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Institute of Medicine (US) Committee for the Study of Health Consequences of the Stress of Bereavement; Osterweis M, Solomon F, Green M, editors. Bereavement: Reactions, Consequences, and Care. Washington (DC): National Academies Press (US); 1984.

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Bereavement: Reactions, Consequences, and Care.

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CHAPTER 4Reactions to Particular Types of Bereavement

Of the many musical expressions of bereavement, Gustav Mahler's Kindertotenlieder are among the most poignant and tender Greatly affected by the numerous illnesses of his twelve brothers and sisters, half of whom died, Mahler chose for this song cycle the poems of Friedrich Rucket, who had lost two of his own children


Of the many musical expressions of bereavement, Gustav Mahler's Kindertotenlieder are among the most poignant and tender Greatly affected by the numerous illnesses of his twelve brothers and sisters, half of whom died, Mahler chose for this song cycle (more...)

It is generally acknowledged that the type of relationship lost influences the reactions of the survivor. Because the needs, responsibilities, hopes, and expectations associated with each type of relationship vary, the personal meanings and social implications of each type of death also differ. Thus, it is assumed that the death of a spouse, for example, is experienced differently from the death of a child. 75

This chapter summarizes and discusses current knowledge about the various psychosocial responses to particular types of bereavement. The focus is on loss of immediate kin—spouse, child, parent, and sibling. There is also discussion of the response to suicide, often regarded as one of the most difficult types of loss to sustain. Other types of particularly difficult losses, such as multiple simultaneous deaths resulting from accidents or natural disasters and deaths caused by war and terrorism, are not discussed.


The death of a husband or wife is well recognized as an emotionally devastating event, being ranked on life event scales as the most stressful of all possible losses. 29 The intensity and persistence of the pain associ ated with this type of bereavement is thought to be due to the emotional valence of marital bonds linking husbands and wives to each other. Spouses are co-managers of home and family, companions, sexual partners, and fellow members of larger social units. Although the strength of particular linkages may vary from one marriage to another, all marriages seem to contain each of these linkages to some extent.

The death of a spouse ends the relationship but does not sever all relational bonds. The sense of being connected to the lost figure persists—sometimes exacerbating a sense of having been abandoned, sometimes contributing to a sense of continuing in a relationship, although with an absent partner.

There are two distinct aspects to marital partnerships. First, both husband and wife look to the other to collaborate in the setting of marital policy: How should money be used? Where should the family live? Should they have children? If so, how should they be raised? Loss of a spouse leaves the survivor to plan alone. Occasionally, when a marriage has been filled with conflict, the survivor finds rueful gratification in now being able to decide matters without argument. But most often, and especially if there are children, widows and widowers complain of having to shoulder all responsibilities alone. The burden of sole responsibility for children is especially difficult. 74

The partnership of marriage also serves to divide familial labor. Following the death of a spouse, the survivor is left with unfamiliar tasks to be accomplished in addition to accustomed ones. The loss of the husband may mean the loss of the family's chief income producer, imposing on the widow not only sole responsibility for managing the family's finances, but also the problem of compensating for the husband's absent contribution. The sudden need to manage finances and, perhaps, enter the labor force may be particularly stressful for older widows who never received training in money matters and who frequently lack practical job skills. Early socialization for dependency on their spouses has left many elderly widows ill-prepared for earning and managing their money. Insurance and pension payments may provide a sudden augmentation of capital, but such payments constitute a one-time event that the widow may not know how to use wisely.

For most men, the loss of a wife means the loss of the partner who had taken responsibility for child care and home management. Some bereaved husbands, regarding themselves as ill-equipped to take over this role, employ housekeepers; others find some way of using the services of other women in their families; still others manage on their own, perhaps sharing responsibilities with children.

If there are children in the home, the surviving parent may feel unable to meet their children's demands for attention and understanding. The single parent can be vulnerable to overload and emotional exhaustion, 74 especially since their enormous and constant effort seems so largely unrecognized.

Companionship in many marriages consists only of sharing daily routines, outings, and bed—activities which themselves can facilitate well—being. In other marriages, however, the relationship is characterized by an intense sharing of intimate lives. In all cases, the death of a spouse necessitates finding substitute companions or tolerating a lonelier life; the loss of a spouse who had been a ''best friend" represents additional impoverishment.

As already suggested, the death of one's spouse means the loss of one's sexual partner. According to the research of Glick et al., 25 some widows totally lose interest in sex as one aspect of grief and are celibate for some time after their husbands' deaths, although with the passage of time, at least some report unsatisfied yearnings. Widowers' grieving appears less likely to involve loss of sexual yearning.

Finally, the death of a spouse is likely to alter a person's social role and standing in the community, with widows and widowers frequently excluded from the sociability of couples. Widows who had participated in leisure activities as members of a couple and widowers who had relied on their wives to arrange their social lives may find that bereavement ushers in a time of social marginality. Survivors who have trouble in establishing new friendships may be most prone to experiencing feelings of isolation; Lopata, 43 in a study of midwestern widows, found that this was especially likely among those in lower socioeconomic classes. Problems of social isolation may be particularly pronounced among elderly widows who frequently cannot afford social outings and who may live some distance from grown children. Failing health among the elderly may also make it difficult to engage in social activities following bereavement.

