Living Through Loss, 2nd ed. by Nancy R. Hooyman, Betty J. Kramer, and Sara Sanders (introduction)

Introduction

This is a book about the inexplicable, the mysterious, and the universal nature of mortality and other loss experiences. Death, loss, grief, and pain are pervasive and inevitable aspects of the human experience. They touch us in different ways and at different times in our families, communities and cultures. As we confront the mystery of loss, we face questions about who we are and why we are here. Whether professional practitioners, educators or clients, each of us must deal with issues of meaning and purpose in our life in our own way and in our own time.

This book is written for social workers and other human service and health care professionals who assist people experiencing profound losses. It is for anyone who has loved and experienced loss and for those committed to living life fully no matter what challenges life offers them. This is a book for the searchers, the seekers, and the doubters, for those willing to ask the difficult questions and who struggle with the ambiguity of the answers when trying to understand the pain of loss and the meaning of life. It is for those committed to the journey and the adventure of life, even in its darkest moments.

Although we immerse ourselves in the literature, draw on our and others’ life experiences, and suggest interventions that may be helpful to those grieving, we do not consider ourselves “experts.” Indeed, individuals, families, and communities that we work with are often the experts who teach us the most about life and death, love and loss. Instead, we join you, the reader, on this journey. It has been more than fifteen years since the first edition of Living Through Loss. This second edition benefits from the insights and perspectives we have gained from the feedback provided by our readers, reviewers, and a new author, Sara Sanders. We have grown in our understanding related to losses in our own lives, and the literature has markedly changed since the first edition as well. We hope you and your colleagues will be inspired to reflect 1

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on and discuss the many meanings of loss presented here and that your family and friends, and the individuals, families, and communities you serve will benefit from your deeper understanding of loss and grief.

The Pervasiveness of Loss Although we typically refer to grief and loss, the more appropriate sequence is loss and grief because loss precedes grief. The pain of loss and the resultant grief are universal human experiences, and we absorb continuous change and loss daily. As Pagels wrote after the deaths of her young son and her husband, no one escapes terrible loss as a life-changing event that forever alters their outlook and the shape of their lives.1 Most of us think of death as the greatest loss, but its magnitude depends on our relationship with the person who has died. For example, a divorce after thirty years of marriage may be more devastating than the death of a distant relative or even of a partner if death brings a sense of relief from a conflictual marriage.2 Some people think that they have never grieved if they have not experienced a relative’s or friend’s death, but we are grievers a thousand times over in our lives.3 We are subject to many “little deaths” through losses and the subsequent lessons they teach us, including giving up our impossible expectations of others and ourselves.4 When we lose someone we love through death, divorce, or separation; when we lose our health and mobility; when our birth or foster parents die; or when we lose our job or home, we lose a part of ourselves—the self before the loss.

Loss follows any event perceived to be negative by the individuals involved that results in long-term changes to their relationships, patterns of thought and emotion, and ways they view the world. The global coronavirus pandemic in 2020, never imagined when we began the second edition, has resulted in the loss of a way of life once considered “normal.” Countless profound losses, both individual and collective, range from loved one’s deaths, to one’s health, to unemployment and declining income, especially for women, to disruptions in students’ learning, to upended routines and plans, to insecurity and uncertainty about the future and to mental illness and suicide. These events have disproportionately negatively affected Black and Brown populations and low-income communities. The imperative of social distancing has meant that grieving individuals have been unable to engage in public rituals of mourning that typically provide social support to survivors. The lack of social interaction during all life stages and the loss of the world we once knew will reverberate for years after the rate of infection is slowed by vaccines. Yet many people may not know how to voice or name their grief.

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February 22, 2021 was a dark day for the United States, with over 500,000 Americans dead from COVID-19. The sheer numbers make it hard for people to comprehend, to make a personal connection and to put faces and stories to them, in part because many of these deaths occurred in isolation and away from loved ones. Each death has left an unknown number of people grieving—partners, parents, children, neighbors, and friends; a ripple effect that swept across our country and the world. It is understandable that many of us have become numb to the numbers repeated daily on the news. But as President Biden emphasized on that dark day, we need to take the time to remember and reflect so that we can heal and find purpose as one nation.5 The loss and grief from the coronavirus pandemic are interconnected with the pandemic of racism in our society because of the health and mortality inequities faced by Black and Brown people. The pandemic of racism, embedded in our society for over 400 years, was brought to the forefront through highly visible instances of police brutality and other types of racial injustice in 2020; these heightened our awareness of the pervasiveness of the collective loss and grief of communities of color. Just as we must remember those who died from COVID-19, we must never forget the lives lost because of systemic racism.

