded that the successful completion of grieving might result in increased creativity. Among the less gifted, a new relationship or new satisfactions may occur following bereavement. Creativity does not always reflect a successful working through of grief, however. It may also be an attempt to cope via restitution, reparation, or discharge. ³⁷

Silverman and Cooperband ⁴³ observed dramatic personal growth in some older widows who had been in traditional marriages. For women who had relied on their husbands to assume the bulk of responsibility for the couple, a myriad of new skills may be acquired as the widow is forced to assume tasks and behaviors formerly the province of her spouse.

Pathological Outcomes

Prolonged or Chronic Grief. Parkes and Weiss, ³³ in a clinical study of 68 normal widows and widowers, found that prolonged or chronic grief (defined as persistent grieving without diminution in intensity despite the passage of time) is the most common type of pathologic grief. In the research of Vachon et al., ⁴⁴ it was found that prolonged severe grief (chronic grief) accounted for the poorest outcome in almost all cases. Survivors who manifested chronic grief were described by Parkes and Weiss as having become "stuck" in the grieving process. A certain comfort and reassurance against anxiety was observed among those who displayed this reaction. The inability to work through grief seemed preferable to the bleak hopelessness anticipated should the bereaved truly relinquish the lost relationship.

One measure of the possible frequency of prolonged or chronic grief reactions derives from the epidemiologic findings of Clayton and Darvish ⁹ discussed in Chapter 2. Although the vast majority of widows and widowers no longer had symptoms one year after bereavement, approximately 12-15 percent still reported symptoms that were sufficient to meet the criteria for clinical depression.

According to Parkes and Weiss, ³³ in prolonged or chronic grief the normal phases may become protracted or excessively intense, making resolution and adaptation impossible for the survivor. There may be excessive anger, guilt and self-blame, or depression that lasts longer than usual. Because these types of behavior do not differ from normal bereavement responses, it can be difficult to diagnose chronic grief. One indication would be the lack of a sense of future in a person whose loss occurred several months earlier. For example, if someone who was bereaved a year ago actively resists engagement with his or her present life—wondering, it seems, "What is there for me now?"—chronic grief could be suspected. This assessment would stem not so much from the person's sadness as from his or her active resistance to changing that feeling. Not only is there no movement, but there also is a sense that the person will not permit any movement. It is the felt intensity of anger, self-blame, or depression that makes the reactions pathologic.

Absent Grief. Not all the bereaved report feelings of distress and other symptoms of typical grief, regardless of the apparent importance of the relationship with the deceased. Bowlby, who has devoted his career to the clinical study of response to separation and loss, describes this phenomenon as follows ⁴:

After the loss they take a pride in carrying on as though nothing happened, are busy and efficient, and may appear to be coping splendidly. But a sensitive observer notes that they are tense and often short-tempered. No references to the loss are volunteered, reminders are avoided and well-wishers allowed neither to sympathize nor to refer to the event.

Bowlby reports that the bereaved person might appear to be coping effectively, but there are clues that all is not well. For example, the bereaved may continue to experience undue anxiety when recalling memories of the deceased or may forbid references to the death. Expressions of sympathy from others may be experienced as intolerable.

Parkes and Weiss ³³ conclude that absent grief is a relatively infrequent form of pathologic grieving; nevertheless, they confirm that it does occur. They describe the process as a "fending off" of threatening emotions that are too painful to bear. Examples of such painful emotions are guilt over previous death wishes or a perceived inadequacy in loving and caring for the deceased. Over the course of many years of clinical observation of the bereaved, Horowitz ²⁰ has found that denial is a form of coping that may be temporarily useful—if reality receives more and more attention as time passes. He has observed that it is typical for most bereaved persons to go through a period of denial; denial that continues for weeks or months, however, may be cause for concern. Horowitz has found that some denial may be adaptive in reducing fear and allowing pacing of decisions, enabling the patient to feel less troubled. But extended postponing of awareness of what must be faced may lead to hazardous choices of action.

