Sorrow concealed, like an oven stopp’d,
Doth burn the heart to cinders where it is.
SHAKESPEARE, Titus Andronicus
A GREAT DEAL of the literature on disordered mourning derives from the work of psychoanalysts and other psychotherapists who have traced the emotional disturbances of some of their patients to a bereavement suffered at some earlier time. Not only has an enormous amount been learned from these studies about the psychopathology of mourning but it was these findings that first drew attention to the field and led on to the more systematic studies of recent years. In this chapter we start by drawing on the findings of these recent studies because, based as they are on fairly representative samples, they present a broader and more reliable perspective in which to view the problems than can findings drawn exclusively from psychiatric casualties. Once the scene is set, however, the therapeutic findings become an invaluable source for deepening our understanding of the processes, cognitive and emotional, that are at work.
Disordered variants of mourning lead to many forms of physical ill health1 as well as of mental ill health. Psychologically they result in a bereaved person’s capacity to make and to maintain love relationships becoming more or less seriously impaired or, if already impaired, being left more impaired than it was before. Often they affect also a bereaved person’s ability to organize the rest of his life. Disordered variants can be of every degree of severity from quite slight to extremely severe. In their lesser degrees they are not easily distinguished from healthy mourning. For purposes of exposition, however, they are described here mainly in their more extreme versions.
In one of the two disordered variants the emotional responses to loss are unusually intense and prolonged, in many cases with anger or self-reproach dominant and persistent, and sorrow notably absent. So long as these responses continue the mourner is unable to replan his life, which commonly becomes and remains sadly disorganized. Depression is a principal symptom, often combined or alternating with anxiety, ‘agoraphobia’ (see Volume II, Chapter 19), hypochondria or alcoholism. This variant can be termed chronic mourning. At first sight the other variant appears to be exactly the opposite, in that there is a more or less prolonged absence of conscious grieving and the bereaved’s life continues to be organized much as before. Nevertheless, he is apt to be afflicted with a variety of psychological or physiological ills; and he may suddenly, and it seems inexplicably, become acutely depressed. During psychotherapy with such people, which is sometimes undertaken for ill-defined symptoms and/or interpersonal difficulties which have developed without any breakdown having occurred, and sometimes after breakdown, the disturbances are found to be derivatives of normal mourning though strangely disconnected, both cognitively and emotionally, from the loss that led to them.
Opposite in many respects though these two variants are they none the less have features in common. In both, it may be found, the loss is believed, consciously or unconsciously, still to be reversible. The urge to search may therefore continue to possess the bereaved, either unceasingly or episodically, anger and/or self-reproach to be readily aroused, sorrow and sadness to be absent. In both variants the course of mourning remains uncompleted. Because the representational models he has of himself and of the world about him remain unchanged his life is either planned on a false basis or else falls into unplanned disarray.
Once it is realized that the two main variants of disordered mourning have much in common the existence of clinical conditions with features that partake of both, or that represent an oscillation between them, gives no cause for surprise. A common combination is one in which, after a loss, a person for a few weeks or months shows an absence of conscious grieving and then, perhaps abruptly, is overwhelmed by intense emotions and progresses to a state of chronic mourning. In terms of the four phases of mourning described in Chapter 6 absence of conscious grieving can be regarded as a pathologically prolonged extension of the phase of numbing, whereas the various forms of chionic mourning can be regarded as extended and distorted versions of the phases of yearning and searching, disorganization and despair.
Because the two variants have elements in common not all the terms used to describe them are distinctive. In fact a variety are in use. For the first variant Lindemann (1944) introduced the term ‘distorted’ and Anderson (1949) ‘chronic’; for the second, terms such as absent (Deutsch 1937), delayed, inhibited and suppressed are used.
In addition to these two main variants of disordered mourning there is a third, less common one—euphoria. In some individuals this may be of such severity that it presents as a manic episode.
Before describing these variants further it may be useful to look afresh at the painful dilemma facing every mourner in order to see at what points in the course of mourning the pathological variants diverge from the healthy ones. So long as he does not believe that his loss is irretrievable a mourner is given hope and feels impelled to action; yet that leads to all the anxiety and pain of frustrated effort. The alternative, that he believes his loss is permanent, may be more realistic; yet at first it is altogether too painful, and perhaps too terrifying, to dwell on for long. It may be merciful, therefore, that a human being is so constructed that mental processes and ways of behaving that give respite are part of his nature. Yet such respite can only be limited and the task of resolving the dilemma remains. On how he achieves this turns the outcome of his mourning—either progress towards a recognition of his changed circumstances, a revision of his representational models, and a redefinition of his goals in life, or else a state of suspended growth in which he is held prisoner by a dilemma he cannot solve.
Traditionally the mental processes and also the ways of behaving that mitigate the painfulness of mourning are known as defences and are referred to by terms such as repression, splitting, denial, dissociation, projection, displacement, identification and reaction formation. An extensive literature, which seeks to distinguish different processes and to explain them in terms of one or another model of the mental apparatus and of one or another fixation point, has grown up; but there is no agreed usage of terms and much overlap of meaning. In this volume a new approach is adopted. As already described in Chapter 4, the model of the mental apparatus drawn upon is one based on current work on human information processing. In keeping with this new approach and in order to avoid the many theoretical implications that every traditional term has accreted, terms that are less theory laden and that keep closer to the observed phenomena are used.
My thesis is that the traditionally termed defensive processes can all be understood as examples of the defensive exclusion of unwelcome information; and that most of them differ from each other only in regard to the completeness and/or the persistence of the exclusion. Many are found in both healthy and disordered variants of mourning, but a few are confined to the disordered. In a first step towards sorting them out, let us consider first those that in a majority of cases are fully compatible with a healthy outcome.
Arising from his study of London widows Parkes (1970a) lists a number of such processes. One or more of them, he inferred, were active in every subject of his series. Each widow, he found, presented her own idiosyncratic pattern and no correlation between one process and another emerged. He lists the following:
(a) processes that result in a bereaved person feeling numbed and unable to think about what has happened;
(b) processes that direct attention and activity away from painful thoughts and reminders and towards neutral or pleasant ones;
(c) processes that maintain a belief that loss is not permanent and that reunion is still possible;
(d) processes that result in recognition that loss has in fact occurred combined with a feeling that links with the dead none the less persist, manifested often in a comforting sense of the continuing presence of the lost person.
Since there are good reasons to think that processes of the fourth type, so far from contributing to pathology, are an integral part of healthy mourning, they are excluded from further consideration in this chapter. Processes of each of the other types may, however, take pathological forms.
The criteria that most clearly distinguish healthy forms of defensive process from pathological ones are the length of time during which they persist and the extent to which they influence a part only of mental functioning or come to dominate it completely. Consider, for example, the processes that direct attention and activity away from painful thoughts and reminders and towards neutral or pleasant ones. When such processes take control only episodically they are likely to be fully compatible with health. When, by contrast, they become rigidly established they lead to a prolonged inhibition of all the usual responses to loss.
The extent to which processes of defensive exclusion are under voluntary control is often difficult to determine. There is in fact a continuum ranging from what seem clearly to be involuntary processes, such as the numbing which is a common immediate reaction to bereavement, to the deliberate avoidance of people and places likely to evoke painful pangs of pining and weeping. As regards the subject’s awareness, the processes listed under heading (c) are particularly variable. On one dimension they range from a clear and conscious belief that loss is not permanent to a belief that is so ill-defined and remote from consciousness that it may require much therapeutic work to make it manifest, with examples occurring of every intervening gradation of which the human mind is capable. On another dimension such beliefs range from being open to new information, and therefore to revision, to their being shut away and resistant to any information that might call them in question.
In addition to these various types and forms of defensive process there are at least two other types that occur during mourning which, unless present only fleetingly, appear never to be compatible with a healthy outcome. They comprise:
(e) processes that redirect anger away from the person who elicited it and towards someone else, a process usually referred to in the psychoanalytic literature as displacement;
(f) processes whereby all the emotional responses to loss become cognitively disconnected from the situation that elicited them, processes that in traditional terminology may be referred to as repression, splitting or dissociation.
Almost any combination of the processes described may be active in any one person, either simultaneously or successively. This presents a problem for theorists and accounts, it seems likely, for many of the disagreements that occur.
