-an Psychological Association, Inc. 0033-2909/99/S3.00
Psychological Bulletin 1999, Vol. 125, No. 6, 760-776
Toward an Integrative Perspective on Bereavement George A. Bonanno and Stacey Kaltman Catholic University of America For nearly a century, bereavement theorists have assumed that recovery from loss requires a period of grief work in which the ultimate goal is the severing of the attachment bond to the deceased. Reviews appearing in the 1980s noted a surprising absence of empirical support for this view, thus leaving the bereavement field without a guiding theoretical base. In this article, the authors consider alternative perspectives on bereavement that are based on cognitive stress theory, attachment theory, the socialfunctional account of emotion, and trauma theory. They then elaborate on the most promising features of each theory in an attempt to develop an integrative framework to guide future research. The authors elucidate 4 fundamental components of the grieving process—context, meaning, representations of the lost relationship, and coping and emotion-regulation processes—and suggest ways in which these components may interact over the course of bereavement.
Coping With Loss." Although these challenges have not been without controversy (cf. M. S. Stroebe, van den Bout, & Schut, 1994), reviewers have increasingly acknowledged the limitations of the grief work approach (Bonanno, 1998, 1999a; Bonanno & Siddique, 1999; M. S. Stroebe, 1992; M. S. Stroebe & Stroebe, 1991). As a result, a considerable body of new bereavement research has been generated, guided primarily by theoretical perspectives that were originally developed to explain other psychological phenomena (e.g., emotions, attachment, etc.). In the present article, we evaluate the grief work approach as well as evidence relevant to application of the cognitive stress perspective, attachment theory, social-functional accounts of emotion, and the trauma perspective to bereavement. We then elaborate on the most relevant theoretical features from these approaches in an attempt to develop an integrative framework to guide subsequent bereavement research and theory. Specifically, we elucidate four primary aspects of the grieving process—the context of the loss, the continuum of subjective meanings associated with the loss, the changing representation of the lost relationship, and the role of coping and emotion-regulation processes— and consider how these different aspects may interact with each other over the course of grieving.
The death of a loved one is a ubiquitous human experience; most people, at some point in their lives, must confront the inevitable, and in many cases enduring, pain of interpersonal loss. Over the past century, a considerable body of literature has been generated to describe the phenomenology of the grieving process and the methods by which people might best cope with loss. Much of this literature owes a debt to Freud's (1917/1957) seminal article, "Mourning and Melancholia," in which he described the "work of mourning" as that of severing "attachment to the nonexistent object" (p. 166). In normal mourning, according to Freud, this work takes the form of repeated "reality testing," which gradually allows the ego to free its investment in the "lost object" (p. 163). Complicated or "pathological" mourning was seen as arising out of intense ambivalence that impeded this detachment process. Although Freud proposed these ideas with caution and was concerned primarily with the etiology of depression rather than grief, his views have dominated the bereavement literature over much of the past century. In recent years, the bereavement field has witnessed considerable conceptual and empirical ferment (Bonanno, 1999b). To some extent, this change may be attributed to the rapid influx of new ideas and research on the general nature of stress and trauma reactions. However, much of the impetus has come from within the bereavement field itself. W. Stroebe and Stroebe (1987) first called attention to the fact that, despite the widespread endorsement of the grief work view of mourning in the literature, there was little in the way of solid empirical evidence for such an approach. This stance was repeated more strongly several years later in Wortman and Silver's (1989) highly influential critique, "The Myths of
Methodological Considerations in Bereavement Research Before we begin this analysis, two methodological issues warrant consideration. First, bereavement researchers have used both cross-sectional and longitudinal designs. Cross-sectional designs do not allow for examination of predictor variables but have proved useful in identifying the phenomenological features and correlates of grieving at different points in the mourning process. Longitudinal designs, on the other hand, are limited by the minimal amount of experimental control they afford, but do allow for prospective assessment of predictor variables and generally offer increased ecological validity. In addition, longitudinal designs make it possible for researchers to address a number of different empirical questions from the same data set. This practice offers the advantage of multidimensional assessments (Bonanno, 1998, 1999b; Zisook & Shuchter, 1993) but also increases the likelihood
George A. Bonanno and Stacey Kaltman, Department of Psychology, Catholic University of America. This article was supported in part by Grant 1-R29-MH57274-01 from the National Institute of Mental Health. Correspondence concerning this article should be addressed to George A. Bonanno, who is now at the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, Box 218, 525 West 120th Street, New York, New York 10027. Electronic mail may be sent to
[email protected].
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AN INTEGRATIVE PERSPECTIVE ON BEREAVEMENT
of overreporting similar results. To facilitate evaluation of this concern at appropriate points in this article, we list recent longitudinal studies, their specific methodological details, and the individual research reports they have generated (see Table 1). A second issue is that bereavement studies have varied in their sampling and ascertainment methods, suggesting the potential for selection biases. It is generally agreed that the least biased, or most representative, bereaved samples are obtained by a random sampling of the surviving relatives listed on death certificates. Interestingly, however, random sampling of death certificates has tended to produce low acceptance rates; most of the studies that used this method recruited less than 50% of the bereaved people contacted (M. S. Stroebe & Stroebe, 1989). This is most probably explained by the sensitive nature of the mourning process and by the fact that recently bereaved individuals may have little reason to trust or share their private pain with anonymous researchers. By this same logic, acceptance rates should be considerably higher if a research study is vouched for by a trusted individual. Indeed, the highest acceptance rates have been generated by studies that contacted bereaved participants by means of personal referrals from religious groups, former participants, or medical professionals (M. S. Stroebe & Stroebe, 1989). This pattern appears to suggest that much of the empirical evidence on bereavement may be based on participants who are either unusually willing to participate or who are biased through their association with the referral source. One possible consequence of this scenario may be that, across studies, different types of sampling result in different levels of grief severity and, consequently, in different types of coping behaviors. However, the proportions of bereaved individuals exhibiting elevations in the primary symptoms associated with grief (e.g., depression, mortality, physical health) have been relatively consistent across studies (M. S. Stroebe & Stroebe, 1993; Windholtz, Marmar, & Horowitz, 1985; Wortman & Silver, 1989). More directly, M. S. Stroebe and Stroebe (1989) found that conjugally bereaved individuals who agreed to in-home interviews did not differ in overall levels of depression or somatic symptoms from demographically similar bereaved individuals who refused the interviews but agreed to complete questionnaires. The interview- and questionnaire-only participants were also similar in levels of autonomy, duration of marriage to the deceased, number of dependent children, and expectedness of the loss. However, the interview-only participants did report higher socioeconomic status and greater perceived social support and self-esteem than did the questionnaire-only participants. M. S. Stroebe and Stroebe also compared the questionnaire-only and total-refusal participants for their reasons for refusal and found no meaningful differences. Finally, Jacobs, Hansen, Berkman, Kasl, and Ostfeld (1989) found that conjugally bereaved individuals who agreed to participate in a phone interview did not differ from those who refused in terms of gender, the age of the deceased spouse, or the expectedness of the loss. However, the phone-interview participants were more likely to be White than the phone-interview refusers. Together, these findings suggest that different sampling methods may not produce biased samples with respect to grief severity but may bias the distribution of potential moderator variables (e.g., socioeconomic status, social support, race). We return to this issue at several points in later sections of this article.