Clinical experience with bereaved psychiatric patients has led a number of practitioners to speculate on the psychologic meaning of absent grief. Deutsch, ¹² basing conclusions on a limited number of patients undergoing psychoanalytic treatment, found that grief-related affects were sometimes omitted in persons who were emotionally too weak to undertake grieving. She concluded that where the intensity of affects was too great or the coping ability too weak, defensive and rejecting mechanisms came into play. Other authors have observed that a potentially hazardous outcome of this unconscious refusal to grieve may be depression, often masked by a multitude of physical symptoms. Based on their clinical experience in a major academic health center, Brown and Stoudemire ⁵ advise that "patients who experience persistent symptoms of major depression, often with the development of coincidental unusual physical symptoms, should be carefully considered as having an unresolved or latent grief reaction." Volkan ⁴⁵ observed that patients who do not overtly manifest grieving responses will often appear in a physician's office with physical illnesses that he termed 'depressive equivalents," but that today would more likely be called "somatization." He discovered that these symptoms seldom served as "substi tutes" for depression, and advised that if the physician looks closely enough and asks the correct questions, the depressive symptoms generally will also be found.

Because of pressures to return to the prebereavement state, as well as the unpleasantness for others of experiencing the grieving of the bereaved, absent grief may not be perceived as a problem. The survivor who seems to be doing so well relieves others of the burden of support. The bereaved who goes on with his or her life in a seemingly productive way without suffering the agony of grief looks to many as someone who has finished the process. Too often, however, the process may not even have been started.

Delayed Grief. Whether delayed grief, a concept implying a long period of absent grief (perhaps months or even years) after which grief-like symptoms emerge, even exists is controversial, as noted in Chapter 2. Some experts conceptualize this unusual reaction as a bereavement response while others view it as a new episode of affective disorder.

These different perspectives naturally carry treatment implications. Those who formulate the problem as purely psychologic would be more likely to recommend psychotherapeutic intervention, whereas those who diagnose a major depressive disorder, unrelated to bereavement, might be more inclined to treat the symptoms with antidepressant medication.

Classical Psychoanalytic Theory

The classical psychoanalytic model of bereavement rests largely on Freudian theory. ¹⁶ According to this perspective, grieving presents a dilemma because there is a need to relinquish the tie to the cherished love object if one is to complete the grieving process, but "letting go" of the deceased involves considerable emotional pain. Initially the bereaved person is likely to deny that the loss has occurred, increase his or her investment in the lost person, become preoccupied with thoughts of the deceased, and lose interest in the outside world. Eventually, however, as memories are brought forth and reviewed, the person's ties are gradually withdrawn, grieving is completed, and the bereaved regains sufficient emotional energy to invest in new relationships.

Classical analysts, basing their formulations on experiences with patients undergoing psychoanalysis, infer that relinquishing the loved object takes place largely through identification with the deceased, and they pay considerable attention to the different outcomes of identification following loss. They have found that, in cases in which the deceased was an object of hate or of the mixed emotions of intense ambivalence, identification with the lost person may become a precursor to certain kinds of depression.

Current Psychodynamic Perspectives

A number of contemporary psychoanalytic and psychodynamically oriented practitioners who have worked clinically with the bereaved have elaborated on the premises of Freud and his followers. These observers of the grieving process continue to focus their attention on internal psychic structures, defense mechanisms, and intrapsychic processes, but they also are concerned with interpersonal dynamics and the ways in which relationship issues may affect self-concept and views of others. Based on their clinical experiences, they have described additional ways in which antecedent personality and relationship variables may have an impact on grieving.

Of course, psychologic processes do not take place in a vacuum. A variety of sociocultural factors, including cultural norms, values, belief systems, and financial status, all contribute to the way a bereaved person perceives, interprets, and understands a loss. Preexisting health, as mentioned earlier, also affects responses to and the outcome of bereavement. Thus, to understand fully the individual factors that come into play, consideration must be given to psychosocial influences as well as purely psychologic, social, or cultural issues.

The Role of the Preexisting Personality. Although there are almost no systematic studies of the role played by preexisting personality variables in affecting the process or outcome of grieving, ⁴⁴ clinicians generally agree that such factors do influence every aspect of the grief experience, ranging from the way the loss is initially perceived to the way it is or is not resolved. Habitual styles of perception, thought, coping, and defense determine how a person experiences and handles all life situations, and these same modes are called upon to deal with the stress of bereavement. Clinical experience has shown that people who are characteristically more flexible and able to use more mature coping strategies will deal with bereavement more effectively than others. Those who are psychologically healthier prior to bereavement are expected to experience the pain of loss, but are viewed as unlikely to become overwhelmed or unduly frightened by their feelings.

