This article was downloaded by: [University of Stellenbosch] On: 05 September 2013, At: 12:33 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20 Older adults’ response to the loss of a spouse: The function of spirituality in understanding the grieving process Thecla Damianakis a b & Elsa Marziali b a School of Social Work, University of Windsor, Windsor, ON, Canada b KLAERU, Baycrest, University of Toronto, Toronto, ON, Canada Published online: 14 Oct 2011. To cite this article: Thecla Damianakis & Elsa Marziali (2012) Older adults’ response to the loss of a spouse: The function of spirituality in understanding the grieving process, Aging & Mental Health, 16:1, 57-66, DOI: 10.1080/13607863.2011.609531 To link to this article: http://dx.doi.org/10.1080/13607863.2011.609531 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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This article was downloaded by: [University of Stellenbosch]On: 05 September 2013, At: 12:33Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: MortimerHouse, 37-41 Mortimer Street, London W1T 3JH, UK
Aging & Mental HealthPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/camh20
Older adults’ response to the loss of a spouse: Thefunction of spirituality in understanding the grievingprocessThecla Damianakis a b & Elsa Marziali ba School of Social Work, University of Windsor, Windsor, ON, Canadab KLAERU, Baycrest, University of Toronto, Toronto, ON, CanadaPublished online: 14 Oct 2011.
To cite this article: Thecla Damianakis & Elsa Marziali (2012) Older adults’ response to the loss of a spouse:The function of spirituality in understanding the grieving process, Aging & Mental Health, 16:1, 57-66, DOI:10.1080/13607863.2011.609531
To link to this article: http://dx.doi.org/10.1080/13607863.2011.609531
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose ofthe Content. Any opinions and views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be reliedupon and should be independently verified with primary sources of information. Taylor and Francis shallnot be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and otherliabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to orarising out of the use of the Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Aging & Mental HealthVol. 16, No. 1, January 2012, 57–66
Older adults’ response to the loss of a spouse: The function of spirituality
in understanding the grieving process
Thecla Damianakisab* and Elsa Marzialib
aSchool of Social Work, University of Windsor, Windsor, ON, Canada; bKLAERU, Baycrest,University of Toronto, Toronto, ON, Canada
(Received 22 December 2010; final version received 22 July 2011)
Objective: The objective of this study was to examine the role of spirituality in helping older adults grieve the lossof a spouse in the context of a model of group psychotherapy.Methods: Twenty-four older adults, ranging in age from 65 to 82, whose spouses had died in the previous year,were assigned, in groups of six, to a 14-week group therapy intervention facilitated by trained, experiencedco-therapist social workers. All sessions were audio recorded.Results: Qualitative analysis of the four therapy groups at beginning, middle and ending sessions yielded salientthemes that illustrate associations between spirituality and shifts in self-identity, mourning the loss and social re-engagement.Discussion: Observed were within process acknowledgement of the role played by spiritual beliefs in mourning theloss of a spouse. Implications for group intervention for older adults grieving the loss of a spouse are discussed.
Keywords: older adults; bereavement; spirituality; social engagement; group psychotherapy
Introduction
Little is known about the function of spirituality inaiding older adults grieving the loss of a spouse.Spirituality is to be distinguished from religiosity.Bullis (1996) differentiates religion and spirituality inthe following way: ‘religion refers to the outward formof belief including rituals, dogmas and creeds, anddenominational identity’ while ‘spirituality refers to theinner feelings and experiences of the immediacy of ahigher power’ (p. 2). Koenig, McCullogh, and Larson(2001) define spirituality as the personal search foranswers regarding life, meaning and relationship, andin association with the sacred or transcendent.Spirituality implies ease with self-other reflection anddynamic interaction amongst one’s beliefs, values andbehaviours (Balk, 1999). Consequently, it can behypothesized that older adults who are spiritual maybe able to more effectively reflect on the intra andinterpersonal meanings of having lost a lifetime part-ner. A spiritual self may facilitate the grieving process,enhance self-other reflection and support the manage-ment of life’s challenges and opportunities.
Measuring spirituality is difficult as most scalesconfuse dimensions representing spirituality with thoseassociated with religiosity. However, a qualitativeanalysis of group therapy sessions with older adultsgrieving the loss of a spouse can generate operationalexpressions of spirituality both within group memberto member interactions as well as in the narrativesshared within the group. In addition, within analysis ofthe narratives it is possible to extract associations
between spirituality, a changing sense of self, andways of meeting life challenges in the absence of aspouse. The purpose of this qualitative study wasto illustrate associations between elements of spiritu-ality and bereaved older adults’ grieving processesincluding discussion of the implications for groupintervention programmes located in long-term caresettings.
Background
Bereavement and aging
Spousal bereavement is considered one of the mostdevastating losses during the life course which can leadto decreased well-being and functioning with theexperience of multiple negative emotions includingsadness, helplessness, fear, anger (Dutton & Zisook,2005) and depression (Segrist, 2008). Partner lossamong the elderly, in particular, can lead to a loss ofidentity resulting in increased levels of emotional andsocial loneliness (Balk, 1999; Ramsey & Blieszner,2000; van Baarsen, 2002). Symptoms typical of thegrieving process include confusion, health complaints,reduced immunological and neuroendocrine function-ing, and disrupted social and occupational functioning(Bonanno & Kaltman, 2001).
