good grief: bouncing back from a spouse's death in later life feature article deborah carr O n the night before New Year's Eve 2003—one month before his 40th wedding anniversary—John Gregory Dunne sat down to eat dinner with his wife and writing partner Joan Didion. Moments later, he suffered a heart attack and died instantly. When Dunne, 71, was pro- nounced dead at the hospital later that evening, Didion kept her emotions in check—a hospital staffer called her "a cool customer." Didion, 69, chronicled the year following her husband's death in her 2005 book The Year of Magical Thinking. While critics hailed her work as a "masterpiece" and a "taut, clear-eyed memoir of grief," many readers dis- agreed. In book groups and online chat rooms, readers— many of them newly bereaved themselves—raged against Didion's "cool" memoir. Where was the emotion, the dev- astation, the proof of her love for her late husband? Grieving spouses are supposed to be visibly distraught; something must be wrong with Didion. Sociologists have documented the importance of "feeling rules": the cultural guidelines that shape appro- priate emotional responses to life events and experiences. Those who violate the rules—such as a widow who grieves her husband's death too calmly, for too short a time, or not at all—are maligned as "insensitive" at best and "pathological" at worst. Yet recent research reveals that many older men and women—those 65 and over— survive such losses with only a brief spell of depressive symptoms, while many report no depressive symptoms at all. Still others, released from stressful caregiving respon- sibilities, an unhappy marriage, or from watching their loved one suffer an incurable, protracted illness, enjoy improved psychological well-being. These survivors are neither "pathological" nor "cool." Rather, they reveal that there is no single, universal way to grieve. The ways that older widows and widowers grieve reflect how the couples related during marriage, how their spouses died, the strains experienced during the final weeks and months, and their other roles and relationships that might protect against (or exacerbate) the pain of losing a loved one. the universality of grief Early psychological writings on spousal bereavement claimed that profound sadness is a universal response to loss, so that "virtually everyone whose spouse dies exhibits some signs and symptoms of depression." In fact, depres- sion is assumed to be such a normal, natural, and expected reaction to loss that the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association exempts depressed bereaved persons from a diagnosis of "depres- sion." Stress researchers, too, view spousal loss as poten- tially devastating; survey instruments used to assess life stress, such as the Social Readjustment Rating Scale (SRRS), regard the death of a spouse as the life event that requires the most intense adjustment. Early clinical studies concluded that widows and widow- ers who did not grieve (who experience what is referred to as "absent" or "inhibited" grief) were suffering from denial, inhibition, narcissism, immaturity, or an inability to maintain meaningful relationships with a loved one. Moreover, these symptom-free survivors were considered to be trapped in a state of denial that would later erupt in the form of an intense "delayed grief." The way to regain emotional equi- librium was to "work through" the loss. As Freud described this process, the bereaved person reviews "each single one of the memories and hopes which bound the libido" to the deceased. Therapeutic interventions followed suit, encour- aging widows and widowers to think about their late spous- es, confronting rather than avoiding reminders of the deceased and expressing their feelings through writing, talk- ing, or facial expressions. Therapists assumed that those who did not display overt distress were avoiding the critical task of "working through" their loss. Early studies of bereavement also identified risk factors for severe grief. For instance, adherents of psychoanalytic and attachment theories proposed that losing a spouse was most painful for those whose marriages were conflicted or ambivalent. Freud observed that these people struggled with feelings that oscillated between anger toward and Contexts, Vol. 5, Issue 4, p. 22-27, ISSN 1536-5042, electronic ISSN 1537-6052. ? 2006 by the American Sociological Association. All rights reserved. Please direct all requests for permission to photocopy or reproduce article content through the University of California Press's Rights and Permissions website, at www.ucpress.edu/journals/rights.htm. 22 contexts fall 2006 Why are some older adults devastated when their partners die, while others enjoy improved psychological health and social rela- tions? The experience of loss differs for men and women, and also depends on how one's spouse died and how the couple relat- ed during their marriage. 23 contexts fall 2006 strong attachment to their late spouses. These conflicting feelings made it hard for survivors to let go of their loved ones, yet they felt angry at the deceased for abandoning them. As a result, Freud—and psychoanalytically trained therapists—maintained that the unhappily married would have the greatest difficulty in adjusting emotionally to their loss. Other research showed that spouses were most grief- stricken when their loved ones died unexpectedly. Studies in the 1940s found that the wives of men serving in World War II experienced sadness and anxiety before their spouses died, but they disengaged emotionally and fared reasonably well after the event. In contrast, the relatives of young adults who were killed suddenly and unexpectedly in the infamous 1942 Coconut Grove nightclub fire suffered severe grief. Researchers and clinicians concluded that those who antici- pate the death of a spouse can prepare for it psychological- ly, while those who lose their loved ones suddenly are unprepared, shocked, and psychologically devastated. older bereaved spouses Mounting evidence questions whether depression is uni- versal among the bereaved, whether "absent grief" is pathological, and whether "working through" a loss is nec- essary for recovery. Moreover, recent empirical studies show that sudden deaths are not necessarily more distressing than expected ones, and that bereaved people who had strained marriages actually feel less grief than those who had close and loving ones. Certainly, some widows and widowers experience profound depression in the months and even years following their loss. Many find comfort in confronting and working through their loss. Yet for the majority of older bereaved spouses, death is simply a part of life (albeit a sad part), and recovery and resilience are the rule rather than the exception. Studies of older widows and widowers