Observers with psychological training agree that personality variables also probably relate to the quantity and quality of a bereaved person's social support network, which, in turn, has been found to influence outcome. People with well-integrated personalities are expected to be better integrated socially, because their personality traits enable them to both attract and sustain supportive relationships. Preexisting personality may also be seen as a determinant of the degree to which someone can perceive and use the community support system. It may be that so cial variables are even more important in predicting outcome than intrapsychic conflicts, although most researchers and clinicans believe that these variables are inextricably linked.

The Activation of Latent Negative Self-Images. Clinical experience with a number of bereaved psychotherapy patients has led Horowitz et al. ²² to infer that people who are particularly vulnerable to difficulties following bereavement have latent images of themselves as bad, incompetent, or hurtful. They speculate that loss activates these once-dormant negative images and find that distorted thoughts about the self and others intensify the grieving process, frequently resulting in pathologic responses. Self-concepts that appear to complicate grieving include feeling too weak to function without the deceased (resulting in overwhelming instead of tolerable sadness), considering oneself hostile and somehow responsible for the death (leading to intensified guilt), and feeling damaged or defective (leading to a sense of emptiness and apathy). ^19,21,22

These clinical researchers have found that most people who lose a person who supplied a significant amount of gratification revert to some self-representations of weakness and helplessness. Normally, however, "these self-images may be less desperate in quality, less discrepant with other self-images, and less compelling as organizers of information than the needy self-images of a person with conflicts or developmental defects in this area." ²²

This view of pathologic grieving is based in part on the same conceptualizations that underlie cognitive therapy. In the latter, however, the focus is on the maladaptive attitudes and thoughts themselves, whereas the conceptualizations of Horowitz and his colleagues emphasize the way people think about themselves and others within the context of their interpersonal relationships.

The Ambivalent Relationship. Many clinicians, regardless of their theoretical orientation, point to the quality of the relationship with the deceased as predictive of postbereavement response. Freud, 16 basing his formulations on a limited number of bereaved psychoanalytic patients, maintained that the most "important precondition leading to depression following bereavement was an ambivalent relationship with the deceased prior to the death."

In its most general sense, ambivalence in relationships is universal and not especially significant. Few affectionate relations are uncomplicated by some hostility, and many hostile relations are tempered by affection. "When, however, the strength of these conflicting feelings increases to the point where actions seem unavoidable yet unacceptable, some defensive maneuver is undertaken ... [e.g.] the ambivalence is repressed ... and only one of the two sets of feelings is permitted to become conscious. Usually it is the hostility that is repressed." ³⁰ Because of this hostility—whether overtly expressed, secretly experienced, or unconsciously repressed—a person might feel remorseful after the death of the other.

In their clinical investigation of 68 normal widows and widowers, Parkes and Weiss ³³ found that recovery after conjugal bereavement was more likely to occur in marriages that had been "happy" than in those that had been conflict-ridden. In this study, participants were separated into two categories—those who rated their marriages as having had one or no areas of conflict versus those who had two or more problem areas. Differences between the two groups were highly significant. At 13 months after bereavement, good outcomes were more than twice as likely in the no-conflict group than in the conflict group (61 versus 29 percent). At two to four years postbereavement, the widows and widowers who reported a high level of conflict (many of whom had displayed little or no distress during the first year) were almost twice as likely as their low-conflict counterparts to be depressed, anxious, guilty, in poorer health, and yearning for the dead spouse. From these data, Parkes and Weiss ³³ concluded:

Marital conflict had produced anger, and perhaps, desire for escape, but coexisting with these feelings were continued attachment to the other and even, perhaps, affection. Anger interfered with grieving, and only with the passage of time did persisting need for the lost spouse emerge in the form of sadness, anxiety, and yearning.

The Dependent Relationship. A second type of relationship that may predispose a survivor to difficulties in grieving is one that involves excessive dependency. Parkes and Weiss ³³ caution, however, that it is often difficult to define what is meant by this because

dependency is, in many ways, an unsatisfactory and ambiguous term. It can be taken to mean any situation in which one person relies on another to perform physical functions; thus an amputee can be described as dependent on his wife for functions that formerly he would have performed for himself. Or it can be used to describe any situation in which one person seeks reassurance and comfort from another, as in the case of the frightened child who clings in a dependent way to the mother. Or, as in the case of Queen Victoria, it can be used to describe intolerance of separation from another person (this was the case even during Prince Albert's life).

