Bereavement After Traumatic Death E-Book

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 388

Veröffentlichungsjahr: 2013

Beschreibung

Unless forced by circumstances, people in modern societies go to great lengths to deny death, to the extent that even death of a loved one from natural causes tends to catch us unprepared and unable to cope with its consequences. Death as the result of a sudden, catastrophic event (traffic accident, suicide, a natural disaster, ect.) can have even more extreme effects, sometimes striking survivors so violently and painfully that it leaves an indelible mark. This book speaks about the consequences of such traumatic deaths in a wonderfully simple and straightforward way. The authors describe, step by step, what happens to people after the sudden death of a family member or close friend, the difficulties they face in coping, and how professionals and volunteers can help. With their wide experience, both personally and as internationally renowned authorities, they have written a book for professionals and volunteers who deal with bereavement in language that is accessible to all, so it will also help those who have suffered a traumatic loss themselves to understand what to expect and how to get help.

Leseprobe

Bereavement After Traumatic Death

About the Editors and Authors

Karl Andriessen (Masters of Suicidology, Griffith University, Brisbane, Australia) is a suicide prevention staff member at the Tele-Onthaal (Tele-Help) Federation, Flanders, Belgium; and a researcher in the Faculty of Psychology and Educational Sciences, KU Leuven – University of Leuven, Belgium.

Emma Barker is a research assistant at the Australian Institute for Suicide Research and Prevention (a World Health Organization Collaborating Center for Research and Training in Suicide Prevention and the National Centre of Excellence in Suicide Prevention), Griffith University, Australia.

Alberta Cimitan is a clinical psychologist collaborating with the De Leo Fund Onlus (based in Padua, Italy). She is the coordinator of all care services and the Fund’s helpline.

Diego De Leo (DSc, MD, PhD) is a professor of psychiatry and director of the Australian Institute for Suicide Research and Prevention (a World Health Organization Collaborating Center for Research and Training in Suicide Prevention and the National Centre of Excellence in Suicide Prevention), Griffith University, Australia, and director of the Slovene Centre for Suicide Research, Andrej Marusic Institute, University of Primorska, Slovenia. He is co-founder and chair of Postvention Australia.

Kari Dyregrov (PhD) is the research leader at the Center for Crisis Psychology, Bergen, Norway, and a senior researcher at the National Institute of Public Health, Oslo, Norway. She is the first author of After the Suicide: Helping the Bereaved to Find a Path to Recovery and Effective Grief and Bereavement Support. She took initiative to establish the Norwegian Association for Suicide Bereaved in 1999 and received the Farberow Award in 2007.

Onja Grad is a professor of clinical psychology at the University of Ljubljana, Slovenia, and a clinical psychologist and psychotherapist at the University Psychiatric Hospital, working in an outpatient setting with bereaved patients and families. She is also the head of the telephone crisis line and a supervisor for younger therapists.

Kairi Kõlves (PhD) is a senior research fellow at the Australian Institute for Suicide Research and Prevention (a World Health Organization Collaborating Center for Research and Training in Suicide Prevention, and the National Centre of Excellence in Suicide Prevention), Griffith University, Australia.

John O’Gorman (PhD) is an adjunct professor of psychology at the Australian Institute for Suicide Research and Prevention (a World Health Organization Collaborating Center for Research and Training in Suicide Prevention, and the National Centre of Excellence in Suicide Prevention), Griffith University, Australia.

Katarzyna Anna Ratkowska is a clinical psychologist and a researcher with the De Leo Fund Onlus (based in Padua, Italy).

Bereavement After Traumatic Death

Helping the Survivors

Editors:

Diego De Leo

Alberta Cimitan

Kari Dyregrov

Onja Grad

Karl Andriessen

Library of Congress Cataloging information for the print version of this book is available via the Library of Congress Marc Database

Cataloging data available from Library and Archives Canada

© 2014 by Hogrefe Publishinghttp://www.hogrefe.com

PUBLISHING OFFICES

USA:    

Hogrefe Publishing Corporation, 38 Chauncy Street, Suite 1002, Boston, MA 02111 Phone [phone], Fax [phone] E-mail [email protected]

EUROPE:    

Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, Germany Phone [phone], Fax [phone] E-mail [email protected]

SALES & DISTRIBUTION

USA:    

Hogrefe Publishing, Customer Services Department, 30 Amberwood Parkway, Ashland, OH 44805 Phone [phone], Fax [phone] E-mail [email protected]

UK :    

Hogrefe Publishing c/o Marston Book Services Ltd, 160 Eastern Ave, Milton Park Abingdon, Oxfordshire OX14 4SB Phone [phone], Fax [phone] E-mail [email protected]

EUROPE:    

Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, Germany Phone [phone], Fax [phone] E-mail [email protected]

Copyright Information

The e-book, including all its individual chapters, is protected under international copyright law. The unauthorized use or distribution of copyrighted or proprietary content is illegal and could subject the purchaser to substantial damages. The user agrees to recognize and uphold the copyright.

License Agreement

The purchaser is granted a single, nontransferable license for the personal use of the e-book and all related files.

