Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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Women are more vulnerable to economic risk in widowhood (Lopata, 1993; Wort-

man, Silver, & Kessler, 1993). Those in the oldest cohorts are more likely to be de-

pendent on a spouse for income, insurance, and pension coverage (Blieszner,

1993). It is a concern, then, that women (especially) who experience economic in-

security in widowhood experience increased depression (Van Grootheest, Beek-

man, Van Gronou, & Deeg, 1999). Fortunately, many who fall below the poverty

line after bereavement recover a degree of economic security within a few years

as they begin to receive benefits, find work, or are assisted by family (Bound,

Duncan, Laren, & Olenick, 1991).

Broader forms of social and family support for older bereaved persons have

been the focus of much research. Social support in general has been widely found

to be related to positive physical and mental health outcomes. It provides practi-

cal support, but also an emotional component of felt closeness and acceptance,

and enhances feelings of self-efficacy (Antonucci, Langfahl, & Akiyama, 2004;

Charles & Mavandadi, 2004; Lopata, 1993, 1996). Under conditions of such emo-

tional support, healthy persons tend to experience fewer symptoms and a more

effective immune system. Persons who are already at increased health risk be-

cause of age or chronic illness experience higher levels of function and survival

(Charles & Mavandadi, 2004).

Older adults are likely to be more dependent on family support networks, and

families typically rise to the occasion to provide support. But in late life, support

needs become more complicated and more medical in nature. At this time, the

family network itself may also be aging, becoming smaller, more frail, more

stressed, and less able to provide the kind of support that best matches an older

person’s needs (Hansson & Carpenter, 1994).

Much research has now been conducted on the role of social support specific to

bereavement, but the results have been somewhat of a surprise. Recent reviews of

this literature find main effects for support, but no consistent evidence that it

buffers or protects against the consequences specific to bereavement. Such find-

ings would be consistent with attachment theories of the grief reaction, in that

support appears to help all people with respect to their instrumental, informa-

tional, and general emotional needs, while recognizing that a lost attachment fig-

ure (and what that person provides) cannot be replaced (W. Stroebe, Stroebe,

Abakoumkin, & Schut, 1996; W. Stroebe, Zech, Stroebe, & Abakoumkin, in press).

Sex-related resources also appear relevant in adjustment to late-life bereave-

ments. Reviews of this literature strongly suggest that older bereaved men are at

greater risk (W. Stroebe & Schut, 2001), in part because of the nonnormative na-

ture of the death of the wife. They appear, for example, to experience more de-

pression (Lee, Willetts, & Seccombe, 1998; van Grootheest et al., 1999). Such

increased risk may reflect a selection artifact, however. For example, healthier

widowers are more likely to remarry, so are less likely to be classified as widowed

when included in studies. Similarly, because men live a shorter life, they would

likely be younger (and in an earlier, more intense phase of their bereavement)

when assessed. On the other hand, older widowed men are likely to have less

competent health and nutritional habits, relative to women, and appear less likely

to have the social skill mix needed to access and maintain important social sup-

port networks (Lee, DeMaris, Bavin, & Sullivan, 2001).

An emerging consensus among researchers suggests two general types of cop-

ing, loss-oriented and restoration-oriented, that may be required in a bereavement.

These are most prominently captured in the dual process model (DPM) of coping

Grief and Bereavement 377

with bereavement (M. S. Stroebe & Schut, 1999, 2001). Loss-oriented coping chal-

lenges reflect the emotional distress of losing a beloved attachment figure. Their

focus is on the lost relationship, emotional bonds to the deceased, yearning,

painful memories, coming to terms with irrevocable separation, and finding a

way to work through grief-related feelings of anxiety, depression, and uncer-

tainty. Restoration-oriented coping challenges, on the other hand, involve deal-

ing with secondary stressors associated with the loss. These can involve a need to

make major life adjustments or to deal with the practical consequences of the

death, such as economic disruption, need to assume new responsibilities, or to

learn new practical coping skills having to do with employment, household and

family management, or coming to terms with a world in which the deceased is no

longer present. The DPM proposes that over time bereaved individuals will feel a

need to oscillate between attending to loss- and restoration-oriented coping de-

mands, and that such oscillation can serve as an emotion-regulation mechanism,

allowing occasional respite from emotional process and responding as needed to

practical matters that emerge.