Researchers who assert that excessive dependency may lead to difficulty following bereavement cite as evidence the literature on the psychologic development of the young child. This material suggests that children who successfully complete the separation-individuation pro cess are able to achieve a secure attachment with their parents and to turn to them for protection and nurturing when they feel endangered. The child who, for whatever reason, feels that this protection is not forthcoming or is questionable is said to be more likely to experience the world as a threatening place and to experience anxiety when separated from a parent. In an effort to feel secure, such children have been observed to become clingy, a tendency that Parkes and Weiss ³³ infer is carried into adult relationships. They describe such adults as typically responding to real or threatened separation with fear, distress, and intense anger, and report that this group has particular difficulty in coping with bereavement.

In studies of conjugal bereavement, Parkes and Weiss ³³ and Lopata ²⁷ found that survivors in their samples who had been overly dependent tended to do poorly. The grief responses of the widows and widowers in this previously dependent group were characterized by positions of helplessness, indecisiveness, and intense yearning.

Although excessively dependent spouses may be vulnerable if left on their own, the tendency of many families to reconstitute following bereavement may offer some protection from frightening levels of increased anxiety. After a husband's death some dependent widows move in with sisters or other family members whom they have not seen or socialized with for years, although elderly widows may no longer have surviving siblings or even children to take them in. More concrete problems, such as the inability to drive a car or lack of job skills, deficits that are likely to be especially pronounced among older women, may prove to be better predictors of poor outcome among elderly widows. Older widows also fall into a "high-risk" group in terms of financial difficulties following the death of a spouse, another situation that exacerbates feelings of anxiety, depression, and social isolation.

It should also be noted that the deceased may have been an important source of social and emotional support even when ill and dying. Thus, with the death, the survivor loses not only the person depended on for many years, but also the support that enabled him or her to cope during the illness.

Interpersonal and Attachment Theory Models

Unlike the psychoanalytic models that emphasize intrapsychic dynamics, interpersonal models focus primarily on relationships—the nature of attachment bonds and the psychosocial consequences of breaking them. As already noted, the two perspectives are not mutually exclusive. Both deal with relationships, but psychoanalysts focus more on their personal meaning, while the interpersonal theorists focus more on their social meaning, on social roles, and on role transitions.

Although attachment theory grew out of and incorporates much psychoanalytic thinking, it also incorporates a number of principles from animal ethology. ⁴ The biologic substrate of grief reactions and the function of grief responses—namely, to revive or ensure the survival of the interpersonal relationship or the social group—are emphasized by both Bowlby ⁴ and Darwin. ¹¹

As conceptualized by Bowlby, the propensity of human beings to make strong affectional bonds to particular others is instinctive. Within this framework, bereavement can be viewed as an unwilling separation that can give rise to many forms of emotional distress and personality disturbance. Bowlby, studying young children who were placed in institutional settings away from their parents, observed that when a bond was threatened by separation, powerful attachment behaviors—including clinging, crying, and angry protest—were instigated. When the actual loss of an important relationship occurred, Bowlby found that there was a brief period of protest followed by a longer period of searching behavior. Over time, these behaviors, aimed at reestablishing the attachment bond, usually ceased and despair set in. Eventually, new attachment bonds were formed. However, in some cases chronic stress ensued, leading to emotional or physical illness.

Interpersonal theorists have focused considerable attention on conceptualizations of the phases of grieving described earlier and have observed different interpersonal behaviors in each phase. For example, they have found that people in an early state of disbelief or shock are likely to be socially withdrawn. Preoccupied with a desire to reject the new situation, a bereaved person may even attempt to care for others who are suffering. ⁴² In an angry, yearning phase of grief, the bereaved may actively disrupt social relationships. In a sad phase, they may seek support and allow others to feel that they are being appropriately helpful.

According to this perspective, the bereaved feel capable of engaging in new relationships only as they begin to redefine themselves. Silverman, ⁴² in her extensive experience with the conjugally bereaved, has observed that the bereaved ''need opportunities to practice assuming, at least in part, a new identity that can involve new behavior patterns" that are aligned with the changes that have occurred. Parkes and Weiss ³³ call this identity "a theory of self" that is used in thinking about ourselves, in presenting ourselves to others, and in defining our choices in the world. They found that bereaved persons sometimes chose new satisfactions that were appropriate in light of the role loss but would not have been appropriate before. Thus, one measure of a favorable outcome in bereavement is a survivor's ability to make this transition and redefine his or her role.

