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Guilt in Bereavement: A Review and Conceptual Framework a
Jie Li , Margaret Stroebe
b c
a
, Cecilia L. W. Chan & Amy Y. M. Chow
a
a
Department of Social Work and Social Administration , The University of Hong Kong , Hong Kong b
Department of Clinical and Health Psychology , Utrecht University , Utrecht , The Netherlands c
Department of Clinical and Experimental Psychopathology , Groningen University , The Netherlands Accepted author version posted online: 12 Jul 2013.Published online: 22 Aug 2013.
To cite this article: Jie Li , Margaret Stroebe , Cecilia L. W. Chan & Amy Y. M. Chow (2014) Guilt in Bereavement: A Review and Conceptual Framework, Death Studies, 38:3, 165-171, DOI: 10.1080/07481187.2012.738770 To link to this article: http://dx.doi.org/10.1080/07481187.2012.738770
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Death Studies, 38: 165–171, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2012.738770
Guilt in Bereavement: A Review and Conceptual Framework Jie Li Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
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Margaret Stroebe Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands, and Department of Clinical and Experimental Psychopathology, Groningen University, The Netherlands
Cecilia L. W. Chan and Amy Y. M. Chow Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
Thirty-four quantitative and 9 qualitative studies are reviewed to indicate current understanding of the nature and impact of guilt in bereavement. This overview suggests that guilt is especially prevalent among some vulnerable subgroups, and it is associated with maladaptive health outcomes. Being male, longer bereavement time, and good end-of life experience seem to be associated with less guilt feelings. However, definition ambiguity, measurement difficulties, and cultural insensitivity are evident in studies. Therefore, a multidimensional conceptualization of guilt and a structural model to guide future investigation of this phenomenon in the bereavement context is proposed.
Grief is understood by many researchers to be an emotional syndrome that includes a cluster of emotional components rather than one specific emotion (e.g., M. Stroebe, Hansson, Stroebe, & Schut, 2001). Guilt, a familiar emotion within the grief syndrome, has been long-recognized by writers and widely reported by bereaved persons themselves. Guilt was included as one of the main grief reactions as early as the 1940s (Lindemann, 1944). It has been considered an important aspect of grief both as a normal reaction (Shuchter & Zisook, 1993) and as a manifestation of pathological grief (Parkes, 1975; Raphael, 1975), even being considered a reason for the development of complications in grieving (Rando, 1993). The association
Received 3 April 2012; accepted 4 September 2012. Jie Li is now affiliated with the Department of Psychology, Renmin University of China. Address correspondence to Jie Li, Department of Psychology, Renmin University of China, Beijing, 100872, China. E-mail: jie0619@ gmail.com
between guilt and psychological and somatic problems among bereaved persons has been identified in clinical case reports (Berman, 1978; Tooley, 1975; Zimmerman, 2001). The centrality of this emotion is also reflected in its incorporation as a subscale in classic grief measures, such as the Grief Experience Inventory (GEI; Sanders, Mauger, & Strong, 1985) and the Grief Experience Questionnaire (GEQ; Barrett & Scott, 1989). Thus, there are good reasons to argue the need for sound empirical investigation of guilt in bereavement. Despite the lack of systematic understanding of guilt in the bereavement context, some empirical evidence has accumulated. It seems timely to review this small body of research, to establish what is known about its nature and consequences. To clarify the scope of the review, we first define guilt in bereavement, then summarize and critically appraise empirical studies. Given the limited, rather fragmented state of knowledge, a structural model is then proposed to guide future research.
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GUILT IN BEREAVEMENT: THE DEFINITION
RESULTS
Psychologists have not reached agreement on defining guilt. The lack of conceptual convergence on guilt is well-illustrated in a recent, major review that identifies 23 psychological definitions and 25 measurements of guilt (Tilghman-Osborne & Cole, 2010). Analyzing common features in various definitions (such as moral transgression and behavior), the review concluded that guilt had both affective and cognitive components, involving ‘‘moral transgressions (real or imagined) in which people believe that their action (or inaction) contributed to negative outcomes . . . A sense of responsibility and painful feelings of remorse are part of the guilt’’ (p. 544). The conclusion that there are two components in guilt is similar to definitions proposed by trauma and bereavement researchers (Kubany, 2003; Miles & Demi, 1991–1992; Rando, 1993). Following the conceptualization of guilt as one emotion in grief, and trying to incorporate the core elements in previous definitions, we define guilt in bereavement as ‘‘a remorseful emotional reaction in grieving, with the recognition of having failed to live up to one’s own inner standards and expectations in relationship to the deceased and=or the death.’’
Thirty-four quantitative and nine qualitative studies were identified as relevant for this review. Main findings in qualitative studies suggested that guilt was a common theme in people’s grief experience (Adolfsson & Larsson, 2004; Cacciatore, 2010; Chiu, 2010; Clayton, Halikes, & Maurice, 1971; Hasui & Kitamura, 2004; Kerr, 1994; Smialek, 1978), and that sources of guilt went beyond self blame for the death, including aspects such as survivor guilt and fail to provide a better care (Miles & Demi, 1983; Smith, Nunley, Kerr, & Galligan, 2011). Main findings in quantitative studies provided the empirical evidence on manifestations and outcomes of guilt. They can be summarized into three themes: prevalence of guilt, risk factors and the association between guilt and health outcomes.2
SEARCHING THE LITERATURE To identify studies within this domain, we used guiltrelated words (such as guilt, self blame, regret,1 self reproach) and bereavement related words (such as grief, bereavement, death, loss, and suicide) searching in PsycINFO, Scopus, and EBSCOhost. We also searched studies using grief scales, which included subscales of guilt or self blame, such as the GEI, Revised Grief Experience Inventory (Lev, Munro, & McCorkle, 1993), GEQ, and Grief Cognitions Questionnaire (Boelen & Lensvelt-Mulders, 2005). However, we only included those that analyze the guilt subscales separately. Further literature was identified from the reference lists of relevant studies. We focused on empirical studies published in peerreviewed journals. In drawing conclusions, more weight was given to quantitative studies that adopted large samples and used validated instruments. Six studies emerging from the searches were excluded from the review because the definition of guilt in these studies went beyond ours or they failed to provide enough information on how they measured guilt. Only English-language publications are reviewed in this article.
