Aspects of Grief (Psychology Revivals)

Bereavement in Adult Life

Jane Littlewood

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317613275
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychotherapeutische Beratung

How do bereaved people come to terms with their loss? What factors are important in successful coping?

The death of a loved one is one of the most painful experiences that we have to encounter. If the loved one is a child or partner the experience can be especially devastating. How do we cope? Do our families provide sufficient support? Would professional help be better?

In this book, originally published in 1992, the author provides an in-depth study of the many aspects of bereavement and the grieving process. With ample support from personal accounts of bereaved people, she examines the experience of bereavement: what can go wrong, the importance of social networks, both family and professional, and looks at how society's attitudes to death and dying can affect our ability to cope. There are specific chapters on the death of children in childhood, adolescence and adult life, and on the death of a partner.

The result is a book that will be of importance to all those who have regular contact with the dying and bereaved.

1

THE WAY WE DIE

‘The tame death is the oldest death there is.’

Ariès (1983)

The Hour of our Death

INTRODUCTION

It is difficult to consider reactions to bereavement without looking at social and cultural attitudes towards death and dying. An increase in average life expectancy and changes in patterns of mortality have made deaths outside the older age ranges relatively rare occurrences. Many people now reach middle age without having any direct experience of bereavement. However, research in the area would indicate that coping with death and dying remains profoundly problematic for people in Western societies. Furthermore, it has been suggested that the difficulties associated with these areas have accumulated rather than diminished.

Consequently the first part of this chapter looks at some of the evidence which suggests that death and dying are surrounded by a series of cultural contradictions and distortions. The second part is concerned with the social context in which death occurs and some ways of dying which have been associated with difficulties for the survivors. The third part of the chapter focuses upon the attempts of health professionals to provide improved services for people who are dying, and the final part identifies some of the problems involved in the provision of services in an environment which may be hostile to their aims and objectives.

ATTITUDES TOWARDS DEATH

Ariès (1974, 1983) has looked in detail at changing attitudes towards death in Western societies from the Middle Ages to the present day. The contemporary situation would appear to be bleak. According to Ariès, the history of dying is one in which both control of the dying process and the place of death have changed. At the risk of oversimplifying his scholarly work the main variations may be represented as shown in Table 1.

Table 1 Control of the dying process

Death
Time	Control	Place	Support at the time of death
Middle Ages	Held by the dying person	In the community	Communal
	Held by the dying person’s family	In the home	Family
Present Day	Held by the medical profession	In the hospital	None*

* i.e. outside a small group of health professionals who have sought to change practice in the area.

Ariès characterises the contemporary situation as one in which death has been rendered invisible – simply ‘conjured away’. The majority of deaths now occur in institutions with the dying person isolated from the everyday activities of the society and, perhaps more importantly, from other people. This way of dying contrasts unfavourably with his portrayal of deaths in earlier times where dying people remained in full control of their deaths, dying in the heart of their particular community. Up until the point of death itself dying people had a key role to play in what were undoubtedly social proceedings – that of preparing themselves and others for their death, a ‘tame’ death.

At the present time Ariès believes us to be both ashamed and afraid of death. The dying provoke unease, embarrassment and disquiet. It is seen to be appropriate that they are quietly removed from the community, to die in isolation. This isolation also seems to affect the bereaved. As living reminders of the unspeakable truth of death they may be avoided rather than supported, effectively quarantined – as Gorer (1965) puts it, ‘mourning in reverse’.

Ariès (1983) identifies four models of dying in the present day which correspond to the social and historical changes he identifies. These models have profoundly different implications for people who are dying and people who have been bereaved. Again, at the risk of oversimplifying a complex analysis, the models would appear to have the following components:

MODEL 1	The tame death in which death is a sad, inevitable but natural end to life.
MODEL 2	The romantic death in which death is a great event. An event which confirms and deepens the meaning of an individual’s life.
MODEL 3	The modern death which involves the isolation of the dying and their carers. Death is a meaningless event which could happen to anybody at any time. It is dying which is feared.
MODEL 4	The modern death which involves the total isolation of the dying person. Death is simply ignored, subsumed in everyday reality, an event which must be managed as quickly and as cleanly as possible.

Ariès believes that it is models three and four which capture the way of death in contemporary Western societies (particularly for young adults). Whilst there must be as many ways of dying as there are of living, the awful isolation associated with model 4 has a nightmarish quality about it; there is nothing tame about this way of dying.