concur that only 15–25 percent experience clinical levels of depressive symp- toms in the months immediately following the death, while 25–45 percent report mild symptoms, and anywhere from 30–50 percent report no depressive symptoms. Depressive symptoms typically are measured as the number of times in the past week that a person felt sad, blue, lonely, and lack- ing energy or motivation. (See "The Epidemic in Mental Illness: Clinical Fact or Survey Artifact" in the Winter 2006 issue of Contexts for a discussion of the measurement and diagnosis of depression.) Research tracking people who have lost a spouse over longer time periods further reveals that even those who are distressed initially manage to bounce back reasonably quickly after their loss. One analysis based on the Changing Lives of Older Couples (CLOC), a multiwave study of bereavement among spouses age 65 and older, found that nearly half (46 per- cent) of older widows and widowers were "resilient," show- ing no or few depressive symptoms at both 6 and 18 months after their loss. Rather than showing signs of denial, emotional inhibition, or delayed grief, these relatively symp- tom-free older adults believed that death was a part of life, and they took great comfort in memories of their deceased spouses. One in ten showed what the authors called the "common grief" pattern, experiencing strong depressive symptoms six months after their loss, but improving consid- erably over the following year. Another 10 percent (whom the authors dubbed "depressed-improved") had significant depressive symptoms prior to the loss, but then improved considerably after it occurred. Just 16 percent reported "chronic grief," or strong depressive symptoms for more than 18 months following the loss. Eight percent experi- enced "chronic depression," which encompasses high, con- stant levels of depressive symptoms both before and after the loss. What accounts for the glaring discrepancy between early clinical writings and recent empirical research based on large samples of older adults? And why are some bereaved spouses physically and emotionally incapacitated by their loss, while others show little if any decline in their well-being? In large part, the difference reflects the sam- ples and research methods used. Many early studies were based on clinical observations of widows and widowers who had sought medical or psychiatric help. Studies based on help-seeking populations tend to overstate the prob- lematic consequences of loss because they include only the Deborah Carr studies spousal loss, dying, and how families prepare for the end of life. She writes the "Trends" feature for Contexts. photo by AP 24 most troubled. Other early studies used cross-sectional data, or snapshots at a single point in time of bereaved people. Most of these studies did not track these people over time, nor did they ascertain their characteristics before the death. Because bereaved people often have poorer physical health and economic well-being than their married peers even before the loss, studies that fail to consider pre- loss characteristics may also overstate the harmful conse- quences of a spouse's death. Perhaps most important, classic theories and studies often failed to consider three of the most important influ- ences on spousal bereavement: the age of the husband and wife, how the spouse died, and what the couple's life was like prior to the death. Most early studies focused on age-diverse samples and did not explicitly consider the unique case of older widows and widowers, who not only account for the vast majority of spousal losses each year, but also have distinctive personal resources (and risk factors) that make their bereavement different than it is for younger adults. spousal loss late in life Televised images of distraught widows and widowers often focus on the young— the teenage brides of fallen soldiers in the Iraq war or the junior executives who lost their wives on September 11th. But today the loss of a spouse is a transition over- whelmingly experienced by older adults. Of the 900,000 Americans who lose a mate each year, nearly three-quarters are 65 or older. Patterns of spousal loss mirror mor- tality patterns overall. The death rate, or the number of people who die in a given year per 100,000 in the population, increases sharply beyond age 65. Losing a spouse is simply inevitable for most older married couples. As sociologist Helena Lopata has observed, the only way to avoid such a loss is to avoid marriage. Yet these patterns also suggest that older bereaved spouses have an important cop- ing resource that is seldom available to younger widows and widowers: friends, peers, and siblings who also are adjusting to such a loss. Older adults often "rehearse" for losing a spouse by watching their peers go through the same experi- ence; they can turn to one another for wisdom, practical support, and camaraderie. The meaning of life and death also differs for older and younger persons. Death may be viewed as the natural con- clusion to an elderly spouse's long and meaningful life, rather than the interruption of a life yet to be lived. Most older persons experience such losses after decades of mar- riage. They have raised their children, celebrated the births of their grandchildren, and enjoyed at least a few years of relaxation together after retiring. Few feel they are being robbed of a long future together. Older adults also differ from their younger counterparts in how they respond emo- tionally to stress. Psychologists document that older adults contexts fall 2006 25-34 35-44 45-44 55-64 65-74 75-84 6000 5000 4000 3000 2000 1000 0 Source: U.S. Census Bureau annual death rates per 100,000 people increase steeply after age 65, United States, 2000. -1 -0.5 0 0.5 1 1.5 2 2.5 Preloss 6 months post-loss 18 months post-loss Resilient (46%) Depressed-improved (10%) "Common" grief (11%) Chronic grief (16%) Chronic depression (8%) Source: Bonanno et al., Journal of Personality and Social Psychology (2002) most older people are surprisingly resilient after losing a spouse depressive symptoms (standardized) 25 contexts fall 2006 have lower levels of "emotional reactivity." This means that they are better able to regulate their emotions, and they report less extreme emotional responses than do younger people. Their grief reactions tend to be shorter-lived and less intense than those of younger widows and widowers. cause of death Age is not the only factor that shapes the experience of losing a spouse; the cause of death is also important. Most older spouses die of a chronic illness, or a long-term illness that causes physical pain or disability and often requires intensive care. The leading causes of death today among those age 65 and older are heart disease, cancer, cere- brovascular disease (stroke), chronic lower