1
The ways used to measure regret were scrutinized to decide whether they fall within the definition of ‘‘guilt’’.
The Prevalence of Guilt The prevalence of guilt ranged enormously from 7% (Zisook & Shuchter, 1985) to over 90% (Miles & Demi, 1991–1992; Mizota, Ozawa, Yamazaki, & Inoue, 2006), with most between 30%–60% (Davis, Lehman, Wortman, & Silver, 1995; Lehman & Wortman, 1987; Shanfield & Swain, 1984; Weinberg, 1994). Two possible reasons may account for this diversity. The first is different nature of subgroups under investigation. The two studies reporting over 80% were conducted among particularly vulnerable samples. One was among parents of hemophiliac children who inherit the disease from their mothers (Mizota et al., 2006). The other involved parents in self-support groups, who may seek support for dealing with difficult emotions like guilt (Miles & Demi, 1991–1992). In contrast to these studies, the very low percentage (7%) was reported for spouses bereaved for a longer time (above 4 years) (Zisook & Shuchter, 1985). As will become clear below, guilt diminishes over time. Second, measurements of guilt vary remarkably between studies. The high prevalence ones typically count various sources of guilt (e.g., not doing enough, responsibility for the death, survivor guilt). This naturally increases the chance of guilt being detected. Moreover, some guilt questions asked about the difficulties in dealing with guilt (McMenamy, Jordan, & Mitchell, 2008), whereas others asked about the frequency (Surkan et al., 2006). Thus, the prevalence of guilt bears different meanings in different studies, and it is difficult to make comparisons across them. In conclusion, even though guilt in bereavement is commonly reported in most studies, no general 2 The table summarizing quantitative studies is available in Li. J. (2012). Bereavement guilt in Chinese adult children. Doctoral dissertation in preparation.
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statement about the prevalence is possible or probably even useful. What we need is better understanding of prevalence for specific subgroups and clarification of the guilt content so that it can be measured appropriately.
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Risk Factors Some factors are found to be associated with higher guilt, and they involve (a) situational factors (e.g., time since loss, cause of death, characteristics of deceased, pre-death relationship and palliative care received); (b) personal factors (e.g., gender and religion); and (c) interpersonal factors (e.g., social support) (W. Stroebe & Schut, 2001). Guilt is found to diminish with time in longitudinal studies among bereaved parents (Bohannon, 1991a; Lang, Gottlieb, & Amsel, 1996), but not in crosssectional studies among bereaved spouses (Kowalski & Bondmass, 2008; Zisook & Shuchter, 1985) or among diverse sub-groups of bereaved people (Akiyama, Numata, & Mikami, 2010; Mizota et al., 2006). Whether the time course of guilt differs across subgroups or countries is open to further exploration. Unnatural death has been considered a risk factor for intense guilt (Rando, 1993), but the empirical findings are highly discrepant. One study reported higher guilt in natural compared with unnatural death (Bailley, Kral, & Dunham, 1999), other studies reported the opposite pattern (Gamino, Sewell, & Easterling, 2000; Hazzard, Weston, & Gutterres, 1992; Weinberg, 1995), and one study found no group difference (Harwood, Hawton, Hope, & Jacoby, 2002). Suicide survivors have been described as more vulnerable to guilt than following other types of bereavement (Jordan, 2001). However, a review of well-controlled studies comparing this type of death with others reported mixed results (Sveen & Waly, 2008). Conclusions seem to vary according to the method of inquiry (qualitative or quantitative), and comparison groups (natural death or other kinds of traumatic death; cf. Jordan & McIntosh, 2011). Some studies reported differences according to gender and age of the deceased, but failed to eliminate possible confounding variables. For example, one study found that parents who lost a son experienced higher guilt than those who lost a daughter, but at the same time, more boys died suddenly than girls in this sample (Hazzard et al., 1992). Another study reported younger age of the deceased as a risk factor, yet this may be because younger people are more likely to die from unnatural causes than older people (Gamino et al., 2000). More guilt also follows an ambivalent predeath relationship with the deceased, one characterized by argument, dissatisfaction, and frustration in the relationship (Shanfield & Swain, 1984). Several studies suggested the importance of a ‘‘good ending’’ to alleviate the risk
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of guilt. In cases where the deceased passed away peacefully, end-of-life discussion about the death or afterdeath issues were carried on with the deceased, or adequate medical care was provided, then lower rates or less intensive guilt has been found among family members after the death (Akiyama et al., 2010; Jonasson et al., 2011; Surkan et al., 2006; Ylitalo, Valdimarsdottir, Onelov, Dickman, & Steineck, 2008). Several studies suggest that bereaved mothers experience—or at least, express—more guilt than bereaved fathers (Lang et al., 1996; Mizota et al., 2006; Schwab, 1996). Despite the limited number of studies, the gender differences found in these studies seem convincing, particularly because they eliminate other confounding variables (such as duration of bereavement). Nevertheless, it remains unclear whether the reported difference reflects different levels of guilt actually experienced by women and men, or just the tendency for women to be more expressive about their negative emotions (Simon & Nath, 2004). Religion and social support are assumed to be helpful in adjustment to bereavement (W. Stroebe & Schut, 2001; Wortman & Park, 2008), and their protective effects on guilt are supported by a few studies. One study found an inverse relationship between attending church and feeling guilt (Bohannon, 1991b). Another study found that sharing with and receiving support from the partner was associated with lower guilt among bereaved mothers (Lang et al., 1996). In conclusion, researchers have begun exploring risk factors of guilt, but there is still a dearth of sound empirical evidence. Discrepant findings may suggest the need to investigate interacting effects. For example, one study found that the gender difference was only significant when the bereavement duration was above 2 years (Hyrka¨s, Kaunonen, & Paunonen, 1997). Similarly, finer-grained examination of combinations of factors= subgroups needs to be done to establish, for example, whether guilt only diminishes with time among parents but not spouses, or in western but not eastern countries. More studies are also needed to explore alterable factors, such as coping strategies, besides personal risk factors, such as gender. The latter could be helpful to detect at-risk subgroups, whereas the former can be applied in preventive initiatives and treatment. Guilt and Health Outcomes There are 18 studies exploring the association between guilt and health outcomes. Most studies indicate the detrimental impact—or, at least, association—of guilt on or with maladaptive adjustment. For example, guilt is found to be concurrently or longitudinally associated with psychological distress (Davis et al., 1995; Downey, Silver, & Wortman, 1990; Field & Bonanno, 2001; Field,