In the descriptions of disordered variants that follow I am deeply indebted to the various studies already described in Chapters 6 and 7.
Amongst the eighty bereaved people interviewed by Gorer (1965, for particulars see Chapter 6), there were nine whom he found in a state of chronic despair, despite at least 12 months having passed since their loss. ‘Despair is almost palpable to the lay interviewer; the toneless voice, the flaccid face muscles, the halting speech in short sentences. Three out of the nine . . . were sitting alone in the dark.’ Of the nine, five had lost a spouse (3 widows and 2 widowers), two had lost a mother (both of them middle-aged men), and two had lost grown-up sons (one a married woman and the other a widower). Thus both sexes and several types of loss are represented.
Gorer expresses himself surprised that the proportion of depressed people in his sample (about ten per cent) should have been so large. Other studies of more or less representative samples of bereaved people, however, report no less high an incidence. For example, of the 22 London widows studied by Parkes (1970a) for at least a year, three were in a state at year-end not unlike that described by Gorer. Of the 68 Boston widows and widowers studied by Glick et al. (1974), the majority for two or more years, two widows became alcoholic with depression and two others severely depressed (with one of them repeatedly attempting suicide); and one of the widowers remained deeply depressed and disorganized.2
Although in his account of his findings Gorer avoids using terms such as depression and melancholia (on the grounds that they should be reserved for psychiatric diagnosis), he nevertheless believes those terms to be applicable to the conditions he describes. Probably a majority of psychiatrists would agree with him: one of the three widows whom he had found in a despairing state committed suicide a few months after he had seen her. Yet there is a school of psychiatric thought that holds an opposite view. For example, Clayton and her colleagues (1974), despite having demonstrated that the sixteen bereaved people they describe as depressed were showing features that in all respects conform to criteria they had already adopted for diagnosing a primary affective disorder,3 none the less contend that they should not be so diagnosed. Their reasons are that the condition is reactive to loss and that, in contrast to similar patients in psychiatric care who experience their condition as a ‘change’, the bereaved regard it as ‘normal’. Since the studies of Brown and Harris (1978a)4 show that a majority of all cases of depressive disorder are reactive to a loss, I believe (with them) that such a distinction is untenable. The view taken here is that the great majority of depressive conditions are best looked upon as a graded series, with the more serious forms having morbid features resembling those found in the less serious forms, though perhaps more intense, and with certain other features added.
In the case of chronic mourning it seems clear that depression can be of very varying degree. The following account of a thirty-year-old mother who took part in the second of the two N.I.M.H. studies of parents of fatally ill children (particulars of which are given in Chapter 7) describes a condition lying towards the less severe end of the scale.
Like other parents taking part in this study, Mrs QQ was interviewed twice by a psychiatrist some time after her child’s diagnosis had been conveyed to her. During the interviews, which were closely spaced in time and together lasted from two to four hours, a parent was asked to describe as fully as possible what the experience of being the parent of a fatally ill child was like. In addition to the parent’s report, notes were made of his manner and how he behaved during the interview. Although the interviewer was asking the parents to go through the experience all over again, it was found not only that they were willing to do so but that most of them became deeply engaged and provided information that was neither stereotyped nor superficial. This was because the interviews provided them with an opportunity, first, to confide some of their deepest feelings to someone not personally involved in the crisis and, secondly, by contributing to the research project, to feel that they were able to do something useful in a situation that otherwise made them feel helpless and useless.5
During the final six weeks of her son’s life Mrs QQ always appeared tense and frequently seemed anxious, agitated and tearful. She was constantly preoccupied with how she felt and spoke of being ‘unable to stand it any longer’. During interview it was extremely difficult to get her to focus on the realistic evidence of her son’s steady deterioration. To every attempt to get her to do so she reacted not only by becoming upset but by dwelling on her own sufferings to the exclusion of all else, including discussion of her son’s condition. The physicians and nurses as well as her husband became so anxious and concerned about her condition that they began protecting her from the true facts about her son.
During the two days when her son was dying, however, Mrs QQ’s state of mind changed abruptly. She became much less emotional and agitated and, instead, stayed quietly with her son, tenderly caring for him. For the first time she stated that she knew he was going to die and, when asked about herself, replied quietly that she would be all right. At a follow-up interview later Mrs QQ described these last two days. Inwardly, she said, she had felt just as unhappy and upset as before but all her previous concerns had now seemed unimportant. She realized her son was dying and had wanted to help him to be unafraid; also she had wanted to apologize to him for whatever she had done to make him unhappy. Most of all she had wanted to say goodbye and to caress him in order to express some of the tender feelings for which she could not find words.
In their commentary on the case Wolff and his colleagues note how Mrs QQ’s emotional condition changed in parallel with the direction of her concern. Initially she had avoided thinking about her son and his impending fate, had concentrated all her attention on her own suffering, and had been tense, anxious and agitated. Later, she had shifted her attention towards the boy and began caring tenderly for him; and at the same time had ceased to be preoccupied with her own sufferings and had become relatively calm.
From observations of this kind together with measurements of certain physiological variables,6 Wolff and his colleagues draw a most important conclusion. The level of overt expression of affect is a most misleading guide to how a person is responding to a stressful situation. For, as in Mrs QQ’s case, a high level of overt affect may be part of a response which is largely disconnected from the situation that elicited it. Indeed the very intensity of the affect may play a leading part in helping divert the attention, both of the near-bereaved herself and also of her companions, away from the distressing situation. Conversely, when the situation is recognized and attended to, as happens during healthy mourning, overt expression of affect may be reduced. The principal change, however, is in the quality of affect. Instead of unfocused anxiety, agitation and despair, there is sadness and longing, combined perhaps with fond memories which, although sad, are none the less intensely pleasurable. The distinction drawn by Wolff is one to which I shall constantly be returning.
Let us turn now to an example of a bereaved person whose mourning became far more firmly established and chronic than Mrs QQ’s and who, as a consequence, was admitted to a mental hospital.7
Mr M was 68 when his wife died. They had been married for forty-one years and according to a member of the family he had ‘coaxed and coddled her’ throughout their married life. She died, unexpectedly, after a brief illness. For several days he was ‘stunned’. He made all the funeral arrangements, then shut himself up at home and refused to see anyone. He slept badly, ate little, and lost interest in all his customary pursuits. He was preoccupied with self-reproachful thoughts and had fits of crying during which he blamed himself for failing her. He blamed himself for sending his wife into hospital (fearing that she had picked up a cross-infection on the ward) and was filled with remorse for not having been a better husband and for having caused his wife anxiety by himself becoming ill. At the same time he was generally irritable, blaming his children for hurting their mother in the past and blaming the hospital for his wife’s death. When he went to meetings of a local committee he lost his temper and upset his fellow-members.
His son took him on a trip abroad in the hope of getting him out of his depression but he became more disturbed than ever and broke off the holiday to return to the home which he had cared for fastidiously since his wife’s death.
Ten months after bereavement he was admitted to a psychiatric hospital where, after spending some time in psychotherapy talking about his loss, he improved considerably. It was at this time that I saw him and I was struck by the way in which he talked of the deficiencies of his wife while denying any feeling of resentment. ‘I looked forward so much to when I retired—that was one of the things that cracked it. I wanted to go on holiday abroad but I couldn’t get her to see eye to eye with that. She had been brought up to believe that to go without was essential. I never cured her of that.’ He had bought her a home but ‘she regarded it as a millstone’—nevertheless she became very attached to her home, ‘happier there than anywhere’. Her timorous attitude was reflected in numerous fears. ‘She was afraid of the sea—I never pressed her to go abroad. The children would ask her to do things and automatically she’d say “No”. No man could have wished for a better wife.’
In addition to many features typical of such conditions, we note the combination of ruminating self-reproach with, on the one hand, blame directed at third parties (his children and the hospital) and, on the other, a total absence of criticism or resentment directed towards his wife. Despite his account of the many ways in which she had frustrated and disappointed him, he insists on regarding her as having been a perfect wife. The case illustrates vividly Freud’s contention that the criticisms that a depressed person is directing towards himself often apply not so much to the bereaved as to the lost person. It illustrates also how, whenever persistent anger or self-reproach occur, they are apt to be found together—an association reported by Parkes (1965) as statistically significant in his series of cases.