Even changes with perceived positive outcomes, such as a career move, relocation, retirement, or more family time during coronavirus lockdowns, may evoke loss and grief.6 Although change in itself—whether positive or negative—always contains loss and learning to let go, not all losses precipitate a grief response. Such a response depends on a wide range of personal, family, cultural, and community capabilities as well as the degree of attachment we have to the lost object or person.

Losses can be physical or symbolic, but they always result in some kind of deprivation—we no longer have someone or something we once had. With physical loss, something tangible becomes unavailable, and the clearest example is death: the permanent and total absence of someone we love. Symbolic loss refers to a change in one’s psychological experience of social interactions, such as the loss of sense of identity because of a job demotion or retirement, a diminished sense of safety and predictability because of the twin pandemics of coronavirus and racism, or feeling isolated from other couples after a partner’s death or divorce.

Loss always contains some ambiguity, even when anticipated. Part of this ambiguity is being able to hold opposing ideas of absence and presence simultaneously in our minds, to live concurrently with joy and sorrow. For example, parents of children with complex health conditions or disabilities

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often experience intense grief when their child’s health crises, in effect, create wounds in them. They are losing a piece of themselves as well as their dreams of what their life would be like as parents, but they also love and experience joy with their child.7 As we grapple with our losses, we not only must acknowledge grief as a constant companion, regardless of the amount of time that has passed, but also must learn to open ourselves to joy and engagement in life again even though sadness is part of our new reality.8 Each time we experience loss of any kind, we have to work to find a “new normal” for life without the person or object that we desire. Like a snow globe, the snowflakes of our life will land in new places, forever altering us and how we live. When we experience profound loss, we can no longer maintain the illusion of being inviolable or believe in an omnipotent rescuer. By asking “why me,” we begin to face our own mortality.

The Pervasiveness and Nature of Grief Grief is the normal psychological, social, and physical reaction to loss. It is experienced through our feelings, thoughts, and attitudes; our behavior; and our health and bodily symptoms.9 As Corr et al. noted, to think of grief only as feelings risks misunderstanding and missing the full range of reactions to loss.10 Intensely personal and individualized, grief is based on our own perception of the loss. Moreover, our loss need not be recognized or validated by others for us to feel grief, although the lack of social validation may intensify our loneliness. Given the universality and inevitability of loss, grief is “like a neighbor, who always lives next door, no matter where or how we live, no matter how we try to move away.”11 The grief that follows most losses cannot be “cured” but is a necessary and inevitable part of existence.12 Pagels notes that pain and death are as natural as birth, woven inseparably into our human nature.13 The type of attachment and affinity to someone or something influences how individuals respond to loss and to opportunities for future growth.14 Grief is the price people pay for love and commitment to one another, and grief requires us to accept giving up what we so want. Although joy, light, and love typically precede pain, sadness, and darkness in our lives, this pattern of “good” followed by “bad” is not universal. For example, an adult child may grieve the death of a parent who was abusive, neglectful, or absent; a wife may mourn her divorce from an emotionally distant husband; or a widower may grieve his wife’s death after years of exhausting caregiving. Despite the limitations of some relationships,

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many adults still feel an attachment and experience grief even though the relationship was negative or when the loss is combined with some elements of relief.

Each of us struggles to come to terms with loss in a way that works for us.