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Bonanno, Williams, & Horowitz, 2000; Horowitz et al., 1984; Torges, Stewart, & Nolen-Hoeksema, 2008). One study found a positive correlation between guilt and psychiatric as well as traumatic reactions (Mizota et al., 2006), and another two documented an association between guilt and impaired physical health (Hazzard et al., 1992; Kowalski & Bondmass, 2008). The association between guilt and greater maladjustment is also reflected in positive correlations between guilt and normal or complicated grief symptoms (Akiyama et al., 2010; Boelen & Lensvelt-Mulders, 2005; Boelen, van den Bout, & van den Hout, 2003; Field et al., 2000; Gamino et al., 2000; Mizota et al., 2006; Weinberg, 1994, 1995). Lastly, an inverse relationship between guilt and positive outcome after bereavement further confirms the association between guilt and maladaptive health outcomes (Gamino et al., 2000). In conclusion, the harmful influence of guilt on health outcomes seems apparent based on the results of most studies, despite a few exceptions suggesting no relationship between guilt and psychological distress (Akiyama et al., 2010) or between guilt and complicated grief (Golden & Dalgleish, 2012). Whether guilt is causally related to complicated grief is a matter for further investigation, particularly as there is little well-controlled longitudinal research investigating the predictive effect of guilt. Also, little is known about mechanisms behind the association, and more studies are needed to examine mediators. CRITICAL ASSESSMENT OF THE EMPIRICAL EVIDENCE Gaps in knowledge have already become evident from the preceding review, and some specific limitations in the studies have been identified. Further to this, there are a number of general comments to be made about this body of evidence. We outline the main points next. Conceptualizing Guilt in Bereavement Only a few of the reviewed studies defined guilt or related concepts prior to the investigation, with most providing no definition at all. However, based on measures adopted in different studies, guilt has been variously conceptualized, for example, as a coping strategy (e.g., Garnefski & Kraaij, 2009), a group of cognitions (e.g., Boelen et al., 2003), or an emotion that is part of grief (e.g., Kowalski & Bondmass, 2008). It is difficult to build on the knowledge of guilt in bereavement without clear and consistent conceptualization. Therefore, we defined guilt as an emotional component in grief, given that grief is comprised of all kinds of emotional reactions and given the historical treatment of guilt: It has been documented as one of
these emotions, as well as incorporated as one aspect of grief in classic grief measures. In our view, such a definition provides a common starting point for future investigations. Because guilt is generally conceptualized as part of grief, caution is needed when exploring the relationship between guilt and bereavement outcomes. The overlap of measures may inflate the associations between guilt and negative health outcomes. For example, one study found significant correlations between reported guilt and feelings in grief. However, the result may due—at least in part—to the overlap between guilt and items such as ‘‘remorse’’ and ‘‘regret’’ in the self-constructed measure for grief (Akiyama et al., 2010). Studies that aim to explore the role of guilt on grief outcomes should avoid contamination from similar items in assessing guilt and outcomes. Measuring Guilt in Bereavement We noted that there are multiple sources of guilt in qualitative findings (Kerr, 1994; Miles & Demi, 1983; Smith et al., 2011). However, most quantitative studies we reviewed adopted measures that lack psychometric validity or fail to reflect the complexity of guilt. For example, some studies constructed just one item to measure guilt (e.g., Hazzard et al., 1992; Surkan et al., 2006), and most studies focused on individuals’ self blame for the death, covering few other aspects of the guilt experience (e.g., Downey et al., 1990; Horowitz et al., 1984; Zisook & Shuchter, 1985). The lack of valid measurement may hinder further understanding of guilt in bereavement. For example, different sources of guilt may correlate with different risk factors. One study found that the cause of death does not predict guilt about not doing enough for the deceased, but it did predict perceived responsibility for the death (Bailley et al., 1999). The respective association between different sources of guilt and risk factors, as well as health outcomes, can only be assessed with a tool that delineates guilt into sub-components. Lack of Cultural Sensitivity The importance of cultural sensitivity has been acknowledged by bereavement researchers (Rosenblatt, 2008) and emotion psychologists (Markus & Kitayama, 1991). However, this is missing in studies we reviewed, as most were conducted in western countries. We believe cultural context is critical for this topic because different moral codes in western and eastern countries may lead to diverse elicitors of guilt (Bedford & Hwang, 2003). The subtypes of guilt, as well as the relationship between guilt and psychopathology may differ across countries too. For example, there are over 100 words to describe guilt and shame in Chinese (Li, Wang, & Fischer, 2004). Guilt
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is reported to have less negative consequences for people in collective than individualistic cultures (Wallbott & Scherer, 1995). Taken together, potential cross-cultural differences in the nature and role of guilt in bereavement require more investigation in nonwestern countries.