Illich (1977) is another critic of the contemporary way of dying. He contrasts a past acceptance of mortality with the contemporary denial of it. He calls contemporary attitudes towards death ‘primitive’. Rather than seeing death as a natural, inevitable end to life we seek to attach blame to someone or something because we hold the irrational belief that death, particularly premature death, should ultimately be avoidable:

the witch hunt that was traditional at the death of a tribal chief is being modernised. For every premature or clinically unnecessary death, somebody or something can be found who irresponsibly delayed or prevented a medical intervention.

Illich (1977)

Illich argues that this situation has arisen out of a misguided notion of progress and a belief that advances in medical science and technology would ultimately be able to conquer death itself. Gorer (1965) identified a similar tendency and was bemused by an apparent underlying belief that death was potentially avoidable if one met certain behavioural standards and requirements.

In an early essay on the subject Gorer (1955) argued that death had replaced sex as contemporary society’s major taboo topic. He was concerned with what he called the ‘pornography’ of death and the presentation of dying in an unrealistic framework. People can see the mechanics of death portrayed by the media without experiencing the reality of grief. People die and those who cared about them seek revenge rather than comfort, live to fight another day and feel better by the following morning. Gorer believed that, as the actual experience of deaths in the community became rarer and fewer, and fewer people either saw corpses or experienced bereavement, a relatively realistic view of death had been replaced by a voyeuristic, adolescent preoccupation with it. At the time he was writing he believed that the ‘horror comic’ and the ‘horror movie’ epitomised such tendencies. If one wished to extend his ideas to the present day then some aspects of the media presentation of various issues might provide examples. Peter Tatchell makes the following comments about the presentation of news connected with the virus believed to cause AIDS.

To Fleet Street AIDS was a new cocktail which embodied all the ingredients on which sensationalist journalism thrives, homosexuality, venereal disease, disfigurement, disability and death.

Tatchell (1986)

Whilst there are many other authors who discuss the denial of death and its inadequate, unrealistic portrayal in popular culture, these authors have not been without their critics. For example, Kaufmann (1976) questions a whole range of authors from Feifel (1959) onwards over the denial of death. He points out that art and literature have always addressed these issues in depth and continue to do so. Furthermore, there have been many books written by bereaved people about bereavement, for example, Lewis (1961) and more recently Heike (1985). However, Smith (1982) suggests that, whilst the literature relevant to professionals who work in the area grows daily, the general public seems unaware of this growing body of literature. Kalish (1985) is of the view that despite courses in death education becoming widely available, particularly in the United States, their actual impact may only be marginal. In short, it does not simply seem to be a question of the presence of portrayals of death and dying but rather one of the predisposition to acknowledge what is, and always has been, there.

Overall the evidence would seem to suggest that death and dying have, at least in broad cultural terms, been ‘conjured away’ as Ariès suggests. Despite criticisms of the implicit romanticism of this analysis (Elias 1985) the process of dying in contemporary Western societies must in existential terms be an extremely lonely one. Many people would appear to die in an isolation almost too terrible to contemplate.

DYING IN HOSPITAL: DEATH AS A SOCIAL EVENT

According to Turner (1987), approximately 80 per cent of people who die in the United States do so in hospital. In the United Kingdom Cartwright et al. (1973) put the figure at approximately 57 per cent (hospital or similar institution).

A number of studies have focused upon death and dying in hospital. Some concentrate upon the social processes surrounding death (Glaser and Strauss 1965, 1968; Sudnow 1967) whilst others look in more detail at the psychological consequences of these social processes (Hinton 1967; Kübler-Ross 1969).

Sudnow emphasises the ways in which dying is routinised and thereby moulded to fit the day to day functioning of the hospital as an organisation. His work suggests that, even at the point of death itself, considerations of social worth and status are paramount. For example, he noted that differing amounts of effort were made to revive people who were suspected of being ‘dead on arrival’ at a hospital. He associated the degree of effort with perceptions of the social worth of the person involved – the greater the social worth, the more strenuous the resuscitation attempts. In extreme cases such considerations would appear to be acted out upon corpses. He interpreted his observations of the apparent disrespect shown to the corpses of suicide victims in terms of the social unacceptability of the act of suicide. Presumably, if people did not value their own lives then the social constraints which prevented others from desecrating their corpses were taken to be inapplicable.