respiratory dis- ease, influenza or pneumonia, and diabetes mellitus. Consequently, most older adults find that the final weeks (or even months and years) with their spouses are filled with difficult and emotionally wrenching caregiving chores. Although advances in medical technology have increased the life span of ailing adults, they also increase the burden on spouses to manage complex care and medication regimes. Many life-threatening illnesses are now treated in the home, so spouses must manage everything from insulin shots to morphine use and spinal injections. Even those caring for a relative- ly healthy yet frail spouse often find that caregiving is so time-consum- ing as to tax their emotional resources and prevent them from paying attention to their own health symptoms. Older caregivers report high levels of strain and depressive symptoms when their spouses are still alive, yet many bounce back shortly after their spouses die. One recent study found that by seven months after spousal loss, bereaved caregivers reported depressive symptom scores that were no higher than either bereaved noncare- givers or married older adults. Another study of caregivers for dementia patients showed that they had high levels of depressive symptoms while caring for their spouses, yet showed a dramatic decrease in symptoms after their spous- es had died. More than 90 percent felt that death was a relief to the patient, and 72 percent admitted that the death was also a relief to them. These studies question the assump- tion that expected deaths are necessarily "better" for the survivor; rather, they reveal that losing a spouse is a process rather than an event. For many bereaved spouses, the event of the loss is not as painful as the long "death watch" peri- od, which is often filled with drawn-out suffering. the experience of loss reflects the marriage Another reason that some older people are spared severe distress is that the death of a spouse may be a release from a marriage that was stifling or unrewarding. Although early psychoanalytic writings suggested that those with troubled marriages had the most difficulty in coming to terms with their losses, data from the CLOC study reveal that people with the most close-knit, loving marriages expe- rience the most severe symptoms of sadness and yearning in the first six months after their loss. Yet these symptoms fade as time elapses, and the survivors eventually come to enjoy memories of their beloved spouses without experiencing pangs of grief. The CLOC study also shows that widows and widowers who had the most problematic marriages show better psy- chological health following their loss than do their married peers who remain in such troubled relationships. Married women who are most emotionally dependent on their hus- bands report lower self-esteem than do widows who had been highly dependent on their husbands. Widows experi- ence a boost to their self-esteem when they are freed from a mar- riage that had been stifling. Moreover, both widows and wid- owers who had been highly dependent on their spouses for practical matters, like homemaking or home maintenance, offer the strongest endorsement for state- ments such as "I am a stronger per- son as a result of dealing with the loss of my spouse," and "As a result of having to manage without my spouse, I have become more self-confident." Such people may receive psychological rewards from realiz- ing that they have withstood and survived an event that had earlier seemed insurmountable. "his" and "her" loss? Men and women experience marriage in very different ways, so they also experience the loss of a spouse different- ly. These differences include not only psychological respons- es but also practical readjustments to daily life. In the early 1970s, Jesse Bernard wrote about "his" and "hers" mar- riage. "His" marriage brought men good health, power, and satisfaction, while "her" marriage subjected women to stress, self-sacrifice, and depression. While numerous stud- ies conducted since the 1970s show that marriage benefits both men and women, most sociologists recognize that marriage carries different rewards (and costs) for men and Caregiving is so time-con- suming as to tax their emotional resources and prevent them from paying attention to their own health symptoms. 26 women. Among today's older adults, husbands were typi- cally the "breadwinners" in their marriages and often took responsibility for "masculine" tasks such as making home repairs, paying bills, and managing finances. Their wives usually had sporadic (if any) paid work experience and were responsible for homemaking activities, including meal preparation, child care, and housework. This traditional division of labor means that widows and widowers face different challenges. For women, widow- hood often means a sharp dip in economic resources. Because men earn more than women during their working lives, they receive higher Social Security benefits upon retire- ment or disability. When the husband dies, these monthly checks are reduced. Economists estimate that a widow's cost of living is about 80 percent of what the couple's was, but the monthly Social Security payments decline to just two-thirds of their previous level. Economists also have doc- umented that married couples often underestimate how many years a widow will outlive her husband, so that they often do not save enough money to cover a widow's future needs. Widows are consequently more likely than widowers to experience distress and anxiety about money. Men are more likely than women to experience sickness, disability, and death after their wives die. While popular lore and a handful of early studies claim that these men may "die of a broken heart," the loss of a helpmate and caretaker is the real culprit. Wives typically monitor their husbands' diets, encourage them to exer- cise, remind them to take their medica- tions, and urge them to give up vices like smoking and drinking. When their wives die, these reminders cease as well. Not sur- prisingly, recently widowed men are more likely than married men to die of accidents, alcohol-related deaths, lung cancer, and chronic ischemic heart disease—but not from other causes that are less closely linked to health behaviors. Even worse for men, though, is that their wives are often their primary (if not only) source of social support and inte- gration. Social support is essential for physical and emotion- al health, especially in later life. Today's older men, often raised to be strong and silent, have few close friends with whom they can share their private concerns. Wives often are the family "kinkeepers"—the ones who send birthday cards to the kids, arrange dinner parties with friends, and organ- ize outings with the grandchildren; when a man loses his wife, he also loses his social networks. Women