Most people emerge from the natural grieving process in a healthy manner. However, many people do not receive the support they need to overcome the pain of mourning. They feel they are trapped in their grief-feelings which later surface as the underlying cause of physical and mental problems. For these people mental health treatment is their way back to a healthy life.
Morbid grief has been referred to in the literature as complicated grief, unresolved or exaggerated grief, or pathological grief.
Morbid grief reactions can be defined in different ways: by depth of despair or reaction and time. Morbid grief reactions that are defined by time include those situations in which the survivor has not been able to adapt to the loss, has had an exaggerated or prolonged grief response, has not been able to modify his or her self-image around the loss, and has remained rooted in the death experience with depression and anger (Kastenbaum, 2001; Worden, 2002). The level of despair that signals morbid grief may be unrelated to time; this aspect of morbid grief is defined as a constellation of symptoms (Lindemann, 1944).
The classic work on morbid grief was written by Erich Lindemann (1944), a psychiatrist who observed the bereavement behaviors of 101 patients during a series of psychiatric interviews in a clinic that he had set up following a fire in the Coconut Grove nightclub in Boston. He concluded that there were five characteristics of those suffering with normal grief: somatic distress, preoccupations with the image of the deceased, guilt, hostile reactions, and loss of patterns of conduct. A sixth reaction, seen in those bordering on morbid or pathological grief, is the appearance of traits of the deceased in the behavior of the bereaved. He stressed that successful completion of bereavement involved grief work aimed at helping the bereaved adjust to the environment without the deceased and give expression to the pain of the loss.
Morbid grief is a distortion of normal grief with symptoms that include overactivity without a sense of loss which may include expansiveness and replication of the behaviors of the deceased; the acquisition of behaviors related to the illness of the deceased; a recognized medical disease with a psychosomatic origin; a major alteration in relationships to friends and relatives with avoidance of social interactions; lack of interest and critical attitudes; furious hostility against specific persons; wooden and formal appearance which often covers the hostility; loss of patterns of social interaction; actions detrimental to one’s own social and economic existence; and agitated depression with tension, insomnia, feelings of worthlessness, bitter self-accusation, and punishment (Lindemann, 1944).
One of the issues that affects the family system is the increase in the elderly bereaved population. While the maximum age for human beings has not increased significantly in recent time, the number of people living into their 70s and 80s has grown and will continue to grow into the 21st Century. With this increase comes a larger number of elderly who have experienced bereavement, especially the loss of a spouse. Widowhood affects three out of four women. (In 1998 there were 7.8 million widowed women age 65 and older in the United States and 1.5 million widowed elderly men.) Although the mourning process is shaped by mediators, several features of grief in the elderly deserve to be noted.
Interdependence. Many elderly widows and widowers had been married for a long time, leading to deep attachments and to the entrenchment of family roles. There is interdependence in any marriage. However, in these lengthy marriages, it is possible that the spouses were highly dependent upon one another. Parkes observes that the person who died is often the one who previously had helped the bereaved person handle a crisis. Therefore, the bereaved frequently find themselves turning to someone who is not there (Parkes, 1993).
Multiple Losses. With age, the number of deaths of friends and family members increases. This increased number of losses in a brief period can cause a person to be overwhelmed and possibly not to grieve. Concurrent with the losses of friends, relatives, and family members, are other losses the aging person may experience. These can include the loss of occupation, loss of environment, loss of family constellations, loss of physical vigor, including physical disabilities, the diminishing of one’s senses, and for some, the loss of cerebral functioning. All of these changes, added to losses through death, need to be grieved. But the ability one has to grieve may be lessened because of many losses in an abbreviated time period.
Personal Death Awareness. Experiencing loss of contemporaries such as a spouse, friends, or siblings, may heighten one’s personal death awareness. This increase in the awareness of personal mortality can lead to existential anxiety (Worden, 1976). Counselors need to be comfortable discussing the bereaved’s personal sense of mortality and to explore the extent to which this death awareness might be troublesome.
Loneliness. Many bereaved elderly live alone. A study done by Lopatta showed that younger widows and widowers were more likely to move after the loss, whereas older ones were more likely to remain in the home they lived in at the time of the death (Lopatta, 1996). Living alone can lead to intense feelings of loneliness, particularly intensified by living alone in the same physical surroundings shared with the spouse. There is some evidence that those who had more harmonious marriages experience the most loneliness (Grimby, 1993). Some elderly cannot continue to live alone after the death of a spouse and may require institutional care. There is anecdotal evidence to support the fact that elderly people who are forced to move out of their homes after losing a spouse may be at higher risk for mortality.
