894273

research-article20192019
SGOXXX10.1177/2158244019894273SAGE OpenHolm et al.

Original Research

SAGE Open

The Meaning of Bereavement Following

October-December 2019: 1­–11
© The Author(s) 2019
DOI: 10.1177/2158244019894273
https://doi.org/10.1177/2158244019894273

Spousal Loss: A Qualitative Study of the journals.sagepub.com/home/sgo

Experiences of Older Adults

Anne Lise Holm1 , Elisabeth Severinsson2, and

Astrid Karin Berland1

Abstract
Bereavement and spousal loss lead to emotional and practical problems, especially for those in failing health. The aim of
this study was to explore the meaning of bereavement in older adults after the death of their spouse. The participants took
part in in-depth interviews. The themes and sub-themes were identified using a hermeneutic approach. One overall theme,
Struggling to maintain pride and dignity; three themes; and six sub-themes emerged. The first theme, Understanding health
decline, included one sub-theme: Difficulty asking for help. The second theme, A lonely painful struggle, had three sub-
themes: Striving to avoid feeling sorry for oneself, Searching for meaning when life becomes meaningless, and Sensing that
one’s spouse is present. In the third theme, Feeling misunderstood in the dialogue with others, two sub-themes emerged:
Longing for support to achieve inclusion and Togetherness is the best medicine. It is vital to prevent older adults from
carrying a permanent state of grief with them for the rest of their life.

Keywords
bereavement, dignity, health decline, loss, meaning, pride, older adults

Introduction to maintain close emotional relationships and meaningful

activities in a process of self-management dominated by
Bereavement is considered particularly challenging for resilience (Holm and Severinsson, 2012).
older persons because of concurrent losses outside a Bereavement has been linked to social, mental, behav-
bereavement context (Moss et al., 2001; Naef et al., 2013). ioral, and physical issues, consistent with a stress-induced
Bereavement and spousal loss lead to many emotional and weathering process (Das, 2013). Thus, bereavement is seen
practical problems, especially for those in failing health, as a major stressor that triggers problems such as depression
who struggle with their own limitations when performing and complicated grief (Shear et al., 2011).
everyday activities (Naef et al., 2013). Research on the Holm et al. (2019) examined factors that influence the
experience of bereavement has been applied in fields such health of older widows and widowers. One of the themes that
as psychology, philosophy, and art, where grief and loss are emerged was emotional challenges related to experiences of
examined in ways that enable bereaved persons to search for bereavement, depression, and anxiety, which was based on
meaning after the loss of loved ones (Gillies & Neimeyer, the sub-theme social support as the main strategy for coping
2006). These experiences can split the internal world by with emotional pain and suffering. The second theme was
shattering one’s most fundamental assumptions (Janoff- struggling with poor physical health (Holm et al., 2019). In
Bulman, 2010). According to Janoff-Bulman (2010, p. 133), their longitudinal survey, Van den Berg et al. (2011) found
one must build a non-threatening assumption that contrib-
utes to a resolution of the survivor’s existential dilemma. 1
Western Norway University of Applied Sciences, Haugesund, Norway
Bereavement should be seen in a positive light where the 2
Nursing and Healthcare Research Group, Stavanger University Hospital,
person can face the situation with dignity (Janoff-Bulman, Norway
2010, p. 277). The necessity of meaning making on the part
Corresponding Author:
of bereaved older adults is supported by a review study by
Anne Lise Holm, Professor, Faculty of Health and Social Sciences,
Holm and Severinsson (2012), which suggests that older Western Norway University of Applied Sciences, Bjørnsonsgt. 45, N-5528
widows struggle to perceive meaning and numb their emo- Haugesund, Norway.
tional pain in an attempt to control their feelings. They tried Email: [email protected]