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Grief Work: A Theory in Search of Data The association of bereavement with work can be traced to the phrase, the "work of mourning," coined by Freud (1917/1957) to describe the painful process of severing "attachment to the nonexistent object" (p. 166). In Freud's view, grieving was primarily a private, or intrapsychic process. Initially, Freud noted that the mourner clings to the lost object so intensely that "a turning away from reality ensues" (p. 154). With the passage of time, however, the mourner gradually reviews "each single one of the memories and hopes which bound the libido to the object" until "detachment of the libido from it [is] accomplished" (p. 154). Freud further speculated that in some cases the normal grieving process may be transformed into a "pathological variety" by "the conflict of ambivalence" (p. 161). In such cases, rather than engaging in the work of mourning, the bereaved survivor retains an unconscious identification with the lost object and, consequently, redirects negative feelings about the deceased or the loss inwardly in the form of depressive self-reproaches or guilt. Although Freud (1917/1957) put forth these speculations with great caution and was concerned primarily with elucidating his views about depression rather than mourning per se, the metaphor of the work of mourning was readily adopted by subsequent clinical theorists (cf. Deutsch, 1937; Lindemann, 1944). Over the ensuing decades, the bereavement literature evidenced an increasing emphasis on the importance of working through the thoughts and emotions associated with the lost relationship, with particular emphasis on negative material and on relinquishing the attachment bond to the deceased (Belitsky & Jacobs, 1986; Bowlby, 1980; Cerney & Buskirk, 1991; Lazare, 1989; Osterweis, Solomon, & Green, 1984; Raphael, 1983; Sanders, 1993). Perhaps the most intriguing aspect of the grief work perspective is that, despite its historic dominance of the bereavement literature, its basic tenets have yet to be upheld empirically (W. Stroebe & Stroebe, 1987; Wortman & Silver, 1989). Ten years ago, Wortman and Silver (1989) identified a number of unsupported, but widely accepted, myths about coping with loss, including the assumptions that working through grief is necessary and that most people recover from and fully resolve a loss. Indeed, Wortman and Silver (1989) concluded that not only was there "relatively little empirical evidence relevant to the issue of 'working through' " grief but that the available evidence actually suggested that "early signs of intense efforts to 'work through' may portend subsequent difficulties" (p. 352). M. S. Stroebe and colleagues (M. S. Stroebe, 1992; M. S. Stroebe et al., 1994) subsequently affirmed these conclusions, although they noted that the absence of clear operational definitions for the grief work assumptions made their empirical evaluation difficult. Despite this caveat, several recent studies have managed to directly examine facets of grief work. In an initial study, M. S. Stroebe and Stroebe (1991) assessed grief work behaviors using a prospective design and a small set of self-report and interview questions. Only a few of the grief work items were linked to long-term adjustment, and they applied only for the male participants, prompting M. S. Stroebe and Stroebe to conclude that "the view 'Everyone needs to do grief work' is an oversimplification" (p. 481). More recently, several studies from large-scale, longitudinal projects have directly contradicted predictions from the grief work perspective. Bonanno, Keltner, Holen, and Horowitz (1995)
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Table 1 Recent Studies Generating Multiple Research Reports Comparison sample
Parent study and individual research reports San Diego, CA: Conjugal loss Schneider, Sledge, Shuchter, and Zisook (in press) Shuchter and Zisook (1993)
350 350
None Married, matched for age, gender, duration of
Zisook, Chentsova-Dutton, and Shuchter (1998) Zisook, Paulus, Shuchter, and Judd (in press)
350 350
Zisook, Schneider, and Shuchter (1990) Zisook, Shuchter, et al. (1994)
350 21
Zisook and Shuchter (199la)
350
Zisook and Shuchter (1991b) Zisook and Shuchter (1993) Zisook, Shuchter, Sledge, Paulus, and Judd (1994)
350 259 350
None Married, matched for marriage None Married, matched for marriage Married, matched for marriage None None Married, matched for marriage
Design
Sampling method
Prospective Prospective
Death notices Death notices
age, gender, duration of
Cross-sectional Prospective
Death notices Death notices
age, gender, duration of
Prospective Prospective
Death notices Death notices
age, gender, duration of
Prospective
Death notices
age, gender, duration of
Prospective Prospective Prospective
Death notices Death notices Death notices
Prospective
Ad + referrals
Prospective
Ad + referrals
marriage
San Francisco: Gay men, partner loss Folkman (1997) Folkman, Chesney, Collette, Boccellari, and Cooke (1996) Moskowitz, Folkman, Collette, and Vittinghoff (1996) Nolen-Hoeksema, McBride, and Larson (1997) Pennebaker, Mayne, and Francis (1997) Richards and Folkman (1997) Stein, Folkman, Trabasso, and Christopher-Richards (1997) Weiss and Richards (1997) San Francisco: Conjugal loss Bonanno and Keltner (1997) Bonanno, Mihalecz, and LeJeune (1998) Bonanno, Keltner, Holen, and Horowitz (1995) Bonanno, Znoj, Siddique, and Horowitz (in press) Bonanno, Notarius, Gunzerath, Keltner, and Horowitz (1998) Capps and Bonanno (1998) Field, Bonanno, Williams, and Horowitz (in press) Horowitz et al. (1997) Keltner and Bonanno (1997) Kaltman and Bonanno (1999) Tubingen, Germany: Conjugal loss M. S. Stroebe and Stroebe (1989) M. S. Stroebe and Stroebe (1991) W. Stroebe and Stroebe (1993) W. Stroebe, Stroebe, Abakoumkin, and Schut (1996) Illinois and Michigan: Sudden loss of infant Downey, Silver, and Wortman (1990) Lepore, Silver, Wortman, and Wayment (1996) Mclntosh, Silver, and Wortman (1993) Michigan: Sudden loss of child or spouse Lehman, Davis, DeLongis, and Wortman (1993) Lehman, Ellard, and Wortman (1986) Lehman, Wortman, and Williams (1987) New Haven, CT: Conjugal loss Kim and Jacobs (1991) Jacobs, Hansen, Berkman, Kasl, and Ostfeld (1989) Jacobs et al. (1990)
110
Healthy (HIV-) gay men living with partner, sample differences not controlled Healthy (HIV—) gay men living with partner. sample differences not controlled Healthy (HIV—) gay men living with partner, sample differences not controlled None None None None
Prospective
Ad + referrals
Prospective Prospective Cross-sectional Prospective
Ad Ad Ad Ad
30
None
Prospective
Ad + referrals
38 67 42 42 52
None None None None Married, differences controlled statistically
Prospective Prospective Prospective Prospective Prospective
Ad Ad Ad Ad Ad
+ + + + +
referrals referrals referrals referrals referrals
44 89 90 38 87
None None None None None
Prospective Prospective Prospective Cross-sectional Cross-sectional
Ad Ad Ad Ad Ad
+ + + + +
referrals referrals referrals referrals referrals
Cross-sectional Prospective Prospective
Death notices Death notices Death notices
Prospective
Death notices
None None None
Prospective Prospective Prospective
Death notices Death notices Death notices
None Married or parents, matched for age, gender, income, education, number of children Married or parents, matched for age, gender, income, education, number of children
Cross-sectional Cross-sectional
Death notices Death notices
Cross-sectional
Death notices
None None None
Cross-sectional Cross-sectional Cross-sectional
Death notices Death notices Death notices
110 110 30 30 125 30
217 60 60
None None Married, matched for age, gender, socioeconomic status, number of children 60 • Married, matched for age, gender, socioeconomic status, number of children
124 169 124 94 94 80 25 111 102
+ + + +
referrals referrals referrals referrals
AN 1NTEGRATIVE PERSPECTIVE ON BEREAVEMENT examined the avoidance of grief work among recently conjugally bereaved participants by monitoring both their subjective distress and their autonomic arousal as they talked about their loss. Following previous studies, emotionally avoidant participants were defined as those who showed verbal-autonomic dissociation (Newton & Contrada, 1992); that is, they reported relatively low levels of subjective distress but at the same time showed considerable elevations in physiological arousal in response to the task of talking about the loss. The validity of the verbal-autonomic dissociation score as a measure of the reduced awareness of distress has been supported by studies linking it with repressive defensiveness (Asendorpf & Scherer, 1983; Newton & Contrada, 1992; Weinberger & Davidson, 1994; Weinberger, Schwartz, & Davidson, 1979) and with clinical ratings of the avoidance of emotional awareness (Bonanno et al., 1995). Importantly, and in contrast to the grief work assumption, verbal-autonomic dissociation was found to be most prevalent among bereaved individuals who showed the fewest overt grief symptoms across the first 25 months, even when initial levels of grief were statistically controlled (Bonanno et al., 1995; Bonanno, Znoj, Siddique, & Horowitz, in press). In another longitudinal study, Nolen-Hoeksema, McBride, and Larson (1997) coded bereaved gay men's narrative discourse about their loss for evidence of self-analysis, defined as the "participant's attempts to understand the loss and his own reaction to the loss" (p. 857). In contrast to the presumed importance of this process from a grief work perspective, bereavement-related selfanalysis predicted increased depression and reduced positive morale 1 year later, even when initial levels were statistically controlled. A number of additional studies have also provided data inconsistent with, or contrary to, the grief work approach. These data are reviewed as appropriate at later points in this article.