No two people grieve in the same way; therefore, one’s person’s grief should not be considered as a standard by which others evaluate themselves. Wellmeaning friends and professionals may try to reassure us by telling us our grief will end in a certain amount of time, but grief does not follow a particular timetable or a sequence of stages. Indeed, some losses are so profound and life-changing that grief never completely ends; rather, its intensity, acuteness, and form ebb and flow over time. A major loss may never leave us, but it will take on different shapes and shades throughout our life. For these losses, “getting over it” may not be possible or desirable. Once we have lost someone or something we love, we live to varying degrees in grief’s presence.15 The journey of grieving is a path toward learning to live with and accept loss, not closure. As we live with our grief, most people are able to move forward in the face of their pain.16 As Pagels articulates, the mornings gradually become less gray, the evenings less dark.

Nor can the healing process be hurried or magically compressed, although we may implore others to “do something, anything,” to remove the hurt.

To grieve requires considerable time, energy, and attention. There is no simple formula or escape through work, drugs, alcohol, isolation, or anger.

Grief lasts as long as it lasts. Paradoxically, the process of living and grieving makes the strongest demand on us when we feel most exhausted and overwhelmed, creating ineffective as well as adaptive responses, which are highly personalized.17 The internal process of grieving is the hidden side of loss, and people typically do not realize it is occurring unless they choose to acknowledge their deepest feelings of pain. Everyone grieves following a loss, but not everyone will mourn. We live in a society in which people may not feel safe and supported enough to express their internal pain outward through crying, rage, or other intense emotions.18 Instead, we often receive messages to “be strong” and “get over it.”

There is considerable heterogeneity in our responses to loss. The degree and intensity of grief are not hierarchical. The magnitude of our response varies with the way in which a loss occurred; a person’s life experiences and individual capacities; the nature and meaning of the relationship; cultural, religious, or spiritual beliefs; and others’ responses and social supports. It also differs with developmental stages of life, other losses experienced, feelings

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of discrimination and injustice, and past strategies used by the bereaved to deal with loss.19 A presumed hierarchy of loss also overlooks that despite feelings of powerlessness, we can choose how to react to our losses, give them meaning, and incorporate them into the core of who we are and who we will become.

Although life’s greatest and most grievous losses disconnect us from ourselves, they also provide opportunities to create new connections with others, live more deeply, and discover greater meaning in our life. The bereaved achieve such meaning when they are able to consolidate their positive memories, engage in cognitive restructuring of fatalistic thoughts, and integrate the loss into their lives. As reflected in this book’s title, Living Through Loss, the process of creating meaning, perhaps through writing self-narratives or finding unsought benefits such as personal growth or redefined priorities, can be life-changing in positive ways. Such awareness encourages us to live in a more vital and honest manner, changing how we relate to others and how we perceive ourselves. This process prepares us for handling future losses and their resulting pain. By searching for meaning, we learn how to live in an altered world. However, meaning-making is about more than benefit-finding.20 As Pagels realized when left to raise two toddlers on her own, when life turns out different from what we expect, we have to do what life expects of us.21 Paradoxically, the only permanent feature of life is its impermanence. Even as we engage in meaning-making in the midst of the intense pain of loss, acknowledging and living in the awareness of our own mortality can enrich our lives.

Grief affects not only individuals but also family systems, neighborhoods, workplaces, communities (e.g., violence or devastating wildfires), and, in some cases, the nation or world, as occurred on 9/11, in hurricanes Maria and Harvey, during the coronavirus pandemic, in the 2019 Malaysian airline crashes, after school shootings such as those at Sandy Hook and Parkland, and after recent acts of police brutality that enlarged the Black Lives Matter movement. These events created a ripple of complex losses: the immediate loss of death, as well as the longer-term loss of a sense of safety and control and changes in our belief systems and behaviors in our communities or schools.

These events changed our worldview forever, creating cumulative and secondary consequences that continue to reverberate across social systems and generations. The meaning of loss for an individual cannot be separated from the family, community, and cultural meanings ascribed to it as well as the societal response to the bereaved. In other words, grieving has clear intrapsychic components, but it typically involves interactions with others who support or withdraw from the bereaved.22

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The multigenerational legacies of loss in our own families, social environments, and cultures are powerful. For example, most adults who were alive when President John F. Kennedy was assassinated in 1963 can vividly remember how they heard about his death, where they were, and how they felt. Moreover, his death still affects our country. Similarly, future generations will experience and reexperience the traumatic deaths resulting from the coronavirus pandemic, ongoing racial injustice, and the insurrection at the U.S. Capitol on January 6, 2021. Both family systems and communities feel losses across generations, such as the historical collective losses of indigenous populations and the intergenerational violence of slavery or the legacy of countless school shootings and police brutality against Black and Brown people. In the same way, the traumatic deaths and other losses due to the December 2004 tsunami will reverberate across Southeast Asian cultures, families, and communities for decades.