Redefinition of role is one of the main tasks of the bereavement process for the widowed. "Mourning ... is not something that ends and then the widow is able to return to her life as before." 65 To the extent that a widow embraced a traditional role during marriage, she adopted an identity based on social interactions with another (her husband) and with the situation (her marriage) that were stabilized with repetition. When the "other" or the "situation" changes, the identity of the survivor must be modified. In addition, for a widow who did not work outside the home, a husband's absence leaves no object for her work, so her daily activities change. And "since marriage created a system of specialization in knowledge and skills, she [may have] definite gaps in her abilities." 43 These problems again may be particularly evident in elderly widows who are more likely to have had traditional marriages. For such women, who organized their lives around husband and family, conjugal bereavement removes the focus of their lives. With children grown and a lack of job skills or employment experience, they may feel that they have lost their purpose in life.

Bereavement may also initiate a "status passage." For example, perceived as a "sad person," the widow may remind others of the fragility of life. Or, because she is now unattached, she may be seen as a threatening sexual rival. As a single person, the newly bereaved widow may no longer have access to previously available social supports. Clarisa Start, in her first-person account, On Becoming a Widow, 68 recalled finding that "grief teaches you that there are two kinds of people in the world, those who are available and those who are not." In her clinical research, Golan 26 found that the new widow is sometimes forced to change roles sooner than she would like, learning to cope with the insecurity of possible incompetence, handle the anxieties involved with decision making and the stress of taking on this new role, adjust to all that the role implies in terms of status and position in the community and family, and devise new standards of well-being.

Silverman 66 has observed that conjugal loss may also initiate a process that can lead to "dramatic growth or a quiet reorientation." Golan 26 describes a process of moving from "being a wife to being a widow to being a woman." She means by this that a widow must first accept the reality of the loss, signifying that she is no longer someone's wife. In Golan's opinion, however, growth really occurs when the widow gives up her view of herself as a "partnerless half" and strives to enhance her sense of individuality.

Widowed individuals may be seen by members of the extended family as requiring concerned attention. With this increase in sympathy may come a decrease in respect; for example, the widow is now more likely to be perceived as the recipient rather than the giver of advice. Widows and widowers who once provided holiday dinners for the family may now agree to allow a sibling or grown child to assume this responsibility. Reduced standing in the family may lead to reduced confidence in the self.

There seem to be few sex differences in terms of vulnerability to distress following conjugal loss. Differences in outward expressions of grief, including more crying among widows, seem to be based primarily on the tendency for women to be more expressive than men.

There does seem to be a sex difference, however, in the recovery processes following conjugal bereavement. In their research on the first year after spousal death, Glick et al. 25 found that widows usually could not engage in new relationships soon after their husbands' deaths without feeling disloyal. In contrast, widowers did not seem to feel that a new relationship would conflict with their commitment to their deceased spouses. In fact, widowers who established a new quasi-marital relationship a few months after bereavement expected their new partners to be sympathetic to their continued grieving.

Among those past middle age, conjugal bereavement can no longer be considered untimely. Even when the death is long foreshadowed by a slow terminal illness, however, observers generally doubt the occurrence of "anticipatory grief" in the sense of an initiation of grieving and withdrawal from the dying partner. Clinical observations of grieving couples 52,71 reveal (as discussed in Chapter 3) that feelings of attachment may actually intensify (as is typically the case in response to threat) and the marital tie may be further reaffirmed by demonstrations of loyalty and commitment. Consciously admitting and planning for a husband's or wife's demise may make a spouse feel disloyal. Furthermore, following a spouse's death there are so many changes in the sense of self and situation that earlier plans may no longer seem desirable.


Bereavement can certainly be painful whenever it occurs, but many feel that the experience of losing a child is by far the worst 27,72 because it conflicts with our life-cycle expectations. Although once common, deaths of children between the ages of 1 and 14 now account for less than 5 percent of mortality in the United States. 51 In contrast with earlier years when couples sometimes had several children die, most families today lose none. It is now expected in this country that children will live to adulthood.

Nevertheless, 400,000 children under the age of 25 die each year from accidents, diseases, suicide, or murder, leaving approximately 800,000 bereaved parents. 20 And, as life expectancy increases, the number of elderly adults who experience the deaths of their middle-aged children can also be expected to multiply.

In addition to being loved, children take on great symbolic importance in terms of generativity and hope for the future. Childrearing involves decisions, conscious or otherwise, about how to shape a "healthy" person who will be happy and creative as an adult. All parents have hopes and dreams about their children's futures; when a child dies, the hopes and dreams die too. Although some amount of guilt and self-blame are present in most bereavement situations, they are likely to be especially pronounced following the death of a child. This guilt may itself be a psychological risk factor. 38

Although many of the issues are the same as in other types of bereavements, the impact of a child's death may vary depending on the child's age when death occurs, with the death of a newborn feeling somewhat different from the loss of a teenager. As parents in a support group described by Macon 44 reported, "it is not necessarily 'harder' or 'easier' to lose a very young child as opposed to a teenager. It is simply a quite 'different' kind of pain."


Stillbirths, like miscarriages, are regarded by some as "nonevents"' 8 or "nondeaths" 54 of often unnamed "nonpersons." 40 In stillbirth, which occurs approximately once in every 80 deliveries, 41 an anticipated joyful event turns into tragedy. Stillbirth can assume two forms. The more common occurs when the baby was viable until labor, and then dies during labor or delivery. In the second type of stillbirth the fetus dies in utero and the mother is forewarned of the death, sometimes weeks before the delivery. Although this forewarning could provide parents with an opportunity for anticipatory grieving, the tendency to rely heavily on denial when told of an intrauterine death commonly precludes this. Kirkley-Best and Kellner, 35 in their clinical observations, have found that the emotional reaction to both types of stillbirth is similar—both are experienced as "the simultaneous birth and death of the child.''