Although much self-reproach is found to be reproach elicited by the lost person and redirected towards the self and third parties, there are also conditions in which the self-reproach is, at least in some degree, appropriately directed at the self but fastens on some trifling deficiency instead of on one or more real events wherein the bereaved may have been genuinely at fault.
Whereas self-reproach, as often as not associated with reproachful anger directed at third paries, is a feature of all the more severe cases of chronic mourning, there are also cases in which neither is prominent. For example, amongst the sixteen chronically depressed widows and widowers described by Clayton and her colleagues, guilt was said to be present in only two, a feeling of worthlessness in only six, and a tendency to blame someone for the death in only eight (Bornstein et al. 1973). It is, however, not improbable that those findings are due in part to these researchers having relied on a single interview of only one hour’s duration and that longer or repeated interviews would have yielded a higher incidence of cases showing anger, guilt or a sense of worthlessness.
As already stated, Parkes (1970a) found that a few individuals who subsequently develop chronic mourning show little or no response during the weeks immediately after their loss. In some this lull is an extension of the phase of numbing beyond a few days; others seem not even to experience numbing. When mourning starts, which it is likely to do within a month or two, it may be abrupt. It is also likely to be more intense and disrupting than in healthy mourning.
An example of this sequence, given by Parkes, is that of a London widow, Mrs X, who described how, on being told of her husband’s death, she had remained calm and had ‘felt nothing at all’—and how she had therefore been surprised later to find herself crying. She had consciously avoided her feelings, she said, because she feared she would be overcome or go insane. For three weeks she continued controlled and relatively composed, until finally she broke down in the street and wept. Reflecting on those three weeks, she later described them as having been like ‘walking on the edge of a black pit’.
In the Harvard study it was found that those widows and widowers who were doing badly at follow-up two or three years after the loss were likely, during the interviews at three and six weeks, already to have been showing acute disturbance in the form of one or more of the following: unusually intense and continuous yearning, unusually deep despair expressed as welcoming the prospect of death, persistent anger and bitterness, pronounced guilt and self-reproach (Parkes 1975b). Instead of improving during the course of the first year, moreover, as did those who made a reasonably good recovery, these widows and widowers continued to be depressed and disorganized. As a result of their study, Glick and his colleagues (1974) conclude that if recovery has not started by the end of the first year the outlook is not good.
Clayton’s findings regarding despair are comparable. Of the 16 widows and widowers judged depressed at thirteen months, twelve were amongst the 38 who were found markedly depressed one month after their loss; and, in addition to those twelve, a further three were found to be depressed at interview four months after loss. Although depression one month after loss proved to be statistically the most powerful predictor they could find of depression at thirteen months, it should not be overlooked that two-thirds of those who had been judged depressed at one month were none the less doing reasonably well a year later (Bornstein et al. 1973).
A further finding of the St Louis study was that a significantly higher proportion of those found to be depressed at thirteen months than of the remainder reported that they had experienced a severe reaction on the anniversary of their spouses’ death, a finding also reported by Parkes (1972).
Yet another feature predictive of chronic mourning is anger and resentment persisting long after the early weeks. This, Parkes (1972) found, was correlated with the persistence of tension, restlessness, and intense yearning. The latter was illustrated by Mrs J, a widow of 60 whom he interviewed nine months after she had lost her husband, who had died of lung cancer at the age of 78. When reminded that her husband really was dead, she burst out angrily: ‘Oh, Fred, why did you leave me? If you had known what it was like, you’d never have left me.’ Later, she denied she was angry and remarked, ‘It’s wicked to be angry.’ Three months later, on the anniversary of her loss, she recalled every moment of the unhappy day her husband died.
‘A year ago today was Princess Alexandra’s wedding day. I said to him, “Don’t forget the wedding.” When I got in I said, “Did you watch the wedding?” He said, “No, I forgot.” We watched it together in the evening except he had his eyes shut. He wrote a card to his sister and I can see him so vividly. I could tell you every mortal thing that was done on all those days. I said, “You haven’t watched anything.” He said, “No, I haven’t.”’
Thereafter for several years she remained mourning chronically, apparently prepared to continue mourning her dead husband for ever and repeatedly expressing her anguish and disappointment.8
Discussion of the way in which persistence of anger and resentment after a loss can be related both to the patterns of personality found of those who are prone to disordered mourning and to the childhood experiences of such people will be found in Chapters 11 and 12.
The following account of a forty-two-year-old London widow9 illustrates a fairly typical sequence of events:
After her husband’s death Mrs Y had shown very little emotion, a reaction she explained as due to her having been brought up always to bottle up her feelings. When she was a child her home had been unstable. Later, she had made what she described as ‘a marriage of companionship’ which had clearly been unsatisfactory in many respects. Nevertheless she insisted that the last four years had been ‘terribly happy’.
Her husband had died, unexpectedly, on the day on which he was due to leave hospital after being thought to have recovered from a coronary thrombosis. She had been unable to cry and for three weeks had ‘carried on as if nothing had happened’. During the fourth week, however, she was filled with ‘terrible feelings of desolation’, began sleeping badly and had vivid nightmares in which she tried to rouse her sleeping husband. During the day she had panicky feelings; and vivid memories of her husband’s corpse kept coming into her mind. Headaches, from which she had suffered for years, became worse; and she quarrelled with both her mother and her employers. She remained depressed and restless.
Nine months after bereavement she emigrated to Australia. Four months later, in reply to enquiry, she wrote at length describing herself as ‘very depressed’ and ‘missing my husband dreadfully’. She had no friends in Australia, felt insecure, and was worried about her future.
Features described here which occur repeatedly in accounts of people whose mourning is progressing unfavourably are: the death having been sudden, a delayed response, nightmares connected with the death, quarrels with relatives and others, an attempt to escape the scene; and, prior to the bereavement, a history of an unsettled childhood and of having been brought up to bottle up feelings.
Another feature predictive of an unfavourable outcome to mourning is the report that a bereaved person gives after a few weeks about the degree to which he finds relatives, friends and others to be helpful to him in his mourning, or to be unhelpful. This is a variable to which Maddison has drawn attention (Maddison and Walker 1967; Maddison, Viola and Walker 1969) and one discussed further in the next chapter.
During the course of his study Gorer (1965) found six people, four widowers and two widows, who were proud to show him how they had preserved their houses exactly as they had been before the spouse’s death. A widower of 58, whose wife had died fifteen months previously, explained (p. 80):
She had her certain places for different things and I haven’t shifted them at all. Everything is in the same place where she left it . . . Things run just the same as when she was here . . . everything seems, well as a matter of fact, normal . . .
Two other widowers had been buying flowers for their wives at Christmas and on their birthdays for the past four and five years respectively. Queen Victoria, who lost her husband very suddenly when she was only 42, not only preserved every object as Prince Albert had arranged them but continued for the rest of her life to have his clothes laid out and his shaving water brought (Longford 1964).10
To describe this form of response to a loss Gorer introduces the term ‘mummification’. It is an apt metaphor because, by embalming the body and burying it with a quantity of personal and household equipment, the Egyptians were making provision for the dead person’s afterlife. In the form in which it is seen in Western cultures today it may represent the bereaved’s more or less conscious belief that the dead person will return and a desire to ensure that he will be properly welcome when he does so. This hypothesis stems from information given me by a patient, the mother of a young child, whom I was treating because of acute anxiety and depression. After losing her elderly father very suddenly (during an operation for cataract) she had insisted for a year or more that neither her mother’s flat nor her own should be redecorated. In explanation, she told how she believed that the hospital had mistaken the identity of the man who had died, how she held to the belief that her father was still alive, and how important it was that he should find everything unchanged when at length he returned. Although fully conscious, she was keeping this belief to herself because her mother and others might laugh at it.11
Thus mummification is, at least initially, a logical corollary of the belief that the dead person will return. Yet, it may outlive its origins and be continued because to abandon it would set a seal on the loss which the bereaved cannot quite bring himself to do. The widower, whose account (quoted above) of how he kept everything in the house just as it was when his wife was alive and who claimed that ‘everything seems . . . normal’, ended by remarking pathetically: ‘It’s just that it’s my feeling that everything seems empty. When you walk in the room and there’s nobody there, that’s the worst part of it.’
