کار سوگ و داغداری، آشکارسازی و مشاوره: آیا اینها به بازماندگان کمک کند؟

Abstract Bereavement is associated with increased risk of morbidity and mortality. How to protect the bereaved against extreme suffering and lasting health impairment remains a central research issue. It has been widely accepted that to adjust, the bereaved have to confront and express intense emotions accompanying their loss. It has further been assumed that others assist in this process, and that intervention programs are effective. To assess validity of these assumptions, this article reviews research on the impact of expressing and sharing emotions across four research domains (social support; emotional disclosure; experimentally induced emotional disclosure; and grief intervention). In none of these areas is there evidence that emotional disclosure facilitates adjustment to loss in normal bereavement. Implications of these findings are discussed. Suffering the loss of a loved one is a tragedy which is not only characterized by extended periods of anguish and pain, but it also increases risk of depression, physical illness and mortality (e.g., Parkes, 1972/1996 and Stroebe & Stroebe, 1987). However, even though loss of a loved one is generally painful, only a small minority of bereaved persons is likely to suffer enduring health impairment.1 The question how we can protect these bereaved from lasting detriments to their health has been a central issue in bereavement research. Since Freud's (1917) development of the concept of “grief work”, it has been generally accepted by bereavement researchers and practitioners alike that a healthy process of adjustment requires that the bereaved confront and express their feelings and reactions to the death of a loved one, and that failure to do so is maladaptive (for dissenting voices, see Bonannon & Kaltman, 1999, Silver & Wortman, 1980, Stroebe & Schut, 1999, Stroebe & Stroebe, 1991 and Wortman & Silver, 1989). This article questions assumptions that emotional disclosure (and “grief work”) facilitate coping with loss and accelerate adjustment, that support from others during bereavement ameliorates the impact of loss, and that intervention is generally efficacious in facilitating adjustment. The first part of this manuscript presents the theoretical rationale underlying the grief work hypothesis, delineates components of grief work in terms of meaning construction, and discusses the relationship between grief work and emotional disclosure. The second part reviews relevant empirical evidence on four related issues: (1) does social support facilitate adjustment? (2) Does emotional disclosure facilitate adjustment? (3) Does inducing emotional disclosure facilitate adjustment? (4) Do bereavement interventions facilitate adjustment? In reviewing research on these issues we focus mainly (but not exclusively) on marital bereavement, because the majority of studies on the health impact of loss has been conducted on the loss of a marital partner (Stroebe et al., 2001). However, since we are not assuming a qualitative difference between marital bereavement and other types of losses, we will draw on the general bereavement literature whenever relevant studies are available.

Conclusions The findings reviewed in this article challenge beliefs about grief work, emotional disclosure, and beneficial interventions that were considered truisms and as practically self-evident by bereavement researchers only a decade ago. The pattern of findings which emerges from our review is very consistent. Although the support of family and friends is positively associated with well-being among the bereaved, there is little evidence that social support moderates the impact of bereavement on psychological health and/or accelerates adjustment to the loss and this despite the fact that distress levels are rather high among the recently bereaved. Since we had assumed that the facilitation of emotional disclosure was one of the ways through which social support would facilitate coping with loss, the failure to find evidence that disclosure of emotions (whether natural or induced) facilitates adjustment to loss goes some way toward explaining why social support failed to enhance recovery from bereavement. We have argued that offering social support, encouraging emotional disclosure, and helping the bereaved to reframe or reinterpret the meaning of their loss experience are the main functions of bereavement counseling and therapy. The fact that grief counseling and therapy have not proved effective for individuals who were referred to counseling for no other reason than that they had suffered bereavement is also consistent with the general pattern of findings that emerged from our review. Primary preventive interventions are likely to reach the same type of bereaved individuals who are usually being recruited into bereavement research. Why do bereaved individuals with uncomplicated courses of grief fail to derive benefits from assistance with their grief work? According to findings from the Tübingen study (Stroebe