By the time of a stillbirth, the subtle but powerful bonding of parents, especially of mothers, to a baby has usually progressed to a stage of "primary maternal preoccupation" 77 and a narcissistic investment has been made in the child. Fletcher and Evans 22 have found that, in some cases, technology has intensified prenatal bonding. Parents who receive photographs of their infants in utero (a result of increasing use of sonograms for diagnostic purposes) may become more intensely attached to the fetuses because they have a concrete image on which to attach their dreams.

Part of what can complicate the grieving process following stillbirths is a conspiracy of silence. An assumption is often made that the mother is better off not discussing the loss, resulting in her being sedated to suppress distressing responses. When hospital personnel and friends do talk about the death, they may advise the mother that she will be able to "have another baby" or observe that "something must have been wrong with the baby, so it's better this way." Wolff et al. 78 have found from their research, however, that negative feelings may be exacerbated by such responses. Stringham et al. 70 have similarly found that the silence surrounding the bereaved mother seems to confirm feelings of guilt and underscores the "unspeakable" nature of the death.

Frequently observed responses among mothers after stillbirth include anger, loneliness, and a sudden drop in self-esteem. Gilson 24 has found that some mothers feel ashamed of their inability to do what others apparently do with ease, and their feminine identities may be threatened. Anger may be directed toward the self for failing to produce a healthy baby, toward the doctor for providing inadequate care, and toward family and friends for providing insufficient support. 70 Loneliness can emerge because the mother is "grieving the loss of someone who was unknown to one's family and friends." 70 Although the lost child had become increasingly personalized to the parents, especially the mother, throughout the pregnancy, to others the baby remained completely anonymous.

Until recent years, the intensity of the parental attachment was underestimated, resulting in stillborn babies being whisked away before being seen by the parents. Research conducted since 1970, however, indicates that visual and physical contact with the dead infant may facilitate the bereavement process. 70 An increasing number of hospitals are now encouraging parents to name and spend time with the infant, and to collect memorabilia such as pictures, locks of hair, and the nursery bracelet.


Unlike stillborns, babies who live for a few days or weeks are accorded personhood. They are named, looked at, held, talked to, and talked about.

As with stillbirths, the advent of new technologies and surgical procedures can influence reactions to a child's death in the first few days or weeks of life. With the dramatic reduction in the birthweight at which babies can be saved, the death of a very tiny, sick, or deformed newborn is no longer always expected. Parents' hopes may be buoyed with the suggestion of each additional medical procedure, and the added time that the child lives increases their attachment.

This increased ability to extend life can bring additional anguish for other reasons. For example, some parents are now faced with the dilemma of whether or not to agree to surgical intervention that may extend life for only a brief period or that may result in a life of pain and disability. The decision not to intervene, assuring the child's death, has recently resulted in the highly publicized "Baby Doe" situation in which a governmental or other third party brings legal action against the parents, trying to force medical care for the infant. Being forced into an adversarial position is likely to intensify the difficulties parents have in dealing with the loss of their child. If the parents decide to intervene, the baby may die sometime later or live its life with severe handicaps; both circumstances create their own set of emotional and often financial problems for the family.

Because an infant who lives for even a short time in a hospital is known to the staff and family friends, there is usually more support available to parents in the event of death than there is for parents whose infant is stillborn. Nevertheless, many people still ignore the loss and avoid discussion of it, instigating feelings of anger in the bereaved parents. 4 Other troublesome reactions include anxiety about the ability to produce a healthy child, a sense of the unjustness of a child never having had a chance, and feelings of guilt. According to the research of Benfield et al., 4 mothers blame themselves for such deaths far more than fathers do, assuming that they had done something during pregnancy to cause the death, such as smoking, drinking, having intercourse late in pregnancy, or not taking enough care of themselves.

According to data collected by Kennell et al., 34 the presence of other children in a family does not diminish the mother's grief following perinatal death. Similarly, Wilson et al. 76 found that losing one of a set of twins involves as much grief as losing a single newborn. In fact, in some ways, such a loss may be even more difficult because usually less support is available. Others assume that parents are grateful that one baby survived and focus attention on the living child, although, as these researchers discovered, no matter how many children someone has, the loss of any one of them causes painful grief reactions.

Sudden Infant Death

After the neonatal period, the most common form of death in the first year of an infant's life is Sudden Infant Death Syndrome (SIDS), which claims 7,000 to 10,000 lives per year in the United States. SIDS usually occurs between the ages of one week and one year, with a peak occurring in the two- to four-month age group.

Because the cause of SIDS is largely unknown, there is no way to predict with certainty which babies are at highest risk. Although some infants experience recurrent episodes of apnea, when breathing stops for a brief period, prior to their deaths most of these infants appear healthy. The suddenness of SIDS death in seemingly healthy babies may lead to extra difficulties in the bereavement process.

Adding to parents' sorrow are misunderstandings that sometimes arise because of the absence of an immediately identifiable cause of death and the baby's appearance. The bodies of infants that are not discovered for several hours frequently appear bruised. Law enforcement officers, investigating an unexplained death, may suspect child abuse. In an attempt to help avoid upsetting encounters between police and bereaved parents, a program in Washington, D.C. (at the Children's Hospital National Medical Center in conjunction with the District of Columbia Medical Examiner's Office) has been developed to explain SIDS to homicide officers. Seminars that sensitize them to the special vulnerability of SIDS parents have changed the way couples are approached and questioned. 16

Guilt is especially intense in SIDS cases. Based on her own clinical experience and review of the literature, Raphael 57 reports that the unexplainable nature of the death leads parents to a relentless search for a cause. They may repeatedly review their own caretaking behavior in a search for clues, or may consciously or unconsciously blame the other parent. Donnelly 20 has found that clarification of the fact that neither parent was responsible may sometimes be needed in order to preserve the marital relationship following this type of loss.