Ideas of suicide, conceived especially as a means of rejoining the dead person, are common during the early months of bereavement. For example, when interviewed three weeks after their loss one in five of the Boston widows said they would welcome death were it not for the children. Similar ideas were expressed by a number of the London widows, one of whom went as far as to make a half-hearted gesture of suicide.
More serious suicidal attempts and completed suicides, however, are less common. Even so, among the 60 Boston subjects who were followed up between two and four years after loss, one severely depressed widow had repeatedly attempted suicide; whilst among the widows interviewed by Gorer, one committed suicide a few months after he saw her.
Much internal evidence, including the commonly expressed desire to rejoin the lost person, points in most cases to there having been a direct causal link between the completed suicide and a preceding bereavement. This likelihood is strongly supported by an epidemiological study conducted in the south of England by Bunch (1972).
Bunch compared the incidence of a recent bereavement in the histories of 75 cases of completed suicide, 40 of them male and 35 female and aged from twenty-one years upwards, with that of a control group matched for age, sex and marital status. In the group of suicides the incidence of the loss of a parent or a spouse by death during the preceding two years was five times higher than it was for the controls (24 per cent and 47 per cent respectively), a highly significant difference. Differences between the groups for loss of mother and for loss of spouse considered separately also reached statistical significance. An especially high risk group was unmarried men who had lost their mother.
Helene Deutsch was first to draw attention to this condition. In a brief paper published in 1937 she described four adult patients who from early years had suffered severe personality difficulties and episodic depressions. During the course of psychoanalytic treatment, she found, these troubles could be traced to a loss the patients had experienced during childhood but had never mourned: in each case the patient’s feeling life had in some way become disconnected from the event. Since then the condition has become well recognized, and a large number of case reports, most of them referring to losses that occurred during childhood or adolescence, are in the literature, together with much theorizing. Examples are papers by Root (1957), Krupp (1965), Fleming and Altschul (1963), Lipson (1963), Jacobson (1965), and Volkan (1970, 1972, 1975). Nevertheless, the condition can also follow a loss during adult life. For example, Corney and Horton (1974) have described a typical syndrome in a young married woman whose episodes of crying and irritability were found during brief therapy to be related to, but disconnected from, a miscarriage (at 4½ months) which had occurred a few months earlier. Only brief references are made to this body of work, however, since all of it is based on the retrospective method. Here we rely on prospective observations of the condition that have been recorded by those who have studied the course of mourning in representative groups of widows and widowers or of parents who have lost a child.
A brief phase of numbing we now know to be very common following a bereavement; but we do not expect it to last more than a few days or perhaps a week. When it lasts for longer there is reason for unease; for example, we have seen how delay of a few weeks or months may presage chronic mourning. Abundant evidence now shows that delay, partial or complete, can last far longer than that, certainly for years or decades, and presumably in some cases for the rest of a person’s life.
At this point a sceptic might ask how it is that we know that a person’s state of mind is one of disordered mourning and not simply that he is unaffected by the loss and therefore has no cause to grieve. The answer is that in many cases there are tell-tale signs that the bereaved person has in fact been affected and that his mental equilibrium is disturbed. No doubt such signs are more evident in some people than in others; and were they to be totally absent admittedly we should be left guessing. We know enough about them, however, to be able to describe at least some of them.
Adults who show prolonged absence of conscious grieving are commonly self-sufficient people, proud of their independence and self-control, scornful of sentiment; tears they regard as weakness. After the loss they take a pride in carrying on as though nothing had happened, are busy and efficient, and may appear to be coping splendidly. But a sensitive observer notes that they are tense and often short-tempered. No references to the loss are volunteered, reminders are avoided and well-wishers allowed neither to sympathize nor to refer to the event. Physical symptoms may supervene: headaches, palpitations, aches and pains. Insomnia is common, dreams unpleasant.
Naturally there are many variants of the condition and it is impossible to do justice to them all. In some persons cheerfulness seems a little forced; others appear wooden and too formal. Some are more sociable than formerly, others withdrawn; in either case there may be excessive drinking. Bouts of tears or depression may come from what appears a clear sky. Certain topics are carefully avoided. Fear of emotional breakdown may be evident, whether admitted as it sometimes is or not. Grown-up children become protective of a widowed parent, fearing lest reference to the loss by a thoughtless friend or visitor should disturb a precarious balance. Consolation is neither sought nor welcomed.
In illustration of some of these features we describe the responses during her son’s illness of a forty-year-old mother who was taking part in the second of the N.I.M.H. studies of parents of fatally ill children, particulars of which are given in Chapter 7.12
Mrs. I. was an intelligent, sensitive and warm woman, strong-minded and inclined to be controlling. As a mother she devoted much energy to providing for her children and protecting them; but she did so in a martyred way and seemed to have many unmet needs of her own.
During the interview she appeared subdued and somewhat sad and anxious. She expressed no guilt. At times she seemed fairly open with the interviewer, at others guarded and defensive. Throughout she took control of what was discussed and, rather obviously, avoided reference to anything that might be painful, such as thoughts of the future. When asked how she viewed the probable outcome of her son’s illness, she thought there was no need to consider it. Although she gave the impression of finding the interview unpleasant, she also seemed to convey that, because she was being useful, she was willing ‘as usual’ to sacrifice her own interests.
In describing her experiences whilst her son had been ill it seemed to the interviewer that she was adopting a Pollyana attitude. She should be feeling optimistic, she remarked, because her son was doing well; yet to her surprise she was feeling blue and frightened of the future. Much of the time she was keeping feverishly busy making sure that her son was happy by providing for his every need. The truth about his illness she was keeping from him, and she disputed the possibility that he might already be aware of the facts. She made a point always of controlling her own behaviour so that he would not know she was unhappy. In spite of her constant activity and apparent optimism, she admitted she often felt worried that perhaps the drugs her son was taking would not work. She was not sleeping very well and her appetite had diminished; although on occasion she found herself eating compulsively. From her references to her childhood it became evident that there had been considerable unhappiness and emotional deprivation, though she denied feeling any anger towards her parents. From an early age she had become self-sufficient and had taken responsibility for others; and she had developed a ‘protective shell’ for herself, she claimed.
Many people who react in this type of way to a loss, or an impending loss, manage like Mrs I to avoid losing control. Others are less successful and at times, and against their will, become tearful and upset. For example, Parkes (1972) describes Mrs F, a forty-five-year-old widow with three teenage children whose husband, ten years her senior, had died very suddenly.13
For three weeks after her loss Mrs F had felt ‘shocked’; but she had experienced no other emotion and, like Mrs I, had kept herself very busy. Nevertheless, she had been tense and restless, had had headaches and little appetite. At the end of three weeks, she became anxious and depressed and, to her great annoyance, broke down on occasion into uncontrollable tears. Later, however, she took over her husband’s business; and thereafter became engaged in what seemed a ceaseless battle to maintain her status and possessions. From the first she had been unable to discuss their father’s death with her children; nor could she confide in her mother. Instead, she remained tense and anxious, her headaches continued and she developed chronic indigestion. Relations with one of her daughters deteriorated badly.
In commenting on Mrs F’s inability to grieve, Parkes draws attention to four interrelated features of her personality: her image of herself as a poised, sophisticated woman, free of sentiment and able to control her own fate; her claim that her marriage had been one more of convenience than of love, which meant to her that her husband’s death had left her nothing to grieve about; her avowed atheism with its contempt for religious consolation and ritual; and her unwillingness to share thoughts and feelings with anyone.
Perhaps the most extreme case of absence of grief yet on record is that of a parent who participated in the same research project as Mrs QQ and Mrs I.14 This was Mr AA, the thirty-three-year-old father of a leukaemic child.
A salesman by occupation, Mr AA was jovial, responsive and overweight; and he was inclined to be excessively friendly and to work hard to impress. To the research workers, whom he tried to engage in long intellectual discussions, he was eager to be more helpful than was necessary. Yet, although he visited the hospital every day, he avoided spending time with his son. While his wife did the visiting, Mr AA socialized with other parents or watched television in the day-room. His absence from the ward, he explained, was because he found it so distressing to see all the other sick children.
One weekend his wife could not visit and Mr AA was left alone with his son, with whom he spent much longer than usual. During this weekend he had a ninety-minute interview with the psychiatrist who was expecting him on this occasion to reveal at least a little anxiety or distress. That was not so, however. Mr AA seemed exactly his usual self, and proceeded to describe how he preferred to be alone with his son because when his wife was not there the boy showed more interest in him. The nurses’ record of the weekend was that he had appeared in good spirits and had been as usual, pleasant and talkative. Thus to all appearances there was no evidence of any active grieving.