tend to have more extensive social networks. For many women, supportive relationships with friends, chil- dren, and other relatives, as well as participation in commu- nity activities, partially fill the emotional void created by the death of their husbands. Widows report much higher levels of both practical and emotional support from their children than do widowers, reflecting long-established patterns of reciprocity. Because women usually are more involved in raising and nurturing their children than men, these strong relationships offer a unique source of strength to older women when their spouses die. For these reasons, widowers are much more motivated than widows to seek new romantic partners soon after their loss. According to the U.S. Census Bureau, just 2 percent of older widows but 20 percent of older widowers eventually remarry. For widowers, remarriage and dating are ways to bounce back from the loneliness and sadness of loss. Older men who have remarried show levels of mental health that are just as good as—if not better than—those of their peers who are in long-term marriages. Data from the CLOC study show that six months after losing a spouse, one-third of older widowers but just 16 percent of widows say they would like to remarry some day. Not only do men have a greater motivation to remarry— they have more opportunities to find new partners. The sex ratio in the United States today is 1.5 women for every man age 65 and older, and 3 women for every man 85 and older. This gender gap reflects gender differences in late-life mor- tality. Women are more likely than men to outlive their spouses; life expectancy at birth today is 74 for men and 80 for women. Older women also are more likely to remain widowed, given widowers' greater propensity to remarry younger women. Among persons ages 65 to 74, 29 percent contexts fall 2006 8.8% 18.4% 34.6% 29.4% 53.3% 78.3% 0 20 40 60 80 100 65-74 75-84 85+ Women Men Source: U.S. Census Bureau a higher proportion of older women than men are widowed in every age group (2004) 27 contexts fall 2006 of women but just 9 percent of men are widowed. These proportions jump to 78 percent of women and 35 percent of men ages 85 and older. Taken together, these numbers suggest that for older widows, remarriage is seldom an option. how will baby boomers grieve? In the coming decades, the number of older adults who become widowed each year will increase dramatically. Given the sheer size of the baby-boom cohort, with more than 75 million babies born between 1946 and 1964, tens of mil- lions of older Americans will lose their spouses in the com- ing decades. Social gerontologists debate whether adjusting to a spouse's death will be more or less difficult for boomers, compared to their parents' generation. Baby boomers are expected to adapt well to the necessary "practical" or daily life readjustments, although they may find emotional adjust- ment particularly challenging. Female boomers have more education, more work expe- rience, and higher personal earnings than past cohorts of older women. They may depend less on their husbands for income or assistance with chores such as home repair or financial management. Likewise, each cohort of men is more likely than their fathers' generation to take on home- making and childrearing tasks. As the boundaries separating traditional gender roles in marriage blur, widows and wid- owers will likely face fewer challenges (and less anxiety) as they manage homemaking, home maintenance, and finances after their spouses die. Adjusting emotionally to spousal loss may become even more difficult for future cohorts, however. While past gen- erations of older adults often stayed in difficult marriages because of cultural or religious prohibitions against divorce, baby boomers can freely divorce if their marriages are unsat- isfying. If the men and women of the baby boom dissolve troubled marriages, those who remain married until late in life may have particularly warm and close relationships, and may be the most grief-stricken upon their loss. Moreover, increasing numbers of divorced boomers remarry in their 50s and older. For these mature newlyweds, the death of a spouse—even a spouse in his or her 60s—may rob them of a much-anticipated future together. Some family sociologists argue further that the marital relationship has been idealized in recent decades. Young men and women today seek a "soul mate" who shares their interests and passions, rather than a "helpmate" who pays the bills or washes the dishes. The belief that one's partner is an irreplaceable "soul mate" may make losing that person all the more devastating. Such projections need to be assessed empirically in future studies. As Didion observed in The Year of Magical Thinking: "Grief turns out to be a place none of us know until we reach it." recommended resources John Archer. The Nature of Grief: The Evolution and Psychology of Reactions to Loss (Routledge, 1999). A ground-breaking synthesis of ideas from evolutionary psychology, ethology and experimental psychology on the process of grief. Archer argues that grief is a natural reaction to loss, rather than an illness to be cured or a psychiatric disorder. George A. Bonanno, Camille B. Wortman, Darrin R. Lehman, Roger G. Tweed, Michelle Haring, John Sonnega, Deborah Carr, and Randolph M. Nesse. "Resilience to Loss and Chronic Grief: A Prospective Study from Preloss to 18-Months Postloss." Journal of Personality and Social Psychology 83 (2002): 1150–64. A rigorous and innovative analysis of a diverse range of psychological reactions to spousal loss. Deborah Carr, Randolph Nesse, and Camille B. Wortman, eds. Spousal Bereavement in Late Life (Springer Publishing, 2006). Wide-ranging theoretical, empirical, and practice-related essays from social scientists studying the social and psycho- logical consequences of late-life widowhood. Robert O. Hansson and Margaret S. Stroebe. Bereavement in Late Life: Coping, Adaptation and Developmental Influences (American Psychological Association, 2006). An in-depth account of the ways older adults cope with loss, authored by leading scholars of gerontology and bereavement, respectively. Helena Z. Lopata. Widowhood in an American City (Schenkman, 1973). A classic study of older widowed women in the greater Chicago area. Camille B. Wortman and Roxanne Silver. "The Myths of Coping with Loss Revisited." In Handbook of Bereavement Research: Consequences, Coping, and Care (American Psychological Association, 2001). Among the most widely cited works in bereavement research, this article uses compelling data and theory to dispel common myths about coping with loss. 400,000: approximate number of U.S. lives saved since 1960 because of improved safety standards in motor vehicles, about half of them due to seatbelts.