The Death of an Older Child

Deaths are less common among older children than among infants, with accidents the most frequent cause of death, especially in adolescence. In an epidemiologic study including bereaved parents, Owen et al. 51 found that the median age of the dead child was 16.6 years. Accidents accounted for 45 percent of the deaths; leukemia and other cancers accounted for another 18 percent.

Parents whose children die at an older age usually experience many of the feelings already discussed. However, older children lived long enough to develop a well-formed personality and leave their bereaved families with a larger store of memories. As with deaths of younger chil dren, a commonly expressed emotion is anger. In a study of 14 bereaved parents, Sanders 61 found that loss of a child, compared with the loss of a parent or spouse, "revealed more intense grief reactions of somatic types, greater depression, as well as anger and guilt with accompanying feelings of despair." Parents seemed totally vulnerable, as if they had just suffered a physical blow that left them with no strength or will to fight. Describing participants in a support group for bereaved parents, Macon 44 said that "bizarre" responses, regressive behavior, and suicidal thoughts were common. In a comparison of depressed psychiatric outpatients and matched community controls, Clayton 15 discovered that the death of a child in the previous six months had occurred in a surprisingly high proportion of the depressed patients, supporting her view that the "death of a child is the most significant and traumatic death of a family member."

The course of the bereavement process for parents may be considerably longer and more complicated than was previously believed. In a study of 54 parents whose children died from cancer, Rando 56 found an intensification of grief over time, with a decrease in symptom intensity in the second year after bereavement followed by an increase in the third year. This same trend was observed by Levav 38 in his reanalysis of Rees and Lutkins' 58 data. Looking at mortality rates in bereaved parents, he found no significant increases in the first year following bereavement, but very great differences between grieving parents and controls over a five-year period.

It has been found that cause and locale of death can significantly influence the outcome of bereavement, especially in terms of the parents' need to feel a sense of control. In cases where children have long terminal illnesses, such as cancer, it may be important for parents to feel they participated in the child's care, so that after the death they can feel they did all they could. In a study of 37 families of children who had died of cancer in the previous 29 months, Mulhern and his associates 47 found significant differences in the outcomes of parents who opted for home versus hospital care for their dying child. Although preexisting personality traits may have determined which set of parents chose which locale, thus confounding the results, parents who selected hospital care emerged as significantly more anxious, depressed, defensive, socially withdrawn, and uncomfortable, and had greater tendencies toward somatic and interpersonal problems, self-doubt, and unreasonable fears. Martinson et al. 45 found no significant differences in levels of abnormal grief between "home care" and "hospital care" parents, but noted somewhat less difficulty among parents whose children had died at home. Lauer et al. 36 found that these parents were far less likely to experience marital strain than parents whose children died in hospitals.

Parents who can explain and understand why their child's death had to happen also seem to adjust better. Spinetta et al., 67 in a study of 23 sets of parents whose children died of cancer within the previous three years, found that those who did best had a consistent philosophy of life that enabled them to accept the diagnosis and cope with its consequences. Martinson et al. 45 found that 73 percent of their sample reported deriving consolation from religious beliefs.

The death of an adult child is a topic that has been virtually neglected in bereavement research. Based on her own research and the work of others, Raphael 57 concludes that, although the child will probably have left home, "the older parent who experiences the death of an adult child is likely to be deeply disturbed by it." From his clinical observations, Gorer 27 has come to believe that "the most distressing and long-lasting of all griefs, it would seem, is that for the loss of a grown child." Gorer, 27 Raphael, 57 and Levav 38 all infer that untimeliness is what makes this form of bereavement so difficult. Older parents typically feel that it is "unnatural" for a young or middle-aged adult to die while an older parent lives on, which may be a particular form of ''survivor guilt." Ambivalence may also be more of a problem, especially where it centers on a child leaving home and choosing to form a family of his or her own. Elderly parents who lose a middle-aged child may also have lost their caretaker, as a role reversal frequently occurs with the advancing age of children and parents.

Because the bulk of the information available on loss of a child of any age remains anecdotal rather than systematic, current ideas regarding this type of loss must be considered tentative rather than definitive. More empirical data are needed before any firm conclusions can be reached.

Problems in Grieving for a Child

Having a child die can have a devastating effect on a marriage. For couples with a history of good communication and for those able to develop these skills, a child's terminal illness or sudden death may strengthen the relationship. It is not uncommon, however, for marriages to break down under the strain imposed by a child's illness and death. Marital discord and divorce have been reported in 50 to 70 percent of families whose child died from cancer. 33,69 However, as noted earlier, this rate may be considerably lower for parents who cared for a child at home.

One potential factor that can exacerbate marital difficulties may be the different styles of grieving among family members. In a study of 100 parents whose children died of cancer, Martinson and her colleagues 45 found that "fathers were nearly twice as likely as mothers to reply that the most intense part of their bereavement was over within a few weeks to one month after the child's death," although their responses may have reflected the social expectation of fathers to "take it like a man." In three studies of 112 SIDS parents, DeFrain et al. 18 found no difference in the length of time it took men and women to recover from the loss. Nevertheless, DeFrain and his colleagues did note some variations in the responses of fathers and mothers, with fathers reporting more anger, fear, and loss of control than mothers, as well as a desire to keep their grieving private. The mothers responded with more sorrow and depression.