Religion, spirituality and bereavement
Results of several studies show that patternsof adjustment to bereavement are influenced by
various factors, including spirituality (Bisconti,Bergeman, & Boker, 2004). Walsh, King, Jones,Tookman, and Blizard (2002) found that bereavedindividuals with strong spiritual beliefs experience aquicker and more complete resolution of grief incomparison to those who did not hold spiritual beliefs.The ways in which religion and spirituality are consid-ered helpful during the bereavement process vary due toconceptual complexity and methodological flaws insampling, measurement and data analysis (Becker et al.,2007; Stroebe & Schut, 2001; Wortman & Park, 2008).Nonetheless, religion and spirituality are viewedas important constructs associated with bereave-ment and may act as buffers to decline in physi-cal and mental health status (Richardson, 2007).Through the use of cognitive assimilation strategies,positive coping comes into play as the individualattempts to frame the loss within a pre-existingreligious/spiritual schema (Marrone, 1999; Michael,Crowther, Schmid, & Allen, 2003; Pargament, 1997).Some bereaved individuals may acquire new religious/spiritual schemas in order to process the meanings oftheir losses (Marrone, 1999; Thompson, Noone, &Guarino, 2003).
Incorporating the notion of spirituality as animportant component in the grieving process integrateswell with theoretical frameworks that associate griev-ing with finding new meanings in life, enhancingoverall functioning in contrast to regressing to a lessthan optimal quality of life (Balk, 1999; Bonanno &Kaltman, 1999; Folkman, 1997; Wortman & Silver,2001). Furthermore, meaning making is consideredcentral in both adapting to stressful events, such asloss, as well as in experiencing growth and positivechanges (Kim, Kjervik, Belyea, & Choi, 2011).Meaning-based coping allows older adults to focuson ‘changing the meaning of the stressful situation’such as what happened and why (p. 201). In the copingand finding meaning, individuals are more likely tofocus on the positive changes and growth they see inthemselves even during difficult times (p. 202). Feifel(1977) suggests that one of the key goals of thebereavement process is to redefine the self and toreintegrate the revised self into everyday life andsociety. Not all bereaved individuals derive meaningfrom loss (Davis & Nolen-Hoeksema, 2001) and newmeanings vary across individuals despite sharing sim-ilar religious/spiritual beliefs (Golsworthy & Coyle,1999). Furthermore, there is accumulating evidencethat suggests a role for resiliency and positive emo-tions in managing the process of coping with the loss ofa significant other (Bonanno, Wortman, & Nesse,2004; Collins & Smyer, 2005; Ong, Bergeman, &Bisconti, 2004).
Older adults spirituality and bereavement
Religion and spirituality are significantly importantin the lives of older adults (Benjamins, 2004;Benjamins & Finlayson, 2007; Golsworthy & Coyle,
1999; Koenig et al., 2001; Krause, 2010; Moberg, 2008;Murdock, 2005; Ramsey & Blieszner, 2000).Spirituality can have a positive impact on managingthe bereavement process and a belief in the afterlifecan generate a greater acceptance of death of aspouse (Dezutter et al., 2009; Walsh et al., 2002).Also, involvement in religious rituals and activities canenhance coping with life challenges and garner inter-personal support (Bonanno et al., 2002; Koenig et al.,2001; Krause, 2010).
Clinical interventions for bereaving spouses
Studies of the benefits (death acceptance; expression ofemotion; improved coping; enhanced sense of self andgrowth; personal meaning) of clinical bereavementintervention programs (Bonanno et al., 2004; Schut,Stroebe, van den Bout, & Terheggen, 2001) andbereavement therapy groups (Wortman & Park,2008) in particular, are inconclusive (Kato & Mann,1999; Stroebe, Hansson, & Stroebe, 1993). Reviews ofstudies of models of intervention for grieving adultsshow that the outcome results vary according to thestudies’ theoretical frameworks, models of interven-tion, duration of the intervention and therapist skills(Geron, Ginzburg, & Solomon, 2003). For example,Kato and Mann (1999) found that six of eightbereavement groups studied failed to show positiveoutcome effects; the group intervention strategiesvaried; some used educational guidelines while othersused cognitive restructuring techniques. Post losstiming of engagement in a bereavement therapygroup has been associated with reported benefits.Stewart, Craig, MacPherson, and Alexander (2001)showed that widows who joined an eight week groupintervention program within the first year post loss ofthe spouse showed greater improvement in quality oflife compared with a no-treatment control group.A meta-analysis (Currier, Neimeyer, & Berman,2008) of 61 randomized controlled studies of bereave-ment interventions with a range of age and gendergroups found ‘a small but statistically significanteffect immediately following intervention but thattherapeutic outcomes failed to differ reliably fromzero at later follow-up assessments’ (p. 655). Theauthors noted persons categorized as ‘universal’ interms of (bereavement experiences) achieved fewer ifany benefits compared with those categorized as‘selective’ bereavement experiences i.e. in a higherdistress risk group. The authors note that the paucityof favourable response to psychotherapy by thebereaved differs significantly from the positive out-come responses of all patient groups to supportivepsychotherapy.