LATE-LIFE DEVELOPMENTAL PROCESSES

AND BEREAVEMENT

EVELOPMENTAL

ROCESSES AND

OPING WITH

ATE

-L

IFE

EREAVEMENT

A number of developmental processes pertaining to physical health, emotion, and

cognition would be expected to influence coping with bereavement in late life. We

summarize some of these in this section.

HYSICAL

EALTH

TATUS

Diminished health associated with old age would be expected to compound the

problem of adapting to a significant life stressor such as bereavement. The symp-

tomatology of bereavement includes a strong physiological component, which

would be expected to exacerbate preexisting chronic conditions or disease pro-

cess. And the deterioration of the body’s protective and regulatory systems af-

fects one’s adaptive reserves and homeostatic capacity, increasing risk during any

emerging health crisis. Diminished energy can render some active coping strate-

gies infeasible. Sensory loss may lead to increased dependency simply for activi-

ties of daily living and survival. Furthermore, any unresolved, residual physical

symptoms resulting from the bereavement might be expected to play an impor-

tant role in future disablement among older persons (Aldwin & Gilmer, 1999;

Hansson & Stroebe, in press; Jette, 1996).

MOTIONAL

ROCESSES

Research by Lawton, Kleban, Rajagopal, and Dean (1992) suggested a “dampen-

ing” of emotional experience among older adults generally. This involves a gen-

eral narrowing of the “intensity, frequency, duration, or quality” of their

emotional responses (p. 338). Lawton and colleagues found that older persons re-

ported focusing greater effort (and having more success) on managing their emo-

tions. Respondents also reported more stability in their positive moods, attempts

to arrange their lives so as to encounter fewer intense (positive or negative) emo-

tions, and a diminished likelihood of experiencing the physical sensations usu-

ally associated with intense emotional experience.

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There is evidence also that older persons become more effective at emotion reg-

ulation more generally. They tend to report fewer negative emotional experiences

and greater efforts to enhance positive emotions (Birditt & Fingerman, 2003;

Charles, Mather, & Carstensen, 2003; Gross et al., 1997). They also appear to focus

on enhancement of the balance of positive to negative emotions in their relation-

ships with their spouse (Carstensen, Gottman, & Levenson, 1995) and in their in-

teractions with their children (Pasupathi, Henry, & Carstensen, 2002). During an

emotional episode they are more likely to experience more differentiated and

complex emotions, for example, acknowledging the co-occurrence of a greater

number of distinct emotions and of a mix of positive and negative emotions

(Carstensen, Pasupathi, Mayr, & Nesselroade, 2000; Ong & Bergeman, 2004). If

aging is thus associated with a maturation and dampening of emotional experi-

ence, with greater expertise in emotion regulation, and with efforts to manage

relationships with an eye to maintaining a positive emotional balance, older per-

sons would be expected to more easily adapt to stressful life events, even to be-

reavements. The greater emotional heterogeneity and specificity with age

(Charles, 2005; Kunzmann & Gruhn, 2005), however, argues against overgeneral-

izations regarding one’s emotional response to death in later life; individual dif-

ferences in reactivity and specificity in responding to death is a function of the

nature of one’s relationship to the deceased as well as the cause of death.

It is important to point out that the successful management and monitoring of

one’s emotions may be critical in developing and maintaining social support net-

works. In acknowledging and expressing negative emotions (anger, sadness, de-

pression) to a degree, one may invite efforts by family, friends, and neighbors to

provide needed emotional and instrumental support, contributing to one’s qual-

ity of life and sense of well-being (Krause, 2006). Moreover, decreases in negative

affect and increases in positive affect, in concert with increased emotional control

in later life (George, 2006), are likely to make one more attractive as a griever, dis-

couraging the disenfranchised grief (Doka, 1989, 2002) that might otherwise

characterize the loss of a spouse in later life, especially among women, for whom

economic hardship is greater (Utz, 2006).

Interestingly, although existing support networks may be greater and the

death of a husband (or, for that matter, a parent) may be seen as normative in na-

ture, this very sense of the normativeness of loss in later life may come at the cost

of providing opportunities for emotional expression and venting of strong emo-

tions and past regrets or, alternatively, the desire to move on with one’s life. In

this respect, Williams-Conway, Hayslip, and Tandy (1991) found that while health

care professionals attributed more distress and difficulty in adjusting to their

husband’s deaths to widows than the latter reported, such persons significantly

underestimated the extent and depth of widows’ yearning for their husbands and

feelings of isolation. Interestingly, although Sable (1991) found that older women

eventually came to terms with the death of their husbands, many (78%) said that

they simply learned to live without them but that emotionally they would never

get over the loss.