As we grieve new losses throughout life, it is common to revisit earlier losses. Even when we think we have integrated early losses into our lives, grief can catch us unaware and unprepared for the intensity of our feelings.

For instance, parents of a child that died years earlier may feel raw grief at graduations or weddings of their child’s peers because their child is not there to participate. Similarly, a wife may again experience the pain of divorce when her first new relationship ends. Through the process of “regrieving,” it is not unusual to grieve new dimensions of a loss as we mature and view that loss through a different lens stage of life or the changing societal, historical, and cultural context. In addition, some individuals may realize that they never fully grieved an earlier loss, which may once again feel new and raw despite the passage of time.23

Loss Through Death Life and death are two parts of the same story, each requires the other. Death differs from other losses because the deceased is gone forever. Even for those who believe that life continues in some form beyond death, there still is the absence of a physical presence. We miss the touch, smell, smile, hug, tone of voice, and laugh of the individual even as we hold these senses in our memory.

Our grief tends to focus on those left behind rather than on the person who has died.24 Perhaps we must speak of death to understand fully what it means to be in the presence of grief.25 To speak of death is to enter the realm of the supreme mystery, that of the unanswerable questions. Many of us are uncomfortable

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with the feelings of powerlessness and uncertainty initially inherent in loss through death, and our society tends to deny and fear death. We often feel discomfort when expressing our grief and want to avoid the pain and darkness. As Becvar wrote, death is “the horse on the dining room table,” the “elephant in the living room;” it is the one life transition that everyone experiences but few want to discuss.26 Confronting death challenges us to create meaning where none seems to exist, weaving an entirely new picture and story about ourselves, our world, and what it means to live. Loss through death marks the end of one chapter and the beginning of a new one. It can open doors to greater awareness, sensitivity, compassion, and even wisdom, or it can plunge us into longterm darkness. As Roethke implied in his poem “Dark Time,” it is only in the darkness that the eye sees clearly.27 Despite feelings of powerlessness and despair, we have choices to make regarding how we will live in a now dramatically altered context. With death, there is a struggle between “not forgetting” and “moving on.” Bereaved parents, in particular, never want to forget their child and the unique relationship they had, but they realize they need to move forward and continue living without that child, which may create emotional conflict. To be able to move on, people have to be able to draw upon their available supports during the darker, more difficult periods.28 Although this book deals with the loss and grief entailed by death, it is highly relevant for people who are grieving non-death-related losses: children separated from their birth parents through adoption or foster care or unable to play with friends during the coronavirus pandemic; young adults who lost their jobs, income, homes, and future dreams due to the pandemic, middle age adults who lost their daily routine during the pandemic, older adults who must leave their longtime home or are unable to see grandchildren because of coronavirus; immigrants who have lost their country; family systems profoundly changed by relatives’ substance use or severe mental health illness or a history of sexual or interpersonal violence; and communities devastated by gun violence and police brutality. Most non-death-losses entail a loss of dreams. When a dream dies, a sense of potential dies too, and individuals must search within themselves for the seeds of another dream.29 Chronic physical and mental illness and disability create numerous losses for both people surviving with disabilities and their caregivers. The parents of a child with a disability may immediately face the loss of their dreams for their child’s life. They have to live with something unexpected and that they perceive to be unfair and accept what previously might have

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seemed unacceptable. However, as time goes on, they often begin to recognize numerous rewards from raising a child with disabilities. Their grief is long term, or what is termed chronic sorrow, because they may face secondary losses throughout the child’s life and may grieve at milestones (e.g., birthdays, school graduations) missed when they reflect on what might have been.30 Because their grief is associated with the living, it can be unending.