Of importance is the fact that of all the studiesreviewed there were no reports of qualitative analysisof group process. Also, to what degree spirituality orreligiosity is part of the therapeutic dialogue isunknown. Little is known about the process of group
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therapy in terms of understanding the dynamics ofspiritual belief systems, self-identity transformationsand re-engagement in life activities following olderadults’ loss of a spouse. Detailed analysis of thetherapeutic process yields descriptions of what actuallyis transacted in therapy groups for the bereaved; thefocus of the discussion across stages of group devel-opment, group facilitators therapeutic strategies, indi-vidual participant responses with regard to insightsgained and impact on managing the loss of a loved one.There are no manuals that guide group therapistsfacilitation of therapy groups with bereaved olderadults. The results of qualitative analyses contribute togenerating a preliminary guide for therapists interestedin working with the bereaved in a group therapeuticformat. Also, the detailed analysis shows the processthrough which individual group members make gainsin terms of getting on with their lives following the lossof a significant other. Through the qualitative analysisof actual sessions of four therapy groups with bereavedolder adult spouses our objective was to extract themesthat illustrate the interplay of spirituality, the grievingprocess and addressing the challenges of living withoutone’s lifetime partner.
Methods
Twenty-four older adults grieving the loss of a spousewere invited to join therapy groups (in groups of six)facilitated by trained social work co-therapists. Socialworkers and other health care professionals from amulti-service geriatric care institution located in a largeurban centre referred 24 participants who hadexpressed an interest in participating in a weeklypsychotherapeutic group intervention to deal withrecent spousal loss.
The group intervention programme was supportedby a multi-care geriatric service hospital. The hosthospital is a publically funded and privately endowedJewish healthcare facility for older adults. The facilityprovides in-patient care and out-patient services dailyto approximately 2500 people including wellnessprogrammes, residential housing, outpatient clinics,research laboratories, a 472-bed nursing home and a300-bed complex continuing care hospital facility withan acute care unit. Social work therapists interviewedpotential group members. All participants were white,English speaking, adults 65 years or older whosespouses had died in the previous year and who werestruggling with grieving (Table 1). Frequently, thespouses were encouraged to seek help by adult childrenwho were concerned about their parent’s physical andmental health status following the death of the spouse.Excluded were spouses who were diagnosed with amental illness for which they were receiving treatment,with only one applicant being excluded for this reason.Participants learned about the project through the hosthospital clinicians, community health agencies and thehost hospital newsletter. The groups were gender
balanced and ages ranged between 65 and 82.One person had a spouse who died at the institution.Participants were community dwelling older adults;one participant lived on premises in the host hospital’sindependent living residence and several had previ-ously been involved in other programmes (e.g. dayhospital, or out-patient clinics). Two participantsdropped out of the group. One participant requestedadditional individual counselling services but remainedin the group. Length of time since spouse’s death wassix months to a year.
Group psychodynamic psychotherapy, based onYalom’s (Yalom & Leszcz, 2005) approach was used.The aim of these closed groups was to providepsychotherapy to facilitate bereaved spouse’s grievingprocess and enhance coping skills following the loss.The goals included: (a) understanding the meanings ofchange in the bereaved older adult, (b) relinquishingexpectations that cannot be met and (c) accommodat-ing the realities of living without the spouse andmoving on in their own lives. Session topics were thosetypically associated with bereavement groups; loss,isolation, loneliness, communication with the deceased,impact on self-identity, coping style, social stigma, lackof social support, need for change, engagement in newrelationships and the normalization of the grievingprocess. While there was no specific focus on thediscussion of spirituality, religion or meaning of thegrieving process, group participants introduced thesetopics in the course of the group interactive process.The co-therapists received consultation/supervisionfollowing each group session with the aim of identify-ing key group interaction issues that either enhanced ordeterred group cohesion and progress. All of thetherapists were trained and experienced in clinicalpractice with older adult clients. The therapy consistedof 14 weekly, one and half hour group sessions locatedin a long-term care setting. All sessions were audiorecorded with participant signed consent.
For each group audio recordings of two early, twomiddle and two late sessions were submitted toqualitative analysis. The aim was to illuminate the
Table 1. Demographics of group participants (n¼ 24).
Variable n
Gender Women 13Men 11
Age (years) 60–70 1070–80 1280 and over 2
Time of spousesdeath
Six months 11One year 12Over one year 1
Participant’sresidence
Community 23Independent living
(on premises)1
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subjective experiences of bereaved older adults withinthe group process (Sandelowski, 2000). A contentanalysis of the four groups was completed usingmethods by Berg (1995) and Sandelowski (2000).Codes were developed, and initial themes recorded,noting similarities and differences and any negativecases across responses. Researcher notes providedcareful documentation for selection and developmentof codes and themes across responses while focusing onthe stages of group development (e.g. beginning,middle and ending group phases). Following thisinitial analysis, a second coding strategy focused ondetecting expressions of spirituality or religiosity andwhether either was associated with themes extractedfrom analysis of the group narratives. Operationaldefinitions of spirituality and religion from the litera-ture guided selection of codes. Spirituality was distin-guished from religiosity: ‘religion refers to the outwardform of belief including rituals, dogmas and creeds,and denominational identity’ while ‘spirituality refersto the inner feelings and experiences of the immediacyof a higher power’ (Bullis, 1996, p. 2). Also, Koeniget al. (2001) define spirituality as the personal searchfor answers regarding life, meaning and relationship,and in association with the sacred or transcendent.In this respect, meaning making was integral toparticipant’s subjective experiences and defined pur-pose in their lives, regardless of whether their thoughtswere framed in religious or spiritual terms/behaviours.We also identified what codes and themes emergedbased on the stage of group development and interac-tions among group members. For example, did refer-ences to spirituality and/or religiosity differ during andacross different phases of group process – beginningbonding phase, middle intensive working phase andending phase. A second researcher independentlycoded the transcriptions using the operational defini-tions of spirituality and religion. The two researchersconducted frequent reviews and discussions as toconsistencies and discrepancies of their codes, themesand excerpts until consensus was reached. The analyseswere systematic and verifiable moving from the rawdata, descriptive accounts, to identifying specific con-nections between spirituality and the grieving process.Excerpts from the transcripts illustrated the associa-tions among spirituality, religiosity, loss and grieving,self-identity and social engagement.