Role Adjustment. For elderly men, the loss of a spouse and its effect on day-to-day living may be more disruptive than for women. Many men face new roles, particularly homemaking, and may need help adjusting to these roles. When a woman loses her husband, there often is not the same level of disruption in terms of her ability to keep house and her self-reliance as a homemaker. There are certain counseling interventions such as skill building that can be useful when working with the elderly bereaved, especially men.
Support Groups. Support groups for the bereaved can be useful at any age, but it is particularly important for elderly persons, whose network of support is often diminished and whose isolation is often pronounced. Support groups can offer important human contact to those who are experiencing high levels of loneliness. In one study, Lund and colleagues (1985) discovered that both elderly men and women would be willing to participate in support groups. The most eager to participate in a support group were those whose confidant was less available than previously, those with more depression and less life satisfaction, and those who perceived that they were not coping well. There was also more willingness on the part of elderly in the age group 50 to 69 to participate in groups than for those of more advanced age. One should note that perception of support both before and after the death may be more important in assessing support satisfaction than objectively measured social network characteristics (Feld & George, 1994).
Touch. Another useful intervention is touch. Many men and women, but particularly men, who’ve been married for a long time and then lose their spouse, have a strong need to be touched. Without their spouse they may find it difficult to get this need met. A counselor who is comfortable with physical contact can include touching in working with the elderly bereaved. However, any time touch is used therapeutically, the counselor must be clear as to its suitability and must also attend to whether or not the person is willing or ready to be touched.
Reminiscing. Another intervention technique is reminiscing, something that is common among the elderly and can be stimulated therapeutically in an elderly bereaved population. Reminiscing is sometimes called life review. It is a naturally occurring process that brings the person to a progressive return to consciousness of past experiences and, in particular, to the resurgence of unresolved conflicts. It is generally assumed that reminiscing serves an adaptational function for the aging person and that it is not a sign of intellectual decline.
Siblings can often serve as a major resource for life review because they may be the longest-lived relationship for an elderly person. However, the older one becomes the less likely siblings will also be alive (Hays, et al., 1997).
Reminiscing contributes to the maintenance of identity. Even though a person may have lost loved ones, the mental representations of these people endure. Through the process of reminiscing, the past can be reworked. The counselor can encourage the client to reminisce and in doing so, this can have a salutary effect, particularly with conjugal bereavement. Elderly persons never truly lose the deceased, since so much of what the deceased represented is internalized and significant in the present (Moss, Moss, & Hansson, 2001).
Discussing Relocation. The counselor can help elderly persons decide whether they should move from their home. This decision, of course, depends on the ability of the person to take care of him or herself. However, one should never underestimate the importance of a home, where the bereaved may have lived for a long time and which may represent a whole scrapbook of meanings for the older person. To move from the house may reduce a person’s sense of self as well as dilute the tie with the deceased spouse. Being able to remain in their home give elderly people a sense of personal control and offers an arena in which they can recall the cherished past.
Skill Building. It is possible for some of the bereaved elderly to become too dependent on their adult children. Though bereaved, these people have the capacity to develop new skills and, in doing so, can reap the sense of self-esteem that comes through mastery. One bereaved elderly woman called her adult children continually and wanted them to come to her home to fix things, such as the furnace, even when these repairs were needed in the middle of the night. The children were happy to do this for a while, but it became clear to them that their mother needed to learn to call the electrician and to take care of those things that, prior to the death, her husband would have handled. She was very resistant to the suggestion and felt like her children were rejecting her. However, reason finally prevailed, and when she did learn how to handle some of these day-to-day activities, she felt good that she had developed some of these skills. The counselor needs to keep in mind that mastery and self-esteem go together, and this is true for the elderly and the elderly bereaved. However, time for adjustment may be required. Parkes reminds us that both grieving and relearning take time, so a period of “dependency” on others may be required to help elderly persons through this period of transition (Parkes, 1993).