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good grief: bouncing back from a spouse's death in later life feature article deborah carr O n the night before New Year's Eve 2003—one month before his 40th wedding anniversary—John Gregory Dunne sat down to eat dinner with his wife and writing partner Joan Didion. Moments later, he suffered a heart attack and died instantly. When Dunne, 71, was pro- nounced dead at the hospital later that evening, Didion kept her emotions in check—a hospital staffer called her "a cool customer." Didion, 69, chronicled the year following her husband's death in her 2005 book The Year of Magical Thinking. While critics hailed her work as a "masterpiece" and a "taut, clear-eyed memoir of grief," many readers dis- agreed. In book groups and online chat rooms, readers— many of them newly bereaved themselves—raged against Didion's "cool" memoir. Where was the emotion, the dev- astation, the proof of her love for her late husband? Grieving spouses are supposed to be visibly distraught; something must be wrong with Didion. Sociologists have documented the importance of "feeling rules": the cultural guidelines that shape appro- priate emotional responses to life events and experiences. Those who violate the rules—such as a widow who grieves her husband's death too calmly, for too short a time, or not at all—are maligned as "insensitive" at best and "pathological" at worst. Yet recent research reveals that many older men and women—those 65 and over— survive such losses with only a brief spell of depressive symptoms, while many report no depressive symptoms at all. Still others, released from stressful caregiving respon- sibilities, an unhappy marriage, or from watching their loved one suffer an incurable, protracted illness, enjoy improved psychological well-being. These survivors are neither "pathological" nor "cool." Rather, they reveal that there is no single, universal way to grieve. The ways that older widows and widowers grieve reflect how the couples related during marriage, how their spouses died, the strains experienced during the final weeks and months, and their other roles and relationships that might protect against (or exacerbate) the pain of losing a loved one. the universality of grief Early psychological writings on spousal bereavement claimed that profound sadness is a universal response to loss, so that "virtually everyone whose spouse dies exhibits some signs and symptoms of depression." In fact, depres- sion is assumed to be such a normal, natural, and expected reaction to loss that the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association exempts depressed bereaved persons from a diagnosis of "depres- sion." Stress researchers, too, view spousal loss as poten- tially devastating; survey instruments used to assess life stress, such as the Social Readjustment Rating Scale (SRRS), regard the death of a spouse as the life event that requires the most intense adjustment. Early clinical studies concluded that widows and widow- ers who did not grieve (who experience what is referred to as "absent" or "inhibited" grief) were suffering from denial, inhibition, narcissism, immaturity, or an inability to maintain meaningful relationships with a loved one. Moreover, these symptom-free survivors were considered to be trapped in a state of denial that would later erupt in the form of an intense "delayed grief." The way to regain emotional equi- librium was to "work through" the loss. As Freud described this process, the bereaved person reviews "each single one of the memories and hopes which bound the libido" to the deceased. Therapeutic interventions followed suit, encour- aging widows and widowers to think about their late spous- es, confronting rather than avoiding reminders of the deceased and expressing their feelings through writing, talk- ing, or facial expressions. Therapists assumed that those who did not display overt distress were avoiding the critical task of "working through" their loss. Early studies of bereavement also identified risk factors for severe grief. For instance, adherents of psychoanalytic and attachment theories proposed that losing a spouse was most painful for those whose marriages were conflicted or ambivalent. Freud observed that these people struggled with feelings that oscillated between anger toward and Contexts, Vol. 5, Issue 4, p. 22-27, ISSN 1536-5042, electronic ISSN 1537-6052. ? 2006 by the American Sociological Association. All rights reserved. Please direct all requests for permission to photocopy or reproduce article content through the University of California Press's Rights and Permissions website, at www.ucpress.edu/journals/rights.htm. 22 contexts fall 2006 Why are some older adults devastated when their partners die, while others enjoy improved psychological health and social rela- tions? The experience of loss differs for men and women, and also depends on how one's spouse died and how the couple relat- ed during their marriage. 23 contexts fall 2006 strong attachment to their late spouses. These conflicting feelings made it hard for survivors to let go of their loved ones, yet they felt angry at the deceased for abandoning them. As a result, Freud—and psychoanalytically trained therapists—maintained that the unhappily married would have the greatest difficulty in adjusting emotionally to their loss. Other research showed that spouses were most grief- stricken when their loved ones died unexpectedly. Studies in the 1940s found that the wives of men serving in World War II experienced sadness and anxiety before their spouses died, but they disengaged emotionally and fared reasonably well after the event. In contrast, the relatives of young adults who were killed suddenly and unexpectedly in the infamous 1942 Coconut Grove nightclub fire suffered severe grief. Researchers and clinicians concluded that those who antici- pate the death of a spouse can prepare for it psychological- ly, while those who lose their loved ones suddenly are unprepared, shocked, and psychologically devastated. older bereaved spouses Mounting evidence questions whether depression is uni- versal among the bereaved, whether "absent grief" is pathological, and whether "working through" a loss is nec- essary for recovery. Moreover, recent empirical studies show that sudden deaths are not necessarily more distressing than expected ones, and that bereaved people who had strained marriages actually feel less grief than those who had close and loving ones. Certainly, some widows and widowers experience profound depression in the months and even years following their loss. Many find comfort in confronting and working through their loss. Yet for the majority of older bereaved spouses, death is simply a part of life (albeit a sad part), and recovery and resilience are the rule rather than the exception. Studies of