Results
Spirituality supports participants’ reflections of theirself-identity and life purpose
The group members brought up several themes inrelation to their spirituality and identity in all groupphases. These themes included their spiritual pur-pose for being here, experience of a loss of self, senseof self-identity before and after the loss of a spouse.In this discussion, some group members directly usedthe term ‘spiritual’; others used words that reflected
questions of why they continue to exist while theirspouse is gone: ‘nothing matters, the person who youspent your life with is gone’ or ‘I couldn’t care less,what difference does it make now? I don’t even look inthe mirror anymore. Who cares, who’s going to seeme?’ (Session 1, Bereavement group 3). Anotherparticipant questioned her changing identity alongsideher spiritual purpose: ‘Who am I becoming?An independent person? . . .Looking back on the spir-itual side. I am always asking why am I here’(Session 2, Bereavement group 2).
During phase I of the group process, participants’reflections on their sense of purpose lead to furtherquestioning and cognitive confusion on issues of self-identity, who they are currently without caring fortheir spouse. For example, one group member dis-cussed how she has changed since the death of herspouse and her feelings about these changes:
I’m shocked . . . I thought if it happened I’d be okayI thought I’d be the same person who was taking careof him but I’m not. That’s the worst part. That I’m notsick, I’m confused. I can’t keep track of stuff I feel thatI’m making a mess of things. I don’t recognize whoI am and that’s very frightening because I just don’tknow what to do about it. (Session 1, Bereavementgroup 2)
Furthermore, several participants reflected on thecircumstances of the death. Many told stories of theirsurprise and disbelief at their loss because theyanticipated the spouse returning home following hos-pitalization: ‘We never believed she would die. [We]were told by the doctor that she would improve. [The]plan [was] to bring her [here]’. Another woman said:‘My husband wasn’t supposed to die. He went forsurgery for aneurysm. Got an infection. Was 4 monthsin ICU. It wasn’t supposed to happen’, and another:‘He was supposed to come home. He was fine. It’s justlike you can’t believe it. It’s your worse nightmare, it’ssurreal’ (Session 2, Bereavement group 2).
The theme of loss of self was evidenced in thecomparison of one’s identity before and after the lossof a spouse; this came through several times in Phase IIduring group members reflections of a range ofemotions. For example, one group member described,‘I was a very active joyful full of life, full of jokes. . .wewere a very pleasant [couple] to meet us’ (Session 2,Bereavement group 2). In phase II, group membersprocessed a number of areas related to their identityand how it connected to feeling as if they have lost partof their life:
My husband and I were so close it’s like we were onepeople, when you get married you’re like oneperson . . . It’s part of your life it’s part of you . . . It’slike you lost a part of your life . . . you lost a part ofyou . . . (Session 5, Bereavement group 2)
In addition, in the early stages, participants beganto ask about gender differences in the grieving ofemotions. For example, some women associated theirrole as nurturers and carers with the loss they were nowexperiencing. One participant specifically spoke
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about her now lack of interest in cooking: ‘Cooking. Iassociate it with my husband. Going food shopping Ihave my biggest nervous breakdown then’. Anotherwoman realized that her role as wife and mother lefther with little time for self-care: ‘Unfortunately, I wasso involved with my husband and my kids andgrandchildren, I really didn’t spend time with myfriends which I should have done. Cause now whenI really could use a friend, I don’t have a friend’.Another participant agreed with this sentiment(Session 3, Bereavement group 2).
In another group, one participant said, ‘men don’tshow their emotions, they feel it but they don’t showthem in the same way’, followed by another participantwho said, ‘it all depends on the individual. There’s menthat can be more emotional than even women. It alldepends on the person and the circumstances’ (Session4, Bereavement group 3). Some participants, both menand women, felt guilt that they did not do enough incaring for their spouse: ‘He slipped through the cracksat [name of hospital]. Now I’m feeling guilty thatI could have done more. I’m not grumbling. I’m upsetbecause of the way he died. . .I’m sorry that I wasn’tmore demanding’.