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Lack of Exploration of Treating=Reducing Guilt in Bereavement Guilt is an unpleasant feeling that seems to impede psychological adjustment in bereavement, and it may require treatment beyond intervention for other grief symptoms (Constantino & Bricker, 1996). Nevertheless, there is little empirical evidence about the efficacy of intervention for (problematic levels of) guilt in bereavement. Cognitive therapy may be a direction worth exploring. Its effectiveness in treating guilt has been found for trauma survivors (Kubany & Manke, 1995). It is also helpful in reducing destructive aspects of counterfactual thinking in bereavement, which usually relate to self blame for the death (Fleming & Robinson, 2001). One study we reviewed also found supportive evidence for its effectiveness in reducing guilt among suicide survivors (De Groot et al., 2007). Thus, testing the efficacy of treating guilt with cognitive therapy (as well as other treatments) seems a useful and important direction for future research.
FUTURE DIRECTIONS: A FRAMEWORK FOR GUIDING RESEARCH The evidence reviewed above confirms the significance of guilt as an emotion in bereavement. High prevalence of guilt has been identified in several quantitative studies and its detrimental potential in relationship to psychological and physical health and general well-being has been confirmed by empirical evidence. Given its important role in bereavement, guilt deserves more scientific attention and rigorous investigation. Previous studies have made some inroads, suggesting lines of future investigation. However, scientific understanding of this emotion is limited by shortcomings in the available empirical studies. To enhance knowledge about guilt in bereavement, as well as to provide better support for bereaved people who suffer from debilitating guilt, we propose a structural model of guilt in bereavement (Figure 1) for systematic investigation in the future, one that is compatible with cognitive stress theory (Folkman, 2001; Lazarus & Folkman, 1984). In this model, guilt is conceived of as a distinct element in grief, containing both cognitive and affective components. The relationship between these two components is bidirectional (Kubany, 2003). The gap between one’s own inner standards or expectations and
FIGURE 1 The structural model of guilt in bereavement.
one’s cognitions relating to the actual behavior is understood to elicit uncomfortable affective reactions. Conversely, according to Kubany (2003), emotion influences guilt cognitions through mood-state dependant retrieval and through self attribution regarding the negative feeling. Testing this model requires developing valid measures that embrace and reflect the complexity of guilt. With this tool, risk or protective factors can be explored, to outline profiles for high risk subgroups, and enable identification of alterable factors for potential integration in prevention or intervention planning. Furthermore, the relationship between guilt—or more specifically, each component of guilt—and different kinds of health outcomes, both negative and positive, can be investigated within the framework of this model. Possible mediators between guilt and maladaptive outcomes can be investigated, to gain deeper understanding of mechanisms underlying harmful effects. Last but not least, examination of possible moderators that may buffer the impact of guilt is also a meaningful direction for research, as it can add knowledge on dealing with and treating guilt in bereavement. Clearly, testing the various parameters of such a model and determining the range of manifestations and phenomena associated with guilt in bereavement is a large, multifaceted endeavor. This model and our definition of guilt only provide one possible starting point for different teams of investigators. Meanwhile, other researchers may propose alternative research models and conceptualizations, which can stimulate further thinking and discussion on this important phenomenon. We hope to call researchers’ attention to guilt in bereavement, to increase scientific understanding as well as to provide useful knowledge for practical application, particularly for the treatment of complications in grieving associated with extreme guilt feelings.
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Smialek, Z. (1978). Observations on immediate reactions of families to sudden infant death. Pediatrics, 62, 160–165. Smith, M. E., Nunley, B. L., Kerr, P. L., & Galligan, H. (2011). Elders’ experiences of the death of an adult child. Issues in Mental Health Nursing, 32, 568–574. doi:10.3109=01612840.2011.576802 Stroebe, M., Hansson, R., Stroebe, W., & Schut, H. (2001). Introduction: Concepts and issues in contemporary research on bereavement. In M. Stroebe, R. Hansson, W. Stroebe & S. Henk (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 3–22). Washington, DC: American Psychological Association. Stroebe, W., & Schut, H. (2001). Risk factors in bereavement outcome: A methodological and empirical review. In M. S. Stroebe, R. O. Hansson, S. Wolfgang, & S. Henk (Eds.), Handbook of bereavement research: Consequences, coping and care (pp. 349–371). Washington, DC: American Psychological Association. Surkan, P. J., Kreicbergs, U., Valdimarsdo´ttir, U., Nyberg, U., Onelo¨v, E., Dickman, P. W., & Steineck, G. (2006). Perceptions of inadequate health care and feelings of guilt in parents after the death of a child to a malignancy: A population-based long-term follow-up. Journal of Palliative Medicine, 9, 317–331. doi:10.1089= jpm.2006.9.317 Sveen, C. A., & Waly, F. A. (2008). Suicide survivors’ mental health and grief reactions: A systematic review on controlled studies. Suicide and Life Threatening Behavior, 38(1), 13–29. Tilghman-Osborne, C., & Cole, D. A. (2010). Definition and measurement of guilt: Implications for clinical research