Making copies or printouts and storing a backup copy of the e-book on another device is permitted for private, personal use only.

Other than as stated in this License Agreement, you may not copy, print, modify, remove, delete, augment, add to, publish, transmit, sell, resell, create derivative works from, or in any way exploit any of the e-book’s content, in whole or in part, and you may not aid or permit others to do so. You shall not: (1) rent, assign, timeshare, distribute, or transfer all or part of the e-book or any rights granted by this License Agreement to any other person; (2) duplicate the e-book, except for reasonable backup copies; (3) remove any proprietary or copyright notices, digital watermarks, labels, or other marks from the e-book or its contents; (4) transfer or sublicense title to the e-book to any other party.

These conditions are also applicable to any audio or other files belonging to the e-book.

Format: EPUB

ISBN 978-1-61334-455-2

eBook-Herstellung und Auslieferung:

Foreword

Without question, the loss of a loved one is difficult and problematic for the surviving family and loved ones. However, deaths that occur under sudden and often violent circumstances produce their own burdens and issues among grieving relatives and significant others.

The editors and individual chapter authors of this book have produced an important compilation of information to address the range of traumatic losses – by accidents, suicides, homicides, sudden deaths of infants, or from natural disasters. These losses share several commonalities as outlined and detailed here. Among these commonalities is the non-normative nature of the losses. These deaths are not those we ordinarily conceptualize when thinking about how or when we expect that someone will die. People die at all ages and from numerous causes, of course, but the deaths considered here seem “improper” to us on many levels, largely because they are not the norm. For instance, they do not occur with some forewarning over a period of time or are not accompanied by a known or diagnosed disorder or medical condition or necessarily at an advanced age. They are sudden and unexpected as well as often violent, and therefore produce a different and perhaps complicated process and trajectory when those who remain behind after the death attempt to mourn and confront the loss as part of the continuation of their own lives. As non-normative losses, they also fall somewhat out of the realm of the experience, and perhaps even the training, of those caring individuals who provide therapy, support, and other assistance during the survivors’ mourning.

Traumatically bereaved individuals as well as mental health professionals or others who provide assistance to these bereaved will find clear, understandable explanations of terms, common experiences, and even theories of grief and bereavement in this collection. Not only is basic knowledge about grief and mourning presented, but also addressed are the myths (those inaccurate beliefs so often held and voiced) surrounding loss and particularly grieving for traumatic deaths. Further enhancing this information throughout the book are quotations from traumatic death survivors that reveal their very personal experiences, thoughts, and feelings. Traumatic death survivors will find the book to be informative, compassionate and sensitive, helping, and healing. What to expect as one tries literally to survive the sudden, unexpected, and often violent death of a loved one is conveyed in an accessible form. At the same time, caregivers will discover the book’s emphasis on postvention – those efforts performed in the aftermath of a sudden and unexpected death intended to help individuals deal with their loss and the frequently complicated bereavement processes that occur. These chapters will provide caregivers with a better understanding and insights to facilitate the help they provide to traumatic grief survivors on their healing journey. Important potential aspects of postvention are discussed, including, for example, social support systems as well as more formal structures such as support groups and therapy.

This volume adds to the resources available regarding losses by suicide as well as other sudden and traumatic deaths. It is apparent that more information exists and is conveyed here with respect to loss by suicide, but it is clear also that the shared aspects of sudden, unexpected, and traumatic loss will be informed more generally by what has been revealed about loss specifically to suicide. It is also hoped that research and clinical experience regarding the other specific traumatic losses will be encouraged and expanded.

This book is a tremendously valuable resource that will benefit the caring community of individuals who attempt to help in the healing journey of the traumatically bereaved as well as the survivors of these losses themselves as they proceed on their journey.

John L. McIntosh, PhD Interim Executive Vice Chancellor for Academic Affairs and Professor of Psychology Indiana University South Bend, IN, USA September 2013

Foreword

Along the sides of the rural highway to the clinic I attend there are shrines to people who have lost their lives while traveling this route. Over time the memorials change – new flowers, a child’s teddy bear, once-used clothes, and other belongings – as tokens of remembrance. They acknowledge the importance to family and friends of the lives lost and invite others to share in the grief and celebration of these lives.

Suicide in a family or of a close friend is devastating, leaving behind a person with unanswered questions and mixed emotional feelings. Such loss can affect workplaces, clubs, schools, and whole communities such as a rural village or township.

In Australia a memorial quilt has been made by the Salvation Army for those who have taken their lives. It displays the faces of young people. Beside each face is an account of their cherished role in the family, the positive memories they have left behind, and then the questions: Why did he/she do this? What went wrong? Why didn’t we know? Could we have done things differently?

This book explains why such actions are so important to those intimately affected by someone’s traumatic death but also their significance for local and wider community networks.

The personal accounts of how others experience grief will help validate the feelings of loss, disappointment, and bewilderment at the complexities, which are so often experienced. There are suggestions of how to help – practical things to do, appropriate responses to childhood grief, to a parent’s loss of a child, and to distress in school and workplace communities.