Overall, participants reflected a great deal ofstrength and resiliency in coping with their significantloss. In a few cases, participants’ excerpts reflectedthree views with respect to coping and personalmeaning: (a) a renewed competency; (b) an accommo-dating function and (c) a sense of personal strength orresilience to move forward and maintain a positiveperspective. For example, a younger older adult foundrenewed competency: ‘I feel so good because I’ve beentalking about doing yoga for years and I didn’t. . . andnow I finally did something’ (Session 5, BereavementGroup 2) whereas another older adult reflected in thisway: ‘We would have been married fifty four years.That was a long time. That was my life. So I’ve livedmy life. That’s how I feel’ (Session 7, Bereavementgroup 3). The majority of participants highlighted theirpersonal resiliency regardless of their age, for example:‘You’re as old as you think you are’ (Session 5,Bereavement group 3), ‘I felt that I made some positivesteps forward’ and ‘I can think of him now withhumour, not with heartache...because I’m doing thingsI’ve wanted to do for a long time and I just keptdelaying them’ (Session 11, Bereavement group 1).
Spirituality supports the belief that the relationshipendures
Belief that the relationship persists is reflected incommunication with the loved one after their death.Communication after death commonly provides thebereaved spouse with a source of comfort by main-taining a connection following loss; it is the belief orawareness of another presence or spiritual life (Park &Benore, 2004; Russac, Streighner, & Canto, 2000).This theme was brought up several times during all
three group phases, ‘is there a way that you can stilltalk to them and still have them in your life?’ Forexample, one group member discussed a dream theyhad involving a conversation with their spouse whichprovided great comfort (Session 2, Bereavement group4). Participants’ belief that there existed a spiritualpresence helped deal with the most prominent theme ofpersonal loss, social loneliness and lack of socialengagement. One group member stated, ‘Maybe I’mnot alone but when I’m sitting at home, it’s not even ahome anymore. . . it’s just a place where I live’ (Session1, Bereavement group 3). Another participant stated,‘And I said to him, ‘what are you doing dear?’ And hesaid, he doesn’t like being alone. But that could havebeen downstairs, you know in the den because he reallydidn’t like being alone’ (Session 2, Bereavement group3) or ‘And you know, there’s nobody to talk to, so Italk to a picture and tell [my spouse] what I think’(Session 1, Bereavement group 3). One bereavedspouse used videos to feel close to his deceasedspouse, ‘I ordered three tapes of her so wheneverI want I can see her not only on the picture butworking [in the symphony]. . .’ (Session 2, Bereavementgroup 2).
A spiritual void was experienced alongside a loss ofself and social disengagement
The lack of friendships outside of the couple relation-ship contributed to group members’ loneliness andawareness of their current social disengagement.One group member stated:
And, uh, unfortunately I was so involved with myhusband and my kids, and my grandchildren, what-ever, and I just, um, I didn’t really spend the time withfriends which I should have done. Cause now whenI really could use a friend, I don’t have a friend.(Session 1, Bereavement group 3)
The theme of a changing and shifting identitycontributed to feeling lost in the world and to groupmembers’ loss of a sense of purpose, even in theirfamiliar surroundings, such as their own home.One participant articulated the extent of her pain anddifficulty to move forward and relate to herself as awidowed person: ‘I wish to die. I don’t know how to doit with, how to do it with me’ (Session 7, Bereavementgroup 3). One group member stated, ‘If I’m at homealone, I feel that nobody wants me anymore, nobodycares about me anymore, I’m lost’ (Session 5,Bereavement group 2). Another group memberphrased it in religious terms in trying to understandlife’s painful purpose: ‘I can’t understand the purposeof all this pain. It seems God made some mistakes here.Intellectually, I understand what they say is thepurpose. It’s so painful that you don’t want to getnear another person’ (Session 8, Bereavement group 4).Another group member expressed a lack of purpose inher activities: ‘Friday night we did have Chanukah.I cooked up a storm and took it to my daughters.
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It was pleasant but purposeless for me. I’m just doingthese things but there’s no heartfelt satisfaction’(Session 5, Bereavement group 2). Several groupmembers experienced a strong personal void evenamongst family, ‘I mean I’m not alone in the house,I have my sons, but there’s a tremendous void, at nightthe same thing’ (Session 5, Bereavement group 3).And another group member echoed a tone of empti-ness or ‘nothing[ness]’ with questions related to life’smeaning and purpose: ‘But then I come home youknow. . .there’s just nothing. It’s like that song, Is ThatAll There Is?’ (Session 7, Bereavement group 4).
Spiritual and/or religious practices and ritualsenhanced the grieving process
Participants spoke of a number of rituals and/orspiritual–religious practices which enhanced theirgrieving process i.e., facilitated emotional processing,reinforced their sense of identity, relationship andsocial engagement. Spiritual behaviour included thespiritual practices or actions engaged in rituals at thetime of death and burials; visiting cemeteries; prayer,meditation, or worship; including private and public,organizational and non-organizational (Nelson-Becker, Nakashima, & Canda, 2007; Richards &Folkman, 1997). This was in direct contrast to thosetimes when group members stated they ‘wished theycould cry’ and kept busy to avoid processing theirfeelings of pain and loss.
