Q: Dr. Bonanno, your study dealt with patterns of grief following the loss of a loved one. What can you tell us about these patterns?
A: There are clear outcome patterns, but they vary with different people. There are generally three outcome patterns: chronic grief, common grief, and resilience or absent grief. Chronic grief is someone who has a dramatic, high level of depression and grief after a loss, and they don't get better for several years. The common grief pattern is usually people who show an elevation of symptoms — depression, distress, difficulty concentrating, etc., and somewhere within a year or two, they return to normal. And the third type are those who don't show any disruption in their normal functioning. And that last pattern is very common, sometimes up to half the people will show that.
Q: Is there a distinction between chronic grief and chronic depression?
A: In this study, I think we're the first study to ever do this, we also measure chronic depression. You have to be able to have data before the loss, and that's not easy to do. You can't really ask people that question after a loss because it's well known, it's well established, that depressed people tend to remember more negative events — it's called the depressive memory bias. When you're feeling sad, you remember sad things because memory works by cues. So we know that memory works that way, and we've been arguing that you can't really say that these people were depressed beforehand because they said they were, because you don't know. We measured depression beforehand and we separated out people who were chronically depressed from people who were not depressed and then became depressed after the loss. One of the things that we found in that study is that we had fewer people who really showed chronic grief, and one reason is because most everyone died of natural causes. When people are anticipating the loss, or the person dies of natural causes, it seems that that helps. The people who tend to have the most chronic grief, the most painful bereavement, are people who lose loved ones through sudden, violent death. If you know the loved one is dying, I think there's a chance to say goodbye to them, a chance to talk with them, to be with them and, for lack of a better word, process the fact that they're going to die. When people die sudden, violent deaths, it seems that the bereaved people, the survivors, replay it over and over in their minds because it has a traumatic flavor to it.
Q: Why do certain people not exhibit any grief patterns?
A: Up until recently, it hasn't really been known. Most investigators in the field, I think, would say that people who don't show grief have something wrong with them — they either are defensive, or cold, or they never cared about the person to begin with, or they weren't attached. I had argued no, maybe they're just healthy people. We followed a group of people in Michigan over six years in a bereavement study where we knew a lot about the people before the loss occurred. We showed that about half the sample showed no symptoms at any point in the study. They just were not depressed before or after the loss, and we found that they were healthy people. They had fine relationships. The interviewers did not find them cold or aloof, and they did not score high on a measure we had of avoidant attachment. That doesn't mean that a healthy person won't grief also, but it seemed that they [a person who feels no grief] might feel sad, they might miss the person, but they keep functioning. We know that the people who don't show grief, it's fair to say, are healthy people.
Q: What signs may indicate that someone is not coping, more or less, normally?
A: There are some signs. One we found in our research is that there is acute grief — people who are grieving so severely initially. Ten years ago we may have thought that they're grieving terribly, but they'll get over it. We know now that when people grieve very acutely that does not bode well for their getting better, because it's really hard to recover from that. I've been arguing recently that people who cannot get it off their minds at all, those are the people who are not likely to do well. We find that the people who do well over time are able to regulate themselves a little bit, they're able to put it out of their minds at least for some of the time. We have chores in life, historically, for the last couple of hundred years; the two main chores in life are to work and to love — to accomplish things and to be close to other people. So regardless of one's roles, whether they're a housewife or a business executive, we have one of those two tasks to do. We have to be close to people, take care of people, or produce and be able to concentrate and be productive. If people can't do those things, that's a bad sign. What happens is this kind of cascading loss. People often feel like they've lost a part of themselves. If they can work, if they can be close to their children or friends or parents, they can still have other parts of themselves. When people really struggle, they're unable to concentrate, they become distant and do not find much pleasure in the people that they are close to. This means that they are not doing well, and it tends to expand the loss in a way because it comes to be more than the loss of loved one. It becomes a loss of your life in a sense.
Q: What characteristics define acute grief?
A: There are two sets of things — depression and trauma symptoms. Trauma symptoms only seem to occur when people have lost a loved one through violent death. Trauma symptoms include also having thoughts about the death and about the person that are constantly dominating your mind — you can't get them off your mind, you can't control it. Anxiety doesn't seem as common.
Q: What do you suggest to those coping with a loss?
A: I would suggest three different sets of things. People who are not showing grief symptoms, don't do anything — they're fine. In fact, they can be harmed by intruding on their lives. They don't need to talk about it, but I think in this culture we have this sense that people need to talk about it — if they don't talk about it, something is wrong — no, leave those people alone. In people who are showing moderate levels of grief symptoms, it is sometimes a matter of getting used to the pain, which passes with time. What I've noticed is that people who show the common grief pattern sort of gradually regain their life by getting involved in new activities and rethinking who they are and what their life means. Rather than focusing on the loss, focus on who they are and where they're going to go next — more concrete goals. Focusing on what the change has meant in their life, rather than focusing on how they feel about it. They're developing a new identity to some extent, so they would appreciate support from their friends, and if they're seeing a therapist or any kind of mental health professional, they might benefit from help in that end of their life. Also, in cases when people lose a spouse, they often have to start thinking about getting involved with another person. Now, men do that more quickly than women. There's a lot of evidence for that.
Q: Is there a reason for that?
A: Men show more grief initially, men grieve more severely. I don't think any of the ideas have held up well, but a few people early on argued that a woman had more social support network and men concentrated their social support in their wife. When their wife died, they grieved more because they lost their support, so they would go find someone else to fill that void. I don't think that's held up really, but it's not easy to measure these things. I'm cautious in making that statement because I don't really know if that's true or not. It may be culture bound.
Q: You have studied bereavement both in the United States and in China. Are there any notable cultural differences you've found in terms of grieving?
A: Americans grieve the loss of a child very severely; they grieve much more profoundly when they lose a child than when they lose a spouse. That's been shown in a few studies and we found that in our study, but the Chinese didn't do that. They grieved the loss of the spouse and the loss of a child the same. So there are cultural differences.
Q: What would you suggest to a friend trying to support someone who is grieving?
A: What I suggest is to be available to them socially. People who lose a loved one often have to find new things to do. They, to some extent, look for new pieces of identity. Often when we lose someone close, we lose a large part of our social world.
Q: What about talking to friends about their loss?
A: I think it's very important to let the person talk about the loss at their own pace; if they don't want to, you don't need to bring it up. And I feel very strongly about this based on our research. We've published a couple of the only papers done on laughter during bereavement, and we found that people laugh and smile a lot when they talk about their losses, early on even. We are able to measure genuine laughter from polite laughter because we measure facial expressions — these muscles around the eyes will only contract when we have genuine positive emotion, and it's very difficult to do that voluntarily. We found that people did it a lot, and that it had enormous social benefits. People who laughed more had better relations with people. We showed films to observers, and they felt better about the bereaved people when they laughed. From this, we kind of speculated a bit, but it's OK to laugh, it's OK to forget and just have fun. We have this cultural idea that somehow we're not supposed to be doing that. I think that's what friends can do — get out and have fun, get a break and allow the luxury of talking about it when they want to. We did a questionnaire where we asked people to tell us how much they think about their loss, express their pain, and think about it in three different contexts. We found that they did the least grief work with friends, and I think this really speaks to this issue. Good friends are people you might want to talk about things with, but you also want to be with them because they're alive — they're people you're still connected to. So you don't want that relationship to be heavy and tense all the time. I think most people feel they need to be serious around bereaved people, but bereaved people report actually that that's not really helpful to them.