older widows and widowers concur that only 15–25 percent experience clinical levels of depressive symp- toms in the months immediately following the death, while 25–45 percent report mild symptoms, and anywhere from 30–50 percent report no depressive symptoms. Depressive symptoms typically are measured as the number of times in the past week that a person felt sad, blue, lonely, and lack- ing energy or motivation. (See "The Epidemic in Mental Illness: Clinical Fact or Survey Artifact" in the Winter 2006 issue of Contexts for a discussion of the measurement and diagnosis of depression.) Research tracking people who have lost a spouse over longer time periods further reveals that even those who are distressed initially manage to bounce back reasonably quickly after their loss. One analysis based on the Changing Lives of Older Couples (CLOC), a multiwave study of bereavement among spouses age 65 and older, found that nearly half (46 per- cent) of older widows and widowers were "resilient," show- ing no or few depressive symptoms at both 6 and 18 months after their loss. Rather than showing signs of denial, emotional inhibition, or delayed grief, these relatively symp- tom-free older adults believed that death was a part of life, and they took great comfort in memories of their deceased spouses. One in ten showed what the authors called the "common grief" pattern, experiencing strong depressive symptoms six months after their loss, but improving consid- erably over the following year. Another 10 percent (whom the authors dubbed "depressed-improved") had significant depressive symptoms prior to the loss, but then improved considerably after it occurred. Just 16 percent reported "chronic grief," or strong depressive symptoms for more than 18 months following the loss. Eight percent experi- enced "chronic depression," which encompasses high, con- stant levels of depressive symptoms both before and after the loss. What accounts for the glaring discrepancy between early clinical writings and recent empirical research based on large samples of older adults? And why are some bereaved spouses physically and emotionally incapacitated by their loss, while others show little if any decline in their well-being? In large part, the difference reflects the sam- ples and research methods used. Many early studies were based on clinical observations of widows and widowers who had sought medical or psychiatric help. Studies based on help-seeking populations tend to overstate the prob- lematic consequences of loss because they include only the Deborah Carr studies spousal loss, dying, and how families prepare for the end of life. She writes the "Trends" feature for Contexts. photo by AP 24 most troubled. Other early studies used cross-sectional data, or snapshots at a single point in time of bereaved people. Most of these studies did not track these people over time, nor did they ascertain their characteristics before the death. Because bereaved people often have poorer physical health and economic well-being than their married peers even before the loss, studies that fail to consider pre- loss characteristics may also overstate the harmful conse- quences of a spouse's death. Perhaps most important, classic theories and studies often failed to consider three of the most important influ- ences on spousal bereavement: the age of the husband and wife, how the spouse died, and what the couple's life was like prior to the death. Most early studies focused on age-diverse samples and did not explicitly consider the unique case of older widows and widowers, who not only account for the vast majority of spousal losses each year, but also have distinctive personal resources (and risk factors) that make their bereavement different than it is for younger adults. spousal loss late in life Televised images of distraught widows and widowers often focus on the young— the teenage brides of fallen soldiers in the Iraq war or the junior executives who lost their wives on September 11th. But today the loss of a spouse is a transition over- whelmingly experienced by older adults. Of the 900,000 Americans who lose a mate each year, nearly three-quarters are 65 or older. Patterns of spousal loss mirror mor- tality patterns overall. The death rate, or the number of people who die in a given year per 100,000 in the population, increases sharply beyond age 65. Losing a spouse is simply inevitable for most older married couples. As sociologist Helena Lopata has observed, the only way to avoid such a loss is to avoid marriage. Yet these patterns also suggest that older bereaved spouses have an important cop- ing resource that is seldom available to younger widows and widowers: friends, peers, and siblings who also are adjusting to such a loss. Older adults often "rehearse" for losing a spouse by watching their peers go through the same experi- ence; they can turn to one another for wisdom, practical support, and camaraderie. The meaning of life and death also differs for older and younger persons. Death may be viewed as the natural con- clusion to an elderly spouse's long and meaningful life, rather than the interruption of a life yet to be lived. Most older persons experience such losses after decades of mar- riage. They have raised their children, celebrated the births of their grandchildren, and enjoyed at least a few years of relaxation together after retiring. Few feel they are being robbed of a long future together. Older adults also differ from their younger counterparts in how they respond emo- tionally to stress. Psychologists document that older adults contexts fall 2006 25-34 35-44 45-44 55-64 65-74 75-84 6000 5000 4000 3000 2000 1000 0 Source: U.S. Census Bureau annual death rates per 100,000 people increase steeply after age 65, United States, 2000. -1 -0.5 0 0.5 1 1.5 2 2.5 Preloss 6 months post-loss 18 months post-loss Resilient (46%) Depressed-improved (10%) "Common" grief (11%) Chronic grief (16%) Chronic depression (8%) Source: Bonanno et al., Journal of Personality and Social Psychology (2002) most older people are surprisingly resilient after losing a spouse depressive symptoms (standardized) 25 contexts fall 2006 have lower levels of "emotional reactivity." This means that they are better able to regulate their emotions, and they report less extreme emotional responses than do younger people. Their grief reactions tend to be shorter-lived and less intense than those of younger widows and widowers. cause of death Age is not the only factor that shapes the experience of losing a spouse; the cause of death is also important. Most older spouses die of a chronic illness, or a long-term illness that causes physical pain or disability and often requires intensive care. The leading causes of death today among those age 65 and older are heart disease, cancer, cere- brovascular disease (stroke), chronic lower respiratory dis- ease, influenza or pneumonia, and diabetes mellitus. Consequently, most older adults find that the final weeks (or even months and years) with their spouses are filled with difficult and emotionally wrenching caregiving chores. Although advances in medical technology have increased the life span of ailing adults, they also increase the burden on spouses to manage complex care and medication regimes. Many life-threatening illnesses are now treated in the home, so spouses must manage everything from insulin shots to morphine use and spinal injections. Even those caring for a relative- ly healthy yet frail spouse often find that caregiving is so time-consum- ing as to tax their emotional resources and prevent them from paying attention to their own health symptoms. Older caregivers report high levels of strain and depressive symptoms when their spouses are still alive, yet many bounce back shortly after their spouses die. One recent study found that by seven months after spousal loss, bereaved caregivers reported depressive symptom scores that were no higher than either bereaved noncare- givers or married older adults. Another study of caregivers for dementia patients showed that they had high levels of depressive symptoms while caring for their spouses, yet showed a dramatic decrease in symptoms after their spous- es had died. More than 90 percent felt that death was a relief to the patient, and 72 percent admitted that the death was also a relief to them. These studies question the assump- tion that expected deaths are necessarily "better" for the survivor; rather, they reveal that losing a spouse is a process rather than an event. For many bereaved spouses, the event of the loss is not as painful as the long "death watch" peri- od, which is often filled with drawn-out suffering. the experience of loss reflects the marriage Another reason that some older people are spared severe distress is that the death of a spouse may be a release from a marriage that was stifling or unrewarding. Although early psychoanalytic writings suggested that those with troubled marriages had the most difficulty in coming to terms with their losses, data from the CLOC study reveal that people with the most close-knit, loving marriages expe- rience the most severe symptoms of sadness and yearning in the first six months after their loss. Yet these symptoms fade as time elapses, and the survivors eventually come to enjoy memories of their beloved spouses without experiencing pangs of grief. The CLOC study also shows that widows and widowers who had the most problematic marriages show better psy- chological health following their loss than do their married peers who remain in such troubled relationships. Married women who are most emotionally dependent on their hus- bands report lower self-esteem than do widows who had been highly dependent on their husbands. Widows experi- ence a boost to their self-esteem when they are freed from a mar- riage that had been stifling. Moreover, both widows and wid- owers who had been highly dependent on their spouses for practical matters, like homemaking or home maintenance, offer the strongest endorsement for state- ments such as "I am a stronger per- son as a result of dealing with the loss of my spouse," and "As a result of having to manage without my spouse, I have become more self-confident." Such people may receive psychological rewards from realiz- ing that they have withstood and survived an event that had earlier seemed insurmountable. "his" and "her" loss? Men and women experience marriage in very different ways, so they also experience the loss of a spouse different- ly. These differences include not only psychological respons- es but also practical readjustments to daily life. In the early 1970s, Jesse Bernard wrote about "his" and "hers" mar- riage. "His" marriage brought men good health, power, and satisfaction, while "her" marriage subjected women to stress, self-sacrifice, and depression. While numerous stud- ies conducted since the 1970s show that marriage benefits both men and women, most sociologists recognize that marriage carries different rewards (and costs) for men and Caregiving is so time-con- suming as to tax their emotional resources and prevent them from paying attention to their own health symptoms. 26 women. Among today's older adults, husbands were typi- cally the "breadwinners" in their marriages and often took responsibility for "masculine" tasks such as making home repairs, paying bills, and managing finances. Their wives usually had sporadic (if any) paid work experience and were responsible for homemaking activities, including meal preparation, child care, and housework. This traditional division of labor means that widows and widowers face different challenges. For women, widow- hood often means a sharp dip in economic resources. Because men earn more than women during their working lives, they receive higher Social Security benefits upon retire- ment or disability. When the husband dies, these monthly checks are reduced. Economists estimate that a widow's cost of living is about 80 percent of what the couple's was, but the monthly Social Security payments decline to just two-thirds of their previous level. Economists also have doc- umented that married couples often underestimate how many years a widow will outlive her husband, so that they often do not save enough money to cover a widow's future needs. Widows are consequently more likely than widowers to experience distress and anxiety about money. Men are more likely than women to experience sickness, disability, and death after their wives die. While popular lore and a handful of early studies claim that these men may "die of a broken heart," the loss of a helpmate and caretaker is the real culprit. Wives typically monitor their husbands' diets, encourage them to exer- cise, remind them to take their medica- tions, and urge them to give up vices like smoking and drinking. When their wives die, these reminders cease as well. Not sur- prisingly, recently widowed men are more likely than married men to die of accidents, alcohol-related deaths, lung cancer, and chronic ischemic heart disease—but not from other causes that are less closely linked to health behaviors. Even worse for men, though, is that their wives are often their primary (if not only) source of social support and inte- gration. Social support is essential for physical and emotion- al health, especially in later life. Today's older men, often raised to be strong and silent, have few close friends with whom they can share their private concerns. Wives often are the family "kinkeepers"—the ones who send birthday cards to the kids, arrange dinner parties with friends, and organ- ize outings with the grandchildren; when a man loses his wife, he also