OGNITIVE

ROCESSES

Cognitive competence would also seem relevant to the ability to cope with both

loss-oriented and restoration-oriented challenges. For example, studies have

Grief and Bereavement 379

found that many older adults are able to maintain into late life those abilities asso-

ciated with crystallized intelligence (verbal meaning) as well as everyday problem

solving (Hayslip & Sterns, 1979; Horn & Hofer, 1992; Marsiske & Margrett, 2006;

Schaie, 1994). The maintenance of such skills are largely tied to the accumulation

of experience as well as opportunities for the everyday use of one’s skills. In light

of the relative familiarity of the experience of loss in later life, reliance on previous

coping strategies that have proven useful in the past can indeed be adaptive in cop-

ing with the loss-oriented and restoration-oriented aspects of late-life loss. Such

changes therefore suggest a continued ability to deal with loss-oriented chal-

lenges in bereavement (e.g., finding meaning in the death, resolving relationship

issues). On the other hand, to the extent that restoration-oriented coping (e.g.,

with finances, housing, employment) may require numeric or abstract reasoning

abilities, it may be a concern that such abilities are more sensitive to the aging pro-

cess. Under such circumstances, formal assistance in coping or, at the minimum,

meaningful and timely social support may be important.

More broadly, the cognitive literature suggests important adaptive possibilities

in late life, some of which seem relevant to coping or adaptation with bereave-

ment. For example, some older persons would be expected to have developed in

their cognitive abilities in such a way as to suggest postformal thought (Sinnott,

1996). This would be expected to reflect a greater complexity in thinking about

problems, increased appreciation for the contextual variables that shape problems

and potential solutions, and an increased sensitivity to multiple perspectives and

for how understanding of a problem may change with time and experience. Sim-

ilarly, many older adults may have benefited from their considerable life experi-

ence, acquiring factual and procedural expertise and perspective with respect to

managing life’s problems (Baltes, Smith, & Staudinger, 1992). Maturation and de-

veloping wisdom about life matters would be expected to enhance both loss- and

restoration-oriented coping and adaptation.

The development of age-appropriate coping strategies and skills would also

be expected to enhance adaptation to late-life bereavement. Older adults are ob-

served to continue actively coping, but goals for coping and strategies appear to

change in response to life stressors that are becoming chronic and less control-

lable (Aldwin, 1991; Lazarus, 1996). At least three models of coping in old age

are of interest in this connection. First, there is often a shift in emphasis from

problem-focused to emotion-focused coping (Aldwin, 1991). Second, a shift

from assimilative to more accommodative coping has been noted (Brandstadter

& Renner, 1990). Accommodative coping recognizes a need in old age to under-

stand one’s realistic limits, revise or lower coping standards, and find new ways

to satisfy needs and to accommodate to changing circumstances. In this respect,

accommodative coping represents the use of what Schultz and Heckhausen

(1996) have termed secondary control: altering one’s view of the world or oneself

rather than attempt to directly alter the course of events or change the external

environment. Finally, Baltes and Baltes (1990) proposed three coping strategies

in their model of selective optimization and compensation. This model ac-

knowledges that it is adaptive in late life to recognize that it will be difficult to

continue to maintain competence in all domains of one’s life and that it will be

important to make some choices regarding those life goals and abilities that are

most important to continue to pursue (selection). Having made these choices, it

is possible to focus (and intensify) remaining efforts and energies on those

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selected goals and abilities (optimization). At some point, however, most older

adults are likely to experience the loss of a valued ability through irreversible

age-related change. At such times it will be important to find alternative strate-

gies or resources with which to compensate for those losses (compensation).

Considerable research now confirms the adaptive value of such shifts in coping

in late life, as evidenced by maintenance of one’s sense of mastery, well-being,

and life satisfaction in the face of age-related loss (e.g., Freund & Baltes, 2002;

Rothermund & Brandtstädter, 2003).