It will be remembered, however, that one of the aims of the project was to investigate the effects on a person’s endocrine secretion rates of his undergoing a prolonged stressful experience. Accordingly, throughout the time his son was ill, readings were being taken of the excretion rates of certain of Mr AA’s steroids. The results were dramatic. During the weekend when he was alone with his son the rate spiked to more than double its usual level. This finding strongly suggests that during the weekend certain physiological components of mourning were being activated even though the usual psychological and behavioural components were missing. In view of Mr AA’s earlier behaviour it came as no surprise that, when at length his son’s condition deteriorated and death was imminent, he found a good reason to stay away from the hospital.
Although the people I have been describing are averse to dwelling on the loss that they themselves are about to suffer or have suffered, and are thankful that they are not prone to distressing emotion like others, they are none the less apt, like Mrs I, to concern themselves deeply and often excessively with the welfare of other people. Often they select someone who has had a sad or difficult life, as a rule including a bereavement. The care they bestow may amount almost to an obsession; and it is given whether it is welcomed, which it may be, or not. It is given, also, whether the cared-for person has suffered real loss of some kind or is only believed to have done so. At its best this caring for another person may be of value to the cared-for, at least for a time. At its worst, it may result in an intensely possessive relationship which, whilst allegedly for the benefit of the cared-for, results in his becoming a prisoner. In addition, the compulsive caregiver may become jealous of the easy time the cared-for is thought to be having.
Because a compulsive caregiver seems to be attributing to the cared-for all the sadness and neediness that he is unable or unwilling to recognize in himself, the cared-for person can be regarded as standing vicariously for the one giving the care. Sometimes the term ‘projective identification’ is given to the psychological process that leads to this kind of relationship; but it is a term not used here because, like many similar terms, it is used in more than one sense and stems from and implies a theoretical paradigm different to the one adopted here.
Since it is usual for compulsive caregiving to develop initially during childhood as a result of experiences about which a good deal is now known, further discussion of the pattern and its psychopathology is postponed to later chapters see (Chapters 12, 19 and 21).
In sharp contrast to the tendency for chronic mourners to retain all the possessions of the deceased in a mummified condition ready for use immediately he returns, those who avoid grieving are likely to jettison clothes and other items that might remind them of the person they have lost. In a precipitate and unselective disposal items that others would value are consigned to oblivion.
Yet there are exceptions. Volkan (1972, 1975) describes a number of patients who, despite not having grieved a relative’s death, had none the less secretly retained certain items which had belonged to the relative. These items, perhaps a ring, a watch or a camera, or else a photograph or merely something that happened to be at hand at the time of the death, were kept especially safe but neither worn nor used. Either they were not looked at at all or else they were looked at only occasionally and in private. One man, who was 38 when his father died at a ripe age, kept his father’s old car and spent large sums on it to keep it in good order, despite never using it. A woman, Julia, in her early thirties when her mother died, retained, unused, a luxurious red gown which she had originally bought for herself but which had subsequently been pre-empted by her mother, with whom she had lived and whom she had cared for devotedly for many years.
In the latter case there was clear evidence that Julia was expecting her mother to return. During psychotherapy, begun eight months after bereavement, she described her special retention of the gown and how she imagined her mother in some way emerging from it. She also described dreams in which her mother, undisguised and living, appeared, and from which Julia awoke in a panic feeling that perhaps her mother ‘might not be gone’.15 In the case of the man, who also developed symptoms and who during psychotherapy told about his retention of his father’s car, Volkan presents no evidence of this kind. Yet, if the theory proposed is correct, we should expect to find that this man, too, was expecting that his father would return and would want to use the car.
Sooner or later some at least of those who avoid all conscious grieving break down—usually with some form of depression. That they should do so is not surprising; but the question arises why they should do so at the particular moment they do.
It is now well established that there are certain classes of event that can act as precipitants of breakdown. These include:
Each of these four classes of event, it should be noted, is readily overlooked even by someone who is knowledgeable of these precipitants. By someone ignorant of such possibilities and/or whose theoretical expectations divert his attention elsewhere there is no chance whatever of their being noted. For these reasons we have no information about the relative frequency with which events of each of these kinds act as precipitants.
For almost anyone who grieves a death each anniversary is likely to bring recurrence of the same thoughts and feelings as were experienced earlier. Those who become chronically depressed, we know, are likely to be especially upset at such times (Bornstein et al. 1973). This being so, it is no surprise that some of those who have never consciously grieved their loss should suddenly, and apparently inexplicably, develop a strong emotional reaction on such an occasion, despite the loss having occurred perhaps many years earlier. The following example is described by Raphael (1975):
Soon after the second anniversary of her husband’s death Mrs O presented in a state of psychotic depression. Prior to breakdown she had appeared, at least to her children, to be dealing well with her loss. She had neither cried nor spoken of her husband at any time since his death; but each morning she had placed his clothes out as usual, and each evening she had set his meal at the time of his expected return from work. The children described how proud they were of their mother’s fortitude and how they never referred to their father because they thought the two had been so close that it would be bad for their mother to be reminded of him. After her breakdown she confessed that, unknown to her children, she had carried on long conversations with her husband every night.
During therapy Mrs O was encouraged to talk of her husband and their relationship in considerable detail, aided by family photographs, and to express her feelings in an atmosphere in which they were accepted as natural. In this setting she wept for the first time. Initially she dwelt on her husband’s good qualities and insisted that he had met her every need, loved her and protected her. Only later was she able to admit how much she had always depended on him and how angry and helpless she had felt at what had seemed to her to be his desertion.
Although there is now an extensive literature on anniversary reactions, it is striking in how many of the cases reported the loss to which there is belated reaction is that of a parent during childhood or adolescence (see, for example, review by Pollock 1972).
All those who try to help people who are in psychological difficulties after a recent loss know how frequent it is for current grief to arouse, sometimes for the first time, grief for a loss sustained many years previously. Lindemann (1944) reports the case of a woman of 38 whose severe response to her mother’s recent death was deeply compounded by hitherto unexpressed grief for her brother who had died in tragic circumstances twenty years earlier.
Another example (taken from the experience of an acquaintance) is of a woman in her forties who found herself weeping bitterly after the death of her parakeet which had formerly belonged to her mother. Astonished that she should grieve so deeply, she soon realized that the recent loss had aroused grief for her mother who had died at a good age a couple of years previously and whom she had not mourned deeply. In view of the quick recognition of the connection and the subsequent time-limited response we may suppose this to have been a relatively healthy reaction.16
A probable explanation of the tendency for a recent loss to activate or reactivate grieving for a loss sustained earlier is that, when a person loses the figure to whom he is currently attached, it is natural for him to turn for comfort to an earlier attachment figure. If, however, the latter, for example a parent, is dead the pain of the earlier loss will be felt afresh (or possibly for the first time). Mourning the earlier loss therefore follows.17
As is the case with anniversary reactions, we find that a great deal of the literature about the way current losses can activate or reactivate grieving for an earlier loss refers to the loss of a parent, or perhaps of a sibling, sustained during childhood or adolescence. The same is true of the third and fourth classes of precipitant event. Because of that, further discussion of all these precipitants is postponed to a later chapter.
Many people who have failed to mourn the loss of someone important to them though they suffer no actual breakdown feel none the less deeply dissatisfied with their lives. Gradually they may come to realize that their personal relations are in some way empty, especially relations with members of the opposite sex and with children. The following account by a widow, quoted by Lindemann (1944), is typical: ‘I go through all the motions of living. I look after my children. I do my errands. I go to social functions, but it is like being in a play; it doesn’t really concern me. I can’t have any warm feelings. If I were to have any feelings at all I would be angry with everybody.’ Terms such as ‘depersonalization’ and ‘sense of unreality’ are used to describe these states of mind; and, when loss has occurred during childhood and absence of conscious grieving is long entrenched, the condition may be referred to by Winnicott’s term ‘false self’ see (Chapter 12).