Participants’ demonstrated how spiritual or reli-gious rituals enhanced the grieving process by helpingto express a number of emotions such as anger andloss, at times in connection with physical symptoms.For example, ‘So I knew my husband’s picturewas there in the ritual so I told him he has a nerve’(Session 6, Bereavement group 3). To which the othergroup member replied, ‘I was at the cemetery yesterdayactually and at first I wasn’t angry. I didn’t even knowwhat to say to him and then I said, ‘‘I don’t know whatto say to you. Look what you have done’’’ (Session 7,Bereavement group 3). Another group member joinsthe discussion, ‘this week we were lighting Chanukahcandles, that really got to me and upset my stomachand the whole thing [of grieving] started all over again’(Session 7, Bereavement group 3).
Spiritual behaviour was identified by anothergroup member by going to the Synagogue to sayKaddish; this provided her with structure during thegrieving process, ‘Second day I go, everyday I go to theSynagogue to say Kaddish. I have to say Kaddisheleven months’ (Session 2, Bereavement group 3).When there was a ‘reaching out’ by religious orspiritual community members this also providedsocial support and maintained engagement, ‘And oneof them immediately came up to me at the funeraland said that he wanted to say Kaddish for him,since he goes to Shul three times a day. So all that stuffgives me a lift’. Rituals enacted privately by the
bereaved partner after shared rituals emerged.Rituals of going to the cemetery were discussed.For example, one group member talked about howlong they had to wait before visiting the cemetery,‘My son told me you don’t go for a year’ (Session 2,Bereavement group 2). One participant said shehonours her spouse by sending out pictures of himwith other members of the family: ‘I took pictures.This Christmas, I sent everyone the picture of themwith Frank’ (Session 5, Bereavement group 1).Another group member discussed visiting theirspouse’s grave, ‘I have been quite a few times beforethey put the stone up. My eldest one finds it comfort-able going. He doesn’t like to go to Shul because itbrings up all sorts of painful memories but he finds it’sa comfort to go to the cemetery’ (Session 2,Bereavement group 2).
Moving forward: Creating meaning and purpose,a new or continued self, and social re-engagement
Participants’ ability to ascribe meaning and purpose totheir lives in the bereavement process helped facilitatetheir efforts to move forward. In the later stage,participants frequently related their meaning makingprocess to a feeling of belonging, entering newrelationships, social re-engagement and a changed orrenewed self. With regards to belonging, one groupmember focused on being around other people andstaying socially engaged, ‘You have to be with people.You have to belong. . .you have to be with others’(Session 7, Bereavement group 1). Another groupmember talked about getting to a point where he hasinvited friends over for coffee – which he called‘unbelievable’. He viewed this as moving ahead andother group members commended him for his progress(Session 11, Bereavement group 2).
Themes of loss of purpose and meaning in relationto a loss of self-identity decreased significantly duringphase III. The themes related to identity that appearedin phase III included either or both a continuity of selfand a changed identity before and after the loss of one’sspouse. The therapist’s interventions included helpingmembers reconcile their painful and significant loss andgrief with a sense of either a new or continuedunderstanding of self in relationship to a renewedmeaning and purpose. For instance, several groupmembers identified a changed self by describing the newtasks normally completed by their spouse which posedchallenges and new meanings, ‘I never planted before inmy life since [name of spouse] used to and all of asudden I planted this year’, or another group member,‘I know how to boil water, how to cook an egg. . .I’mlearning’. These new ‘tasks were not like before to keepbusy and avoid feeling the loss’ but rather offered ‘newvalue, direction and interest’. At other times thetherapist emphasized the continuity of the self,‘So what aspects of yourself remain the same?’As one group member replied, ‘I was a very take
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charge kind of person, very assertive then and I still am,nothing has changed in me like that’ (Session 11,Bereavement group 2).
Discussions of remarrying or beginning lovingrelationships came out during phase II, ‘No, I’vebeen a loner all my life and other than my wife well I’vebeen a loner so. I know my wife told me that if I wait,I should wait about a year and then go out looking forwomen’ (Session 5, Bereavement group 3). However,several members felt guilt at this prospect (e.g., ‘whenI’’ laughing, I feel guilty’ or ‘I have to make it okay tofeel good and purposeful again to someone’), did notfeel ready or see the likelihood they will enter into anew relationship, ‘I’m not necessarily looking for amale companion at this point. . .I don’t want to gothere’ (Session 5, Bereavement group 3). In phase III,this theme further reflected participants’ efforts toreconcile their loss and grief with honouring theuniqueness of the deceased spouse and the lifetimethey have shared together gave new meaning andpurpose to moving forward. For example, one womandiscussed her attempt to spend time with another man,‘We had a group of friends. One was a couple, he askedme out and I went. . .but there is no one like myhusband’ (Session 11, Bereavement group 1). Anothergroup member discussed how one can both connectwith new people and still honour their spouse:‘A friend of mine has now remarried but he stillgoes to his late wife’s grave with flowers everyday’(Session 11, Bereavement group 2).