Formal studies of grief – especially prolonged and disabling grief – and the interventions that have been shown to be helpful are described and their potential for replication in other places and settings is presented. Philosophy and religion can provide solace and some comfort, at least.

This book covers what can be done to provide support and succour in work settings, schools, and front-line services – such as in mental health teams where such tragedies occur only too frequently. And for individuals and groups that aim to support and intervene, there are practical examples of community networks and resources that can be emulated or set up in other environments.

In Australia, where Professor Diego De Leo is the director of the Australian Institute for Suicide Research and Prevention, suicide bereavement is a national priority. The government has funded projects to provide practical assistance following suicides, service coordination, access to professional help, counseling, community networking, and especially appropriate interventions for indigenous communities in which suicide rates are so high.

Those who manage or work in programs to help and support the bereaved in many countries will have their resolve and involvement strengthened by the analyses and problem-solving approach set out in this book. The arguments are strong for greater collaboration, shared resources, and multidisciplinary enquiry and research.

Ian W. Webster Physician Chair of the Australian Suicide Prevention Advisory Council Australian Government Department of Health and Aging Canberra, ACT September 2013

To Them.

Their physical absence is unbearable,

their emotional presence overwhelming.

Acknowledgments

This book is a result of the enthusiasm around the activities of the De Leo Fund of Italy. We are indebted to all of those colleagues who have joined the Venetian network to assist those bereaved by a traumatic death, and who have donated their time to that cause with great dedication.

An initial version of this book was published in Italy by ALPES. We are very grateful to Roberto Ciarlantini, the owner of the company, for having made the rights of this book available for free. The profits from this book go entirely to the De Leo Fund.

We are also indebted to the members of the board of the Fund, for their generous availability on so many occasions. We want to particularly name Mariapia Garavaglia, Marco Trabucchi, Mario Cortella, and Paolo Brinis – their support has been invaluable.

Federica Zoppellaro Cimitan and Cristina Trevisan De Leo have been the driving force behind many of the activities of the Fund. Cristina in particular has given a great amount of her time to the concrete realization of this volume.

Many other people have helped the Fund, and indirectly this book. We would like to mention the continuing support of Marino Cimitan, Ludovica Maestranzi, Wendy Iverson, and Lorenzo Spinnato.

Lastly, we can not forget the huge role Brian Mishara and Vanda Scott had in planning and realizing the De Leo Fund International. Thank you!

Table of Contents

Forewordby John L. McIntosh

Forewordby Ian Webster

Acknowledgments

Introduction

Chapter 1

The Loss of a Loved One: Theories of Adaption

Alberta Cimitan and Diego De Leo

Chapter 2

Reactions to Traumatic Death

Kari Dyregrov, Alberta Cimitan, and Diego De Leo

Chapter 3

Surviving Suicide

Kari Dyregrov, Onja Grad, Diego De Leo, and Alberta Cimitan

Chapter 4

Grief in the Family

Kari Dyregrov, Alberta Cimitan, and Diego De Leo

Chapter 5

Social Networks as a Source of Support

Kari Dyregrov, Diego De Leo, and Alberta Cimitan

Chapter 6

Support in the Work and School Environment

Kari Dyregrov, Diego De Leo, and Alberta Cimitan

Chapter 7

Dreams and Symbols in the Process of Mourning

Onja Grad, Diego De Leo, and Alberta Cimitan

Chapter 8

Suicide After a Loss or Around Anniversary Times

Emma Barker, John G. O’Gorman, and Diego De Leo

Chapter 9

Traumatic Bereavement for the Therapist: The Aftermath of a Patient Suicide

Katarzyna Anna Ratkowska, Onja Grad, Diego De Leo, and Alberta Cimitan

Chapter 10

Postvention: How to Organize It

Onja Grad, Diego De Leo, Kari Dyregrov, Karl Andriessen, and Alberta Cimitan

Chapter 11

Helping With Complicated Bereavement

Diego De Leo, Kari Dyregrov, and Alberta Cimitan

Chapter 12

Peer Support and Self-Help Groups

Kari Dyregrov, Diego De Leo, and Alberta Cimitan

Chapter 13

Support Groups for the Bereaved

Diego De Leo and Alberta Cimitan

Chapter 14

Spreading Awareness for Bereavement Support: Working With the Media

Karl Andriessen, Diego De Leo, and Alberta Cimitan

Chapter 15

Spreading Awareness: The Charter of Rights of Suicide Survivors

Karl Andriessen, Diego De Leo, and Alberta Cimitan

Chapter 16

Is Suicide Grief Different? Data From Empirical Studies

Kairi Kõlves and Diego De Leo

Chapter 17

Suicide Postvention for Different Groups in Different Cultures: All Different, All the Same?

Onja Grad

Chapter 18

Future Perspectives on Assisting the Bereaved

Katarzyna Anna Ratkowska, Diego De Leo, and Alberta Cimitan

References

Introduction

The memory of joy is no longer joy; the memory of pain is pain still. Lord Byron

In the world, every year, more than 1.2 million people die on the streets (World Health Organization [WHO], 2009). Road accidents are the second leading cause of death among those aged between 5 and 29 years. Low- and middle-income countries have the highest mortality rates for this cause, with more than 90% of all deaths resulting from road accidents, although they have only 48% of all circulating vehicles (WHO, 2009).