Applying General Psychological Perspectives to Bereavement The growing disenchantment with the grief work perspective has resulted in somewhat of a theoretical vacuum. Since the grief work perspective has so dominated the theoretical literature on bereavement (W. Stroebe & Stroebe, 1987), few alternative models of coping with loss have been developed (Bonanno, 1998). Recently, bereavement researchers have examined the grieving process through the lens of alternative theoretical perspectives that were originally developed to explain specific behavioral phenomena across a range of situational contexts. In this section, we consider several of such perspectives: cognitive stress theory, attachment theory, the social-functional account of emotion, and trauma theory. It stands to reason that each of these more generalized approaches will account for only a portion of the bereavement data. However, by the same token, their application to bereavement also offers straightforward operational definitions and more empirically testable hypotheses than were afforded by the grief work perspective. In this section, we review the empirical evidence relevant to several different features from each perspective and suggest avenues for future empirical investigation.
The Cognitive Stress Perspective Cognitive stress theory provides a systematic and theoretically coherent framework from which to consider difficult life events
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and their relationship to psychological and physical health. When applied to bereavement, cognitive stress theory affords a crucial distinction from the traditional grief work assumption. Whereas in the grief work concept, the death of a loved one is conceptualized uniformly as a severely difficult event that must be confronted and worked through, a cognitive stress perspective places its primary emphasis on the bereaved survivor's subjective evaluations of the difficulties surrounding the loss. Cognitive appraisal. In cognitive stress theory, an event is psychologically stressful only to the extent that it is "appraised by the person as taxing or exceeding his or her resources and endangering his or her well being" (Lazarus & Folkman, 1984, p. 19). Primary appraisals assess what is at stake in a given situation; that is, the degree to which the person may come to some harm or benefit. Secondary appraisals assess possible coping options to prevent harm or to improve the prospects for benefit. An application of the appraisal concept to bereavement indicates that the degree to which a loss is stressful depends almost exclusively on how it is evaluated by the bereaved survivor. In other words, a person may experience pain or sadness at the loss of a loved one but may not necessarily experience the loss as an enduring stressor. Support for the mediating role of cognitive appraisal in adjustment to loss was provided by several recent studies that used content analyses of verbal bereavement narratives. Stein, Folkman, Trabasso, and Christopher-Richards (1997) coded bereaved gay men's appraisals about the death of their partner in the first month after the loss. In contrast to traditional assumptions that grief is an almost exclusively negative state, positive appraisals (e.g., a positive attitude toward death, or a belief in self-growth from difficult events) were more common than negative appraisals. More important, positive appraisals were associated with improved morale, more positive states of mind, and less depression 12 months after the loss, and these associations remained significant when shortterm goals and plans and initial scores on the outcome measures were statistically controlled. In a similar study, Capps and Bonanno (1998) coded appraisals from middle-aged widows and widowers at the 6-month point in bereavement. Positive appraisals were again more common than negative appraisals. Further, although positive appraisals were unrelated to outcome, negative appraisals were associated with increased grief 25 months after the loss, as measured by clinical interviews, and this association remained significant when initial interviewer ratings of grief, perceived social support, and the quality of the conjugal relationship were controlled. Finally, Field, Bonanno, Williams, and Horowitz (in press) asked the same conjugally bereaved participants to engage in an imaginary "empty-chair" monologue with their deceased spouse, and then coded the monologues for appraisals of different types of blame. Appraisals of blame toward the deceased were associated with daily ratings of anger and with increased distress 6 months later. The latter effect remained significant when initial distress was controlled. Coping. When an event, or person-environment encounter, generates psychological stress, deliberate coping strategies are instigated. These strategies either alter the deployment of attention to or away from the source of distress (e.g., distancing), change the meaning of the situation (e.g., self-blame, optimism, positive reappraisal), or lead to behaviors that directly alter the nature of the person-environment encounter (e.g., seeking social support, escape-avoidance) (Folkman & Lazarus, 1990). Folkman,
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Chesney, Collette, Boccellari, and Cooke (1996) measured selfreported coping strategies among bereaved gay men who had cared for their dying partners. After initial increases in depressive mood following the partner's death were controlled for, levels of depression at 7 months postloss were predicted by prebereavement stressors (daily hassles) and by the prebereavement use of distancing and self-blame to cope with the burden of caregiving. Other reports from this same longitudinal study have documented additional associations between preloss and postloss coping and various forms of outcome (e.g., positive mood; Folkman, 1997; Moskowitz, Folkman, Collette, & Vittinghoff, 1996). It is worth noting, however, that the generalizability of these findings may have been limited by their exclusive reliance on retrospective self-report coping scales, which tend to oversample maladaptive strategies (Aldwin, Sutton, Chiara, & Spiro, 1996) and have shown only weak relationships with more immediate measures of coping (Bonanno et al., 1995; Placek, Smith, Espe, & Rafferty, 1994; Stone et al., 1998). The relative efficacy of a particular coping strategy depends on the person-environment encounter. An important implication of this idea for bereavement, in marked contrast to the grief work assumption, is that avoidant coping may potentially serve an adaptive function (Lazarus, 1985). In considering various coping strategies for bereavement, for instance, W. Stroebe and Stroebe (1987) concluded that "it would seem plausible that sedation or distraction should help to lessen the emotional impact of the loss" (p. 97). Similarly, Bonanno et al. (1995) advocated the potential efficacy of relaxation strategies and other coping tools that might allow bereaved individuals to "defer or minimize emotional processing of the loss" (p. 986). This more flexible view of cognitive or emotional avoidance is consistent with results reviewed earlier that linked verbal-autonomic response dissociation during bereavement with a less symptomatic grief course (Bonanno et al., 1995, in press). In a related finding, according to scores from structured clinical interviews for grief severity, repressive copers (individuals who reported low levels of anxiety but scored highly on an indirect measure of defensiveness) recovered from initial grief more quickly than did other bereaved participants (Bonanno, 1994).
the traditional grief work assumption. As noted earlier, Freud (1917/1957) speculated that the work of mourning is aimed primarily at the gradual severing of the attachment bond to the lost object, and this view has perpetuated, relatively unchanged, in subsequent writings about grief work (e.g., Raphael, 1983, p. 187). Somewhat ironically, Bowlby (1980), who is perhaps the most prominent attachment theorist identified with the grief work view, was distinguished from other grief work theorists in his late-career emphasis on the importance of a continued bond with the deceased. As Fraley and Shaver (1999) recently pointed out, in his later writings, Bowlby (1980) concluded that the pain of grief leads to a reshaping of internal representational models and a reorganization of the attachment configuration, both of which include the "persistence of the relationship" with the deceased.
The Attachment Perspective
Similarly, Klas, Silverman, and Nickman (1996) observed that
From the perspective of attachment theory, grief over the death of a close friend or relation is part of the natural repertoire of behavioral responses that evolved to foster proximity with and minimize separation from the object of attachment. Attachment behaviors emerge during infancy, when proximity to the caregiver favors survival. If separated from their caregiver, for instance, infants commonly show distress and protest responses—adaptive behaviors designed to hasten the search for, and return of, the caregiver. Because it is assumed that attachment behaviors are part of the human evolutionary inheritance, Bowlby (1963,1977, 1980) and others have extended the model of infant-caregiver attachment to understand intimate relations in adulthood. Grief over the death of a loved one during adulthood is thought to manifest initially as a protest response, followed by despair and disorganization at the realization that the deceased cannot return. Continuing bonds. Until recently, few investigators have considered the attachment perspective independently from its links to
As the first year of mourning draws on ... half or more of the widows and widowers reach a state of mind in which they retain a strong sense of the continued presence of their partner, (p. 96)
The adaptive value in retaining a continued attachment to the deceased, which Bowlby (1980) felt had "too long gone unrecognized" (p. 98), is evidenced most clearly in the sense of meaning and continuity of identity that such an enduring bond might afford. Whereas many bereavement investigators view an ongoing sense of the deceased's presence as bordering on pathological (Kim & Jacobs, 1991; Lazare, 1989), Bowlby noted that "for many widows and widowers it is precisely because they are willing for their feelings of attachment to the dead spouse to persist that their sense of identity is preserved and they become able to reorganize their lives along lines they find meaningful" (p. 98). More recently, Shuchter and Zisook (1993) have espoused a similar view, noting that the empirical reality is that people do not [italics in original] relinquish their ties to the deceased, withdraw their cathexes, or "let them go." What occurs for survivors is a transformation from what had been a relationship operating on several levels of actual, symbolic, internalized, and imaging relatedness to one in which the actual ("living and breathing") relationship has been lost, but the other forms remain or may even develop in more elaborate forms, (pp. 34)
remaining connected seemed to facilitate both adults' and children's ability to cope with loss and the accompanying changes in their lives. These "connections" provided solace, comfort, and support, and eased the transition from the past to the future, (pp. xvii-xviii)
The possibility of a continued relationship with the deceased is well-accepted outside the bounds of Western European cultures. Indeed, myriad anthropological accounts show that a continued bond with the deceased is common in most Asian, African, and Hispanic cultures (Bonanno, 1998, 1999b; Kastenbaum, 1995; Opoku, 1989). In Chinese ancestral worship, for instance, elaborate and precisely enacted ceremonies are devoted to honoring the continued relationship with deceased relatives (Ahern, 1973). Further, historical analyses suggest that the continued bond idea was once common at earlier periods in Western European societies (Bonanno, 1998; M. S. Stroebe, Gergen, Gergen, & Stroebe, 1992).