Crisis Theory

According to crisis theory, the death of an important other disturbs the survivor's "homeostasis" or equilibrium. ⁸ The bereavement is conceptualized as a stressful life event that highlights preexisting personality problems that previously may have lain dormant or did not seriously interfere with the person's ability to function. Because the crisis creates an acute situation, the bereaved may be in danger of increased disorganization. At the same time, however, because the loss intensifies and exaggerates already existing problematic ways of coping and defending, the death may provide an opportunity to recognize and work on what may have been formerly entrenched, unconscious issues. Thus, the potentially traumatic life event is viewed as presenting potential for positive growth and change.

Cognitive and Behavioral Theories

Theory emerging from cognitive therapy provides a model for understanding a variety of depressive and anxiety disorders. Developed by Beck, ³ a psychoanalytically trained psychiatrist, this model emphasizes the link between distorted thinking and psychopathology. Its focus on the relationship between disturbed thinking and dysphoric feelings parallels the thinking of some current dynamic theorists (e.g., Horowitz et al. ²²), thus reflecting some of the convergent thinking noted earlier among theorists with different orientations.

Cognitive therapists have not explicitly delineated the psychologic processes specific to bereavement, although Beck's cognitive model of depression could be applied to pathologic grief reactions. According to this conceptualization, a person's affect and behavior are based on the way he or she structures the world. People who experience episodes of clinical depression carry negative views of themselves, their futures, and their experiences. Extrapolating from this model, it could be assumed that bereavement might instigate a chain of negative thoughts that could intensify or prolong grief in those persons who had a premorbid tendency to see themselves and the world in a negative light. In such individuals, the death of someone important might be interpreted as deliberate rejection based on their inherent defectiveness. These persons might then experience themselves as social outcasts and, because of this, feel excessively sad and lonely. Negative ideas may predate the loss, at least to some degree, but the reality of the loss tends to reinforce those ideas. Thus, pessimistic expectations of the future and negative views of the self that may have existed prior to the bereavement become intensified.

According to the cognitive theory of Gauthier and Marshall, ¹⁷ grief may become distorted if attempts are made to inhibit it. For example, if a grieving person is led to believe that it is bad to think about the deceased because the pain produced by memories will be intolerable, that person may develop secondary anxiety when intense bereavement-related experiences occur. Clinical experience has led Gauthier and Marshall to infer that when intrusive thoughts about the deceased then occur, the immediate reaction is to attempt to avoid them for fear of losing control. This is said to produce ideal conditions for suppression of grief-related ideas, possibly leading to further distress because troubling trains of thought are not resolved.

Behaviorally oriented clinicians and researchers generally are less concerned with describing internal, underlying processes and personal meanings of loss than are representatives of other schools of thought. Their emphasis is exclusively on troubling, manifest behaviors that emerge following bereavement and on any environmental factors that foster or reinforce such behaviors. They regard grief as "a particular case of the more general malady of depression ¹⁷" and devote considerably more attention to the development of models to explain the phenomena of clinical depression. Of the few who do address the subject of bereavement, the major emphasis is on developing and assessing methods of intervention.

Behaviorists who are specifically concerned with grief reactions (e.g., Mawson et al. ²⁸ and Ramsay ³⁸) focus primarily on pathologic grief. They liken persistent distress of more than one year's duration that is initiated or exacerbated by bereavement to other forms of avoidance such as phobias or obsessive-compulsive behaviors. Ramsay's ³⁸ clinical experience has led him to conclude that persons likely to become "stuck" in pathologic grief reactions are those whose prebereavement response patterns were to avoid confrontation and to escape from difficult situations. He has found that, following the death of someone important, these people fail to enter situations that could trigger their grief. In other words, they avoid stimuli that could elicit undesired responses, such as crying. Because such stimuli are avoided, however, they find it impossible to work through their grief.

Mental health professionals with a behavioral orientation also view severe or persistent grief as a function of inadequate or misplaced social reinforcement. For example, Ramsay ³⁸ has found that persons suffering from pathologic grief have lost a major portion of the positive reinforcers in their lives. He describes a typical case of this as the widow whose reinforcement consisted of doing everything for her husband and who finds everything meaningless when he dies. According to this theory, because people feel powerless in the face of death, they conclude that all action is futile and stop responding in ways that would eventually alleviate their stress.

Gauthier and Marshall ¹⁷ have found that grief reactions may be prolonged or exacerbated if family or friends provide excessive social reinforcement for grieving behavior. They caution that if people in the social environment fail eventually to withdraw attention for grieving or do not provide consistent encouragement for more adaptive behavior, they are in effect encouraging the continuation of manifestations of grief.