and practice. Clinical Psychology Review, 30, 536–546. doi:10.1016= j.cpr.2010.03.007 Tooley, K. (1975). The choice of a surviving sibling as ‘scapegoat’ in some cases of maternal bereavement: A case report. Journal of Child Psychology and Psychiatry and Allied Disciplines, 16, 331–339. doi:10.1111=j.1469-7610.1975.tb00367.x Torges, C. M., Stewart, A. J., & Nolen-Hoeksema, S. (2008). Regret resolution, aging, and adapting to loss. Psychology and Aging, 23(1), 169–180. doi:10.1037=0882-7974.23.1.169 Wallbott, H. G., & Scherer, K. R. (1995). Cultural determinants in experiencing shame and guilt. In J. P. Tangey & K. W. Fischer (Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 465–487). New York, NY: The Guilford Press. Weinberg, N. (1994). Self-blame, other blame, and desire for revenge: Factors in recovery from bereavement. Death Studies, 18, 583–593. doi:10.1080=07481189408252702 Weinberg, N. (1995). Does apologizing help? The role of self-blame and making amends in recovery from bereavement. Health and Social Work, 20, 294–294. Wortman, J. H., & Park, C. L. (2008). Religion and spirituality in adjustment following bereavement: An integrative review. Death Studies, 32, 703–736. doi:10.1080=07481180802289507 Ylitalo, N., Valdimarsdottir, U., Onelov, E., Dickman, P. W., & Steineck, G. (2008). Guilt after the loss of a husband to cancer: Is there a relation with the health care provided? Acta Oncologica, 47(5), 870–878. doi:10.1080=02841860701766145 Zimmerman, J. (2001). Dyspepsia as a somatic expression of guilt: A case report. American Journal of Clinical Hypnosis, 44, 57–61. doi:10.1080=00029157.2001.10403456 Zisook, S., & Shuchter, S. R. (1985). Time course of spousal bereavement. General Hospital Psychiatry, 7, 95–100. doi:10.1016=01638343(85)90017-9
Death Studies Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/udst20
Guilt in Bereavement: A Review and Conceptual Framework a
Jie Li , Margaret Stroebe
b c
a
, Cecilia L. W. Chan & Amy Y. M. Chow
a
a
Department of Social Work and Social Administration , The University of Hong Kong , Hong Kong b
Department of Clinical and Health Psychology , Utrecht University , Utrecht , The Netherlands c
Department of Clinical and Experimental Psychopathology , Groningen University , The Netherlands Accepted author version posted online: 12 Jul 2013.Published online: 22 Aug 2013.
To cite this article: Jie Li , Margaret Stroebe , Cecilia L. W. Chan & Amy Y. M. Chow (2014) Guilt in Bereavement: A Review and Conceptual Framework, Death Studies, 38:3, 165-171, DOI: 10.1080/07481187.2012.738770 To link to this article: http://dx.doi.org/10.1080/07481187.2012.738770
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Death Studies, 38: 165–171, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2012.738770
Guilt in Bereavement: A Review and Conceptual Framework Jie Li Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
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Margaret Stroebe Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands, and Department of Clinical and Experimental Psychopathology, Groningen University, The Netherlands
Cecilia L. W. Chan and Amy Y. M. Chow Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
Thirty-four quantitative and 9 qualitative studies are reviewed to indicate current understanding of the nature and impact of guilt in bereavement. This overview suggests that guilt is especially prevalent among some vulnerable subgroups, and it is associated with maladaptive health outcomes. Being male, longer bereavement time, and good end-of life experience seem to be associated with less guilt feelings. However, definition ambiguity, measurement difficulties, and cultural insensitivity are evident in studies. Therefore, a multidimensional conceptualization of guilt and a structural model to guide future investigation of this phenomenon in the bereavement context is proposed.
Grief is understood by many researchers to be an emotional syndrome that includes a cluster of emotional components rather than one specific emotion (e.g., M. Stroebe, Hansson, Stroebe, & Schut, 2001). Guilt, a familiar emotion within the grief syndrome, has been long-recognized by writers and widely reported by bereaved persons themselves. Guilt was included as one of the main grief reactions as early as the 1940s (Lindemann, 1944). It has been considered an important aspect of grief both as a normal reaction (Shuchter & Zisook, 1993) and as a manifestation of pathological grief (Parkes, 1975; Raphael, 1975), even being considered a reason for the development of complications in grieving (Rando, 1993). The association
Received 3 April 2012; accepted 4 September 2012. Jie Li is now affiliated with the Department of Psychology, Renmin University of China. Address correspondence to Jie Li, Department of Psychology, Renmin University of China, Beijing, 100872, China. E-mail: jie0619@ gmail.com
between guilt and psychological and somatic problems among bereaved persons has been identified in clinical case reports (Berman, 1978; Tooley, 1975; Zimmerman, 2001). The centrality of this emotion is also reflected in its incorporation as a subscale in classic grief measures, such as the Grief Experience Inventory (GEI; Sanders, Mauger, & Strong, 1985) and the Grief Experience Questionnaire (GEQ; Barrett & Scott, 1989). Thus, there are good reasons to argue the need for sound empirical investigation of guilt in bereavement. Despite the lack of systematic understanding of guilt in the bereavement context, some empirical evidence has accumulated. It seems timely to review this small body of research, to establish what is known about its nature and consequences. To clarify the scope of the review, we first define guilt in bereavement, then summarize and critically appraise empirical studies. Given the limited, rather fragmented state of knowledge, a structural model is then proposed to guide future research.