In many high-income countries, mortality related to road traffic injuries has declined over the years, albeit it still represents an important cause, whereas in most low- and middle-income countries such a welcome trend has not yet been observed. About half of the deaths relate to vulnerable road users (pedestrians, cyclists, moped riders, and motorcyclists), and this proportion is higher in poorer nations (WHO, 2009). In many countries, legislation relating to road safety is inadequate and/or infrequently adopted. To be effective, prevention of accidents requires multisectoral interventions that need coordinated efforts between different institutions. So far, only a limited number of countries have adopted a national strategy to prevent traffic-related accidents.

Suicide is also an alarming phenomenon: In the last 45 years it has increased by 60% (Bertolote & Fleischmann, 2005). According to WHO, each year there are about 1 million people in the world who decide to take their own life, and this figure is predicted to increase by 50% by the year 2020 (Bertolote & Fleischmann, 2005). Similar to the estimates for road accidents, it has been estimated that 85% of all suicide deaths occur in low- and middle-income countries (Krug et al, 2002). In many industrialized countries, suicide is the second or third cause of death among adolescents and young adults.

Although these data are troubling, only a few countries have included suicide prevention as one of their priorities: In many societies, there is a substantial lack of awareness of suicide as a serious problem; in others, to openly discuss this phenomenon is still taboo. However, some countries have developed national programs to fight suicide, and have organizations that advocate for preventative efforts. International organizations have also been established, such as the International Association for Suicide Prevention (IASP), which brings together experts from various disciplines with the aim of promoting scientific exchanges and advancing preventive activities.

In 1999, WHO launched the Suicide Prevention (SUPRE) campaign, with the objective of identifying, evaluating, and possibly reducing risk factors for suicide. SUPRE was meant to increase international awareness of the problem of suicide. One of the aims of this important initiative was also to provide support to family and close friends of people who had died by suicide. And in fact, in recent years, the level of interest devoted to postvention – the term coined by Shneidman in 1971 to indicate tertiary prevention for those relatives, partners, or friends who have survived the suicide of a loved one – has expanded significantly. There is a clear need to help and assist these people, who often continue to suffer for a long time the consequences of that traumatic type of death.

In 1999, the IASP established a taskforce dedicated to suicide “survivors.” One of its objectives was to publish (in collaboration with WHO) a list of the existing agencies, services, and nongovernmental organizations (NGOs) – at the European level – whose main aim was to support survivors.

In 2000, a suicide survivor from Australia, Raylee Taylor, provided the first draft for a WHO publication on how to set up a support group for survivors: Preventing Suicide: How to Start a Survivor’s Group (revised in 2008; WHO, 2008a). In subsequent years (2003–2010), the Australian government brought forward a number of initiatives in the area of suicide prevention, including the distribution of a support package for survivors originated by the Ministerial Council for Suicide Prevention of Western Australia: Information & Support Pack for Those Bereaved by Suicide and Other Sudden Death (Clark & Hillman, 2007).

As evidenced by the IASP-WHO inquiry, specialized structures have been created also in European countries in support of the family and friends of people who have died by suicide. In this volume, we particularly describe work carried out in nations such as Norway and Belgium.

The social and psychological impact of suicide on family and community members is enormous. Shneidman (1969) stated that for every death by suicide at least six people are deeply affected by the psychological, somatic, social, and financial consequences of the traumatic event. And if suicide occurs in a school or a work environment, its impact can easily fall on hundreds of people. With a few important peculiarities, grief reactions of suicide survivors have characteristics in common with bereavement due to other forms of unexpected and violent death (such as a road accident, homicide, sudden infant death syndrome [SIDS], accident in the work environment, natural disaster, etc.). For this reason, experts agree in using the term traumatic grief to generally refer to the process of mourning related to all unexpected and sudden deaths.

In the term mourning we usually include a very wide range of psychophysical processes, both conscious and unconscious, triggered by the loss of a person of attachment. Mourning, then, shall be used to refer to both the set of psychological reactions and individual behaviors that are experienced due to the loss of a significant person, and also the rituals and social and collective practices that are publicly observed within different cultures, around the event of death (Crozzoli Aite, 2003).

For all traumatic deaths we should probably assume – as suggested by Shneidman for suicide – that at least six people who survive the event will be deeply affected by it. It is therefore important that we give careful consideration to all those people who live this type of painful experience, and especially to those individuals who do not seem to have enough resources to be able to cope with their own grief or to discover how to get ahead in life without the loved one.

In this volume, we talk about traumatic bereavement in a surprisingly simple and straightforward way, “taking advantage” of tragic personal experiences and, professionally, of three scholars who have a well-established international reputation in the field of postvention. So in a language accessible to all, we describe step by step what happens after a sudden and unexpected death, including the most common reactions, and what kind of problems survivors face after the loss of a family member or close friend.