The theme of moving forward presented itself inseveral ways during phases II and III; beginning a newchapter in one’s life, having the desire to continue togrow and in their later years, remaining active andbusy, and the belief that time will heal. Beginning anew chapter in one’s life emerged in many participants’narratives, ‘It’s a new life, you close one chapter andstart another’ (Session 7, Bereavement group 2) or‘moving on does not mean forgetting’ (Session 10,Bereavement group 3) or another participant, ‘myhouse doesn’t have the same meaning for me. So Idecided to move. . .to start something new. . .but you gowith your memories’ (Session 9, Bereavement group 2).In an effort to re-establish personal meaning andpurpose and to positively move forward through theirsignificant loss, some group members reframed theirlife as an older person choosing to continue to remainactive and engaged, ‘my life has changed enormously.I’m not ready to sit back and, you know, let time pass.I’m always an active person; enjoy going and doingand I get invited, I’m out all the time’ (Session 5,Bereavement group 3). Another participant wanted tobecome more involved following the loss of her spousein a way that reflected a meaningful use of her time andher personal and social value in her later years:
I want involvement with people . . . I found it verydepressing when I felt that my friends were looking atme as if I was a burden. What should we do with old[Jean]?. . . . . . I’m not just looking to fill thetime . . . (Session 13, Bereavement group 2)
The belief that time would help with healing theloss was brought up during phase II: ‘When I’m home Ihave memories. But the last time I was at home, I feltbetter, not like the first time. I think that time is thebest medicine for all of us’ (Session 5, Bereavementgroup 3).
Discussion
The results of this study highlighted the subjectiveexperiences of 24 older bereaved adults, ranging in agefrom 65 to 82 who had lost their spouse from sixmonths to one year, experiencing normal grief process.Group members revealed a number of themes thatemerged within a model of psychotherapeutic groupintervention which was located in a long-term carefacility over the course of 14 weeks.
Our results are consistent with previous studieswhere religion and spirituality is recognized as having asignificant role in the lives of older adults (Benjamins,2004; Benjamins & Finlayson, 2007; Golsworthy &Coyle, 1999; Koenig et al., 2001; Krause, 2010;Moberg, 2008; Murdock, 2005; Ramsey & Blieszner,2000). Several studies show that patterns of adjustmentto bereavement (i.e. quicker and more completeresolution of grief) are influenced by various factors,including spirituality (Bisconti et al., 2004; Walsh et al.,2002) alongside the use of cognitive assimilationstrategies which may reframe the loss within a pre-existing religious/spiritual schema in order to processthe meanings of the loss which can then aid positivecoping (Marrone, 1999; Michael et al., 2003;Pargament, 1997; Thompson et al., 2003). Less under-stood, however, are the ways in which participants’subjective experiences of spirituality impacts theirexperience of themselves and their identity in socialcontext.
In this study, participants’ highlighted five themespertaining to spirituality and/or religiosity and theways they reframed their losses: (a) spirituality sup-ports participants’ reflections of their self-identity andlife purpose, (b) spirituality supports the belief that therelationship endures, (c) a spiritual void was experi-enced alongside a loss of self and social disengagement,(d) spiritual and/or religious practices and ritualsenhanced the grieving process and (e) moving forwardand creating renewed purpose, a new or continuedunderstanding of the self, and social re-engagement.Participants provided subjective accounts of the waysin which spirituality appeared to support their reflec-tions of their self-identity, meanings of life purpose andquestions as to their role in the world without theirspouse. For example, references to spiritualityappeared across all group phases, but with greateremotional depth in the middle or working phase of thegroup. Feifel (1977) also states that one of the keygoals of the bereavement process is to redefine the selfand to reintegrate the revised self into everyday life andsociety. Several participants talked about moving
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forward by becoming more socially engaged, but feltguilty at this prospect. In the final phase of the group,some members appeared to manage their guilt, becamemore socially active while continuing to honour theirdeceased spouse. Furthermore, the therapy did notfocus on spirituality and/or religiosity and its potentialbenefits – rather, as would happen in any psycho-dynamic group therapy approach (Yalom) the groupmembers talked about their emotional and behaviouralreactions to the loss of a spouse. From our analysis ofthat dialogue we extracted the spirituality and/orreligiosity themes that appeared relevant to the partic-ipants in their managing the loss of a significant otherand/or in creating meaning and purpose.
At times, spirituality is defined broadly as part ofcreating personal meaning and purpose in one’s life oras the personal search for answers regarding life,meaning and relationship, and in association with thesacred or transcendent (Koenig et al., 2001). In thisstudy, participant’s excerpts demonstrate meaningmaking was integral to participant’s subjective experi-ences and defined purpose in their lives, regardless ofwhether their thoughts were framed in religious orspiritual terms/behaviours. Consistent with other stud-ies, participants’ ability to ascribe meaning andpurpose to their lives during the grieving processhelped their efforts to move forward (Kim et al., 2011).However, in ‘working through’ these feelings in asupportive context of the group psychotherapy allowedfor the fuller recognition, expression and integration ofboth the emotional, psychological and spiritual aspectsof the grieving process (Stroebe, 1992; Yalom &Vinogradov, 1988).
Overall, participants questioned, in the early stagesof the groups, whether gender might affect expressionof emotions evoked by the grieving process. However,there were no gender differences and both men andwomen spoke of the themes represented in thefindings. This may have been influenced by thevoluntary nature of the psychotherapeutic group andmembers’ choice to participate in order to cope withtheir loss. Our results demonstrated older adults’overall strength and resiliency in dealing with theirsignificant loss and any age differences between groupmembers did not affect the broader themes reported onthe function of spirituality in the grieving process. In afew cases, our findings did suggest some age differenceswith respect to coping strategies in constructingpersonal meaning: those in the younger older adultgroup found renewed competency while those in theolder adult group reflected a more accommodatingfunction.
