Although the loss of a loved one affects everyone, some people are affected more severely than others. In Freud's [1
] seminal paper, ‘mourning and melancholia’, he acknowledged that all grief was not the same and that some particular grief was actually pathological (what he called melancholia) regarding a person's inability to interact with and manage the external world. Since Freud's contribution to distinguishing normal from abnormal grief, grief experiences to a loss of a loved one have been divided into non-pathological and pathological reactions.
Prigerson and her colleagues [2
] have operationalized this distinction as uncomplicated and complicated grief. Prigerson et al.
] define complicated grief as a cluster of experiences that include: separation distress; post-traumatic stress; and an inability to cope with the loss of a loved one. Complicated grief has been further divided into anticipatory grief reactions and bereavement reactions. Research has demonstrated that these two experiences, pre- and post-death grief, are unique phenomena from each other and other psychiatric diagnoses. Despite this, very little research has studied complicated grief pre-loss. Additionally, these few studies have not focused on the factors that predict complicated grief (e.g. [4
]), and even fewer have examined these factors in relation to the pre-grief experience. Of the studies that have examined complicated grief pre- and post-loss, the limited research has focused on primarily middle- to older-aged samples. Very little research has examined the experience of complicated grief in the younger adult population (younger than 50 years old).
Beery et al.
] examined complicated grief pre-loss in 70 elderly participants. These subjects were, on average, 50 years old and older. Beery et al.
] examined the effects of changes in role function, caregiver tasks, caregiver burden, and gratification on complicated grief symptoms. They found that caregiver burden and depression significantly affected levels of complicated grief. This study did not examine age as an independent variable. Van Doorn et al.
] examined the effects of marital quality and attachment styles on complicated grief pre-loss in 59 participants who were on average 50 years old and older. Their findings suggest spousal caregivers of terminally ill patients who have a secure, supportive spouse and an insecure attachment style contribute independently to the severity of complicated grief symptoms. They found that younger age was related to complicated grief pre-death. However, the age ranged from 40 to 87 years; therefore, few younger caregivers were included in the sample.
Kelly et al.
] examined the effects of adverse life events, coping responses, past bereavement and separation experiences, relationship with the patient, and the severity of the patient's illness on pathological grief pre- and post-loss in 178 caregivers of terminal cancer patients ranging in age from 22 to 87 years old. Their research did not use pathological grief measures, which they acknowledged to be a limitation of their design. Instead, general measures of social functioning, adjustment and coping were used. Additionally, the average age for participants was approximately 69 years old and age was not included in their empirical model.
] examined whether age and mode of death predicted the intensity of anticipatory grief reactions (before the term complicated grief pre-loss had been coined) in a sample of 200 widows whose spouses died of illness or accident 6–9 months prior to the study. Age was found to be a more significant predictor of grief intensity than mode of death. Regardless of the mode of death, the young widow (18–46) suffered a more intense grief than middle (47–59) or older widows (60–73). This is the only study to include young participants in the examination of anticipatory grief, but the sample size for the young widows, (N
= 10), makes the reliability of this finding questionable.
The limited research on this construct thus far has not specifically operationalized complicated grief, have had a relatively small sample, lacked a cohort of younger subjects, and have not yet established predictive variables associated with complicated pre-grief. Perhaps with the inclusion of both younger and older caregivers that reflect an adequate range of ages, elevations for complicated grief would appear in both of these groups.
Since the development of the ICG by Prigerson and her colleagues [8
], few studies have looked at factors that relate to complicated grief [9
]. Vanderwerker and Prigerson [9
] examined the role of social support and technological connectedness as protective factors in bereavement. Ellifritt, Nelson, and Walsh [10
] used a different bereavement risk questionnaire to diagnose complicated grief, but they also found that lack of social support is a significant risk for complicated bereavement. Maddison and Walker [11
] showed that widows at greater risk for unresolved grief perceive themselves to have more unmet needs in interpersonal relationships than did those with resolved grief outcomes. Bereavement is a social process that involves numerous relationships. Therefore the interaction with others is a necessary component of bereavement, allowing the caregiver to come to an acceptable understanding as to why the death occurred [12
]. Despite this knowledge of the interaction between social support and bereavement, no studies have used social support as a factor in understanding the pre-death grief experience.
Individual differences in optimism also play an important role in the adjustment to stressful life events [13
]. Previous research has demonstrated that optimists use different strategies to cope with stress than do pessimists and that these coping strategies contribute to a better adjustment to a stressful life event [14
]. In a study by Robinson-Whelen, Kim, MacCallum, and Kiecolt-Glaser [16
], caregivers and noncaregivers were examined for the effects of recent negative life events on their levels of optimism, pessimism and psychological distress. This study found that caregivers expressed less optimism than noncaregivers, and caregivers showed a trend toward more pessimism. Additionally, pessimism predicted subsequent psychological health problems. To date, no studies have been conducted examining the relationship between pessimism and the experience of complicated grief pre-loss. In light of the research that has demonstrated relationship between pessimism and psychological health, it is important to examine if a pessimistic view puts caregivers at more risk for a pathological grieving reaction.
This study attempts to fill the gaps in the current pre-grief literature by studying caregivers of terminally ill cancer patients, ranging in age from early twenties to late eighties. Few studies have examined complicated grief pre-loss and no studies have examined the role of social support, pessimism, depression, stressful life events and access to mental health services in the experience of complicated grief before the loss of a loved one. This study hypothesizes that there will be elevations in complicated grief pre-loss for younger and older groups as compared to middle-aged adults, and that variables such as social support, pessimism, depression, stressful life events, and access to mental health services relate to higher levels of complicated grief pre-loss.