THE INTERFACE OF BEREAVEMENT WITH OTHER

LATE-LIFE EVENTS AND TRANSITIONS

The previous discussion of the contextual influences on late-life bereavement

warrants some discussion of other late-life transitions, some of which are norma-

tive and some of which are not, and their relationship to grief and bereavement.

In this respect, we briefly discuss the grandparent role, grandparents raising

grandchildren, retirement, and relocation from one’s home to a nursing home or

assisted living facility.

RANDPARENTING

It is has observed that later life can be understood in the context of gains and

losses (Baltes, 1997), wherein the proportion of gains and losses experienced

changes with increased age. With regard to grandparenting, it is reasonable to as-

sume that for many older adults, the acquisition of the grandparent role is viewed

positively, especially given the fact that grandparents actively and accurately an-

ticipate the nature of their role as such in advance of the birth of their grandchild

(Somary & Stricker, 1998). Yet grandparents, especially if they are actively in-

volved in the lives of their grandchildren and contingent on the meaning they as-

sign to the grandparent role, may be asked to become more involved in child care.

Involvement in their grandchild’s life may reflect a productive and fulfilling

manifestation of a “companionate” style (Cherlin & Furstenberg, 1986); however,

responding to the expectation that one will necessarily share child care responsi-

bilities (i.e., a surrogate parent style) can potentially interfere with one’s sense of

privacy in the context of marriage and lifestyle choices (e.g., being able to travel).

Such consequences have not been the subject of empirical research; nevertheless,

they are losses with which some grandparents may cope.

More important, some grandparents may grieve over the loss of contact with

their grandchildren. As the adult child helps to mediate the degree of contact be-

tween grandparents and grandchildren (Uhlenberg & Hammill, 1998), disagree-

ments between adult children and their parents about child-rearing issues can

undermine opportunities for and the quality of relationships with grandchil-

dren. In this respect, “token” grandparents report feeling emotionally isolated

from their grandchildren (Kornhaber, 1996).

Another manifestation of the grief that grandparents feel is when they lose

contact with their grandchildren because of the divorce of their adult child, or

through family disagreements, or because of geographical separation. Drew and

Smith (2002) reported that such grandparents experienced intense grief, lowered

quality of life, and poorer emotional and physical health; the effects of a family

Grief and Bereavement 381

feud had the most impact, followed by divorce, and then geographic separation.

In the context of divorce, Edrenberg and Smith (2003) found that relationships

with grandchildren were most satisfying when visits with both a daughter and a

grandchild were maintained, even when contact with the latter was frequent. In

this respect, being prevented from having contact with grandchildren via rela-

tionships with adult children-in-law has profound negative emotional conse-

quences for grandparents, as also is the case when an adult child dies or when the

adult child remarries after divorce (Kruk, 1995). In the event of divorce, less phys-

ical and emotional contact with grandchildren is associated with poorer physical

health and emotional well-being (Drew & Smith, 1999). Some states have enacted

laws to guarantee grandparents’ visitation rights in the event of divorce (Falk &

Falk, 2002). Complementarily, when grandparents divorce, they report feeling

less close to their grandchildren, less likely to play a friend role, and more con-

flicts with grandchildren, though such effects are moderated by the quality of

the relationship with the adult child (King, 2003).

In the event of a grandchild’s death, grandparents are often seen as “forgotten

grievers” (Ponzetti & Johnson, 1991) to the extent that attention is focused on the

impact of the child’s death on the parents (see Reed, 2003). It is often presumed

that grandparents have had more experience with death, and so will need less

support and education in their adjustment to their grandchild’s death. The scien-

tific literature is just emerging as it relates to grandparents’ emotional needs

when a grandchild dies, but it has been observed that their grief is likely to be

twofold: They grieve for their adult child as well as for themselves (Reed, 2003).

Family customs and rituals may not meet a grandparent’s needs, and grandpar-

ents are put in the delicate position of attempting to support their adult child as

well as meet their own needs for support from others. In many respects, such

grandparents’ grief is indeed disenfranchised (Doka, 1989, 2002).