This work is designed for professionals and volunteers involved in bereavement support, but it is also one of the few books that can be read with profit even by those who have suffered the traumatic loss personally, and want to know what to expect and how to best be helped.

Diego De Leo and Alberta Cimitan

1

The Loss of a Loved One:

Theories of Adaption

Alberta Cimitan and Diego De Leo

The death of a beloved person is a universal experience, a painful event, and leaves an indelible memory, which inevitably disrupts the lives of the survivors. The experience of loss nearly always has an impact on the overall situation of the entire family group and nearest friends. It would be simplistic to consider the impact of a loss without paying attention to the multiple consequences and implications of such an event (De Leo, 2010a).

Psychological reflections on loss and on issues related to the affective state of mourning characterize many perspectives, both interpretive and theoretical. We owe to Sigmund Freud the conceptualization of grief as a constant experience of our lives that occurs whenever we suffer a loss. This consideration of mourning was used by Freud to explain the depressive phenomena linked both to the loss of a beloved person and to that of a significant internal object, meaning by this the internalized image of another human being.

With Mourning and Melancholia (Freud, 1915/1976), psychoanalytic theory began to put in close relation melancholia (depression) and mourning, considering the latter as a psychic condition. The bereaved person is forced to suffer the detachment from an object on which he/she has made “libidinal” investments: Libidinal energy is withdrawn from the lost object and reinvested in the ego until the mourning is resolved, making this energy available for new investment. This process can bring to an end the “work of mourning.”

For Freud, the libidinal disinvestment could take a long time; it is difficult to say which aspects are to be disinvested first and whether the entire process follows a specific sequence. An important aspect of Freud’s elaborations on the bereavement process regards the repression of aggressive feelings toward the deceased. In fact, the presence of these implies that a certain part of the work of mourning is accomplished at an unconscious level, with the failed (or incomplete) recognition/acceptance of the suffered loss.

Even if libidinal energies are being withdrawn from the lost object, the ego ends up identifying with it. Thus anger and resentment are directed toward the self with the “advantage” that this self-punishing mechanism avoids the expression of open hostility toward the person who died. According to Freud, then, when there are ambivalent feelings of both love and hostility, the process of mourning can be much more difficult and “abnormal” (Freud, 1915/1976).

Melanie Klein (1940) assumed that the condition of mourning involves the temporary regression to early stages of development, with the consequent danger of collapse and disintegration of the inner world of those who have suffered the loss. The emotional development of every child goes through the integration of libidinal and aggressive drives connected to the pleasant and frustrating features of the objects, which – by virtue of this merger – become total. This process is accompanied by the anguish of loss of partial objects (previous libidinal investments), thereby leading to the emergence of feelings of sadness and guilt. Every process of mourning in adulthood would be the reissue of feelings experienced during the psychic life of childhood in relation to separations from significant figures. In Klein’s view, the elaboration of mourning thus coincides with a reconstruction of the inner world, only possible if the subject in early infancy has been able to consolidate the relationship with their good objects.

Again from the psychoanalytical perspective, Erich Lindemann (1944) was perhaps the first to provide important insights into unexpected and traumatic grief, basing them primarily on observations performed on family members of soldiers who died in the Second World War, and on the victims of a fire that erupted in a night club in Boston, Massachusetts–the Cocoanut Grove. His work anticipates many of the concepts that are now part of posttraumatic stress disorder. In fact, he identifies five main elements in reaction to a violent and unexpected bereavement: somatic disorders, concerns with the image of the deceased person, feelings of guilt, hostility, and disorganized behavior. There are two types of reactions to traumatic grief: a “delayed” form, potentially lasting for several years, and a “distorted” one, characterized by social withdrawal, psychosomatic disorders, hypochondriac elaborations, and manic hyperactivity. For Lindemann, mourning involves the verbalization of experienced guilt and the management of feelings of fear and hostility, and passes through the emancipation of the relationship with the lost object, the readjustment to the environment, and the formation of new relationships.

In the psychological analysis of mourning, a vital contribution was made by Bowlby (1969, 1973, 1980) and his assumption of an ambivalent relationship between attachment and loss. According to the author of the attachment theory, childhood experiences of relationships influence the style of personality and relationship in adulthood. The way people deal with separation and loss of a loved one is then related to patterns of internalized relationships with each other. In the third volume of Attachment and Loss, entitled Loss, Sadness and Depression (Bowlby, 1980), Bowlby focuses on the psychopathological consequences of mourning, taking into consideration the many forms of developmental blocks and regressions that the individual may experience after a significant loss. The author stresses that, to overcome the consequences that the loss brings with it, subjects face lengthy and complex dynamics and intricate intrapsychic and interpersonal processes. For Bowlby, grief is essentially similar to separation anxiety. He considers mourning as the forced separation from an attachment figure, which is followed by a period of protest and then a longer period of research of the missing figure (analogous to animal behavior). After some time, these reactions cease, since they are not effective in allowing the reunion with the attachment figure. The individual then enters a phase of despair and depression, followed by the reorganization phase, characterized by the restoring/restructuring of one’s own life condition. The “internal” presence of the deceased can be comforting and facilitate this reorganization (Cleiren, 1991).