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GUILT IN BEREAVEMENT: THE DEFINITION
RESULTS
Psychologists have not reached agreement on defining guilt. The lack of conceptual convergence on guilt is well-illustrated in a recent, major review that identifies 23 psychological definitions and 25 measurements of guilt (Tilghman-Osborne & Cole, 2010). Analyzing common features in various definitions (such as moral transgression and behavior), the review concluded that guilt had both affective and cognitive components, involving ‘‘moral transgressions (real or imagined) in which people believe that their action (or inaction) contributed to negative outcomes . . . A sense of responsibility and painful feelings of remorse are part of the guilt’’ (p. 544). The conclusion that there are two components in guilt is similar to definitions proposed by trauma and bereavement researchers (Kubany, 2003; Miles & Demi, 1991–1992; Rando, 1993). Following the conceptualization of guilt as one emotion in grief, and trying to incorporate the core elements in previous definitions, we define guilt in bereavement as ‘‘a remorseful emotional reaction in grieving, with the recognition of having failed to live up to one’s own inner standards and expectations in relationship to the deceased and=or the death.’’
Thirty-four quantitative and nine qualitative studies were identified as relevant for this review. Main findings in qualitative studies suggested that guilt was a common theme in people’s grief experience (Adolfsson & Larsson, 2004; Cacciatore, 2010; Chiu, 2010; Clayton, Halikes, & Maurice, 1971; Hasui & Kitamura, 2004; Kerr, 1994; Smialek, 1978), and that sources of guilt went beyond self blame for the death, including aspects such as survivor guilt and fail to provide a better care (Miles & Demi, 1983; Smith, Nunley, Kerr, & Galligan, 2011). Main findings in quantitative studies provided the empirical evidence on manifestations and outcomes of guilt. They can be summarized into three themes: prevalence of guilt, risk factors and the association between guilt and health outcomes.2
SEARCHING THE LITERATURE To identify studies within this domain, we used guiltrelated words (such as guilt, self blame, regret,1 self reproach) and bereavement related words (such as grief, bereavement, death, loss, and suicide) searching in PsycINFO, Scopus, and EBSCOhost. We also searched studies using grief scales, which included subscales of guilt or self blame, such as the GEI, Revised Grief Experience Inventory (Lev, Munro, & McCorkle, 1993), GEQ, and Grief Cognitions Questionnaire (Boelen & Lensvelt-Mulders, 2005). However, we only included those that analyze the guilt subscales separately. Further literature was identified from the reference lists of relevant studies. We focused on empirical studies published in peerreviewed journals. In drawing conclusions, more weight was given to quantitative studies that adopted large samples and used validated instruments. Six studies emerging from the searches were excluded from the review because the definition of guilt in these studies went beyond ours or they failed to provide enough information on how they measured guilt. Only English-language publications are reviewed in this article.
1
The ways used to measure regret were scrutinized to decide whether they fall within the definition of ‘‘guilt’’.
The Prevalence of Guilt The prevalence of guilt ranged enormously from 7% (Zisook & Shuchter, 1985) to over 90% (Miles & Demi, 1991–1992; Mizota, Ozawa, Yamazaki, & Inoue, 2006), with most between 30%–60% (Davis, Lehman, Wortman, & Silver, 1995; Lehman & Wortman, 1987; Shanfield & Swain, 1984; Weinberg, 1994). Two possible reasons may account for this diversity. The first is different nature of subgroups under investigation. The two studies reporting over 80% were conducted among particularly vulnerable samples. One was among parents of hemophiliac children who inherit the disease from their mothers (Mizota et al., 2006). The other involved parents in self-support groups, who may seek support for dealing with difficult emotions like guilt (Miles & Demi, 1991–1992). In contrast to these studies, the very low percentage (7%) was reported for spouses bereaved for a longer time (above 4 years) (Zisook & Shuchter, 1985). As will become clear below, guilt diminishes over time. Second, measurements of guilt vary remarkably between studies. The high prevalence ones typically count various sources of guilt (e.g., not doing enough, responsibility for the death, survivor guilt). This naturally increases the chance of guilt being detected. Moreover, some guilt questions asked about the difficulties in dealing with guilt (McMenamy, Jordan, & Mitchell, 2008), whereas others asked about the frequency (Surkan et al., 2006). Thus, the prevalence of guilt bears different meanings in different studies, and it is difficult to make comparisons across them. In conclusion, even though guilt in bereavement is commonly reported in most studies, no general 2 The table summarizing quantitative studies is available in Li. J. (2012). Bereavement guilt in Chinese adult children. Doctoral dissertation in preparation.
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statement about the prevalence is possible or probably even useful. What we need is better understanding of prevalence for specific subgroups and clarification of the guilt content so that it can be measured appropriately.