Although Sudnow’s work may be criticised on the grounds that few alternative explanations of his observations were considered, perhaps the observations themselves should not be too surprising. If Ariès (1983) is to be taken seriously, then Sudnow’s work could be interpreted as a study of some of the ways in which the occurrence of an event which should not occur is dealt with, i.e. by aggressively invoking and adhering to the very norms and mores of everyday reality which are under threat. However, this is not necessarily the only or the best way that exposure to death and dying may be dealt with.

Glaser and Strauss (1965) also conceptualise dying as a form of ‘status passage’. This passage is guided by beliefs concerning appropriate and inappropriate behaviour. These beliefs are ordered into a series of expectations about dying (‘dying trajectories’) which are believed to define various forms of ‘normal’ and ‘abnormal’ ways of dying. One function of casting ahead a dying trajectory is to limit, perhaps unrealistically, the uncertainty that those attending people who are dying may feel about the event of death. A summary of their findings is given in Table 2.

Table 2 Dying trajectories

	Occurrence of death within foreseeable future
Time of death	Certain	Uncertain
Known Unknown	Some accidents Terminal illness	Radical surgery Chronic illness

In the case of some accidents (e.g. road traffic accidents) the time of death may be known or its occurrence in the near future predicted with some degree of certainty. For example, a person may be found to be dead on arrival at a hospital or so badly injured that no effective treatment is available. Alternatively, if radical surgery is required then death may become a probability or a risk rather than a virtually certain outcome.

In the case of terminal illness the situation is one in which death is reasonably certain to occur in the foreseeable future but the precise timing, i.e. in days, weeks or months, remains uncertain. The case of chronic illness is associated with an even higher degree of uncertainty over both whether or when death may occur as a result of the condition.

Glaser and Strauss were mainly concerned with deaths occurring in hospital. Obviously, not all deaths do occur in hospital although most are associated with a hospital setting at one time or another. For example, most accident victims would presumably have little contact with a hospital prior to their death. Whilst degree of contact with a hospital is one variable associated with different dying trajectories, the potential for an individual’s actual awareness of impending death is another.

Kalish (1985) has suggested that if people are given a choice they would choose to die in old age of a cause which is associated with no period of hospitalisation or prior warning. A sudden death. Paradoxically the death most people say they would like to die may be one of the most traumatic for the people who cared about them to come to terms with. Both age at death and perceptions of the suddenness of a death are important, if somewhat contradictory, factors which may affect reactions to bereavement. Parkes (1972) has indicated that unanticipated deaths may be associated with complications arising during the bereavement process. Kaufmann (1976) suggests that there is an association between death and old age which may make deaths in the older age ranges less difficult to come to terms with than the deaths of younger people. Also, Illich (1977) has indicated that premature deaths are those most likely to be associated with a tendency to seek revenge or allocate blame for the death. Furthermore, both Gorer (1965) and Parkes (1972) forward a ‘timeliness’ hypothesis which implies that deaths believed to be timely, i.e. generally those occurring in the older age ranges, seem to be less distressing for people who have been bereaved than ‘untimely’ deaths, i.e. those occurring in the younger age ranges. Nevertheless, it must be said that ‘timeliness’ may equally well be a function of the state of a relationship and the perceptions of the two people involved. Age may not necessarily be an important factor. For example:

A man in his seventies expressed anguish over the death of his wife, also in her seventies. They had married in their fifties and he felt that she had been badly abused by her first husband. He wanted to have the time to ‘make all that up to her’ – he felt that he hadn’t had long enough.

A woman in her forties still grieved deeply for her mother seven years after the death. The women felt her mother had survived a hard, unhappy life in poverty with very little material comfort or emotional support. She had hoped to be able to share some of her own happiness. Her mother died long before she felt she had shared enough.

However, actual evidence...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Copyright Page
• Dedication
• Table of Contents
• List of tables
• Acknowledgements
• Introduction
• 1 THE WAY WE DIE
• 2 RITUALS AND MOURNING CUSTOMS
• 3 EXPERIENCES OF GRIEF
• 4 MODELS OF BEREAVEMENT: SEARCHING FOR MEANING
• 5 MODELS OF SOCIAL SUPPORT AND PROFESSIONAL SUPPORT NETWORKS
• 6 INFORMAL SUPPORT NETWORKS
• 7 THE DEATHS OF CHILDREN IN CHILDHOOD, ADOLESCENCE AND ADULTHOOD
• 8 THE DEATHS OF PARTNERS AND PARENTS
• Bibliography
• Name index
• Subject index