The family systemic and relational symbolic approach considers mourning as an event that can only be analyzed in the interpersonal context in which it takes place. To understand the reaction to the situation of the bereaving individuals, we must consider the resources, history, relations, and dynamics of the family to which they belong (Andolfi & D’Elia, 2007).

Within the systemic approach, the concept of the family constellations of Bert Hellinger should be mentioned (Hellinger, 2003). According to this recent (and somewhat controversial) perspective, our lives are conditioned by fates and feelings that are not only ours but are also part (and a consequence) of the lives of our ancestors. So it seems that we continue to act within an archaic structure, blind and unconscious, under the charge of cohesion and belonging to the family system. Therefore, if a family member has taken their own life, a member of succeeding generations – someone who knows nothing about this predecessor – will bring upon himself/herself this fate and will eventually follow that tragic destiny. So, according to Hellinger, serious illness, death wishes, and problems at work may result from systemic family tangles that can be brought to light through the reconstruction of the “constellations.”

In the cognitive behavior approach, the central role is played by thoughts and beliefs of the person: The same event can trigger different emotional and behavioral responses, depending upon the significance individuals assign to it. For example, the emotional response to the death of a loved one might be, at any given time, sadness, if the predominant thought is to have suffered an irreparable loss, or anger, if we believe that we have suffered a gross injustice.

The cognitivist Guidano (1987) states that loss and grief can represent an interruption of the sense of self as perceived by the subject; therefore, mourning can end only when the subject has become able to reorganize their sense of self. In this perspective, importance is given to the analysis of changes in the vision of the self, others, and the future, as a result of the loss.

Several other authors have made important contributions to our understanding of bereavement, based on cognitive principles (e.g., Marris, 1974; Parkes, 1970, 1987) or on more purely behavioral or sociobiological ones – for example, Littlefield and Rushton’s study (1986) on the biological “value” of the deceased is of considerable interest.

In general, however, from the 1980s onwards the contributions to the scientific model of stress have focused on clinical-theoretical constructs mainly related to the stress of separation. According to these studies, the loss of a loved one may be followed by dysfunctional thoughts and beliefs (e.g., conviction of one’s own guilt), with these ideas also leading to emotional disorders, both acute and chronic (e.g., depression), as well as to inappropriate coping strategies in dealing with the stress and the changes that mourning entails (Sgarro, 2008).

Some Key Terms

Before going deeper into the central themes of mourning, it is appropriate to clarify some aspects of our terminology. In many articles, we find that the term bereavement indicates the loss of a loved one and the state of mourning that follows; however, many authors use the term grief interchangeably, which certainly identifies the same concept but, in particular, focuses on its reactive aspects (the lowering of mood and changes in behavior following the loss).

Some confusion may also arise from the distinction between the terms survivors and bereaved, since they are also often used interchangeably. Survivor is used to designate those individuals who are left behind after the traumatic death (e.g., a death due to suicide) of a loved one. As mentioned above, bereaved refers to the mourner, and is a term applied in the context of any cause of death, including a natural cause (e.g., stroke or cancer). Survivor is a term used especially in American contexts, while the second – bereaved – is more commonly used in countries of the British Commonwealth (the United Kingdom, Australia, New Zealand, South Africa, etc.). Although in this book the terms survivor and bereaved are often used interchangeably, we prefer to use the term bereaved for someone who lost a loved one. We tend to consider those as survivors who have remained alive after a natural disaster or a catastrophic event, e.g., people who have been in a tsunami, mass shooting, earthquake, accident, etc. Of course one may be both a bereaved person as well as a survivor (e.g., someone who has been in a tsunami and lost a close person).

Suicide survivor is also an expression that can have different meanings: Used as just mentioned, it indicates those who are left in the world after a “dear and near” one has died by suicide, but suicide survivors are also those who have made a suicide attempt that did not lead to death (De Leo, Bertolote, & Lester, 2002). In this book, suicide survivors is used to refer to those “left behind” after a death due to suicide. We will never use this term to refer to those who made a suicide attempt.

“Normal” Mourning

The Stages of Mourning in Various Theories

The reactions following the death of a loved one can be very intense and powerful; people may feel anxious, lonely, and confused. Feelings and reactions difficult to understand and communicate to the other may easily arise: disbelief, shock, anger, fear, and guilt. Like a wound that needs time to heal, mourning is a painful experience of separation that takes time and effort to gradually find a different balance and a new meaning in life.

To better understand the pain of people who have suffered a loss, in recent years several scholars have questioned the effects of grief and the factors that facilitate or hinder its elaboration and acceptance. In the course of months or years, many of the bereaved are able to give meaning to the experience of mourning, integrating it into their life history (Barry, Kasl, & Prigerson, 2001; Latham & Prigerson, 2004; Prigerson, 2005). However, at least at the beginning, the “normal” pain that results from the loss of a loved one is accompanied by feelings of disbelief and unreality and various manifestations of physical and mental discomfort.