AN INTEGRATIVE PERSPECTIVE ON BEREAVEMENT
Finally, recent empirical studies have supported the continuedbonds hypothesis in the contemporary United States. Shuchter and Zisook (1993) found that 71% of the widows and widowers they interviewed during the first 2 months of bereavement felt that their deceased spouses were still with them at times and 61% felt that their deceased spouses were watching out for them. An additional 39% of the sample reported that they talked with their deceased spouses regularly. Bonanno, Mihalecz, and LeJeune (1998) coded core emotion themes from conjugally bereaved individuals' verbal descriptions of their lost relationship at the 6-month point in bereavement and found that over 80% of the participants described themes indicative of an enduring positive bond. Further, these themes were associated with reduced somatic complaints at later assessments, and these associations remained significant after controlling for initial symptoms and more objective evaluations of adjustment in the lost relationship. Ambivalence. When death occurs in the context of a normal or healthy attachment, it has been widely assumed that positive or idealized representations of the deceased serve the function of buffering the bereaved survivor from the pain of the loss (Putterman, Gallagher, Thompson, & Lovett, 1990; Lopata, 1979; Parkes & Weiss, 1983). In contrast, complicated bereavement has long been thought to result from an ambivalent attachment that "comes to the fore" (Freud, 1917/1957, p. 161) following the loved one's death and interferes with grief resolution (Bowlby, 1980; Freud, 1917/1957; Krupp, 1972; Lazare, 1989; Lindemann, 1944; Parkes & Weiss, 1983; Rando, 1993; Raphael, 1983; Sanders, 1993). In terms of the behavioral organization of the ambivalent attachment pattern, ambivalent adults both desire and reject the objects of their attachment, thus experiencing extreme distress at separations but also difficulty accepting resolution of separation episodes. When applied to bereavement, this hypothesis predicts that ambivalence toward the deceased in the early months after a loss will lead to prolonged or chronic grief reactions. Support for the ambivalence-prolongs-grief hypothesis has come exclusively from clinical anecdotes and observational studies. For example, on the sole basis of anecdotes provided by research participants, Parkes and Weiss (1983) concluded that "where the preceding marriage was ambivalent, we tended to see delayed grief and subsequent problems in recovery" (p. 132). The absence of more concrete empirical support for the ambivalenceprolongs-grief hypothesis may be due simply to the difficulties researchers have encountered in operationally defining the construct (Sincoff, 1990). Both interview assessments and questionnaire measures of ambivalence have been vague and unreliable. This may be explained in part because people are not able to reliably report on the existence of ambivalent feelings (Thompson & Zanna, 1995). In addition, Likert-type questionnaire items tend to confound ambivalence with indifference or indecision (Kaplan, 1972). Bonanno, Notarius, Gunzerath, Keltner, and Horowitz (1998) recently addressed these problems in the context of bereavement by adapting a strategy used in attitudinal research (Kaplan, 1972; Scott, 1966; Thompson & Zanna, 1995). Accordingly, they developed a questionnaire measure, the Semantic Representations of Others Scale (SROS), which asked respondents to evaluate the positive qualities of a specified person while ignoring his or her negative qualities and to separately evaluate the negative qualities of the same person while ignoring his or her positive qualities. The
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separate positive and negative ratings were then combined algorithmically into a single index of ambivalence such that extreme ratings in both the positive and the negative direction produced higher ambivalence scores. In support of the validity of the SROS, ambivalence toward spouses, whether deceased or alive, was inversely correlated with a standard measure of relationship adjustment, the Dyadic Adjustment Scale (DAS; Spanier, 1976), and positively correlated with interpersonal problems and neuroticism. Further, supporting Bowlby's (1980) reasoning that ambivalence during bereavement manifests as yearning for the deceased and then as anger at the thought of being abandoned, bereaved individuals with higher SROS ambivalence scores were more likely to show facial expressions of sadness followed by anger when they talked about their loss. When ambivalence toward deceased spouses, measured 6 months after the loss, was compared with grief-related outcome across 25 months of bereavement, clear support for the ambivalence-prolongs-grief hypothesis was not observed (Bonanno, Notarius, et al., 1998). Interestingly, however, the opposite predictive pattern was observed: The severity of the initial grief reaction predicted later increases in ambivalence, as well as later decreases in DAS scores. Further, these associations remained significant when the initial correlation between the variables was statistically controlled (Bonanno, Notarius, et al., 1998). In other words, regardless of how they initially represented the deceased or the lost relationship, participants who showed strong initial grief reactions tended to become more ambivalent about their deceased spouse and to remember the lost relationship as less well-adjusted over time. There are several possible explanations for these results. For instance, downgrading the lost relationship may be a way of minimizing its importance, thereby allowing severely grieved individuals a means of eventually extricating themselves from the pain of their enduring attachment. Alternatively, severely grieved individuals may become more aware of the negative aspects of the lost relationship over time because of state-dependent memory biases not unlike those observed in depression (Clark & Teasdale, 1982). It is hoped that further research will untangle these possibilities.