They may feel disillusionment, aloneness, and vulnerability when others do not recognize their sorrow nor express support. Adults with a chronic illness or disability (e.g., spinal/brain injury, or dementia) may not only lose control over their physical body and autonomy but also grieve the loss of intimate and sexual relationships. Everyday relationships are central to understanding the meaning of loss for those who must depend on others. As Benwell demonstrates in The Last Leaves Falling, for those living with ALS, changes in physical ability bring anger, rage, fear, and grief as they watch their health decline.31 When illness or injury occurs at any time during life, a person’s self-image of competence is replaced by a new self-image as a patient whom others treat objectively. Life-threatening accidents, such as spinal cord injuries, can profoundly change a person’s sense of self. However, the losses that individuals face during functional decline may be minimized through supporting others dealing with illness, and they may lead to gains in personal growth and self-acceptance.32 Dreams are lost in unemployment, separation or divorce, and involuntary relocation. Unemployment or retirement losses may be multiple: the lack of income, a sense of security, status, and self-identity, and perhaps of one’s home. At the same time, individuals may engage in meaning-making as they reflect on their current situation and their future.33 Trying to see the unexpected gains from such losses, similar to developing new dreams, helps individuals explore new sources of meaning Divorce or separation requires letting go of dreams along with all that was invested in the relationship, and other social networks, family structures, and previous roles may also be lost. Dreams may be abandoned as a result of a loss of place through immigration, moving (e.g., trading a longtime family home for a small assisted-living facility), or being unable to afford a home (e.g., eviction, homelessness). These losses can be profound because place defines our sense of space and the predictability of life. Consider the emotional comfort of being able to “go home,” no matter our stage of life.

Losing the space that is “home” throws us off base psychologically, making it more difficult to deal with secondary losses associated with the loss of physical space.

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Professionals’ Understanding of Loss and Grief Ideally, all human beings should understand the processes of loss and grief.

Unfortunately, many of us will not have the time, space, freedom, or support to do so because our lives are dominated by other demands that keep us from attending to our grief. Social workers and other health care and human service professionals, regardless of their practice setting or clients’ stage of life, must acquire such understanding because loss is at the heart of many issues faced by those with whom we work. Some grief researchers and practitioners contend that a new profession of grief counselors is not needed. They maintain that those in positions to extend care to the bereaved may already possess the knowledge and skills to effectively intervene or need only gain an enhanced understanding and sensitivity about issues of loss and grief.34 This book is relevant for a wide range of health and human service professionals who are often part of interdisciplinary teams working with the bereaved, such as nurses, psychologists, family therapists, physicians, occupational therapists, teachers, chaplains, and home health workers. Professions from multiple helping disciplines are in pivotal roles and understand that grief is an inevitable, ever-present part of their practice. Individuals’ earlier losses and areas of trauma, and whether and how they were resolved, may complicate current life events. For instance, early life trauma and numerous losses faced by older individuals—loss of loved ones, autonomy, friendships, health, and home—can profoundly affect elders’ well-being.35 Understanding how early and current losses combine and the multigenerational implications of loss is needed to provide effective interventions. Yet we also must recognize that facing and overcoming the fear of loss and dealing with tragedy are not things we can do for our clients. Grief is hard, painful work that no one can do for anyone else. Instead, as Worden notes, by feeling the pain of their loss, we assist them through their own journey of grief.36 Social workers and other professionals must acknowledge the nature and centrality of loss and subsequent grief in their own lives. When we accept grief as a given in our life, we can construct a belief system that provides meaning and a safe context in which to facilitate others’ journeys of grief and healing. Because death and loss are so often feared or denied in American society, professionals must cognitively and affectively confront and accept the inevitability of their own death to work effectively with those grieving.37 Our comfort with our mortality varies with what we bring from our family of origin, family history, culture’s norms, and religious or spiritual beliefs. We all receive a variety of messages in our families, both implicit and explicit,

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about whether death is an uninvited stranger or a welcome guest.38 Becoming conscious of those messages is the first step toward working effectively with the bereaved.

Topics central to preparing social workers and other professionals for navigating through loss and grief with individuals at different life stages include the bereaved’s psychosocial needs; the efficacy of interventions; variations by culture, race, ethnicity, gender, disability, sexual orientation, socioeconomic status, and religion/spirituality; as well as the impact of loss, particularly trauma, on family systems, generations, and communities across the life course.39 All social workers, not only those in end-of-life care, can benefit from such education because loss and grief transcend working with the dying.