In any discussion of the bereaved elderly it is important to keep in mind that research has shown that stresses experienced by these bereaved may be stronger prior to the death than afterward. This is particularly the case when one has been the primary caretaker of a sick spouse. If this is true, then one might want to begin interventions early and not wait until after the death has occurred.
While most of the focus in this discussion of elderly bereavement has been on spousal loss, other family deaths are also frequently experienced. Among these are the deaths of siblings and the deaths of grandchildren. In the latter case bereavement support is often focused on the bereaved parents to the exclusion of the grandparent’s grief.
It is important not to assume that all elderly bereaved are in need of counseling.
Besides, there is particular concern for elderly pet owners and their bereavement. Loss and sequential bereavement is a prevailing theme in the lives of the elderly. By old age, most have lost parents, spouses, siblings, friends, and children to death. Their physical strength, stamina, and mobility may have been compromised. If they are retired, a piece of their identity has been lost along with the routines associated with work. Many elderly live alone. In view of these losses, commonly associated with advancing age, it is not surprising that many older people develop profoundly deep relationships with their pets.
Loving and caring for a pet allows the older person to feel connected to and companionable with another, to feel unconditional and consistent love, and to feel touched by another both physically and emotionally. The constant proximity offered by a pet, with the pet staying by the owner′s side day and night, is a source of great comfort (Sable, 1995).
Ross and Baron-Sorensen (1998) pointed out that an elderly person′s ability to work successfully through the grief over the death of a pet might be inhibited by a diminishing support system. Not only may there be fewer people in an elderly person’s day-to-day life but, also, many people may not respond supportively to the death of a pet. In addition, elderly people may not be aware of existing support services or may not be able to afford or be able to travel to obtain such services to help them adjust to their bereavement situation.
The greatest concern for profound bereavement reactions is for the elderly pet owner who lives alone. The social isolation of the elderly person′s life and the dependency on his or her pet as a companion puts him or her at highest risk for complicated and pathological bereavement reactions.
The use of dance, song, and visual arts in religious and magical ways to cure physical or emotional ills dates back to antiquity. Aristotle recognized the value of dramatic play for relaxation “as a medicine” and noted the value of tragedy as catharsis because it allows for the “purgation of emotion” (Courtney, 1968, p. 10), and Greek tragedies encouraged the expression of such emotions as pity and fear as the actors identified with characters.
During the twentieth century there has been dramatic growth in and acceptance of the use of creative arts or expressive therapy with the sick. Creative arts therapies are closely allied with and have been greatly influenced by psychoanalysis, humanistic psychoanalysis, and humanistic psychology. The therapeutic value of the drawing or painting of dreams, which are experienced as visual images and difficult to express in words, was recognized by both Freud (1955) and Jung (1964).
The arts allow for creative expression, development of personal insight, and self-awareness. Similarly, spontaneity, flexibility, and originality resulting from the creative process are encouraged through the use of creative therapies. Art, whether in music, visual media, drama, or dance, is naturally therapeutic. Often, the creative process enables persons to uncover aspects of the self that are blocked from conscious sight. The arts provide a means of expanding the consciousness, of naturally becoming more aware of the self, particularly of the connection between mind and body. It forces persons to become more in personal tune with their senses (sight, hearing, and touch) and bodies. The arts also provide a means to achieve identity. The search for identity, the sense of who one is and where one stands, has always led to music, art, and drama.
Many therapists have effectively used the visual arts as therapy with the elderly. Art therapy has proven to be particularly effective for persons experiencing chronic pain. The expression of pain and the accompanying feelings of anger, rage, guilt, or sorrow through artwork permits catharsis and leads to successful management of the feeling (Landgarten, 1981). Art work is one method of working through feelings of depression for older adults. Art work expressing feelings can be shared and discussed with positive results. Individuals can obtain therapeutic benefits by examining their own feelings and emotions as expressed in concrete form in art works.
Practitioners have used music therapy effectively with the elderly. Music therapy has been used with older participants as an outlet for creative expression, as a vehicle to invoke powerful emotions, and as an aid in grief work and in dealing with the experience of death and dying. Music encourages group participation. Alleviation of feelings of loneliness, hopelessness, depression, and despair in elderly participants has been reported (Bright, 1985).