loses his social networks. Women tend to have more extensive social networks. For many women, supportive relationships with friends, chil- dren, and other relatives, as well as participation in commu- nity activities, partially fill the emotional void created by the death of their husbands. Widows report much higher levels of both practical and emotional support from their children than do widowers, reflecting long-established patterns of reciprocity. Because women usually are more involved in raising and nurturing their children than men, these strong relationships offer a unique source of strength to older women when their spouses die. For these reasons, widowers are much more motivated than widows to seek new romantic partners soon after their loss. According to the U.S. Census Bureau, just 2 percent of older widows but 20 percent of older widowers eventually remarry. For widowers, remarriage and dating are ways to bounce back from the loneliness and sadness of loss. Older men who have remarried show levels of mental health that are just as good as—if not better than—those of their peers who are in long-term marriages. Data from the CLOC study show that six months after losing a spouse, one-third of older widowers but just 16 percent of widows say they would like to remarry some day. Not only do men have a greater motivation to remarry— they have more opportunities to find new partners. The sex ratio in the United States today is 1.5 women for every man age 65 and older, and 3 women for every man 85 and older. This gender gap reflects gender differences in late-life mor- tality. Women are more likely than men to outlive their spouses; life expectancy at birth today is 74 for men and 80 for women. Older women also are more likely to remain widowed, given widowers' greater propensity to remarry younger women. Among persons ages 65 to 74, 29 percent contexts fall 2006 8.8% 18.4% 34.6% 29.4% 53.3% 78.3% 0 20 40 60 80 100 65-74 75-84 85+ Women Men Source: U.S. Census Bureau a higher proportion of older women than men are widowed in every age group (2004) 27 contexts fall 2006 of women but just 9 percent of men are widowed. These proportions jump to 78 percent of women and 35 percent of men ages 85 and older. Taken together, these numbers suggest that for older widows, remarriage is seldom an option. how will baby boomers grieve? In the coming decades, the number of older adults who become widowed each year will increase dramatically. Given the sheer size of the baby-boom cohort, with more than 75 million babies born between 1946 and 1964, tens of mil- lions of older Americans will lose their spouses in the com- ing decades. Social gerontologists debate whether adjusting to a spouse's death will be more or less difficult for boomers, compared to their parents' generation. Baby boomers are expected to adapt well to the necessary "practical" or daily life readjustments, although they may find emotional adjust- ment particularly challenging. Female boomers have more education, more work expe- rience, and higher personal earnings than past cohorts of older women. They may depend less on their husbands for income or assistance with chores such as home repair or financial management. Likewise, each cohort of men is more likely than their fathers' generation to take on home- making and childrearing tasks. As the boundaries separating traditional gender roles in marriage blur, widows and wid- owers will likely face fewer challenges (and less anxiety) as they manage homemaking, home maintenance, and finances after their spouses die. Adjusting emotionally to spousal loss may become even more difficult for future cohorts, however. While past gen- erations of older adults often stayed in difficult marriages because of cultural or religious prohibitions against divorce, baby boomers can freely divorce if their marriages are unsat- isfying. If the men and women of the baby boom dissolve troubled marriages, those who remain married until late in life may have particularly warm and close relationships, and may be the most grief-stricken upon their loss. Moreover, increasing numbers of divorced boomers remarry in their 50s and older. For these mature newlyweds, the death of a spouse—even a spouse in his or her 60s—may rob them of a much-anticipated future together. Some family sociologists argue further that the marital relationship has been idealized in recent decades. Young men and women today seek a "soul mate" who shares their interests and passions, rather than a "helpmate" who pays the bills or washes the dishes. The belief that one's partner is an irreplaceable "soul mate" may make losing that person all the more devastating. Such projections need to be assessed empirically in future studies. As Didion observed in The Year of Magical Thinking: "Grief turns out to be a place none of us know until we reach it." recommended resources John Archer. The Nature of Grief: The Evolution and Psychology of Reactions to Loss (Routledge, 1999). A ground-breaking synthesis of ideas from evolutionary psychology, ethology and experimental psychology on the process of grief. Archer argues that grief is a natural reaction to loss, rather than an illness to be cured or a psychiatric disorder. George A. Bonanno, Camille B. Wortman, Darrin R. Lehman, Roger G. Tweed, Michelle Haring, John Sonnega, Deborah Carr, and Randolph M. Nesse. "Resilience to Loss and Chronic Grief: A Prospective Study from Preloss to 18-Months Postloss." Journal of Personality and Social Psychology 83 (2002): 1150–64. A rigorous and innovative analysis of a diverse range of psychological reactions to spousal loss. Deborah Carr, Randolph Nesse, and Camille B. Wortman, eds. Spousal Bereavement in Late Life (Springer Publishing, 2006). Wide-ranging theoretical, empirical, and practice-related essays from social scientists studying the social and psycho- logical consequences of late-life widowhood. Robert O. Hansson and Margaret S. Stroebe. Bereavement in Late Life: Coping, Adaptation and Developmental Influences (American Psychological Association, 2006). An in-depth account of the ways older adults cope with loss, authored by leading scholars of gerontology and bereavement, respectively. Helena Z. Lopata. Widowhood in an American City (Schenkman, 1973). A classic study of older widowed women in the greater Chicago area. Camille B. Wortman and Roxanne Silver. "The Myths of Coping with Loss Revisited." In Handbook of Bereavement Research: Consequences, Coping, and Care (American Psychological Association, 2001). Among the most widely cited works in bereavement research, this article uses compelling data and theory to dispel common myths about coping with loss. 400,000: approximate number of U.S. lives saved since 1960 because of improved safety standards in motor vehicles, about half of them due to seatbelts.