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Risk Factors Some factors are found to be associated with higher guilt, and they involve (a) situational factors (e.g., time since loss, cause of death, characteristics of deceased, pre-death relationship and palliative care received); (b) personal factors (e.g., gender and religion); and (c) interpersonal factors (e.g., social support) (W. Stroebe & Schut, 2001). Guilt is found to diminish with time in longitudinal studies among bereaved parents (Bohannon, 1991a; Lang, Gottlieb, & Amsel, 1996), but not in crosssectional studies among bereaved spouses (Kowalski & Bondmass, 2008; Zisook & Shuchter, 1985) or among diverse sub-groups of bereaved people (Akiyama, Numata, & Mikami, 2010; Mizota et al., 2006). Whether the time course of guilt differs across subgroups or countries is open to further exploration. Unnatural death has been considered a risk factor for intense guilt (Rando, 1993), but the empirical findings are highly discrepant. One study reported higher guilt in natural compared with unnatural death (Bailley, Kral, & Dunham, 1999), other studies reported the opposite pattern (Gamino, Sewell, & Easterling, 2000; Hazzard, Weston, & Gutterres, 1992; Weinberg, 1995), and one study found no group difference (Harwood, Hawton, Hope, & Jacoby, 2002). Suicide survivors have been described as more vulnerable to guilt than following other types of bereavement (Jordan, 2001). However, a review of well-controlled studies comparing this type of death with others reported mixed results (Sveen & Waly, 2008). Conclusions seem to vary according to the method of inquiry (qualitative or quantitative), and comparison groups (natural death or other kinds of traumatic death; cf. Jordan & McIntosh, 2011). Some studies reported differences according to gender and age of the deceased, but failed to eliminate possible confounding variables. For example, one study found that parents who lost a son experienced higher guilt than those who lost a daughter, but at the same time, more boys died suddenly than girls in this sample (Hazzard et al., 1992). Another study reported younger age of the deceased as a risk factor, yet this may be because younger people are more likely to die from unnatural causes than older people (Gamino et al., 2000). More guilt also follows an ambivalent predeath relationship with the deceased, one characterized by argument, dissatisfaction, and frustration in the relationship (Shanfield & Swain, 1984). Several studies suggested the importance of a ‘‘good ending’’ to alleviate the risk
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of guilt. In cases where the deceased passed away peacefully, end-of-life discussion about the death or afterdeath issues were carried on with the deceased, or adequate medical care was provided, then lower rates or less intensive guilt has been found among family members after the death (Akiyama et al., 2010; Jonasson et al., 2011; Surkan et al., 2006; Ylitalo, Valdimarsdottir, Onelov, Dickman, & Steineck, 2008). Several studies suggest that bereaved mothers experience—or at least, express—more guilt than bereaved fathers (Lang et al., 1996; Mizota et al., 2006; Schwab, 1996). Despite the limited number of studies, the gender differences found in these studies seem convincing, particularly because they eliminate other confounding variables (such as duration of bereavement). Nevertheless, it remains unclear whether the reported difference reflects different levels of guilt actually experienced by women and men, or just the tendency for women to be more expressive about their negative emotions (Simon & Nath, 2004). Religion and social support are assumed to be helpful in adjustment to bereavement (W. Stroebe & Schut, 2001; Wortman & Park, 2008), and their protective effects on guilt are supported by a few studies. One study found an inverse relationship between attending church and feeling guilt (Bohannon, 1991b). Another study found that sharing with and receiving support from the partner was associated with lower guilt among bereaved mothers (Lang et al., 1996). In conclusion, researchers have begun exploring risk factors of guilt, but there is still a dearth of sound empirical evidence. Discrepant findings may suggest the need to investigate interacting effects. For example, one study found that the gender difference was only significant when the bereavement duration was above 2 years (Hyrka¨s, Kaunonen, & Paunonen, 1997). Similarly, finer-grained examination of combinations of factors= subgroups needs to be done to establish, for example, whether guilt only diminishes with time among parents but not spouses, or in western but not eastern countries. More studies are also needed to explore alterable factors, such as coping strategies, besides personal risk factors, such as gender. The latter could be helpful to detect at-risk subgroups, whereas the former can be applied in preventive initiatives and treatment. Guilt and Health Outcomes There are 18 studies exploring the association between guilt and health outcomes. Most studies indicate the detrimental impact—or, at least, association—of guilt on or with maladaptive adjustment. For example, guilt is found to be concurrently or longitudinally associated with psychological distress (Davis et al., 1995; Downey, Silver, & Wortman, 1990; Field & Bonanno, 2001; Field,
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Bonanno, Williams, & Horowitz, 2000; Horowitz et al., 1984; Torges, Stewart, & Nolen-Hoeksema, 2008). One study found a positive correlation between guilt and psychiatric as well as traumatic reactions (Mizota et al., 2006), and another two documented an association between guilt and impaired physical health (Hazzard et al., 1992; Kowalski & Bondmass, 2008). The association between guilt and greater maladjustment is also reflected in positive correlations between guilt and normal or complicated grief symptoms (Akiyama et al., 2010; Boelen & Lensvelt-Mulders, 2005; Boelen, van den Bout, & van den Hout, 2003; Field et al., 2000; Gamino et al., 2000; Mizota et al., 2006; Weinberg, 1994, 1995). Lastly, an inverse relationship between guilt and positive outcome after bereavement further confirms the association between guilt and maladaptive health outcomes (Gamino et al., 2000). In conclusion, the harmful influence of guilt on health outcomes seems apparent based on the results of most studies, despite a few exceptions suggesting no relationship between guilt and psychological distress (Akiyama et al., 2010) or between guilt and complicated grief (Golden & Dalgleish, 2012). Whether guilt is causally related to complicated grief is a matter for further investigation, particularly as there is little well-controlled longitudinal research investigating the predictive effect of guilt. Also, little is known about mechanisms behind the association, and more studies are needed to examine mediators. CRITICAL ASSESSMENT OF THE EMPIRICAL EVIDENCE Gaps in knowledge have already become evident from the preceding review, and some specific limitations in the studies have been identified. Further to this, there are a number of general comments to be made about this body of evidence. We outline the main points next. Conceptualizing Guilt in Bereavement Only a few of the reviewed studies defined guilt or related concepts prior to the investigation, with most providing no definition at all. However, based on measures adopted in different studies, guilt has been variously conceptualized, for example, as a coping strategy (e.g., Garnefski & Kraaij, 2009), a group of cognitions (e.g., Boelen et al., 2003), or an emotion that is part of grief (e.g., Kowalski & Bondmass, 2008). It is difficult to build on the knowledge of guilt in bereavement without clear and consistent conceptualization. Therefore, we defined guilt as an emotional component in grief, given that grief is comprised of all kinds of emotional reactions and given the historical treatment of guilt: It has been documented as one of