The Social-Functional Approach to Emotion Although grief is sometimes confused with emotion, closer examination reveals that the phenomenological properties of each are clearly distinct (for a detailed exposition of this point, see Bonanno, 1999c). Whereas grief unfolds slowly as a relatively long-term, multidimensional response to a specific and encompassing event (e.g., interpersonal loss), emotions manifest as rapid, fleeting, and organized response systems that mediate the individual's immediate situational needs. From a social-functional perspective, emotions mediate both intrapersonal functioning (e.g., emotions activate situation-specific behavioral patterns, such as the anger or flight responses, and coordinate experiential, behavioral, and physiological response systems) and interpersonal functioning (e.g., emotions communicate and evoke responses in others that help maintain the social order and intimate relationships; Barrett & Campos, 1987; Bonanno & Keltner, 1997; Darwin, 1872; Ekman, 1992; Keltner & Buswell, 1996; Levenson, 1994). Negative emotions. Emotion theorists have tended to distinguish the various negative emotions from one another by their
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short-term adaptive and functional relevance. Consider anger and sadness—two emotions commonly associated with bereavement. Although emotion theorists do not always agree on the precise function of these emotions, anger is generally assumed to externalize blame, mobilize resources, and help ward off attack by communicating a readiness to defend the self, whereas sadness is unrelated to blame, but fosters reflection, resignation, and acceptance, and evokes sympathy and helping responses in others (Izard, 1977, 1993; Lazarus, 1991; Stearns, 1993). It is reasonable to assume that anger and sadness also serve these short-term functions during bereavement. However, when negative emotions are enacted repeatedly or indiscriminately, they become less functionally relevant and tend to lead to untoward personal and social consequences (Keltner, Ellsworth, & Edwards, 1993; Keltner, Moffitt, & Stouthamer-Loeber, 1995; Lemerise & Dodge, 1993; Levenson & Gottman, 1983; Watson & Clark, 1984; Watson & Pennebaker, 1989). Persistent expressions of anger, for example, threaten to damage interpersonal relationships and undo social supports (Cole & Zahn-Waxier, 1992; Keltner et al., 1993). Similarly, prolonged sadness has been associated with withdrawal and despair as well as with the elicitation of rejection from others (Ellsworth & Smith, 1985; Lazarus, 1991). Bonanno and Keltner (1997) recently argued that theories of coping with loss need to more fully account for "the potentially adaptive role of reduced expression and experience of negative emotions" (p. 134). In explicit contrast to the traditional emphasis on working through negative grief-related emotions, they reasoned that the capacity to minimize negative emotions during bereavement makes it possible for a grieved person to continue to function in areas of personal importance, such as performing in the work place or caring for others (Shuchter & Zisook, 1993; W. Stroebe & Stroebe, 1987). In addition, they noted that the minimization of negative emotions frees up resources for problem-focused coping and thereby can facilitate adaptation to the long-term difficulties occasioned by the loss of a loved one, such as changes in economic or family configurations. In support of these assertions, Bonanno and Keltner (1997) reported that facial expressions of anger, contempt, disgust, and fear, as well as a negative expression composite, that were coded from videotapes of conjugally bereaved individuals describing their lost relationship at 6 months postloss, were each positively correlated with interviewer ratings of grief at 14-months postloss. Interestingly, facial expressions of anger, the emotion most consistently believed by grief work theorists to require expression during bereavement (Belitsky & Jacobs, 1986; Cerney & Buskirk, 1991), were the most strongly associated with increased grief at 14 months and were still correlated with increased grief at the 25month point in bereavement. Further, the relationship of negative emotional expression to increased grief remained significant when both the initial grief-emotion overlap and self-reported emotion were statistically controlled. There have been several attempts to use content analyses to examine the relationship of verbal expressions of emotion to grief outcome. Pennebaker, Mayne, and Francis (1997) counted positive and negative emotion words from bereaved gay men's verbal narratives. They did not report the data for positive or negative emotions separately. Unexpectedly, however, neither the difference between positive and negative word usage nor the total use of emotion words were predictive of 1-year outcome. Findings con-
sistent with the social-functional model were reported in a more elaborate content analysis of positive and negative emotional experiences. Capps and Bonanno (1998) found that bereaved participants whose verbal narratives showed greater proportions of negative emotional experiences (e.g., "It makes me sad to remember.") had more frequent somatic complaints 2 years later, and this result remained significant when initial somatic complaints and perceived social support were statistically controlled. Positive emotions and laughter. The expression of positive emotion associated with a loss has been largely ignored by grief work theorists. When positive emotions have been mentioned, it has typically been in the context of denial or avoidance of grief work (e.g., Sanders, 1993). From a social-functional perspective, however, positive emotions serve an adaptive function that "may ameliorate the stress of bereavement by increasing continued contact with and support from important people in the bereaved person's social environment" (Bonanno & Keltner, 1997, p. 134). Additionally, Lazarus, Kanner, and Folkman (1980) noted that positive emotions serve as breathers that both temporarily free a person from the stress of an experience and allow pleasurable diversionary activity, as sustainers that foster the persistence of coping efforts, and as restorers that replenish damaged or depleted resources or foster the development of new resources. Support for the adaptive role of positive emotion during bereavement has come primarily from Bonanno and Keltner's (1997) study of grief-related facial expressions. In this case, the facial data were coded for both genuine or Duchenne laughs and smiles, which involve movement of the orbicularis occuli muscles around the eyes and have been linked to genuine positive emotion and positive interpersonal consequences, and polite or non-Duchenne expressions, which do not show these same associations (Duchenne de Bologne, 1862/1990; Frank, Ekman, & Friesen, 1993). As in previous studies, only the genuine or Duchenne expressions during bereavement were correlated with the experience of positive emotion. Further, in contrast to the traditional dismissal of positive emotion during bereavement, Duchenne laughter and smiling were exhibited by the majority of the participants as they described their lost relationship. Finally, Duchenne laughter and smiling were correlated with reduced grief at 14 and 25 months postloss. As with negative emotions, these correlations tended to remain significant when initial grief and self-reported emotion were controlled. On the basis of these results, Bonanno and Keltner (1997) concluded that the salutary function of positive emotions during mourning creates an "appropriate corollary to the common observation of social isolation and loneliness as intrinsic features of severe grief reactions" (p. 134). In a subsequent report, Keltner and Bonanno (1997) provided further evidence for the social benefits of laughter during bereavement. These findings are of particular relevance to our concerns in this article because they counter the primarily intrapersonal emphasis of the grief work perspective and emphasize the interpersonal or social aspects of bereavement (Averill, 1968; Parkes & Weiss, 1983). Keltner and Bonanno (1997) found that conjugally bereaved individuals who showed genuine laughter at least once while they described their lost relationship also reported better adjustment in the lost relationship and were less ambivalent about a current close friend or relative than were nonlaughers. In addition, when untrained observers were shown videotapes of the bereaved participants with the sound
AN INTEGRATIVE PERSPECTIVE ON BEREAVEMENT turned off, they experienced more positive emotion and less frustration when viewing bereaved participants who laughed compared with those who did not laugh.
The Trauma Perspective A number of investigators have begun to consider the death of a close friend or relative as a specific instance of the larger category of possible traumatic experiences a person might endure. A trauma perspective on bereavement provides a unique and important emphasis on different types of losses, the role of meaning, and the social need to talk with others about particularly difficult or traumatic losses. Traumatic losses. It has become increasingly evident that grief reactions often involve more than simple depression (Horowitz et al., 1997; Prigerson et al., 1995; Wortman, Silver, & Kessler, 1993). From a trauma perspective, losses that result from violent deaths (e.g., homicide) are likely to instigate reactions similar to post-traumatic stress disorder (PTSD; Figley, Bride, & Mazza, 1997; Horowitz, 1986; Janoff-Bulman, 1992; Raphael, Middleton, Martinek, & Misso, 1993; Stevens-Guille, 1999). Preliminary support for this supposition came from studies that compared grief reactions after violent death and natural death across nonmatched samples (e.g., Rynearson & McCreery, 1993) and studies that examined the role of interpersonal loss in exacerbating the development of PTSD in the context of other stressor events (e.g., combat; Green, Grace, Lindy, & Gleser, 1990). More recently, two studies provided direct evidence for the association of violent deaths with trauma symptoms. Zisook, Chentsova-Dutton, and Shuchter (1998) examined data from a large sample of conjugally bereaved adults at the 2-month point in bereavement. The criterion for PTSD was met by about 10% of the participants whose spouses had died of natural causes, regardless of whether the death was expected or not. In contrast, over one third of the participants whose spouses had died of suicide or accidents met the PTSD criterion. In a related study, Kaltman and Bonanno (1999) examined depression and PTSD symptoms prospectively among midlife, conjugally bereaved individuals. Participants whose spouses had died from violent deaths (e.g., suicide, accident, homicide) showed more PTSD symptoms across the 25 months of the study than did other participants. Again, the expectedness of the loss, by itself, was unrelated to trauma symptoms. Interestingly, both violent- and natural-death bereaved groups showed elevated depression. However, for natural-death participants, depression decreased over time, whereas for the violent-death participants, depression remained elevated over 25 months. Together, these findings suggest that violent deaths may not only lead to the development of trauma reactions but that they also tend to exacerbate the more general grief response. The meaning of a loss. The trauma perspective places crucial emphasis on the meaning of the traumatic event. Particularly disturbing events, including the death of a loved one, are thought to challenge or even shatter individuals' core assumptions about themselves, the world around them, and other people (JanoffBulman, 1992; Parkes, 1971, 1988; Parkes & Weiss, 1983). Thus, recovery hinges, to some extent, on the survivor's struggle to integrate his or her understanding of the event into broader meaning structures (Janoff-Bulman, 1992; Silver, Boon, & Stones, 1983). However, the available empirical evidence suggests that,