Lack of synchrony may make it difficult for couples to support or understand each other. As one grieving mother in DeFrain's study 18 reported, "I was an open, throbbing wound, and he wanted to have sex. It was very hard for me to understand that he was also in pain and that he felt our closeness would be healing." Involvement in one's own grief may diminish empathy for the other. In relationships lacking a pattern of stable communication, help from friends, relatives, or mental health professionals may be needed to facilitate mutual understanding.

Another potential complication involves the discrepancy between a parent's real feelings for his or her child and the feelings he or she believes should exist. As with any human relationship, feelings for a child are marked by ambivalence. But as Raphael 57 points out, "societal attitudes strongly suggest that all parents must be perfectly loving, and all [children] are perfectly lovable." When a child dies, guilt over negative feelings comes to the fore.

Parents who depend heavily on a child for need-fulfillment can also experience complicated responses. Some women with negative selfconcepts may be able to stabilize an acceptable sense of self only by being "good mothers." The mother feels useful and competent because the child is emotionally dependent on her. A death in this type of case, especially of an only child or of a child who had been unconsciously singled out to "care for" the mother, will disturb the mother's view of herself.

For a parent whose relationship with a child had added meaning because of the parent's painful past, death brings an additional strain. In cases where the parent used the relationship with the child to rework relationship conflicts from his or her own childhood, the child's death may be experienced as the loss not only of a son or daughter, but of some other relationship from the past as well.

Parents may also feel particularly threatened by the sense of vulnerability and helplessness associated with a child's death. A feeling expressed by a significant number of parents in the study by DeFrain et al. 18 of SIDS parents was the sense of impotence. When a child dies, parents realize the limits of their protective powers and may feel haunted by this realization.

When children who have significant roles in existing parental conflict die, the bereavement process may take a pathologic course. Orbach 50 conceptualized one mother's unresolved grief as follows: "When the irrational jealousy of her husband reached a peak of accusations, she [had] prayed for her son to become ill on the premise that this would lead to increased marital unity." When the child died of leukemia, she attributed the death to the parental quarrels.

The advisability of having another child soon after a child's death is controversial. In a study of six replacement children in psychotherapy, Cain and Cain 11 found that "the parents' relationship with the new, substitute child [was] virtually smothered by the image of the lost child." Although these authors warn that attempts to replace a dead child with another are "fraught with danger," it must be remembered that these findings are based on observations of an extremely small, disturbed sample.

Lewis 40 warns that replacement pregnancies can be used to deny the fact of the first child's death and may interrupt grieving. Poznanski 55 has observed clinically that the gradual giving up of a dead child prepares parents to "reinvest their energies in other relationships. " She asserts that if they are not ready to do this, they cannot raise a new child in an emotionally healthy environment.

While a number of clinicians (e.g., Cain and Cain, 11 Legg and Sherick, 37 Lewis, 40 and Poznanski 55) recommend waiting until the bereavement process is completed before having another child, it may be that such advice is overly prescriptive. Being treated as a replacement is certainly apt to be burdensome to a child, but waiting until there is recovery may not be the solution either, especially since it is often observed that grieving for a lost child never entirely ends.


The type of bereavement most common in adulthood is the loss of a parent. In their study of life events in 2,300 persons matched for demo graphic characteristics to U.S. census data, Pearlin and Lieberman 53 found that 5 percent of the population lost a parent within one year. Despite the relative frequency and universality of the event, very little research has been done in this area. In contemporary Western society, the loss of a parent in adulthood is not expected to produce serious effects, although some studies have shown a higher tendency to thoughts of suicide, an increased rate of attempted suicide, and higher rates of clinical depression. 1,5,9,9,42 Of course, the way an adult responds to any bereavement depends on prior experiences with losses throughout life, including those during childhood. Empirical data regarding continuing effects of parental loss experienced during childhood are discussed in the next chapter.

In a study of 35 persons seeking treatment following the death of a parent, compared with 37 field subjects who had also lost a parent but who had not sought treatment, Horowitz et al. 30 found that "the death of a parent is a serious life event that can lead to a measurable degree of symptomatic distress." Furthermore, the data suggested that the death of a mother was harder to sustain than the death of a father, possibly because of her earlier status as the nurturing caretaker. 31 Another theory suggests that because in three out of four marriages the husband dies first, 39 most adults lose their fathers by death before their mothers. When the second parent dies, some adults may mourn the loss of having "parents." The death of the second parent may "leave the child bereaved for the loss of the specific relationship, stripped of all living parents, and also with a reactivated mourning process for the earlier parental death.'' 31

In contrast to these findings, several studies reported that the loss of a parent in adulthood was the least disruptive and caused the least intense grief reactions. 51,61 In a sample of 39 adult sons and daughters with a median age of 48.3, Owen et al. 51 found a "striking characteristic of their response to be the absence of grief . .. adult sons and daughters reported the fewest adjustment problems ... the smallest increase in the consumption of tranquilizers or barbiturates as well as the smallest increase in the consumption of alcohol ... the least preoccupation with the memory of the deceased ... and the lowest levels of physical complaints." Concurring with these findings, Sanders 61 speculated, "for the most part, these 'adult children' were caught up in their own busy world which soon engulfed them. They had families, jobs, and daily responsibilities which allowed little time to dwell upon the deceased parent." Rather than the passage of time, however, it may be other factors that account for the relatively low level of grieving in adults who lose parents. In most cases, attachment feelings have for some time been di rected toward other figures, such as mates and children. Such feelings, although briefly redirected toward parents following their deaths, usually turn back toward current figures after a relatively short time.