these emotions, as well as incorporated as one aspect of grief in classic grief measures. In our view, such a definition provides a common starting point for future investigations. Because guilt is generally conceptualized as part of grief, caution is needed when exploring the relationship between guilt and bereavement outcomes. The overlap of measures may inflate the associations between guilt and negative health outcomes. For example, one study found significant correlations between reported guilt and feelings in grief. However, the result may due—at least in part—to the overlap between guilt and items such as ‘‘remorse’’ and ‘‘regret’’ in the self-constructed measure for grief (Akiyama et al., 2010). Studies that aim to explore the role of guilt on grief outcomes should avoid contamination from similar items in assessing guilt and outcomes. Measuring Guilt in Bereavement We noted that there are multiple sources of guilt in qualitative findings (Kerr, 1994; Miles & Demi, 1983; Smith et al., 2011). However, most quantitative studies we reviewed adopted measures that lack psychometric validity or fail to reflect the complexity of guilt. For example, some studies constructed just one item to measure guilt (e.g., Hazzard et al., 1992; Surkan et al., 2006), and most studies focused on individuals’ self blame for the death, covering few other aspects of the guilt experience (e.g., Downey et al., 1990; Horowitz et al., 1984; Zisook & Shuchter, 1985). The lack of valid measurement may hinder further understanding of guilt in bereavement. For example, different sources of guilt may correlate with different risk factors. One study found that the cause of death does not predict guilt about not doing enough for the deceased, but it did predict perceived responsibility for the death (Bailley et al., 1999). The respective association between different sources of guilt and risk factors, as well as health outcomes, can only be assessed with a tool that delineates guilt into sub-components. Lack of Cultural Sensitivity The importance of cultural sensitivity has been acknowledged by bereavement researchers (Rosenblatt, 2008) and emotion psychologists (Markus & Kitayama, 1991). However, this is missing in studies we reviewed, as most were conducted in western countries. We believe cultural context is critical for this topic because different moral codes in western and eastern countries may lead to diverse elicitors of guilt (Bedford & Hwang, 2003). The subtypes of guilt, as well as the relationship between guilt and psychopathology may differ across countries too. For example, there are over 100 words to describe guilt and shame in Chinese (Li, Wang, & Fischer, 2004). Guilt
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is reported to have less negative consequences for people in collective than individualistic cultures (Wallbott & Scherer, 1995). Taken together, potential cross-cultural differences in the nature and role of guilt in bereavement require more investigation in nonwestern countries.
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Lack of Exploration of Treating=Reducing Guilt in Bereavement Guilt is an unpleasant feeling that seems to impede psychological adjustment in bereavement, and it may require treatment beyond intervention for other grief symptoms (Constantino & Bricker, 1996). Nevertheless, there is little empirical evidence about the efficacy of intervention for (problematic levels of) guilt in bereavement. Cognitive therapy may be a direction worth exploring. Its effectiveness in treating guilt has been found for trauma survivors (Kubany & Manke, 1995). It is also helpful in reducing destructive aspects of counterfactual thinking in bereavement, which usually relate to self blame for the death (Fleming & Robinson, 2001). One study we reviewed also found supportive evidence for its effectiveness in reducing guilt among suicide survivors (De Groot et al., 2007). Thus, testing the efficacy of treating guilt with cognitive therapy (as well as other treatments) seems a useful and important direction for future research.
FUTURE DIRECTIONS: A FRAMEWORK FOR GUIDING RESEARCH The evidence reviewed above confirms the significance of guilt as an emotion in bereavement. High prevalence of guilt has been identified in several quantitative studies and its detrimental potential in relationship to psychological and physical health and general well-being has been confirmed by empirical evidence. Given its important role in bereavement, guilt deserves more scientific attention and rigorous investigation. Previous studies have made some inroads, suggesting lines of future investigation. However, scientific understanding of this emotion is limited by shortcomings in the available empirical studies. To enhance knowledge about guilt in bereavement, as well as to provide better support for bereaved people who suffer from debilitating guilt, we propose a structural model of guilt in bereavement (Figure 1) for systematic investigation in the future, one that is compatible with cognitive stress theory (Folkman, 2001; Lazarus & Folkman, 1984). In this model, guilt is conceived of as a distinct element in grief, containing both cognitive and affective components. The relationship between these two components is bidirectional (Kubany, 2003). The gap between one’s own inner standards or expectations and
FIGURE 1 The structural model of guilt in bereavement.
one’s cognitions relating to the actual behavior is understood to elicit uncomfortable affective reactions. Conversely, according to Kubany (2003), emotion influences guilt cognitions through mood-state dependant retrieval and through self attribution regarding the negative feeling. Testing this model requires developing valid measures that embrace and reflect the complexity of guilt. With this tool, risk or protective factors can be explored, to outline profiles for high risk subgroups, and enable identification of alterable factors for potential integration in prevention or intervention planning. Furthermore, the relationship between guilt—or more specifically, each component of guilt—and different kinds of health outcomes, both negative and positive, can be investigated within the framework of this model. Possible mediators between guilt and maladaptive outcomes can be investigated, to gain deeper understanding of mechanisms underlying harmful effects. Last but not least, examination of possible moderators that may buffer the impact of guilt is also a meaningful direction for research, as it can add knowledge on dealing with and treating guilt in bereavement. Clearly, testing the various parameters of such a model and determining the range of manifestations and phenomena associated with guilt in bereavement is a large, multifaceted endeavor. This model and our definition of guilt only provide one possible starting point for different teams of investigators. Meanwhile, other researchers may propose alternative research models and conceptualizations, which can stimulate further thinking and discussion on this important phenomenon. We hope to call researchers’ attention to guilt in bereavement, to increase scientific understanding as well as to provide useful knowledge for practical application, particularly for the treatment of complications in grieving associated with extreme guilt feelings.
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