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for many bereaved individuals, the death of a loved one may elude comprehension. Lehman, Wortman, and Williams (1987) reported that the majority of bereaved individuals who had lost a spouse or child through violent death 4 to 7 years earlier continued to talk about their loss; to review memories, thoughts, or mental pictures of the deceased; and to search for some meaning or explanation for the death. Importantly, Schwartzberg and Janoff-Bulman (1991) observed similar findings even when violent deaths were excluded, suggesting that meaning may be elusive even in nontraumatic losses. More recently, Davis, Nolen-Hoeksema, and Larson (1998) reported data that distinguished the relative impact of two different aspects of meaning during bereavement: making sense of the loss and finding benefit in the experience. Interestingly, participants who reported that they had found some meaning in the loss had less distress initially but were just as distressed as other participants at later assessments (13 and 18 months), whereas participants who reported finding benefit in the loss experience had reduced distress at later assessments. Further, the meaning variables were found to mediate the relationship of several contextual variables (age of the deceased, religious or spiritual beliefs, and optimism) on adjustment. The distinction between these different types of meanings and their mediating role in relation to other factors suggests an important avenue for further research. Talking about the loss. Related to the emphasis on meaning is the assumption that describing one's thoughts and emotions about traumatic events to others promotes cognitive restructuring. Traditional grief work theorists have also assumed that grieving individuals "have a need to express their responses to a loss or death" (Corr, Nabe, & Corr, 1994, p. 199) and that they should "verbalize and ultimately make peace with their hostility," "speak with friends and relatives about the deceased" (Lazare, 1989, p. 393), and "talk freely and at length" about their experiences prior to and after the loss (Bowlby, 1980, p. 199). The difference between the grief work and trauma theories on this point, however, lies in the presumed purpose of verbal disclosure. From a grief work perspective, verbal disclosure is simply one of many ways to work through and ultimately relinquish the attachment to the deceased. In contrast, from a trauma perspective, verbal disclosure promotes integration and cognitive restructuring of the more difficult aspects of the loss, as well as the exploration of more efficacious possible selves, and fosters the self-regulation of distressing emotions and bodily reactions (Greenberg, Wortman, & Stone, 1996; Pennebaker, 1989; Pennebaker & Francis, in press; van der Kolk, 1994, 1996). Although there is abundant evidence for the general healthpromoting impact of disclosing secretive or traumatic information (Pennebaker, 1989, 1993), preliminary research on the consequences of verbal disclosure during bereavement has been inconclusive (Pennebaker & O'Heeron, 1984; Pennebaker et al., 1997). One explanation for the inconsistent effects is that the consequences of talking about losses may depend in part on the receptivity of would-be listeners (Harber & Pennebaker, 1992; Kelly & McKillop, 1996). There is growing evidence that the repeated communication of intense negative states, such as sadness or distress, may overwhelm and, in some instances, actually drive away people in the social environment who might otherwise offer interpersonal support (Coyne, 1976; Gottlieb & Wagner, 1991; Pennebaker, 1993; Silver, Wortman, & Crofton, 1990). Thus, the extent to which verbal disclosure informs adjustment may depend
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at least in part on whether the social environment is perceived to be receptive, supportive, or willing to offer help (Kelly & McKillop, 1996). A recent prospective bereavement study provided compelling support for this idea. Lepore, Silver, Wortman, and Wayment (1996) examined the complex relationship between talking about the loss, perceived social constraints against disclosure, intrusive thoughts (cognitive processing) related to the loss, and depressive symptoms among mothers who had lost a child to Sudden Infant Death Syndrome. As expected, the amount of talking about the loss declined steadily across time, whereas perceptions of the constraints against disclosure remained constant. Also, as expected, the amount of talking about the death was inversely associated with perceived social constraints against disclosure. When these relationships were examined over time, the moderating effects of perceived social constraints about disclosure were evident in two different statistical interactions. The first interaction suggested that perceived social constraints moderated the relationship between intrusive thoughts (cognitive processing of the loss) in the first 3 weeks of bereavement and the amount of actual talking about the loss at later assessments. Among bereaved mothers who perceived relatively little social constraint about disclosing, the amount of actual talking about the loss at later assessments was predicted by initial levels of intrusive thoughts. However, for bereaved mothers who perceived social constraints against disclosure, the more intrusive thoughts they had initially, the less likely they were to talk about the loss at later assessments. Thus, perceptions of social constraints against disclosure appeared to inhibit the urge to talk about loss-related intrusive thoughts. A second interaction suggested that perceived social constraints about disclosure also moderated the relationship between initial levels of intrusive thoughts about the loss and later depression. In this case, for mothers who perceived their social environments as constrained against disclosure, high initial levels of intrusive thoughts about the loss predicted later depression. It is important that future research explore these types of interactions and examine whether the moderating impact of perceived constraints generalizes to other types of losses.
Toward Integration The perspectives reviewed in the preceding section were developed to explain a particular array of psychological events across a variety of situational contexts. When applied to the context of bereavement, each of these perspectives offered well-developed explanatory hypotheses for select features of the grieving process. Because alternatives to the grief work view have only recently been considered, however, relatively few empirical studies that addressed these hypotheses were available, and most of the studies that were available came from the same longitudinal data sets (see Table 1). Nonetheless, these data provided important preliminary support for many of the hypotheses and suggested promising avenues for the empirical investigation of others. In the final section of this article, we elaborate on the most promising features of each theoretical perspective in an attempt to develop an integrative, conceptually sound, and empirically testable framework for understanding individual differences in grieving and for guiding future research. Specifically, we consider bereavement in terms of four primary components—the context of the loss, the
continuum of subjective meanings associated with the loss, the changing representations of the lost relationship over time, and the role of coping and emotion-regulation processes—and suggest several ways in which these components may interact with each other over the course of grieving.
The Context of the Loss A full understanding of the grieving process must begin with the context in which the loss occurs. Although myriad contextual factors may be considered, the bereavement literature has narrowed this question to a relatively finite set, including age, gender, income level, type and expectedness of the loss, previous experiences with loss or depression, and perceived social support (Bonanno, 1999b). Unfortunately, the data on these factors have been generally inconclusive (Lund, Caserta, & Dimond, 1989; Parkes & Weiss, 1983; Sanders, 1993; Windholtz, Marmar, & Horowitz, 1985). One possible explanation for the inconsistencies across studies may be sampling biases, as discussed earlier. We propose here, however, that another reason may be the interaction of different contextual factors. Because few empirical studies have attempted to examine such interactions, we suggest several likely possibilities that might be addressed in future bereavement research. The trauma perspective emphasized the particularly stressful nature of violent deaths, as well as their unique association with trauma symptoms and prolonged depression. It is important to continue to examine the consequences associated with bereavement from violent deaths, as well as from other types of losses, and to explore whether these consequences interact with different aspects of the grief process. For instance, it has been commonly assumed that the death of a child is an exceptionally painful loss. Preliminary evidence appeared to confirm this assumption (e.g., Sanders, 1980). However, this evidence was confounded by sample differences in age and degree of forewarning (M. S. Stroebe, Hansson, & Stroebe, 1993). A subsequent study that controlled for these variables demonstrated the opposite result: Conjugal loss produced greater long-term difficulties than did child loss (Lehman, Wortman, & Williams, 1987). In a related vein, Crawford, Salter, and Jang (1989) provided intriguing data suggesting that the best predictor of grief severity in relation to the loss of a child was not the child's chronological age but rather the child's reproductive value. Reproductive value refers to the likelihood that a child will produce offspring. Although this value varies to some extent across cultures, it generally peaks between 15 and 25 years of age (Fisher, 1930). An examination of cognitive appraisals after the death of a child may help elucidate whether losses of children at different ages are understood by the surviving parents in dramatically different ways and in ways that are different from other types of losses. Age is another variable that may interact with many facets of the grief experience. For example, Bonanno and colleagues (Bonanno & Keltner, 1997; Bonanno et al., in press) have emphasized that their findings, which link the minimization and dissociation of negative emotion with a relatively mild grief course, were obtained with midlife samples. Because midlife is typically a highly active period, often characterized by peak career and interpersonal demands (Bumpus & Aquilino, 1995), the dissociation or minimization of negative emotions may be a particularly adaptive and useful