The death of a parent may have many meanings for an adult child. For some, who perceived their mothers and fathers as caretakers, providers of praise, and permission-givers even after the parents had to be physically cared for themselves, the death may mean the loss of security. 30 For others, it is the loss of that perfect, unconditional love experienced only as a child.

A subtle role change often occurs when an adult child's parent dies. The death is often experienced as a "developmental push," propelling the adult into the next stage of life. It is well known anecdotally that many adults, upon the loss of their parents, suddenly feel the weight of responsibility as the oldest generation in the family. This, coupled with the awareness that there are no longer parents to fall back on, may effect a more mature stance in parentally bereaved adults who no longer think of themselves as children.


A review of the literature reveals a rather striking absence of data about adults' responses to the death of a sibling. Presumably, this type of loss has been ignored because it is viewed as having less impact than the death of a spouse, child, or parent. In most cases, adult siblings no longer live together and they may not even have much social contact. Nevertheless, it is rare to find adult siblings who have completely severed ties with one another. 60 Observation suggests that many sisters and brothers continue to visit each other, share memories, reunions, and responsibility for aging parents, and psychologically influence each other explicitly and implicitly, such as in the selection of marital partners. 49 Despite an earlier view that sibling relationships were simply a function of and subordinate to a child's relationship to parents, researchers are now commenting on the special characteristics unique to the sibling bond. 49 The empathy siblings form for one another when they are young may continue into adult life, making this tie a potentially profound one.

As in other types of bereavement, the quality of the preexisting relationship with the deceased is likely to color an individual's perception and experience of the loss. The seeds of the sibling relationship are planted in childhood, but the same characteristics that were salient then continue to affect the nature of the adult tie. In an exploratory study of adult sibling relationships, Ross and Milgram 60 found that shared childhood experiences and critical life events (including parental deaths) influence the level of sibling closeness in adult life. Geographical proximity can increase either closeness or distance, depending on other factors, but complete lack of closeness is unusual. Sibling rivalry, a variable that may contribute to postdeath feelings of guilt, was found to continue throughout life in varying degrees of intensity, with rivalrous feelings peaking during early adult years. In addition, sibling relationships assume great importance among the elderly, probably making sibling loss in old age a particularly significant event.

Some of Bank and Kahn's 3 observations regarding childhood bereavement could also apply to adult sibling ties. For example, they noted that sibling death may be difficult to resolve if previous identification with the deceased sibling was too close or fused, or if it was too polarized and rejecting. Although the intensity of such closeness or hostility would probably be attenuated by the time siblings reach adulthood, such feelings could complicate grief reactions.

Another factor that may influence the response to sibling loss is the cause of death. A surviving sibling may find it more difficult to accept a loss if the sister or brother died of an illness to which the survivor may also be genetically predisposed or be a carrier, which would place the bereaved's children at risk. Anxiety following a sibling's death may be particularly acute among the elderly if it exacerbates an already present fear of one's own impending death.

Bank and Kahn 3 assert that, regardless of age, death of a sibling forces brothers and sisters to reorganize their roles and relationships to one another and to their parents. Under certain circumstances, a death can jolt surviving siblings into becoming more alert, sensitive, and concerned—particularly if they conclude that they could have prevented the death had they been more caring. Death of "the most responsible" sibling can force survivors to face their need to contribute to their parents' well-being now that the deceased sibling no longer assumes this role. As with formerly traditional wives who can mature through the bereavement experience, siblings who had previously considered themselves less capable can grow through this imposed need to become a caretaker.


Bereavement is painful no matter what the cause, but bereavement following the suicide of a close friend or family member has been called a "personal and interpersonal disaster." 64 Other kinds of death that complicate bereavement include homicide, suicide, multiple simultaneous losses, and accidents in which the survivor was complicit, such as an automobile accident in which the survivor was driving. All these types of bereavement are important and merit comparative study. In this report, however, only suicide will be discussed as an example of an especially difficult loss.

It is estimated that more than 27,000 people commit suicide in the United States each year. Men are three times more likely than women to commit suicide, and whites are almost twice as likely as blacks. 48 Elderly white men have the highest suicide rate of all. 10 Many observers have commented that reported figures are extremely conservative due to the ambiguous circumstances of some deaths and to society's need to deny suicide. Even given this conservative figure, however, suicide leaves in its wake a sizable number of survivors who must deal with a complex set of feelings and social problems.

Survivors of suicide have long been thought to be at greater risk for physical and mental health problems than individuals who are bereaved from other causes of death. Indeed, as discussed in Chapter 2, there is some evidence to suggest increased mortality among the widowed whose spouses committed suicide. There also is good evidence that children whose parent committed suicide are at risk for enduring adverse consequences and for suicide itself ( Chapter 5). 63

Clinical observations of suicide survivors 12,65 reveal that they experience some reactions that are unique to this type of bereavement, as well as displaying typical bereavement reactions in exaggerated form.

While the death of a close relative by any cause may leave the survivor with feelings of abandonment and rejection that may be irrational, the feeling of rejection following suicide is almost universal. As one survivor put it: "He could not have loved me; he did not think I was worth living for." 73

In their study of suicide survivors, Lindemann and Greer 42 found "there is a tendency ... to look for a scapegoat. And, as is the fate of most scapegoats, the victim is usually one of their own members and frequently the one least able to bear the added burden." This tendency to search for blame, though common following other types of deaths, is greatly increased following a suicide. The surviving spouse, parents, or even child may be blamed for not seeing the signs of the impending suicide or for not meeting the needs of the deceased.