A related issue pertains to the grief grandparents face when raising a grand-

child. As the circumstances that make such caregiving more likely are negative

and often socially stigmatizing (i.e., the death or divorce of an adult child, incar-

ceration, parental abuse, or abandonment of the child; see Hayslip & Kaminski,

2005), the gravity of these grandparents’ needs for social support and under-

standing will likely not be appreciated or understood by others (Miltenberger,

Hayslip, Harris, & Kaminski, 2003–2004). The loss or interruption of future

plans, a lessening of one’s privacy, the loss of income or good health, as well as the

loss of the formerly defined relationship with a grandchild that one must now

care for, represent factors that are often perceived as irreversible and, indeed,

quite personal by custodial grandparents. As stated by Baird (2003, p. 64), a cus-

todial grandparent, “There are constant reminders of losses incurred: the retire-

ment of a friend, watching a neighbor’s grandchild come and go, lack of personal

time with a spouse, lost contact with another friend.”

The grief of grandparents raising grandchildren who are either HIV positive

or whose parents have died from HIV disease is overwhelming (Joslin, 2002; Win-

ston, 2003). Not only are such grandparents stigmatized, but they suffer from a

lack of emotional and tangible support from others, when it is highly likely that

their HIV-positive grandchild will also die. Such grandparents, who are often

African American and whose grief is often disenfranchised, sometimes experi-

ence an overwhelming sense of loss and depression and manifest behaviors and

thoughts characteristic of pathological grief (see earlier discussion). Some studies

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(e.g., Winston, 2003) suggest that it is the grandparents’ own sense of a spiritual

relationship with God as well as their sense of familism (see Joslin, 2002; Poindex-

ter & Linsk, 1998) that enables them to cope with the profound sense of isolation,

feeling different, and hopelessness that often accompanies caring for an HIV-

inflected child.

ETIREMENT AND

ELOCATION

Although there is little published research on grief among older persons as it re-

lates to retirement and relocation, each transition clearly implies a separation

from something that one has imbued with a great deal of emotional and psy-

chosocial importance. In the case of retirement, the loss of one’s identity as a pro-

ductive member of society and as a provider for one’s family, as well as the loss of

relationships with friends and coworkers, are issues confronting most individu-

als who retire from the workforce (see Adams & Beehr, 2003).

Although preretirement planning may mitigate the adjustments that are other-

wise present when persons retire, or in some cases when retirements are un-

planned (i.e., when persons must retire due to ill health or if they are part of a

movement to downsize), specific discussions of the role of grief in adjusting to or

preparing for retirement are notably absent in the literature. Likewise, although

changes in well-being are typically identified as a primary consequence of retire-

ment planning or adjustment to the retirement role, the role of grief in this pro-

cess has gone unexplored. In this respect, Blazer (2002), in the context of

interpersonal therapy for late-life depression, recommends consciously connect-

ing depression to the life transition (e.g., retirement) as well as helping the older

person reframe the life transition in more positive terms. The role of grief in help-

ing or hurting the development of a postretirement identity as well as a factor in

determining adjustment to retirement certainly requires more attention than it

has garnered thus far.

URSING

OME

LACEMENT AND

RIEF

Nursing homes (and assisted living facilities) rarely provide resources for fami-

lies to deal with the grief they are experiencing in having to make the decision to

institutionalize a family member, or to help older persons come to terms with the

necessary abandonment of the house in which they may have spent most of their

adult lives, raised their children, and enjoyed their relationship together. Al-

though professional resources are rare, Silin (2001) does provide guidelines for

families in dealing with the grief that accompanies making health care decisions

in the nursing home context. Casarett, Hirschman, and Henry (2001) note that as

patients approach death, their needs for hospice care in the context of the nursing

home increase, though such needs are different from those of community-based

hospice patients. Their shorter, more rapid death trajectory may make it difficult

to meet not only their needs for pain control, but also the family’s needs for end-

of-life care.

Keay (2002) notes that many staff are not trained in providing end-of-life care

to patients and families. Staff also experience grief and may need advocates in

taking an active role in planning and decision making, in addition to transferring

the older patient to a hospital in a timely manner, when death seems imminent.

Grief and Bereavement 383

Nursing home staff need to be better trained in listening and communication

skills in meeting the family’s needs.

In contrast to the attention paid to the family, we know little about the sense of

loss older persons themselves experience when they must give up personal pos-

sessions or part with friends and neighbors in order to move into a nursing home

(see Quadagno, 2002), or when a husband and wife are separated from one an-

other after having been institutionalized. As relocation effects are substantial in

their impact on both mortality and mental health via a breakdown in social sup-

port networks and enforced isolation (see George, 2006), it is likely that grief,

which accompanies the perceived irreplaceable loss of one’s health and independ-

ence with admission to a long-term care facility, accounts for at least some impact

on health and mortality among older persons relocating to nursing homes.