AN INTEGRATIVE PERSPECTIVE ON BEREAVEMENT strategy at that stage in life. In contrast, losses at later stages in life tend to be characterized by different concerns (e.g., the bereaved survivor's own health or capacity to function independently) and different outcomes (e.g., fewer depressive symptoms). Thus, it may be that emotional dissociation is a less adaptive coping response in later life. To cite another example, sudden or unexpected losses are thought to be more anxiety-provoking than anticipated losses and, consequently, to result in more severe grief reactions (e.g., Epstein, 1993; Parkes, 1975b). Although there is some empirical support for this assumption (Ball, 1977; Lundin, 1984; Parkes & Brown, 1972; Sanders, 1993; Vachon et al., 1982), many of the studies that have examined the expectedness of the loss have reported null findings (Bonanno et al., 1995; Clayton, Halikas, & Maurice, 1973; Fulton & Gottesman, 1980; Maddison & Walker, 1967; Schwartzberg & Janoff-Bulman, 1991; Zisook & Shuchter, 199la). To some extent, expectedness is confounded with type of loss (Kaltman & Bonanno, 1999). However, it is also possible that expectedness interacts with differences in the ages of the samples: Older bereaved individuals may be more prepared for loss, and, thus, samples with older participants may be less likely to show a general expectedness effect (Parkes, 1975a; W. Stroebe & Stroebe, 1993). Still another possibility is that the actual degree of expectedness of the loss may have less influence on grief course than the participant's subjective experience of expectedness, which is likely to vary in relation to age, personality, cultural context, quality of the relationship, and other factors (Bonanno, 1999a; Rosenblatt, 1993). The influence of gender on the course of grieving is another area worthy of continued empirical investigation. There is some consensus in the bereavement literature that men tend to become more depressed after the loss of a spouse than do women (M. S. Stroebe & Stroebe, 1983; W. Stroebe & Stroebe, 1987; Umberson, Wortman, & Kessler, 1992). However, the reason for this difference is not yet clear. One possibility, consistent with the cognitive stress perspective, may be that the loss of a spouse results in different perceived deficits for widows and widowers (W. Stroebe & Stroebe, 1987; Wortman, Silver, & Kessler, 1993). For instance, in a national survey of 3,614 adults, widows were more likely than widowers to experience increased financial strain, whereas widowers were more likely than widows to experience the strain of increased household tasks (Umberson et al., 1992). Of particular importance for our concerns here is that different types of strain were found to mediate depression for widowed men and women. Depression for widows increased with financial strain and strained relationships with children, and decreased with the receipt of help with household tasks. In contrast, depression for widowers increased with time spent doing household tasks, but decreased with the performance of maintenance tasks, the receipt of social support from children, and the receipt of social visits and phone calls. Unfortunately, due to the cross-sectional nature of these data, it was not possible to untangle the direction of causality between the variables. A similar type of analysis using a prospective design would make it possible to examine how gender might interact with appraisal and coping, with changes in perceptions of the lost relationship, and with grief-related outcome variables over the course of bereavement. Social support is also an important contextual moderator in need of further study. It has been widely assumed that perceived social
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support serves as a buffer against adversity. However, a recent empirical study that examined perceived social support during bereavement failed to demonstrate buffering effects (W. Stroebe, Stroebe, Abakoumkin, & Schut, 1996). In explanation of this result, W. Stroebe et al. surmised that, although well intentioned, the support that conjugally bereaved individuals receive from friends or relatives cannot adequately compensate for the loss of support previously received from the spouse. An alternative explanation for this result, however, may be that bereaved participants' appraisals of support in their interpersonal environments are relatively unrelated to the actual supportive behaviors of others. In general, bereaved individuals tend to report inadequate social supports (Lehman, Ellard, & Wortman, 1986), particularly if they are experiencing depressive symptoms (Nuss & Zubenko, 1992). In addition, bereaved individuals' perceptions of social support have been found to be almost completely uncorrelated with the supportive responses they actually evoked in others (Capps & Bonanno, 1998). These are important questions for future research. Finally, cultural influence is a significant, but grossly understudied, factor in bereavement. Myriad theoretical and anthropological accounts have identified cultural variations as well as similarities in the experience of, and response to, interpersonal loss (Ahern, 1973; Bonanno, 1998; Brandt, 1954; Corr et al., 1994; Eggan, 1950; Herskovits, 1938; Kalish & Reynolds, 1981; Kastenbaum, 1995; Leonard, 1990; Mandelbaum, 1959; Metuh, 1982; Moore, 1980; M. S. Stroebe et al., 1992; Opoku, 1989; Rosenblatt, 1993; Rosenblatt, Walsh, & Jackson, 1976; Paz, 1961; Price & Price, 1991; Wikan, 1990). Somewhat surprisingly, however, the question of cross-cultural variations in mourning has not yet been addressed using a systematic and comparative empirical design. It is imperative that this deficit be remedied, not only to verify and document the naturalistic observation data, but also to identify the ways in which cultural differences may interact with or moderate other facets of the grieving experience.
A Continuum of Subjective Meanings By nature, human beings are fundamentally meaning-making creatures (Baumeister, 1991; Baumeister & Newman, 1994; Ochs & Capps, 1996). As the grieving process unfolds, bereaved individuals will begin to consider the meaning of their loss in the broader context of their ongoing lives. The various theoretical perspectives we reviewed in the previous section suggest that the subjective meanings associated with interpersonal loss manifest on a continuum extending from relatively mundane appraisals related to immediate pragmatic matters, to concrete evaluations of specific problems occasioned by the loss (e.g., changes in level of income), to deeper and more encompassing questions about emotional wellbeing and identity, to the most profound existential concerns about the meaning of life and death. From a cognitive stress perspective, cognitive appraisal accounts for a portion of the individual differences typically observed in grief outcome in terms of the ways bereaved individuals construe both the potential harm wrought by a loss and their ability to cope with the loss. An important feature of the concepts of appraisal and coping in relation to the long-term nature of the grieving process is that they are fluid rather than static processes. The instigation of appraisal and coping processes inevitably alters the person-environment interaction, resulting in subsequent ap-
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praisals, or reappraisals, and subsequent coping efforts, and these continue in an ongoing, cyclical manner (Folkman & Lazarus, 1988). The available data suggest, however, that appraisals are relatively more variable across time than are coping and other regulation processes. Coping behaviors have shown moderate cross-situational correlations and appear to be at least in part informed by personality (Carver, Scheier, & Weintraub, 1989; Folkman, Lazarus, Gruen, & DeLongis, 1986). In contrast, cognitive appraisals show only relatively weak cross-situational correlations and are more likely to be influenced by changes in the situational context (Aldwin, Folkman, Schaefer, Coyne, & Lazarus, 1980; Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). At present, there is no well-developed explanatory mechanism within cognitive stress theory to accommodate the long-term variability in appraisals that likely occur over the course of bereavement. We propose inclusion of the concept of retrospective reappraisal (Bonanno, 1997). We conceive of retrospective reappraisal as a person's long-term evaluations of the impact of the loss and how well he or she has coped over time. In the language of cognitive stress theory, retrospective reappraisals may be thought of as extended primary reappraisals, pertaining to long-range evaluations of the personal harm done by the loss, and extended secondary reappraisals, pertaining to long-range evaluations of the effectiveness of the coping strategies that have been used. However, retrospective reappraisals differ phenomenally and temporally from the commonly described form of cognitive appraisals. Normally, cognitive appraisals are proximal and continuous, focusing on the immediate person-environment encounter (Lazarus, 1991). We conceive of retrospective reappraisals as more distal and sporadic, and as concerning temporally varied aspects of the long-term coping processes. Whereas cognitive appraisals are instigated by any potentially threatening situation, retrospective reappraisals are more clearly linked to those situations that call particular attention to the longitudinal course of grieving, such as the anniversary of the death event or beginning a new job to better meet the financial changes wrought by the loss (Bonanno, 1997). Thus, retrospective reappraisals can be expected to inform and interact both with coping processes and contextual moderator variables over the course of bereavement. From a trauma perspective, a central task in the recovery from a distressing event, such as the death of a loved one, is to gain perspective or in some way incorporate the loss into existing meaning structures. The available evidence suggests that for many bereaved individuals, making sense of or fully understanding a loss may be extremely difficult if not impossible (Lehman et al., 1987; Schwartzberg & Janoff-Bulman, 1991). Rather, what appears to foster adaptation is the eventual experience of personal benefit from the loss (Davis et al., 1998; Shuchter & Zisook, 1993). One means by which this may be achieved over time is through retrospective reappraisals that are based on either temporal comparisons (e.g., "I am now a stronger person," or "The loss has shown me what is important in life.") or social comparisons (e.g., "Compared to some of the things other people must go through, I have nothing to complain about."). A similar type of long-term reinterpretation of the loss event, that is worthy of further research is suggested by the concept of stress-related growth (Park, Cohen, & Murch, 1996; Tedeschi & Calhoun, 1996).