It must be emphasized that the final remark of Lindemann’s patient—that were she to have any feelings at all she would be angry with everybody—is a half truth only. Anger there would certainly be, directed at the person she had lost. But in addition to anger, and at least as important if she were ever to feel herself again, would be for her to discover within herself also yearning for her husband and sorrow for his loss.
Because here also many such conditions are products more of childhood experience than of adult, further discussion is once again postponed.
In our discussion in Chapter 6 of the common responses to loss much attention was given to the continuing sense of the dead person’s presence; and it was emphasized that, whereas perhaps half of all bereaved people locate the dead person somewhere appropriate, for example in the grave or in his favourite chair, and experience him or her as a companion, a minority locate the dead person somewhere inappropriate, for example within an animal or physical object, or within another person, or within the bereaved him- or herself. Since it is only these inappropriate locations that can be regarded as pathological, the distinction is of key importance. Because the term identification has been used rather loosely to cover all these conditions and others besides, and has also accreted much complex theory, it is used here very sparingly.
Mislocations when established seem always to be associated with uncompleted mourning; most often they are part of chronic mourning. When the mislocation is within the self, a condition of hypochondria or hysteria may on occasion be diagnosed. When the mislocation is within another person a diagnosis of hysterical or psychopathic behaviour may be given. Such terms are of no great value. What matters is that the condition be recognized as one of failed mourning, and as the result of a mislocation of the lost person’s presence.
To regard some new person as in certain respects a substitute for someone lost is common and need not lead to any special problem (though there is always some danger that invidious comparisons will be made). To attribute to another person the complete personal identity of someone lost, however, is a very different matter because far-reaching distortions of the relationship become inevitable. This is particularly serious when the individual affected is a child; this is done, it seems likely, more frequently than within an adult, if only because it is easier to endow an infant with a ready-made identity drawn from another person than it is an adult whose own identity is already established. The ready-made identity attributed to an infant by a bereaved parent may not only be that of a dead sibling: it may be that of one of the child’s grandparents or that of his dead father or mother.
An example of a widow mislocating her husband in her young child is described briefly by Prugh and Harlow (1962, p. 38).
This woman’s husband, with whom she is said to have had a close relationship, died six months after she had given birth to a son who greatly resembled him. Thereafter her relationship to the boy was deeply influenced by her identification of him with her husband; for example, for several years she spent much time dressing him to look like his father. Not surprisingly difficulties developed between son and mother: later on he became rebellious, ran away and began associating with a delinquent group.
The difficulties this woman had in mourning her husband were thought to be connected with her own father having died when she was a young girl.
A 35-year-old widow whose relationship to her baby began in a similar way is reported by Raphael (1976).
At the time of her husband’s death following an operation, Mrs M was seven months pregnant with her first child. Soon afterwards the baby, a boy, was born prematurely. After Mrs M’s return from hospital with the baby the interviewer called. Although Mrs M cried briefly and sadly at times, all her thoughts were on the baby and it soon became evident that she saw the baby as a ‘reincarnation’ of her husband, a word she herself used. She insisted the baby had ‘long fingers just like his father’s and a face just like his father’s’ and that consequently her husband was still with her. Each time the interviewer sought to encourage her to express grief Mrs M insisted the baby represented a replacement of her husband.
In subsequent interviews18 Mrs M’s idealization both of her husband and the baby gave way to more realistic pictures of both, and also to a more realistic appreciation of her own feelings. She felt isolated and uncared for, she said, like ‘a ship without a rudder’, and she envied the baby for all the care and attention he was receiving. Subsequently her mourning progressed fairly favourably.
Examples of children whose psychiatric disturbances are traceable to their having been treated from conception onwards simply as replicas of dead siblings are given by Cain and Cain (1964). Deriving their data from a study of six children, four boys and two girls aged between seven and twelve years, these authors present the following history as fairly typical.
A child of latency age or early adolescence, with whom one or both parents has had an especially intense relationship, dies. His parents mourn this tragic loss and one or both develop a state of chronic mourning in which despair, bitter self-accusation, and persistent longing for and idealization of the dead child are prominent. A decision is then taken to have another child (in half the cases encouraged by their doctor in order to give the grieving parent something new to live for). In five of the six cases the parents already had other children and previously had had no intention of having more.
In none of the cases described, however, had the birth of the new child done much to ease the parents burden of chronic mourning. Indeed, the atmosphere of the homes seems to have remained funereal, with one or both parents still totally preoccupied by the child who had died and still wrestling incessantly with questions such as why had the death occurred and how would things have been had it not done so. Since the role in which the new child was cast was that of being a replica of the lost sibling, his every expression and performance was constantly compared with the parent’s image, strongly idealized, of the sibling. Similarities would be noted with satisfaction, differences ignored or else deplored. The parent’s insistence that the new child was a replica could persist even when he or she was of the wrong sex.
Inevitably the substitute child would be hedged around with restrictions lest he also contract an illness or incur an accident and die too. Every symptom, however trifling, would be treated as ominous, every hazard exaggerated. Occasionally a mother might enforce a restriction by threatening to kill herself were anything to happen to this child too.
The effects on these children of being treated thus had been calamitous. Never allowed an identity of their own, they had grown up knowing themselves to be in their parent’s eyes merely inadequate replicas of their dead siblings. Because, moreover, the originals had died, the substitute children confidently supposed they would die too. Meanwhile they were perpetually anxious, frightened like their parents of every ailment and hazard, and strongly bound to the parent’s apron-strings. Two of the children developed symptoms similar to those the sibling had had before he died: a boy whose brother had choked on a piece of bread suffered continually from a ‘clogged’ throat and gasped for air; a girl whose brother had died of leukaemia, during which he had experienced peculiar sensations in his arms, developed pains in her arms. Each of these children was approaching the age at which the sibling had died. The clinical states of the six are said to have ranged from ‘moderately severe neuroses to (two) psychoses’.
The parents, especially the mothers, who had treated their children in these highly pathogenic ways were thought by the authors to have shown various neurotic features before they had suffered the traumatic loss. Cain and Cain refer, first, to the ‘guilt-ridden, generally depressive, phobic and/or compulsive personalities’ of these mothers and, secondly, to the especially intense ‘narcissistic investment’ each had had in the child who had died. They were struck also by the number of losses these mothers had suffered during their own childhoods. As we see in Chapters 11 and 12, all these findings are characteristic of persons prone to develop chronic mourning.19
In making these generalizations Cain and Cain are keenly aware that they are based on data obtained long after the relevant events. They are aware also that the sample of children, because drawn from a psychiatric clinic, is inevitably biased, and can cast no light on the proportion of parents who, grieving a lost child, engage in this sort of behaviour. They note, too, that because of the personality problems of the parents, disturbances in their relationships with their children were likely to have occurred in any case. The field is one that clearly merits further research.
To locate a lost person’s presence within an animal or physical object may be thought unusual. Yet it may well be commoner than we know: for not only do a majority of people in the world believe in some form of reincarnation, often in animal form, but according to Gorer (1965) beliefs of this kind are held by about one in ten of native-born Britons today.
Mislocations of these kinds are illustrated by the case of Mrs P who at the age of 30 had been admitted to a psychiatric hospital because of a chronic emotional disturbance which had developed soon after her mother had died.20 The sequence of events was as follows:
When her mother died Mrs P consciously directed her search towards making contact with the departed spirit. In company with her sister she improvised a planchette with which she ‘received’ messages which she believed came from her mother.
At a seance she noticed a toby jug which seemed to resemble her mother. She felt that her mother’s spirit had entered into this jug and she persuaded her sister to give it to her. For some weeks she kept the jug near at hand and had a strong sense of the presence of her mother. However, the jug proved a mixed blessing since she found that she was both attracted and frightened by it. Her husband was exasperated by this behaviour and eventually, against her will, he smashed the jug. His wife noticed that the pieces, which she buried in the garden, ‘felt hot’—presumably a sign of life.
Mrs P did not give up her search. Shortly after the jug was broken she acquired a dog. Her mother had always said that if she was ever reincarnated it would be in the form of a dog. When I interviewed Mrs P three years later she said of the dog: ‘She’s not like any other animal. She does anything. She’ll only go for walks with me or my husband. She seems to eat all the things that mother used to eat. She doesn’t like men.’
Mrs P’s mother is described as having been an assertive and somewhat dominant woman, and Mrs P herself as having been a devoted daughter.