Our hope for you, our readers, is that this book will deepen your self-awareness and knowledge, increase your ability to assist yourself and others grieving losses, and point to resources to assist you in your work. The bereaved person must engage in the hard and painful process of grief, but professionals with culturally appropriate skills and evidence-informed resources can provide accurate information, put forth realistic and appropriate expectations, and use effective interventions that help reduce feelings of pain, confusion, and anger. Death is as natural as birth, and our clients are our true teachers in understanding the meaning of loss as they show us the many facets of grief.

Underlying Themes of This Book The themes that underlie our approach to loss and grief differentiate this book from others, particularly those focused on dying and end-of-life care.

• Grieving is an extremely complex, ambiguous, and individualized experience with physical, emotional, cognitive, cultural, and spiritual dimensions.

People grieve very differently, so there is no cookbook or linear approach for professionals to use. Instead, this book often raises questions rather than providing easy answers.

• What is considered healthy grieving varies widely. For example, what was once considered “pathological,” such as continuing bonds to the deceased, is now viewed as normal and desirable. Indeed, what is considered “normal” or “complicated” changes over time and within different sociocultural and historical contexts. There is no right or wrong way to grieve, and some bereaved individuals may experience complicated grief and prolonged grief disorder. Uncomplicated grief is the most frequent appropriate response to loss, whereas major depression is a mental disorder

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that can complicate the grieving process. We avoid using words such as pathological, resolved, or normal grief, but those concepts, deeply rooted in early grief work theories , sometimes appear in our discussion of theoretical perspectives and complicated grief processes. Within the overarching concept of grief are different types of grief that have clinical significance, such as anticipatory grief, disenfranchised grief, ambiguous loss, chronic sorrow, and complicated grief (see chapter 2).

It is essential for professionals to recognize cultural and religious/spiritual norms regarding loss, rituals, and constructions of grieving and meaningmaking to understand the significance of loss for members of different groups across the life course. When possible, we include examples of such variations.

Congruent with our discussion of variations in how we grieve, particularly gender-based differences, we have used inclusive definitions of families.

Throughout, the word partner refers to a spouse in a heterosexual marriage or a life partner in either a LGBTQ relationship or a heterosexual, nonmarried relationship. This definition recognizes and honors the range of intimate committed relationships. Widow and widower represent all types of partner relationships, not just legally married couples. The words wife and husband, however, are used when research findings are explicitly based on married couples, whether heterosexual or gay.

We no longer use the definition of cultural competency from the first edition because it is too narrowly focused on individual attitudes and behaviors such as an appreciation of diversity. Cultural competency paved the way for increased awareness and knowledge of cultural differences, but it ignores the fact that race is not synonymous with culture. There is no one Black, Asian American, or Latinx culture. Moreover, understanding a particular culture such as Hmong or Somali does not mean that we are less biased against Hmong or Somali people; knowing about someone’s culture does not stop stereotyping based on racialization.40 Cultural competency is no longer salient in light of the unjust deaths of Black and Brown people that result from systemic racism, which has been highlighted by their higher death rates during the coronavirus pandemic, shocking police brutality on the streets of our cities, and the calls to action of the Black Lives Matter movement. Cultural competency fails to address white privilege and the lifelong cumulative toll of systemic and institutional oppression based on a foundation of racism that requires structural change.41 Racial and economic inequality rooted in slavery has been challenged by the civil rights movement, and the resulting inequities have been highly

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visible during the coronavirus pandemic in terms of access to health care and the vaccines. It is imperative for practitioners to address how racism, white privilege, power inequities, and oppression are built into every institution in American society and affect interactions with people of color.42 Institutional racism, codified in systems and formal and informal rules and policies, exacerbates inequality in outcomes such as physical and mental well-being and mortality.43 Moreover, Black and Brown people are exposed to more deaths across the life span, and health risks posed by grief and bereavement add to the disadvantages that they face historically and intergenerationally.44 These structural factors undoubtedly affect how people of color grieve—both individually and collectively—the losses of loved ones as well as of their health, employment, community, and safety.