Changing Representations of the Lost Relationship
The development of meaning after a loss is mirrored to some extent by changes in the representation of the lost relationship over time. Crucial to the attachment perspective is the observation that the pain of grief leads to a gradual redefinition, reorganization, and elaboration of the representation of the lost relationship into an enduring continued bond. The idea of continued bonds was generated primarily from clinical observations and anthropological accounts of ancestor worship. Several recent studies have also provided important preliminary empirical support (Bonanno et al., 1998; Shuchter & Zisook, 1993). In contrast to the grief work approach, however, which emphasized the relinquishment of the bond with the deceased, the attachment perspective views continued bonds as serving an important adaptive function. Continued bonds foster the continuity of identity, reinforce coping efforts, and provide comfort and support during the transition to a new life (Bowlby, 1980; Klas, Silverman, & Nickman, 1996; Shuchter & Zisook, 1993). Interestingly, the empirical investigation of a related aspect of the attachment perspective pertaining to ambivalence has suggested a limitation to the continued bond idea. Specifically, Bonanno, Notarius, et al. (1998) demonstrated that when initial grief reactions are severe, they tend to erode the representations of the lost relationship in the direction of less favorable evaluations and increased ambivalence. In other words, there appears to be an optimal or manageable level of grief that allows for the reorganization of the bereaved survivor's representational world into a supportive and ongoing bond with the deceased. When that level is exceeded and grief becomes unmanageable, there appears to be a need to downgrade or minimize the importance of the lost relationship, perhaps in the service of breaking a too-painful attachment bond (Bonanno, Notarius, et al., 1998). At minimum, the limited empirical evidence that is available suggests that the changing representations of the lost relationship play an important, if not fully defined, role in the grieving process. Further, insofar as the concepts of a positive bond and ambivalence pertain to subjective interpretations of the lost relationship, they offer a parsimonious fit with the general emphasis on subjective meaning and appraisal emphasized by other theoretical perspectives. As additional research data on these constructs become available, it should be possible to more fully determine the nature of bereaved individuals' representations of the lost relationship, the extent that these representations are influenced by other aspects of the grieving process, and how changes in these representations influence or are influenced by the course of grieving.
Coping and Emotion Regulation Among the factors that are believed to inform grief-related health and well-being, coping strategies and emotion regulation processes offer perhaps the most promising avenues for further empirical investigation. From a cognitive stress perspective, a range of empirically derived coping strategies may potentially mollify or exacerbate the stress of loss. The flexibility of the cognitive stress perspective with regard to coping offers a particularly appealing alternative to the traditional grief work approach. Preliminary research has demonstrated the role of coping strategies in mediating adjustment to loss. However, because this evidence comes primarily from two longitudinal projects, both of which deal
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with partner loss (see Table 1), the challenge remains for future bereavement research to continue cataloguing the particular coping strategies that might function most effectively for different types of losses. A particularly important form of coping, associated with cognitive restructuring, is the act of talking with others about difficult events (Greenberg et al, 1996; Pennebaker & Francis, in press). Surprisingly, the evidence for the efficacy of verbal disclosure during bereavement was inconclusive. When considered in the context of other aspects of bereavement, however, it becomes clear that talking about the loss is likely to interact with retrospective ' reappraisals, with changes across the course of bereavement in the representation of the lost relationship, and with the particular social milieu in which the loss occurs. In this vein, it is important to consider Lepore et al.'s (1996) finding that verbal disclosure during bereavement was moderated by perceived social constraints about disclosure. Thus, we concur with Kelly and McKillop (1996) that talking about traumatic events may only be helpful when listeners are discreet, nonjudgmental, or likely to help. Otherwise, it may be preferable to rely on other methods of coping. A crucial question for future bereavement research is to determine how overt coping strategies, typically measured by selfreport scales, might overlap or interact with the ephemeral processes associated with emotion. From a cognitive stress perspective, coping strategies serve as mediators of emotion (Folkman & Lazarus, 1988). Appraisal is thought to produce emotion, which in turn influences the selection of coping strategies. Coping changes the person-environment encounter and instigates reappraisal processes, which in turn generate new sets of emotional responses. In contrast to this view, however, recent evidence has shown that emotion may be generated solely on the basis of relatively simple cognitive processes that are inaccessible to conscious awareness (LeDoux, 1989, 1996; Scherer, 1993). Thus, emotion may not always inform deliberate coping strategies. Further, emotion is not a unitary phenomenon but, rather, manifests in multiple channels, including experiential, expressive, and physiological responses. These different response channels often occur in a partially independent or dissociated manner such that emotion may be present at one response channel and absent, or even contradicted, at another response channel (Ekman, 1992; Izard, 1977; Lang, Kozak, Miller, Levin, & McLean, 1980; Leventhal, 1984; Schwartz, Fair, Greenberg, Freedman, & Herman, 1974; Schwartz, Fair, Salt, Mandel, & Klerman, 1976). Thus, emotion is not likely to show a consistent pattern of relationships with deliberate coping strategies. One route to the integration of the coping and emotion perspectives may be found in the burgeoning literature on emotion regulation. From a developmental perspective, regulation of the experience and expression of emotion is widely acknowledged as a primary maturational task (Campos, Campos, & Barrett, 1989; Eisenberg & Fabes, 1992; Hubbard & Coie, 1994). In adults, the regulation of emotion has been conceptualized in terms of its role in the maintenance of mental health and in the negotiation of stressful or traumatic life events (Gross & Mufioz, 1995; Keltner et al., 1995; Lazarus, 1991), including bereavement (Bonanno & Keltner, 1997). Crucial to our concerns here, the regulation of emotion may at times encompass both deliberate or strategic processes, similar to those captured by self-report coping scales, as well as more spontaneous or automatic regulatory processes that
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are not likely to be available to conscious awareness and not easily captured by self-report instruments (Bonanno et al., 1995; Gross, 1998; Gross & Munoz, 1995). An especially important aspect of emotion regulation during bereavement appears to be the regulation or dissociation of negative emotions and the enhancement of positive emotions, particularly laughter (Bonanno & Keltner, 1997; Bonanno et al., in press; Bonanno et al., 1995). In the context of the framework developed in this article, we conclude that these processes foster adjustment to loss because they help maintain relatively high levels of functioning and thus contribute to retrospective reappraisals that the pain of loss can be coped with and that life can and does go on after the death of a loved one. As with much of the data in this domain, however, the evidence in support of this conclusion comes primarily from a single longitudinal study (see Table 1) and makes further research imperative. It is important to examine more closely, for example, how negative and positive emotions might be accentuated or inhibited in relation to other aspects of bereavement—such as the expectedness of the loss, the age of the bereaved survivor, and the quality of the lost relationship—and whether these factors might moderate the association between emotion and social relations with others (Keltner & Bonanno, 1997). It is also important to determine whether the salutary influence of positive emotions, such as laughter, on bereavement can be induced deliberately with intentional strategies such as attending humorous movies or receiving encouragement from friends to share in amusing moments (Bonanno, 1999d).
Summary: The Challenge for Future Bereavement Researchers The grief work perspective has so dominated the bereavement literature that few alternative theoretical perspectives on bereavement have been developed. When several highly critical reviews appeared in the late 1980s (W. Stroebe & Stroebe, 1987; Wortman & Silver, 1989), alerting bereavement theorists to a glaring absence of empirical support for the basic tenets of the grief work approach, somewhat of a theoretical vacuum was created. In the ensuring decade, however, bereavement researchers and theorists partially filled that vacuum by conducting empirical studies that were guided by more specialized theoretical perspectives borrowed from other areas of psychology. We began this article by affirming and extending Wortman and Silver's (1989) conclusion that the empirical data on bereavement either fail to support or directly contradict the grief work assumptions. We next reviewed alternative perspectives on bereavement derived from cognitive stress theory, attachment theory, the social-functional perspective on emotion, and trauma theory. Preliminary empirical support was available for many of the features of each perspective. However, there are also many aspects of these perspectives that have yet to be examined. In the final section of this article, we attempted to provide an integrative perspective on bereavement that might guide future research by elucidating the role of contextual factors, the continuum of subjective meaning, the changing representations of the lost relationship, and the regulation of coping and emotion. Each of these areas was conceptualized as having an ongoing impact on the course of bereavement. However, it was also assumed that many of the features of the grieving process would interact with or moderate other fea-
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tures. At different points in this article, we considered some of these possible interactions (e.g., the survivor's age may moderate the impact of the expectedness of the loss; talking about a loss may have different consequences, depending on the receptivity of the social environment; the role that representations of the lost relationship play in the grieving process may depend on the type of loss; and minimizing negative emotion may free up resources for problem-focused coping). Our review was not meant to be, and clearly could not be, exhaustive on this point. However, these considerations suggest a fundamental challenge for the next decade of bereavement research. It is our hope that the integrative framework we elucidate here will facilitate research on the basic features of the grieving process and inspire bereavement researchers to move forward with the difficult task of mapping the complex interactions between these features across the course of bereavement.
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