Theoretical models for understanding the grievingprocess have contributed to the development ofbereavement theory and intervention practices thatsupport the notion that ‘working through’ grief relatedemotions is necessary in order to attain eventual griefresolution. This is consistent with our group data.Participants’ spoke of their feeling out of control orfrozen in their emotions pre group. The participants’
group excerpts linked spirituality with participants’emotions and self-identity i.e., temporary cognitivedisorganization of both personal and social construc-tions of who they are. Even ongoing relationships withchildren and others did not satisfy the void they wereexperiencing. Therapists could continue to explorethese ‘crisis of meaning’ in the beginning and workingphases of the group process towards new meanings aswell as personal and social re-engagement as becameevident in the later stages of the group process.Therapists ideally would not prematurely judge ormisdiagnose shifts of identity and accompanyingquestions of meaning as negative to the group processpotentially limiting the full benefits and depth of griefwork. In this study, spiritual and/or religious practicesand rituals enhanced the grieving process for manyparticipants because they felt in a supportive groupenvironment they were able to express their emotions,such as anger and sadness. Combining activities suchas looking at old photographs and videos with thememory of their spouse created a felt spiritual presencethat the relationship endures which provided comfort(Boerner & Heckhausen, 2003; Dannerbaum &Kinnier, 2009). The therapists’ further acceptance ofand sensitivity to the combination of spiritual andreligious activities and rituals (e.g. going to synagogue,the cemetery, lighting candles, saying prayers) and inthe context of community allowed participants to gainsupport both within the group and in members’ socialenvironments. This is consistent with the expandingresearch literature of the benefits of a spiritual orreligious community towards improved functioningand the health of older adults (Krause, 2010). Theseobservations support our notion that the results of thequalitative analysis could be used as a preliminaryguide to therapists interested in facilitating therapygroups for older adults mourning the loss of a spouse.As suggested above, detailed analysis of the stages ofgroup process that include both between membertransactions and therapist intervention strategies pro-vide rich data as to what actually happens in therapygroups for the bereaved.
While there is considerable evidence of the poten-tial problems associated with bereavement includingemotional, psychological and social (Bennett, Smith, &Hughes, 2005; Stroebe, Schut, & Stroebe, 2005), asmall but growing body of literature challenges theassumption that these difficulties are a precursor andan inevitable outcome of the bereavement processesand for older adults (Bonanno, 2004; Bonanno et al.,2004; Ong et al., 2004). In this study, older adults notonly endured the painful loss of their spouse butdescribed how they maintained a positive affect andsocial re-engagement through new activities and hopein their later years. Participants’ excerpts demonstratethe ways in which they were able to reconcile andhonour their past life with their spouse while movingforward towards personal and social re-engagementand involvement in new activities and relationships.Contrary to social stereotypes of older adults’ limited
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adaptive and functional capacities, group members’
excerpts demonstrate the value of professional thera-
pists validating both their struggles with loss of
meaning and accompanying changes in self-identity
necessitated by the loss of their spouse with maximiz-
ing their human potential through this life change.
Furthermore, all therapists working with older adults
in group therapy could potentially incorporate notions
of spirituality and religiosity in the bereavement
process by understanding the associations with self-
identity, loss of meaning, purpose and social re-
engagement. The role of resiliency and positive emo-
tions alongside notions of spirituality as a buffer to a
presumed decline in physical and mental health (Ong
et al., 2004; Richardson, 2007) requires further explo-
ration for older adults experiencing a significant
interpersonal loss.The study was limited by the small sample size
and the inclusion of a primarily homogeneous group
of participants. Also, we did not differentiate in the
analysis, education, income or other demographical
differences, if any. Consequently, the degree to which
the findings are transferable to other bereavement
groups for older adults is unknown. Of relevance is
the participants spontaneously shared the importance
of religious affiliations and spiritual beliefs in their
lives, especially as these related to their coping with a
significant loss. The host hospital is a publically
funded and privately endowed Jewish healthcare
facility for older adults. Possibly mutual identification
with the Jewish faith contributed to group members
ease in raising issues pertaining to religious and
spiritual themes. However, non-Jewish rituals were
also mentioned by group members. This could be an
indicator of the supportive and non-judgemental
attitudes of the group therapists, allowing the partic-
ipants to expand on subjective experiences of the
bereavement process. While the content analysis
revealed that a spiritual belief system appeared to
support the grieving process, further studies are
needed to explore the interactions between the pro-
cessing of difficult emotions and the role of spiritu-
ality and/or religiosity in enhancing the healing
process. For example, does spirituality, religiosity
and/or humanistic ideation explored in a supportive
group environment contribute to self-reflection and
reframing of older adults’ grieving process in the
context of their developmental life stage?
Acknowledgements
The authors would like to thank the participants for beingpart of this study and sharing their experiences; and theSocial Work Therapists: Shawn Fremeth, Renee Climans,Christina Black, Beverly Adler, and Ruth Goodman. Theauthors acknowledge and thank the Katz Centre forGerontological Social Work Research, Baycrest, for theirfinancial support.
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