• Professionals must draw upon critical race theory, engage in critical reflexivity of their own implicit biases and their responsibility for privilege, and engage in the hard work of anti-racism. They also need to take account of how injustices faced by other marginalized populations, such as LGBTQ individuals, affect their experiences of loss and grief without eclipsing the pervasiveness of institutionalized racism. Throughout we articulate the need for practitioners and researchers to take account of injustices that affect loss and grief experiences of marginalized populations who disproportionately experience deaths, poor health, and other losses, and their resultant deep pain, anguish, and trauma.

• It is essential to recognize how the developmental stage of life interacts with and is made more challenging by loss and grief. For example, the loss of one’s job through retirement at age seventy has a very different meaning than that of a single mom of young children who lost her job and only source of income during the coronavirus pandemic. Whether losses are developmentally on time (e.g., death of a partner in her eighties) or off time (e.g., death of a partner in his twenties) also affects the grieving process. The accumulation of loss during a lifetime magnifies the grief with each loss, especially in old age. Each chapter that discusses loss at a different stage of life—childhood, adolescence, young adulthood, middle adulthood, and old age—is organized according to customary developmental processes and tasks and developmentally congruent interventions for that life stage, although much of what we know about developmental stages is unfortunately based largely on white populations.

• Grief across the life course is a more appropriate term than “life span” because of increasing recognition of the larger social, political, economic, and physical environment and cultural and historical context in which we live.

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What is considered a loss may vary markedly for an adolescent in a lowincome community with high rates of violence, a single mother struggling to maintain her family as she flees an abusive situation, an immigrant father separated from his children at the border, or an upper-middle-class parent of a child with disabilities but who has extensive resources. This larger environment and the resultant racial, ethnic, gender, sexual identity, and class inequities affect individual and social capabilities brought to the grief process, and they are given greater recognition in this second edition. The pervasiveness of racial injustice is also discussed at different life stages, particularly adolescence and young adulthood; however, evidenceinformed individual and community-level interventions specific to losses faced by populations of color are critically needed.

• Our focus is on grief counseling rather than grief therapy because the vast majority of our readers are more likely to offer counseling than therapy.

Grief counseling refers to the facilitation of the process or tasks of uncomplicated grieving to relieve suffering and help the bereaved to adapt.45 It generally involves one-to-one, family, or group interventions designed to encourage the expression of feelings and to support those seeking help for their bereavement-related distress. Grief therapy refers to processes used by highly trained professionals involving specialized intervention techniques to address more traumatic, complicated, or chronic grief.46 • Efficacious evidence-informed interventions are presented in chapters 5, 7, 9, 11, and 13, following our discussion of losses characteristic of different life stages. Evidence-informed interventions are limited for young adulthood and middle age. We highlight the need for more empirical evaluations of interventions with bereaved individuals at all life stages and particularly for those from different cultures and populations who daily confront racism, homophobia, sexism, or classism. We also recognize the conceptual and methodological limitations of bereavement outcome research that constrain our understanding of the effectiveness of grief counseling and therapy and, in fact, often do not distinguish between the two. Unfortunately, most evaluative studies use generic measures of health, depression, and anxiety rather than measuring grief, and effects by type of intervention are not always distinguished. An additional limitation is that interventions may work better for adults who seek help on their own compared to those recruited into intervention studies, and interventions may be more effective for people who are younger who have more complicated or traumatic grief reactions.47 Despite these limitations in the literature, we suggest interventions for most types of loss over the life course.

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• Most people are resilient and may experience psychological growth, development, and well-being through loss over time.48 Such abilities emerge in individuals, families, cultures, and communities and interact with and modify the relationship between adversity (e.g., loss) and physical and mental well-being. In contrast to intrapersonal models of grief, we emphasize social, family, community, and cultural capabilities as moderating variables. The concept of resilience resonates with social work’s strengths perspective and the ecological model of person and environment.

• We interweave our personal and professional experiences with the evidence-based literature throughout rather than drawing unrealistic boundaries between the personal, the clinical, and the scholarly.