Mislocations of the dead person within the self take several forms; each of them leading to symptoms that can accurately be termed identificatory. One form is a conscious sense of his presence within. One of the London widows who had this experience is already referred to briefly in Chapter 6. Another, Mrs D, described her experience as follows: ‘At dawn, four days after my husband’s death, something suddenly moved in on me—invaded me—a presence, almost pushed me out of bed—terribly overwhelming.’ Thereafter she had a strong sense of her husband’s presence near her but not always ‘inside’ her. At the end of the year she claimed to be seeing many things ‘through his eyes’. This was a condition that may well have been felt by her as alien and which was almost certainly pathological since at the end of the year she was still socially isolated and full of self-reproach. ‘I feel criminal,’ she said, ‘terribly guilty.’ Throughout their married life, it emerged, she and her husband had been at odds and she had often regarded him as sacrificing the family’s interests by irresponsible behaviour (Parkes 1972, pp. 103, 137–8).
In discussing the responses of fighter pilots to the deaths in action of comrades in arms, Bond (1953) describes a condition which may be comparable to that of Mrs D, though less conscious. Whereas the usual response to a friend’s death was one of revenge, there were cases in which a pilot became convinced that he would suffer the same fate as his friend and he seemed thenceforward to court it. In describing a typical case, Bond continues: ‘He now is looking at his flying from an entirely different view. No longer is he a young and happy airman about to win great victory for his country but he is a young man going out to die in the exact replica of the way that a friend has died.’ After treating a number of these young men psychotherapeutically Bond concluded that the relationship between the survivor and the dead pilot had been ambivalent: ‘In each one of these boys it was not hard to find the angry thought or the selfish thought that gave them satisfaction in their friend’s death.’ Recognition of this and expression of grief led to recovery.
Another form of mislocation within the self results in the bereaved developing symptoms of certain kinds, often but not always symptoms similar to those of the bereaved’s last illness. In this form of disordered mourning the mislocation of the lost person’s presence within the self, if that is how it is to be understood, is completely unconscious.
Among those to give examples are Murray (1937) and Krupp (1965); Parkes (1972, pp. 114–16) also describes a number of cases. Of eleven patients seen by him who were in a psychiatric hospital because of hypochondriacal or hysterical symptoms that had developed within six months of a bereavement, four had pains resembling those of coronary thrombosis, one a pain simulating lung cancer, one a pain similar to one believed to have been suffered by a son killed in a car accident, three showed the effects of a stroke, and there was one case of recurrent vomiting. In all cases the symptoms had developed after a close relative had died from a condition the symptoms of which the patient’s own symptoms simulated.
A dramatic example described by Parkes is that of a woman who was already in psychotherapy at the time her father died, following a stroke which had paralysed the left side of his body. She had nursed him for several weeks before the end. The night after he died she had a dream (reported to her therapist next day) in which she saw her father lying in his coffin. He had reached up at her and had ‘stroked’ the left side of her body, whereupon she awoke to find the left side of her body paralysed. In this case the paralysis soon wore off and she had no further symptoms of that nature. As in so many other cases of disordered mourning, here too the previous relationship had not been happy; during psychotherapy she dwelt at length on how in earlier years her father had harmed her in various ways.
Disordered mourning is not confined to Western cultures. For example, Miller and Schoenfeld (1973) report that amongst the Navajo it is relatively common for depressive states, sometimes with hypochondriacal symptoms, to follow a bereavement; and, from the descriptions they give, it appears that these conditions differ in no way from the chronic mourning seen in the West. In illustration the authors give details of a 48-year-old married woman who was referred for psychiatric help because of pain in two parts of her body. First, there was a line of pain running from ear to ear across her forehead; and, secondly, there was pain running midline down her abdomen. The patient described the pains as being sharp. They had begun about three months after the death of her nephew whom she had raised and had regarded as a son. On investigation it turned out that an autopsy had been performed on the boy and that, afterwards, the patient had been the member of the family to dress the body. Her own midline abdominal pain corresponded with the midline autopsy incision, and her head pain corresponded in reverse with the routine incision used in order to examine the skull and brain.
It is to be noted that Navajo mourning customs are like those of their neighbours, the Hopi, described in Chapter 8, namely extremely brief and with expression of emotion so far as possible to be avoided. In addition, there is a taboo on touching the body, which this patient had broken. Although there is a Navajo ceremony designed to deal with such problems, she had refrained from asking for it because of her ostensible Christian beliefs. Nevertheless, she subsequently consulted a medicine man and went through the appropriate ceremonies. Thereafter she was freed of her symptoms.
Although euphoria is well recognized as an atypical response to loss, it does not occur commonly and there are no systematic studies of it. Such as there are show it to occur in at least two quite distinct forms.
In some cases a euphoric response to a death is associated with an emphatic refusal to believe that the death has occurred combined with a vivid sense of the dead person’s continuing presence. In other cases the reverse appears to hold: the loss is not only acknowledged but is claimed to be greatly to the advantage of the bereaved. No simple theory can cover both.
An example of the first type of response is given already in Chapter 6. When asked whether she felt her husband was near at hand one of the London widows interviewed by Parkes replied, ‘It’s not a sense of his presence—he’s here inside me. That’s why I’m happy all the time. It’s as if two people were one . . . Although I’m alone, we’re sort of together if you see what I mean . . . I don’t think I’ve got the will-power to carry on on my own, so he must be.’ In this last remark the despair and desperation latent in her response stand out bleakly.
A euphoric response of this kind is clearly unstable, and it is apt to collapse and to be replaced by intense grieving. In a small minority of cases, by contrast, the mood may persist, or recur, and hypomanic episodes may ensue. Although no such case has been described in any of the studies so far drawn upon, an example of the sequence is given by Rickarby (1977).
Mrs A was aged 44 with two grown-up children when her estranged husband was killed in a motor accident. When informed of the event, she showed no emotion and set about arranging the funeral, at which she was said to have been ‘falsely cheerful’. Six days after the bereavement she became agitated and overactive, with pressure of speech. In a euphoric state she talked much about her husband, idealizing him and their relationship, and maintained that he was listening to her.
After three weeks in a manic state during which she received drug treatment she became sad and voiced worries about the future. During therapeutic sessions she expressed much anger at her husband for having left her some eight months earlier, as well as anger and guilt about his death.
In fact the marriage had been extremely unhappy for many years, characterized by hostility and withdrawal on both sides. Mrs A was said to have found fault with everyone, to have rejected her husband and children, and to have lavished all her affection on an elderly dog. Three years earlier she had had a severe depressive illness.
In discussing this and three other patients in which there was a connection between a manic illness and a bereavement, Rickarby invokes the psychosomatic hypothesis, advanced by Bunney and others (1972), that a manic episode is a response to a stressful experience in a person genetically predisposed. In view of Mrs A’s personal relations it seems not unlikely that adverse experiences during her childhood had also contributed to her vulnerability.
That childhood loss can increase vulnerability is strongly suggested by a scrutiny of the series of hypomanic adults described by MacCurdy (1925). In several of these patients a prominent feature was their strong insistence on the continuing presence of a parent or sibling who had died many years previously during their (the patients’) childhood.
There are no examples in the studies drawn upon of a widow or widower claiming euphorically that the spouse’s death has been wholly to his or her advantage; though this may be an artifact due to such person’s having refused to participate. Useful information about such responses, however, is given by Weiss (1975b) in his study of married couples who have separated from each other, and it is useful to refer briefly to his findings (pp. 53–6). One example is of a woman in her early forties who had separated from her husband after nearly twenty years of marriage:
I found that I felt quite euphoric for about three months. I sort of did everything that I wanted to do. I hadn’t gone out much, so I went to the theatre. I didn’t do these things before I was married. I sat in a bar, drinking, just talking to anybody. I met just lots of different people.
After three months and having met just one or two people who were really interesting, I found it was an empty life. I realized that my family meant a great deal to me and that there was no family any more. There was just the kids and myself. And the things I had done with my husband, I could no longer do them.
So long as the euphoria lasted, Weiss observed, these individuals seemed to be unusually active and also effective, though latent tension and anxiety might also be evident. For example, an insistence that everything was fine might be belied by a rush of speech or a nervous mannerism.
In Weiss’s experience a euphoric response is extremely fragile and can be shattered by some minor setback or even by merely hearing that it might not last. Once ended it was likely to be replaced by separation distress, and pining for the former spouse.