Music therapy has been used to treat a number of different problems of elderly clients. It has been used effectively with aging residents in longterm care facilities to help alleviate depression and stress. Exposure to player piano music resulted in improved life satisfaction and feelings of well-being for elderly subjects. The role of music in combating the loneliness, isolation, and depression of older people has been emphasized by R. Bright (1985). Music is useful in psychotherapy with the old. Through its strong powers of association and memory-evoking properties, music can help to bring past and present feelings and emotions to the surface so they can be expressed and therapeutically explored.
As a therapeutic technique, creative dramatics has its roots in dramatic play and is closely related to psychodrama. Psychodrama grew out of Jacob Moreno’s (1934) experience with Viennese children at play. Derived from the Greek terms psyche, meaning “mind or soul,” and dramein, meaning “to do or to act,” psychodrama refers to the doing or acting of thoughts and emotions through speech, gestures, and movement (Duke, 1974). In psychodrama individuals play roles and create parts; the emphasis is on spontaneity, creativity, action, process, self-disclosure, risk taking, and the here and now. The individual acts out unconscious thoughts, feelings, and impulses to recapitulate unsolved problems and experience catharsis. The group drama encourages empathy as the players identify with one another. Like psychodrama, creative expression of thoughts, feelings and emotions are encouraged through verbal and non-verbal means of communication.
In the last decade, creative dramatics has been used increasingly with older persons. From data she collected on the effects of drama on the elderly, P. Gray (1974) cites the following as major benefits: opportunity to be of service to others, increased self-confidence resulting from successful memorization and good performance, communication and social interaction skills developed through the group experience, and the emotional outlet provided by the experience. It was proved that those who engage in the drama activities undoubtedly see themselves as younger than those who do not.
Dance as a form of therapeutic intervention has its basis in the development of modern dance and has been used successfully with older adults. S. Zandt and L. Lorenzen (1985), who have used dance with seniors, found that dance helped people relax, reduced stress, and provided tranquility. Older dancers said they felt less lonely, less depressed, and more self-assured as a result of their dancing. S. Zandt and L. Lorenzen used movement sequences that employ rhythmic use of swings, twists, stretches, pulls, and pushes to meet physical needs and stimulate somatic and psychological feelings of comfort, ease, and humor in elderly subjects. It can be concluded that dance/movement therapy with elderly clients can be an enlightening experience that can inspire the therapist and clients to face life and death with love and energy.
Therapeutic Values of Creative Arts Therapy
Creative arts offer the older adult choice. In creative art activities the individual chooses the medium (clay, wood, and fibers), chooses the colors and textures, chooses what to make and how to make it. The art object is personalized. Dance and drama activities also offer opportunities for individual expression. The individual decides what to say or do and in what manner. Choice builds pride, confidence, self-esteem, and a sense of control to offset the negative psychological effects of loss. Through participating in creative activities older adults come to view themselves as active, vital, useful human beings.
The arts are inspirational, infusing the older adult with spirit and zest for life and hope for the future. Creative therapy is a valuable means of releasing fear and doubt, guilt and grief, and decreasing hopelessness, emotions that plague many potentially suicidal elderly individuals. Creative therapy provides a positive experience of participation in a social group, with accompanying feelings of acceptance and belonging, self-esteem and self-concept, and personal competence, mastery, and accomplishment. As such, the arts represent a major technique for reducing suicidal risk in older adults.
Support group therapy
Support group therapy, which was already mentioned before, is one therapy that can effectively reduce depression and suicidal behavior in older individuals. Social support encompasses interpersonal communication and interaction, protective feedback, love and understanding, caring and concern, affection and companionship, financial assistance, respect, and acceptance. Social support is usually provided by family members and kin, close friends, and neighbors. Such support can also be provided by a support group composed of individuals who are facing the same problems and have the same needs and concerns.
Therapeutic Values of Support Groups
The principle of mutual aid or joint struggle against common problems underlies the development of mutual help or support groups. Support groups are patterned after the family or small community and are expressive in nature. They offer members understanding and acceptance as unique personalities with both good and bad qualities, with both strengths and weaknesses. They offer a place where emotions can be freely expressed and where recognition, status, and security are offered. Most support groups are established by and for individuals who are stigmatized, either for a short time or permanently (Traunstein & Steinman, 1973). For example, widows may feel they are “misfits,” “marginals,” or “fifth wheels” in a couple-oriented society. The very word widow has negative connotations and carries a stigma for many women. In a support group, these individuals can find acceptance among others suffering the same plight. When everyone shares the same stigma, one finds acceptance, and feelings of isolation and marginality are reduced.