Over the years, theories of mourning (Bowlby, 1963; Bowlby & Parkes, 1970; Kübler-Ross, 1969) have described the different stages of its development and, although they have never been tested empirically (Prigerson, Shear, Jacobs, Reynolds, Maciejewski, & Davidson, 1999) they have gained wide acceptance anyway, eventually being generalized to various situations of loss. Denial, disbelief and shock, anger, depressed mood, despair, and finally acceptance, represent steps that, although varying with different individual paces and sequencing, happen more or less in all persons.

Some authors (Bowlby, 1980; Engel, 1962; Parkes, 1970) have described the steps by which the person moves into the difficult process of mourning thus:

•   The stage of shock (intense despair, denial, rejection, and anger). This may take a few moments or a few days;

•   The stage of desire and search for the lost person, which can last months or even years;

•   The stage of disorganization and despair, in which the reality of the loss begins to consolidate, and the survivor finds it hard to live in a habitual environment, becomes apathetic, indifferent, and unmotivated;

•   The stage of the reorganization, in which the most painful aspects of grief begin to subside, and the individual feels the sensation of returning to life again.

Mourning thus provides a series of steps that, if properly completed, may lead to the reestablishment of a balance and the cessation of the experience of intense pain (Scocco, Frasson, Costacurta, Donà, & Pavan, 2004).

According to Worden (1991), the bereaved person should attempt to fulfill some tasks to accelerate the recovery process:

1.  Accept the reality of the loss;

2.  Work on their pain;

3.  Limit the presence in the environment of objects that remind them of the deceased;

4.  Disinvest the relationship with the deceased in favor of other relationships.

From her experience with terminally ill patients, Elisabeth Kübler-Ross wrote On Death and Dying, published in 1969, in which she described five different types of reaction to a fatal outcome (cancer related): denial, anger, bargaining, depression, and acceptance. This five-step model is a tool that enables an understanding of the most frequent mental dynamics of the person who has been diagnosed with a terminal illness, but psychotherapists mostly have found that the same model is also applicable in the mourning process. It should be noted that this is a phase and not a stage model; this means that the phases can also alternate, or re-present several times during the bereavement process, with different intensity and without a precise order; this is because emotions do not follow special rules.

Phase of Denial or Refusal: “It is not possible” and “I cannot believe it is happening” are the most frequent phrases voiced when faced with a diagnosis of terminal illness, or at the news that a loved one has died. This phase is characterized by denial; in other words, a “primitive” defense mechanism capable of altering the reality test. This type of defense, usually characteristic of pathological dynamics (psychotic), can be appropriate and functional when facing the communication of a diagnosis of terminal illness or a death, as it protects the person from excessive anxiety and allows them to take time in considering the tragic events while getting organized.

Phase of Anger: After the denial, strong emotions begin to manifest; these are mainly anger and fear, and they are able to explode in all directions, directed toward the family, the hospital staff, and God. The phrase most frequently used is: “Why to me?” This phase represents a very sensitive moment in the reaction to the knowledge of a terminal condition or for the person who is forced to face the reality of bereavement. It represents an extremely critical time, which can constitute both the moment of greatest need of help and also the time of rejection and withdraw.

Phase of Bargaining or Plea Bargaining: In this phase, the person begins to see what they can actually do, and how the project may involve new hope, starting a kind of negotiation, which – according to personal values – can be established with both the people who constitute the social network of the subject, and with religious figures. At this stage, persons begin to regain control of their lives, trying to repair the repairable.

Phase of Depression: This phase occurs when the subject begins to be aware of the loss or, for the terminally ill patient, when the disease progresses and the level of suffering increases. Depression, in this phase, is divided into two types: reactive and preparatory. Reactive depression is due to the awareness of the aspects of one’s own identity, body image, decision making, and social relations that have been lost. Preparatory depression expresses rather the anticipation of losses that are happening or close to happening, or – in case of bereaved people – it manifests itself as the fear of further losses.

Phase of Acceptance: The subject is able to understand and elaborate what is happening or what has happened, and finally becomes fully aware and accepts the reality. During this phase, anger and depression may always be present, though of generally decreased intensity.

Myths About Grieving

As highlighted by the examples above, for decades well-known authors and theorists have written that the process of bereavement follows certain steps, and it is a generally accepted opinion that this is a fact (Parkes, 1998). The reality is that the available studies do not confirm the existence of different phases and that theories on the phases of grief are not actually supported by scientific research (Dyregrov & Dyregrov, 2008). If it is true that most mourners may experience an initial collapse, a phase of shock, a phase of reaction, and a phase of reorientation, this is not necessarily proven in all cases. That the process of mourning should be characterized by well-defined sequences, where emotions follow in a particular pattern, is far from being proven scientifically, but it continues to be a kind of rather passively accepted myth. In reality, there is no one way of crying, as there is no “correct” way of experiencing grief. Each individual must find their own way and at their own pace.