et al., 1996), the most common emotional difficulty suffered by the bereaved is emotional loneliness: the missing of the deceased and the feeling of being utterly alone, even when in the company of friends and family. This finding is consistent with the theoretical reasoning of Weiss (1975) that the loneliness of emotional isolation appears in the absence of a close emotional attachment and can only be remedied by the integration of another emotional attachment or the reintegration of the one who has been lost. Obviously, the latter solution is not feasible in the case of bereavement. It is possible that this type of loneliness only abates with time and that nothing can be done to further the recovery process. There is evidence that losses which are sudden, unexpected and/or due to violence increase the likelihood of grief complications (Stroebe & Schut, 2001). By contrast, bereaved individuals with uncomplicated courses of grief will typically have suffered losses which were less traumatic. Thus, persons in the latter category may have had fewer difficulties in making sense of their loss, because their experience may somehow “fit” their mental models (e.g., following the expected, appropriate death of an elderly person following a life well-lived). Even losses that were unexpected may fit mental models if, for example, the life-style of the deceased increased the risk of an early death. Thus, even though the spouse of a deceased person who had been overweight and a heavy smoker may in retrospect be angry at him or her for not taking better care, the bereaved partner may not need any assistance in making sense of the loss. There are also individual differences in the vulnerability to bereavement complications. Attachment theory provides a useful framework for understanding different patterns of adjustment to loss (Parkes, 2001, Shaver & Tancredy, 2001 and Stroebe et al., in press). According to Bowlby (1980), how individuals react to loss depends on certain childhood experiences, in particular, on the pattern of parental attachment behavior. A secure base has to be provided for the infant by the attachment figure to enable development of a secure pattern of attachment. The child builds implicit mental models of relationships between self and others and develops schemas about how these relationships work. These working models are later used as guides for interpreting experiences and as ways of viewing the world. As Shaver and Tancredy (2001) explained, securely attached individuals can access attachment-related emotional memories without difficulty and discuss them coherently. In line with this pattern, they react emotionally to the loss of an important relationship partner but will not feel overwhelmed by grief. Securely attached individuals are therefore unlikely to suffer the complications associated with bereavement, unless they have undergone an unusually traumatic bereavement. Since they already confront and express their emotions to others, and are able to give coherent accounts of their experiences, they are less likely than insecurely attached individuals to be in need of, or to benefit from, grief intervention (Stroebe, Schut, & Stroebe, in press). Nevertheless, there are bereaved individuals who need help and who derive benefits from grief counseling and therapy. Most typically, these are individuals who have been unable to cope with their loss and for whom the grief reaction has in some way “gone wrong”. The term complicated grief is used to refer to grief reactions which show a marked deviation from the normal pattern and which are associated with maladjustment and psychiatric problems (Prigerson & Jacobs, 2001 and Stroebe et al., 2000). Grief counselors and therapists should focus their efforts on this subgroup of bereaved. Obviously, it would be important to identify these individuals early in the grieving process, before complications have developed. Risk factors for poor bereavement outcome are factors such as the traumatic nature of the death of the loved one, concurrent other stresses, previous psychiatric problems, insecure style of attachment, and initial high level of distress (Stroebe & Schut, 2001). Since there is evidence that initial high level of distress is one of the best predictors of the distress experience later (e.g., Stroebe & Stroebe, 1991), and since high levels of distress may also be a factor which motivates individuals to seek counseling or grief therapy, the need to seek out counseling may be another valid indicator that a person is at high risk for poor bereavement outcome. Although no single risk factor will ever allow us to predict grief complications with any degree of certainty, it would still increase the efficacy of grief counseling and therapy if potential interveners would reserve their services for those individuals who both request this type of help and show an accumulation of (risk-)factors that bereavement research has shown to be associated with an increased likelihood of grief complications (for a review, see Stroebe & Schut, 2001).