In a support group, the members (1) learn by their participation in developing and evaluating a social microcosm, (2) learn by giving and receiving feedback, (3) have the unique opportunity to be both helpers and helpees, and (4) learn by the consensual validation of multiple perspectives (Bednar & Kaul, 1978).
Types of Support Groups
In the last decade the popularity of support groups has greatly increased. Currently, support groups exist for widows and widowers, Alzheimer’s victims and their family caregivers, cancer patients, heart patients, persons with arthritis, and depressed elderly dealing with the problems of grief, loss, and aging. Those working with support groups have noted the many positive effects of such groups on the elderly. Burnside (1988) has described her success with groups of grievers, indicating that such groups help the members by facilitating adjustment to the loss of a spouse and preventing subsequent problems.
B. T. Moeller Petty, and R. Campbell (1976) organized support groups for elderly persons with arthritis. Most of the individuals were experiencing moderate depression in adjusting to the aging process. Participation in a support group decreased feelings of loneliness, depression, and unhappiness, increased knowledge of physical functioning, and resulted in better communication with family and friends and a desire to be more actively involved in life. The members also came to feel that their frustration and problems were “normal” and a part of aging. They made new friends and learned how to use community resources more effectively through their participation in the group. S. Hiltz (1977), who started a program for widows in 1970, reported positive effects. Weekly discussion groups were successful in alleviating feelings of loneliness and providing assurance that the widow was not unique, that others faced similar challenges. Members of the groups cited emotional support as the major benefit obtained from participation. Someone to listen and give sympathy were the benefits most valued by the widows.
Older adults in the community and in institutions can profit from involvement in support groups of all types. Clinicians working with depressed residents in institutions will find support groups a valuable adjunct to therapy. The recently bereaved, those suffering from a particular physical condition such as arthritis, those dealing with the loss of physical function or mobility, and residents who have recently moved in and are experiencing difficulty adjusting to their new environment could all benefit from participation in a support group.
Characteristics of support groups are a consideration. Based on his experience with groups, Lowy (1967) cited three important factors in effective group work: authority, structure and language, and sharing common symbols and meanings. The group’s structure must provide a basis for relating and accomplishing group goals. A format or standard procedure and use of a common language will serve to provide this structure. By including authorative research and sharing of emotions and feelings, the group becomes a support system that provides new ways of thinking about issues.
The role of nursing in group work with the elderly has been well documented by Burnside (1988) and others in the discipline of nursing. Group therapy is the treatment of choice in many cases, and “the testing of the efficacy of working with groups of elders is left for the most part to nurses” (Ebersole, 1976, p. 184). Success in group work can be measured in part by decreased interpersonal friction, personal isolation, and a noticeable change in affect (Ebersole, 1976, p. 184). Interventions such as counseling, group activities, and physiologic assessment are well within the skill repertoire of the clinician and advanced practitioner in gerontologic nursing.
Family Versus Individual Needs
Before concluding, there are two points I want to emphasize. First, it is important to recognize that not everyone in a family will be working on the same tasks of mourning at the same time. Individual family members will process tasks at their own rate and in their own way. For example, it may be that bereavement in the elderly takes a long time, and to some extent, it may not have an end point. Miller and colleagues (1994) talk about a “timeless attachment” to the deceased. Some elderly, particularly the “old-old” may be at a stage in their lives where it is best for them to consolidate their memories and draw on them for sustenance throughout their remaining years.
Families need to be encouraged not to rush a person through the grief experience. I spoke recently with a woman whose father had died 4 months earlier. She was very upset with her mother for continuing to have long crying spells. I tried to help her see that this was a very natural thing and that, in time, her mother would probably cry less.
An important second point is that individual members of a family will sometimes be reluctant to come in for counseling with the entire group. But, even when met with resistance, it is important for the counselor to try and include the entire family in the sessions. When the counselor can assess the feelings of all the family members, the probability is greater that the grief counseling will be effective and that equilibrium will be restored to the family unit.
If family members are reluctant to attend, the counselor can still work with an individual using a family systems approach. Bloch (1991) reminds us that the issue is not the number of people in the counseling room but whether the counselor helps the client to understand family dynamics so that they can transmit this to other relevant members of the system.
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