Summary In our review of the literature and recognition of the many types and meanings of loss, we discuss how developmental tasks interact with some of the most common losses throughout life. We acknowledge that there are losses and interventions that we have not fully addressed, such as those associated with changes in gender identity or becoming homeless. We also recognize that other losses for individuals may emerge as they gain deeper understanding of loss in their lives. We hope that organizing the chapters according to developmental considerations, individual, family, community, cultural capabilities, and resilient outcomes, along with interventions, is useful to your practice and research. At the same time, gaps in research—especially the lack of evidence-informed interventions related to grief and loss for culturally, racially, and socioeconomically diverse populations—prevent us from exploring them fully in each developmental stage.

Chapter 1 more fully defines grief, loss, mourning, and bereavement; reviews major theoretical perspectives; and describes some cultural variations in the experience of loss and grief. Chapter 2 analyzes the dynamics, phases, and challenges of the grief process; discusses the distinctions between healthy grieving and complicated mourning; further explores disenfranchised grief, ambiguous loss, anticipatory grief, chronic sorrow, complicated grief, persistent complex bereavement disorder, and trauma; and examines the various manifestations of grief. In chapter 3, we examine factors that influence how people grieve, including the type of loss; personal capabilities such as spirituality and creating meaning; gender, race, and age; and family, community, and cultural strengths. A resilience model conceptualizes the strengths or

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Introduction

capacities of bereaved individuals, families, and communities, and we explain how resilience affects mental and physical well-being. It takes account of familial, social, and cultural contextual factors, not just individual ones, that affect the integration of loss into one’s life. The losses often experienced at different life stages are examined in the chapters on childhood (chapter 4), adolescence (chapter 6), young adulthood (chapter 8), middle age (chapter 10), and old age (chapter 12). A chapter on appropriate interventions immediately follows each chapter on specific developmental periods (chapters 5, 7, 9, and 13). The intervention chapters analyze the existing evidence about methods effective for different populations and suggest future directions in both practice and research. Working with the bereaved inevitably raises issues about our own mortality as well as our past losses and grief, and chapter 14 addresses professional self-awareness and self-care, including the need to address our implicit biases, racism, sexism, and homophobia.

“This second edition of a splendid book explores the pervasiveness of loss in multiple forms.

The authors examine loss in terms of a range of theoretical understandings and provide approaches to intervention that consider social, cultural, and environmental contexts and influences. This is a rich addition to the consideration of loss.”

A L L A N C O L E , author of Good Mourning: Getting Through Your Grief

“At a time when people are reeling from the many losses dealt by the pandemic, the second edition of this book could not be timelier. The life-span approach taken and interventions provided for each life stage impart a wealth of critical information and guidance to current and future clinicians.”

T R A C Y A . S C H R O E P F E R , University of Wisconsin–Madison

“Living Through Loss is an important, timely, and compelling book that presents an evolved perspective of the universal experiences of loss and grief. This book is authentic, grounded, and written from the authors’ deep awareness and knowledge—leading the reader to a richer understanding of loss across the life course.”

D E B O R A H W A L D R O P , University at Buffalo

“The authors interweave professional and scholarly knowledge with personal experience.

As a clinician and teacher, I found myself tallying up my own losses and acknowledging reverberations of old sorrows. The overall effect is a sense of being grounded in the midst of great complexity—a gift both to the scholar and the clinician.”

W E N D Y L U S T B A D E R , author of Counting on Kindness: The Dilemmas of Dependency

N A N C Y R . H O O Y M A N is the Hooyman Professor Emerita in Gerontology and dean emerita at the University of Washington School of Social Work. Her books include Social Gerontology: A Multidisciplinary Perspective, tenth edition (2017), and Aging Matters: An Introduction to Social Gerontology (2014).

B E T T Y J . K R A M E R is professor emerita at the Sandra Rosenbaum School of Social

Work, University of Wisconsin–Madison. She is coeditor of Men as Caregivers: Theory, Research, and Service Implications (2001).

S A R A S A N D E R S is a professor in the School of Social Work at the University of Iowa, where she also serves as the associate dean for strategic initiatives and director of diversity, equity, and inclusion for the College of Liberal Arts and Sciences.

Elliott S. Cairns

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