LZHEIMER

’

ISEASE

Perhaps more relevant to institutional care is grief associated with the reasons

one is likely to need such care in the first place. In this respect, Alzheimer’s dis-

ease (AD), regarded as a terminal illness by the Alzheimer’s Association, is asso-

ciated with a series of adjustments by both the older person and his or her family

and friends to the loss of the ability to care for oneself and cognitive and physi-

cal/health-related changes that are progressive in nature (Welsh-Bohmer & War-

ren, 2006); it is often preceded by a prolonged period of mild cognitive

impairment (Peterson, 2003). For Alzheimer’s patients and their families and

caregivers, grief is characterized by progressive degrees of reactions to loss as the

patient’s condition worsens. Caregivers must cope with what has been termed

ambiguous loss (Boss, 1999): Their loved one is physically present and still living,

and yet in other ways has died. In this respect, the grief that family members feel

is both ambiguous and anticipatory (see Meuser & Marwit, 2001) in nature. Mar-

wit and Meuser (2002) note the paucity of research on the grief that AD care-

givers experience, and identify diversity in grief reactions as the dominant

characteristic of AD caregiver grief. Such grief is influenced by (a) the caregiver’s

relationship to the patient (spouse, child); (b) caregiver sex; (c) the domain rele-

vant to loss (e.g., loss of the relationship per se, communicative difficulties); (d)

whether home care or nursing home care was provided; (e) whether anger, sad-

ness, depression, or guilt were reported as the dominant emotion; and (f) whether

social support and anticipatory grief were experienced prior to death. All of

these factors influenced postdeath adjustment (Meuser & Marwit, 2001).

Perhaps what differentiates the grief associated with AD is that persons even-

tually no longer resemble—physically, emotionally, cognitively, or interperson-

ally—the person they were prior to diagnosis. Indeed, many spouses grieve long

before death occurs, describing this process as an “endless funeral” (T. Brown &

Kleist, 1999). Alzheimer’s patients may not recognize family members, recall im-

portant events bonding them to spouse or children, or remember who they them-

selves are. Being repeatedly exposed to such changes in a loved one brings about

what caregivers label “chronic sorrow” (Mayer, 2001).

In coping with the progressive loss of the person they once knew, caregivers

and family must give up previously established ways of relating to and communi-

cating with the family member afflicted with AD, deal with a loss of intimacy,

and yet be aware of the impact of grief on what is now a redefined relationship

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with a demented family member; it is for this reason that AD has been likened to

the “long goodbye” by the Alzheimer’s Association. Key to understanding such

grief reactions is the necessity for both Alzheimer’s victims and their families to

reconstruct who they are and their relationships to others (Robinson, Clare, &

Evans, 2005). Such reframing is associated with better postdeath adjustment

among caregivers (Boerner, Schultz, & Horowitz, 2004). Moreover, such benefits

are greater if both caregivers and AD patients, to the extent possible, actively par-

ticipate in efforts to learn about the disease and allow for the expression of sad-

ness, regret, anger, or guilt, all of which are common components of the response

to loss (see S. Sanders & Sharp, 2004). To the extent that Alzheimer’s patients may

ultimately require hospice care, attending to the emotional and psychosocial ad-

justments associated with dying are completely congruent with hospice philoso-

phy, which involves treating the patient and family as a unit, emphasizing quality

of life, and continued attention to issues of grief both before and after the patient

dies (Hayslip & Hansson, in press).

IMPLICATIONS FOR SERVICES, SUPPORT,

AND COUNSELING INTERVENTIONS

Most bereaved persons (including the elderly bereaved) do not experience a trau-

matic or unduly complicated grief experience. Many, however, will experience a

devastating degree of emotional and physical distress, requiring adaptation. As

we have noted, some suffer prolonged health outcomes, for example, in cases

where the bereavement exacerbates preexisting conditions or disease process,

with the potential to contribute to the disablement process. In later life, a conju-

gal bereavement may also disrupt one’s economic security and social support net-

work and for some period of time may increase isolation, loneliness, and the

capacity to live independently. There are, therefore, implied consequences and

costs to society, as some older bereaved persons begin to require more support,

more specialized (perhaps medical) care, and possibly some form of housing sup-

port (Hansson & Stroebe, 2003).