Bereaved individuals also often blame themselves for the death, resulting in what is often called "survivor guilt." In fact, blaming others may be one way of avoiding self-blame. Survivors may question what they did to add to the deceased's stress or may wonder whether they could have foreseen and stopped the act. As suicide researcher Henslin 28 points out, "When one can exercise control over events and in so doing prevent harm to others, our culture demands that it is one's responsibility to do so. Therefore, if one could have acted to have prevented the suicide, one feels that he or she should have done so."

People who have made repeated threats of suicide or actual attempts may leave friends and relatives in conflict when they finally succeed. Menninger 46 has clinically observed that a typical response is "overwhelming bitterness" at having failed in the task of keeping the vulnerable one alive coupled with a sense of relief that the ordeal is finally over. Children, especially, who have been warned that they are "upsetting Mommy" or accused by the parent of "driving me crazy" are especially vulnerable to feelings of guilt following a suicide.

In Bowlby's 7 clinical experience, repeated threats often leave the survivor frightened and frustrated, finally wishing that the other person would just "go ahead and do it." Suicide also may leave survivors with feelings of rage over being abandoned, which in tandem with the sense of relief that the person's problems will no longer demand attention, can intensify survivor guilt. Feelings of anger and relief are generally unanticipated and misunderstood under the circumstances and so may lead to a sense of shame and a denial of their existence. Finally, survivors may feel anxious after the death—worried that they may mimic the deceased's self-destructive act.

The nature and intensity of the survivor's reactions will depend largely on cultural factors, the prior relationship with the deceased, the age and physical condition of the deceased, the survivor's individual personality characteristics, and the nature of the death. Henslin 28 has found that, in some ways, suicide shares with accidental death the qualities of "suddenness, unexpectedness, and violence." It should be noted, however, that there are many different types of suicides and that they may involve different types of responses. For example, in the case of a terminal illness, especially among cancer patients, the sick person may have made a clear decision to abbreviate a life of pain. 17 The impact of this kind of suicide is not known; families in this situation may need information and assistance in anticipating and responding to this type of death.

Communications before the death or suicide notes that blame the survivors directly may place those left behind at even higher risk for problems with guilt and shame. Some clinical observers infer that many suicides are motivated largely by the hostile intent of producing problems, especially guilt, for the family. In a study of suicide notes, Jacobs 32 described two types that clearly made the suicide a hostile act. In one, there is an attempt to hide the intent by claiming that the suicide is aimed at "relieving" or "freeing" the survivor, whereas the other is overtly hostile.

Following suicide, denial is frequently used to mask feelings of guilt, rage, relief, and shame. Resnik, 59 in a study of nine families in which an adolescent child committed suicide, found that this denial may take the form of hostility towards the medical examiner, police, or anyone who calls the death a "suicide." Denial and anger may also contribute to a tendency to idealize the deceased.

In his research, Warren 73 found that some survivors created a "family myth," a rationalization of the true nature of the death, that is used not only for the outside world, but also for the family itself. These forms of denial serve a definite purpose for the bereaved. As Augenbraun and Neuringer 2 have observed, "if the survivor does not accept the possibility that the deceased took his own life, he can avoid facing the notion that the suicidal person willfully abandoned him," allowing him to avoid the pain associated with the deliberateness of the death. A decision to call suicide an "accident" or to attribute it to an illness is often quite conscious, however, and is sometimes told to "protect" children from the truth. Complicity by health care personnel aids this denial, although, as discussed in Chapter 5, fabrications can frighten and confuse children who may already know the real cause of death or sense that what they have been told is untrue. This undermines confidence in adults and reinforces the idea that suicide is a valid source of shame.

A common fear among survivors concerns the "heritage of insanity," leading people to wonder whether others in the family are now "doomed" to kill themselves someday. Indeed, there are data that show a far higher than chance incidence of prior suicide in families of individuals who commit suicide. 6,21 This may be due, in part, to a shared vulnerability to mental illness, specifically depression, or to specific feelings of inevitability and guilt. 73 Warren 73 has observed that a "survivor may feel or fear the inevitability of his own death by suicide at a time coinciding with the parental age at the time of suicide. This feeling of inevitability is usually unconscious, becoming more manifest as the [survivor's] age approximates that of the parent at the time of the suicide. "

Lindemann and Greer 42 have found that identification with a person who has committed suicide may lead a person to perceive this behavior as a viable solution to life's problems. The very fact that the taboo was broken by someone close may serve to legitimize the act, perhaps suggesting to the survivor that he or she will be vulnerable when overwhelmed later in life.

In summary, there are many interacting factors that influence the response to suicide. Feelings of being rejected, guilty, responsible, and socially stigmatized appear to hamper the resolution of bereavement.

The Social Stigma of Suicide

In many cultures, the social stigma of suicide has historical roots. The early Greeks, believing that those who committed suicide must have been greatly wronged to have wanted to die, considered their ghosts to be extremely revengeful, dangerous, and frightening. 14 In other cultures, the bodies of suicide victims had to be buried outside the city walls or were pulled through the streets and stoned. Suicide has also been illegal in many places, including the United States. Most modem Western civilizations no longer adhere to such beliefs and practices, but suicide is still regarded by many to be a moral rather than a mental health issue. Roman Catholics, regarding suicide as a mortal sin, used to forbid memorial mass and last sacraments for a Catholic who died in this way and insurance companies continue to deny benefits to families of people who commit suicide within two years of buying life insurance.