Another false myth is the belief that everyone has to go through the grieving process. In many people, professionals or not, there is the idea that to end the bereavement process, the “work of mourning” is necessary. The work of mourning means going through an emotional process in which people are confronted with the reality of loss, review all the events preceding and following the loss, focus on the memories of the person who has been lost, and gradually reach (complete) detachment from him/her. The process often involves discussing with others what has happened, even if the process can occur in the absence of these discussions. Many people do actually undergo such a process of transformation of their pain, but research shows that a relatively high percentage of persons, up to 20%, do not feel any particular pain, either immediately after the death or later, even when the deceased person is a child (Bonanno & Kaltman, 2001).

Regarding people who have no reaction to pain (either intense or long-term), it is wholly inappropriate to push them to follow a specific model of “working through” their grief, or dictating to them the most “appropriate” response to it. Sometimes society’s expectations and lack of understanding grief can create significant problems. For example, if medical staff and maybe even family and friends believe that the relatives of the deceased person should react in a visible way, the pressure can become enormous, with the result that the bereaved person may begin to believe that there is something wrong with them, because their reactions are not so pronounced. Actually, for these people it should be perfectly legitimate to try to continue living as before, in the most active way possible, and in full contact with the social environment.

Another myth that may raise false concerns is the idea that grief is a process with a beginning and an end. To some extent, this may be true about mourning the death of old people, but it is definitely not so if the death concerns someone young and has happened suddenly, unexpectedly, or dramatically.

On the other hand, people generally think that the suffering due to bereavement only finishes when the person, after the first few months, is able to turn over a new leaf and return to life. A few years ago, a study showed, however, that the pain of mourning may have a very extended time horizon, and even if its general characteristics are not always as persistent and exhausting as in the beginning, the pain returns again and again, particularly in relation to certain periods of the year, such as holidays and anniversaries (Murphy, Johnson, & Lohan, 2002).

Research has also shown how mourning is important for many in developing and then maintaining a “special memory” – an intimate representation of the deceased. In such cases, the deceased becomes an active part of the spiritual life of those people, a sort of private counselor, a real inner helper of particular significance (Neimeyer, 2001). An example of this process of internalization was well illustrated in a study conducted by Dyregrov and Dyregrov (1999), in which they analyzed (12–15 years after the event) the reactions of parents who had lost a son to sudden death in the early months of life (due to SIDS). Through the use of questionnaires and in-depth interviews, it was possible to show that 50% of parents had continued to mourn, while the other 50% had tried to forget the event as much as possible. However, despite the many years that had elapsed since the death, in no case had the parents forgotten their sons, still retaining personal objects and other memorabilia, including counting the lost son in the number of children they had and keeping a strong inner representation of him/her.

It was repressed for all the time. But when I watch something like a movie on children, I feel very strong sensations. Then I feel sick and cry. The pain has always been there. Even if I do not feel it during the day, it’s there. I think it will take another ten years before it goes away.

A Bereaved Person’s Testimony

It is almost impossible to generalize about when the process of mourning ends. Some authors believe that it will never happen; for example, Bowlby (1991) says, “The mourning never ends. Over time, you just feel it a little less.”

The end of bereavement depends on several factors: How and when it started, its intensity, and what sort of obstacles it encountered. Obviously, how close and interconnected the deceased and the survivor were is a factor of primary importance.

One of the signs testifying to adaptation and acceptance of the new reality is represented by the ability of the survivors to think of the deceased without pain, and reinvest emotions in a new life (Worden, 1991). Another sign of return to “active” life is the sense of having acquired new values – and increased wisdom, and not only to have suffered a loss (Grad, 2011).

Fluctuation and Ambivalence in the Mourning Process

Today, the prevalent theories place emphasis on how the bereaved person is divided between dealing in an open way with the loss and in the meantime refusing the things that may remind them of it. This ambivalence becomes basically the way to cope with the loss itself (Stroebe & Schut, 2001) . The mourning person should be able both to deal with what has happened and to come back to life again. These theories seem to be in harmony with the situations encountered in everyday life.

Figure 1.1. The dual process model of coping with bereavement. Adapted from The dual process model of coping with bereavement: Rationale and description, by M. S. Stroebe & H. Schut, Death Studies, 23, 197–224. Copyright 1999 by Taylor & Francis.

Figure 1.1 explains quite clearly what Stroebe and Schut (1999) intend by the dual process of mourning. The daily experiences of the bereaved range from loss-oriented feelings and thoughts (working on pain, intrusive grief, avoidance, and denial of any possible changes, etc.), and the return to life through the ability to avoid memories of the loved one (participation in the life changes, doing new things, getting distracted from the sorrow, avoiding feeling distressed, meeting with new roles and identities, and pursuing new opportunities and relationships).

Pathological Mourning

When confronting the death of a loved one, we are forced to face various phases of suffering that with the time may bring to an end the bereavement process. The pain of mourning is a normal and physiological reaction, which is present in survivors for the period necessary to accept the loss. In some cases, however, the reaction of mourning lasts longer than what could be considered a “reasonable” interval and sometimes even intensifies with time, generating a situation that makes that experience of sorrow pathological.