Recent reviews of the bereavement treatment literature have now concluded

that interventions aimed at reducing grief and related symptoms are not univer-

sally helpful (Jordan & Neimeyer, 2003; Schut, Stroebe, van den Bout, & Ter-

heggen, 2001). For example, Schut et al. reviewed the efficacy studies in three

categories of intervention. The first of these involved primary preventive interven-

tions, in which all persons who had experienced a death received some form of in-

tervention (e.g., crisis counseling, telephone outreach, inclusion in self-help or

therapy groups). The second category involved secondary preventive interventions,

directed toward bereaved individuals considered to be at high risk because they

have insufficient social support or had experienced a traumatic death, had lost a

child, or were experiencing other stressors concurrent to the bereavement. Sec-

ondary interventions included counseling, practical or emotional support, and

mutual help groups. The third category, termed tertiary preventive intervention, fo-

cused on individuals experiencing a complicated or morbid grief or diagnosed

with a bereavement-related psychopathology, and involved a variety of guided

mourning techniques, flooding, desensitization, religious-oriented therapy, be-

havior therapy, and dynamic therapy.

Grief and Bereavement 385

An overall conclusion from the review by Schut and colleagues (2001) was that

the potential utility of interventions to reduce grief-related symptoms appears to

depend on the severity of one’s grief experience. Formal interventions were usu-

ally not helpful when provided to bereaved persons who had not indicated a need

or who did not exhibit any compelling risk factors (i.e., the primary preventive in-

tervention studies), and sometimes were actually associated with increased

symptoms. Similarly, interventions appeared useful only for some bereaved per-

sons selected on the basis of known risk factors (the secondary preventive inter-

vention studies). Only among bereaved persons already exhibiting a complicated

grief or an especially serious bereavement-related outcome (e.g., depressive dis-

order) did therapeutic intervention appear consistently useful (the tertiary pre-

ventive interventions).

A variety of explanations have been proposed for this pattern of efficacy find-

ings. For example, in uncomplicated bereavements (the most frequent category),

coping and adaptation are naturally occurring processes; bereaved controls in

these studies tend to experience a reduction in symptoms over the period of the

study. In the primary and secondary preventive intervention studies, bereaved re-

spondents tend not to be self-referred, but rather are recruited into the research.

It is thus difficult to interpret degree of motivation or need for the intervention.

Finally, delays incurred postdeath in the process of recruiting bereaved respon-

dents for primary and secondary intervention studies mean that these interven-

tions will likely occur later in the course of one’s bereavement, after symptoms

have already begun to recede in response to any coping or adaptation efforts (Jor-

dan & Neimeyer, 2003; Schut et al., 2001).

OALS FOR

NTERVENTION WITH

LDER

EREAVED

ERSONS

Our sense from the research is that in most cases, interventions with older be-

reaved persons will not need to focus primarily on reduction of grief symptoms.

Interventions will be less likely, therefore, to involve formal therapy protocols.

Consistent with recent thinking about geropsychotherapy generally, interven-

tions should probably focus instead on more flexible goals for adaptation, life sat-

isfaction, and social functioning (Arean et al., 2003). From this perspective, goals

would emphasize the management of symptoms and the rehabilitation of func-

tioning, rather than reductions in grief (Hansson & Stroebe, 2003). An emphasis

would be placed on protecting the older bereaved person’s existing strengths and

resources and preventing any disabling consequences of the bereavement (APA

Working Group on the Older Adult, 1998; Jette, 1996; Schulz & Martire, 1998). An

additional theme from the intervention research with older adults is a need to

consider a wider range of potential targets for intervention. The bereavement in-

tervention literature we have cited, for example, tends to focus on the bereaved

individual as the target of intervention, and then measures degree of resolved

grief (Jordan & Neimeyer, 2003; Schut et al., 2001). In addition, we advocate

greater attention to the variability in grief reactions across persons, relationships

types, death trajectories, and environmental contexts.

It is important for the care community to identify for treatment those older be-

reaved persons who are at higher risk because of dispositional or contextual vul-

nerabilities or a difficult psychiatric history or who may have experienced a