In keeping with the view that the euphoria, however effective the activity may be to which it leads, is no more than skin deep are the reflections of those who have been through it. One woman, who during the first months of her separation had described how she was feeling on top of the world, two years later referred to those same first months as having been miserable.
In explanation of his findings Weiss suggests that euphoria reflects an ‘appraisal that the attachment figure is not needed after all, that one can do very well alone’ (p. 54). Its collapse he sees as due to ‘recognition that life without attachment is unsatisfying . . . The world appears suddenly barren, and the individual alone. The resultant distress may be the worse for following so closely a state in which the individual felt entirely self-sufficient’ (p. 56).21
When we compare the condition described by Weiss and the condition described earlier in which there is a vivid sense of the dead person as a living companion, it is clear that, although the moods appear similar, the two conditions are quite different in psychopathology. In the one, attachment desires continue to be directed towards the original figure who is claimed still to be meeting them. In the other, by contrast, desire for attachment is disowned and the claim to self-sufficiency is paramount. In these respects the condition has much in common with prolonged absence of grieving and its related condition of compulsive self-reliance.
This completes our description of the common variants of disordered mourning as they are seen in bereaved adults. Next we consider what we know of the conditions that tend to influence mourning to take a pathological course.
1 For the literature on physical ill health, see Parkes (1970c).
2 Other studies report an even higher incidence of depressive conditions present a year or so after bereavement. Thus of 132 widows in Boston, U.S.A., and 243 in Sydney, Australia, studied by Maddison and Viola (1968) by means of a questionnaire given thirteen months after bereavement, 22 per cent were suffering from depression, over half of whom were thought to be in need of medical treatment. Of 92 elderly widows and widowers, of mean age 61 years, studied in St Louis, Missouri and interviewed thirteen months after bereavement, 16 were showing many depressive symptoms, of whom twelve had been depressed continuously throughout the year (Bornstein et al. 1973).
3 The criteria for diagnosis of depression that they adopted were as follows: at the time of the interview the subject admitted to low mood characterized by feeling depressed, sad, despondent, discouraged, blue, etc., plus four of the following eight symptoms: (i) loss of appetite or weight, (ii) sleep difficulties, (iii) fatigue, (iv) agitation (feeling restless) or retardation, (v) loss of interest, (vi) difficulty in concentrating, (vii) feelings of guilt, (viii) wishing to be dead or thoughts of suicide.
4 Brown and Harris cite the failure of Clayton and her colleagues to classify these states as cases of clinical affective disorder as a startling example of the logical confusion that results whenever aetiological assumptions are built into diagnostic definitions instead of being examined independently.
5 This abbreviated account is taken from Wolff et al. (1964b) who refer to this mother as Mrs Q. Here she is referred to as Mrs QQ to differentiate her from another mother referred to already in this work as Mrs Q.
6 In this study as well as in other ones (e.g. Sachar et al. 1967, 1968) the rate of excretion of certain steroids is found to vary closely with the extent to which a person is attending to the stressful situation or, instead, is diverting his attention away from it. Though absolute levels vary much from person to person, the more effort a person is giving to dealing with the distressing situation the more likely is his excretion rate to be raised. By contrast, rates show no correlation with level of overt affect: thus they remain low both during chronic mourning, when overt affect tends to be high, and also during prolonged absence of grieving when there is little or no overt expression of affect. In keeping with these findings, Mrs QQ’s had a low excretion rate for these steroids during the period when her attention was directed away from her son and towards her own troubles but showed a marked rise during the final two days when her attitude changed and she became deeply concerned for him.
7 This patient was seen during an earlier study by Parkes (1965) in which he interviewed patients admitted to a psychiatric hospital for a condition, usually depressive, that had developed within six months of a bereavement. The account is taken, unaltered, from Parkes (1972, pp. 112–13).
8 Information about Mrs J is given in Parkes (1972, pp. 48, 81, 89 and 125), and in a personal communication. Further reference to the case will be found in Chapter 11.
9 This account is a rewritten version of one given by Parkes (1970a).
10 Gardner and Pritchard (1977) describe six cases in which the bereaved kept the deceased’s body in the house for periods ranging from one week to ten years. Of these individuals, two were manifestly psychotic and one was an elderly and eccentric widow who lived as a recluse. The other three, however, were single men whose mother, with whom each had always lived, had died. One of them, who had kept the body for two years before it was noticed by a window cleaner, had made his mother’s bedroom into a shrine and explained, ‘I couldn’t accept that she had died, I wanted things to go on the same.’
11 A fuller account is given in Bowlby (1963). Other findings from this case of a mother and son, referred to as Mrs Q and Stephen, are to be found in the second volume of this work, Chapters 15 and 20.
12 The account that follows, rewritten to avoid theory, is taken from the appendix to Wolff et al. (1964b).
13 This is a rewritten version of a case described by Parkes (1972, pp. 140–1).
14 This account, also rewritten, is from Wolff et al. (1964b).
15 Information about the relationship Julia had had with her mother is given in Chapter 12.
16 Not all responses to deaths of pets are healthy, however. Both Keddie (1977) and also Rynearson (1978) report cases of chronic disturbed mourning following the death of a pet. In the three cases of adult women described by Rynearson each of the patients seems to have turned to a pet during her childhood as a substitute for an extremely unhappy relationship with her mother. In each the disturbed reaction to the loss of the pet was a reflection of the intensely painful experiences each had had with her mother before she had finally despaired of that relationship and had turned instead to the pet.
17 I am indebted to Emmy Gut for suggesting this explanation.
18 Mrs M, who had also lost an elder brother a few months earlier and a close friend a few days later, was one of a group of widows predicted to have a bad outcome and who were willing to receive therapeutic interviews during the early months of bereavement. Raphael’s project is described in the latter half of the next chapter. The account of Mrs M given above is a rewritten version of Raphael’s.
19 James Barrie, the author of Peter Pan, tells how, from the age of six and a half, he attempted to fill the place of a dead elder brother whose loss had prostrated his mother. The elder brother, David, was killed in a skating accident when aged eleven. The second son in a family of eight, David had always been his mother’s favourite, and she had great ambitions for him. Quiet, studious and successful at school, he was destined for the ministry. After his sudden death mother took to her bed and became a permanent invalid, leaving an elder girl to act as mother to the younger children.
Barrie tells of his attempts to replace David. It began soon after the loss. His mother lay in bed holding the christening robe in which all the children had been baptized. James crept in and heard his mother enquire anxiously, ‘Is that you? Is that you?’ Believing her to be addressing his dead brother, James replied in a little lonely voice, ‘No, it’s no’ him, it’s just me.’ Subsequently his sister told him to get his mother to talk about David; and this she did, to the point where her preoccupation with the dead boy led James to feel totally excluded. Thereafter, in the words of his biographer, Janet Dunbar (1970, p. 22), James became ‘obsessed by the intense desire to become so like David that his mother would not see the difference’.
It seems that in establishing James’s role of impersonating David, his sister, his mother and he himself each played some part. For James, it is clear, the role gave him an access to his mother that he would not otherwise have had. As his mother’s confidant, moreover, he acted almost like a bereavement counsellor; and he listened intently to her long accounts of her own troubled childhood. When she was eight her own mother had died and she had taken on the role of ‘little mother’ to her father and younger brother, who was also called David. It should be remembered that, since the information given above comes from a book about his mother written by Barrie himself, it may well be biased, either wittingly or unwittingly.
Barrie grew up to have many emotional difficulties. His marriage remained unconsummated. On the one hand, he developed strong platonic relationships with married women; on the other, he became a compulsive caregiver, notably to five boys who had been left orphans and of whom he became fiercely possessive. A friend who knew him well wrote: ‘. . . he strikes me as more than old, in fact I doubt whether he ever was a boy’. It is not difficult to trace themes derived either from his mother’s childhood or from his own relationship with her in his plays and stories.
20 This account, unaltered, is taken from Parkes (1972, p. 60).
21 ‘Weiss hazards the view that in this condition attachment feelings have become directed towards the self, and he proposes ‘narcissistic attachment’ as a possible description. I doubt, however, whether this is a useful formulation. He gives no clear evidence that attachment feelings are in fact directed towards the self—only that the person concerned claims to be completely free of attachment to others and acts as though he were.