These social stigmata compound the problems of suicide survivors. Whether from shame or anticipation of blame from others, people are often sensitive about and reluctant to discuss the event. Those who would usually be available for support following the death of someone close may find they are unable to comfort the survivor of a suicide. Possibly threatened by the idea of being powerless to prevent a suicide, they may join in the search for a cause and may even blame the survivor for the death. This failure of the informal support system leaves many survivors socially isolated and dealing with their complex feelings and problems alone. Some find that they can escape feeling ostracized and condemned only by moving, 12 but they are then faced with the isolation and insecurity of a new home and neighborhood that can make the bereavement process more difficult. Given these circumstances, the decision of some families to deny the fact of a suicide seems understandable.

Assisting Survivors of Suicide

Survivors of suicide, more than any other bereaved group, may require some form of professional help. Based on his observations of families of adolescent suicides, Resnik 59 has found that "an early interview after the death is a therapeutic and cathartic experience" that allows the interviewer to establish rapport before defenses have been established. This allows him to provide appropriate subsequent help as the grief work progresses. In her clinical experience, Silverman 65 has found that suicide survivors are often initially wary of those who offer help. They are generally so isolated by the experience, however, that they may need more formal opportunities to ventilate their feelings and more reassurance than other bereaved persons. In recent years, mutual support groups, such as "Survivors of Suicide" and "Seasons," have been developed to bring together survivors of suicides to clarify their understandings of the loss and to find ways of dealing with the often confusing and traumatic aftermath.

Freedman et al. 23 advocate professional psychotherapeutic intervention to alleviate the effects of stress on the "survivor-victims" of suicide, to provide "an arena for the expression of hidden emotions," and to put a "measure of stability into the grieving person's life." In their clinical work with survivors they have found that "most are willing—some are passively eager—to talk," adding that therapists often serve as reality testers, ''not so much the echo of conscience as the quiet voice of reason. "

As is true following all types of bereavement, the degree and type of reassurance needed by a survivor depends on his individual circumstances. Augenbraun and Neuringer 2 have found that "there is little need for therapy [when] the previous relationship between suicide and survivor was positive, minimally ambivalent, and where the fact of the suicide can be ascribed to circumstances outside the control of the survivor." They add, however, that "more often, the survivor has been involved in a conflict relationship with the suicide and the act of suicide itself is in part an outcome of this conflict." More clinical research needs to be done to determine the circumstances that make survivors vulnerable to pathologic outcomes, and to determine which particular interventions are most effective under these circumstances.

Research Issues

As with so much of bereavement research, what is known about suicide survivors comes primarily from clinical case reports of small numbers of patients in treatment. The reports have not systematically examined and controlled for demographic heterogeneity of the sample, time course following suicide, possible psychiatric disorders in family members, or differences in the intensity, duration, and symptomatology of the bereavement. Yet these clinical accounts can provide the basis for further systematic investigation. Both clinical cases and systematic investigations are needed.

Unusual methodological problems create particular difficulties in designing systematic studies of bereavement associated with suicide. Ideally, suicide bereavement should be compared with bereavement following deaths that share some of the same characteristics in order to know of any unique contributions of suicide as distinct from some of its attributes. For example, suicide is a sudden death that should be compared with bereavement following other sudden deaths such as motor vehicle fatalities. As a "volitional" death, suicide is more similar to drinking oneself to death (cirrhosis) or smoking oneself to death after heart disease has been discovered than it is to deaths caused by conditions over which individuals have no control. And comparisons of survivors of other "socially unacceptable" deaths, such as Acquired Immune Deficiency Syndrome (AIDS), might permit the effects of social stigma and suicide to be separated.

In addition, the effects of suicide in different types of relationships— such as parents-to-child, sibling, conjugal, and child-to-parent—should be studied. Further research is also needed on the meanings and responses to different types of suicides, for example drug overdoses in adolescents or suicide among the terminally ill and elderly. More information on the coping styles of suicide survivors could help others deal with the loss through suicide of someone close.

Comparative studies of all these variations and characteristics of suicide are difficult, however, because of the relative infrequency of the event. As pointed out in Chapter 2, studies of relatively rare events require very large samples.


Although only a small number of different types of losses have been discussed in this chapter, they indicate that different kinds of relationships and different sets of circumstances influence the personal mean ings and feelings associated with bereavement. More data are needed on the response to loss of various types of relationships, and under various conditions of death. Much attention has been paid to responses to conjugal bereavement in adults, but there is relatively little information on other types of losses, such as the death of siblings and parents. As the average age at death continues to rise and as medical technology allows the prolongation of lives that previously would have ended naturally, an increasing number of people will have to deal with issues raised by elderly and ailing parents, including the thorny issues surrounding assisted suicide. Responses to loss under all these circumstances deserve exploration in order to provide appropriate assistance to the bereaved.


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    This section is based on material prepared by committee member Robert S. Weiss, Ph.D.


    This section is based on material prepared by Victoria Solsberry, M.S.W., research associate.


    This section is based on material prepared by Victoria Solsberry, M.S.W., research associate.


    This section is based on material prepared by Janice L. Krupnick, M.S.W., consultant.


    This section is based on material prepared by Victoria Solsberry, M.S.W., research associate, drawing on a paper by Barry D. Garfinkel, M.D., Director, Division of Child and Adolescent Psychiatry, University of Minnesota Medical School, Minneapolis.

    Copyright © 1984 by the National Academy of Sciences.
    Bookshelf ID: NBK217848


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