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2 SAGE Open

that bereavement affected health, because healthy years were than for widows. (Fang et al., 2012) found that for widowers,
replaced by years with chronic diseases. The strong effects of the bereavement and spousal loss-related mortality increased
bereavement suggested that monitoring and/or interventions with lower baseline probability of death, particularly from can-
shortly after spousal loss were important for the length and cer and circulatory diseases. For widows, the widowhood-asso-
quality of life of older individuals. Bereavement has also ciated risks seem fairly homogeneous. Another study by (Shah
been associated with health, age, and gender where being a et al., 2013) found that unexpected bereavement has a greater
widower, being older, less well educated, and functionally impact on the risk of death preceded by chronic disease. Thus,
healthy were associated with better health (Krochalk, 2008). a decrease in physical and mental health related to bereavement
Sasson and Umberson (2014) found no gender differences in is evident. The findings highlighted the value of preparing
bereavement effects on depressive symptoms in either the older adults for the death of a spouse with known morbidity
short or long term. The sample included widows/widowers and providing extra support for those who experience a sudden
aged from 51 to 61 years. When regard to gender and and unexpected bereavement (Shah et al., 2013).
bereavement, Martin and Doka (1996) suggested a mascu- Two studies revealed that the use of a support group
line and feminine pattern of grieving. In the masculine pat- reduced grief severity (Bergman & Haly, 2009; Ghesquiere
tern, individuals exhibit more cognitive and active responses et al., 2013). Stroebe et al. (2001) described lack of social
to grief, while the experience and expression of grief in the support, life routines, and financial status as the most stress-
feminine pattern is more emotive. When describing the mas- ful experience related to bereavement. Naef et al. (2013)
culine and feminine patterns, Martin and Doka (2000) moved demonstrated that the need for social support appears to be
away from the notion that grief responses are distinctly gen- related to a sense of loneliness, as well as difficult times of
der-related. Their perspective places less emphasis on gender the day and year. Changes in relationships with significant
as a critical determinant of how individuals grieve and others are described as both a challenge and a resource for
instead proposes that there is a continuum of grieving styles older widows and widowers. It was also found that older per-
from intuitive to instrumental (Martin and Doka, 2000). The sons maintain connections with their deceased spouse (Naef
critical point is that while gender is influential, it does not et al., 2013). Collins (2017) explored the personal communi-
determine grieving styles. Martin and Doka (2000) found a ties of a group of older widowers. The findings illustrate that
more nuanced understanding of the individuals’ pathways of some older widowers have very restricted personal commu-
grief. Doka and Martin (2011) based their understanding on nities, which puts them at greater risk of loneliness and social
two patterns of grieving. One is an intuitive pattern where isolation (Collins, 2017).
individuals experience grief in an emotional way. Intuitive Some qualitative studies have explored how bereavement
grieving is oriented toward the expression of emotions or influences the everyday life of older widows and widowers.
affects. The other pattern is termed instrumental, in which Collins (2014) revealed that the themes that emerged were
grief is experienced physically, such as in restlessness or related to Christmas celebrations, family friction, depen-
cognition. These two patterns can be seen as end points on a dence, additional losses, over-commitment, passivity, and
continuum. The instrumental pattern is typical of the way feeling different. Li (2007) focused on recovering from
many men grieve, due to contemporary patterns of male bereavement in later life by investigating how widowhood
socialization. Doka and Martin (2011) emphasized that there influences subsequent voluntary subsequent willingness to
is no clear relationship between gender and grieving pat- participate as a volunteer and the possible moderating effect
terns, as women can exhibit an instrumental style, while both of voluntary participation in coping with the death of a
widows and widower can demonstrate intuitive patterns. As spouse. The results revealed a greater likelihood of pursuing
highlighted by Doka and Martin (2011), these patterns are voluntary roles a few years after the death of the spouse.
influenced by gender, but not determined by it. Working as a volunteer after spousal loss protected against
High rates of institutionalization and an increased mortality depressive symptoms and an increased/a greater number of
risk are found in widowed older adults compared to their non- volunteer hours enhanced self-efficacy (Li, 2007).
bereaved peers (Elwert & Christakis, 2008; Onrust & Cuijpers, In the research mentioned in this section, bereavement and
2006). Mortality and risk of death have been associated with spousal loss in older adults has been described as emotional
the stress caused by the bereavement on persons who have lost pain, stress, depression, anxiety, grief, loneliness, lack of
their spouse (Alter et al., 2007; Stimpson et al., 2007). The social support, mortality, and risk of death as well as physical
highest risk of death has been reported among widowed adults illnesses and problems. Few studies seem to focus on the
aged 65 years and older in the 24 months after the death of their meaning of bereavement in older adults after the death of their
spouse (King et al., 2017). The likelihood of a widowed person spouse. The intention behind this study is thus to increase
dying has been called the “widowhood effect” and is an exam- understanding of spousal loss and bereavement in older adults.
ple of the influence of social relationships on health (Elwert &
Christakis, 2008). In addition, gender and age differences have
Aim
been found in descriptions of bereavement and risk of death. A
meta-analysis by (Shor et al., 2012) revealed that as age The aim of this study was to explore the meaning of bereave-
increased, hazard ratios decreased more rapidly for widowers ment in older adults after the death of their spouse.
Holm et al. 3

Table 1. Characteristics of the Participants.

Age (n = 7) Sex Time since loss of spouse Participants’ health condition

63 Female 5 years Anxiety, heart failure after the loss.
74 Female 5 years Arthrosis, high blood pressure.
80 Female 20 years Heart failure after the loss; breast cancer.
87 Male 2 years Heart failure after the loss; several hospital admissions.
88 Male 3 years Heart attack after the loss.
89 Male 5 years Heart arrhythmia before and after the loss.
89 Male 10 years Heart failure before and after the loss; heart operation; lung cancer.

Methodology Section had few words to express their feelings related to the mourn-
ing process, especially the men. It was important to make the
Design participants feel safe and some of the time was used to dis-
An exploratory design with a hermeneutic approach was cuss other things, such as their previous work. The inter-
used. This design is both a philosophy and a mode of inter- views were audio-taped and transcribed verbatim.
pretative reading of the text. The authors explored older per-
sons’ experiences of bereavement, focusing on spousal loss. Hermeneutic Interpretive Analysis
Such an approach requires that the authors are aware of their
own pre-understanding (Gadamer, 2004). In this study, the The interpretation of the text can be seen as a process within
authors’ pre-understanding is based on their theoretical and the hermeneutic approach. In the first step, the text was
practical knowledge gained from their professional experi- structured into an analysis that can increase understanding of
ence as mental health nurses (A.L.H. and E.S.), an anesthesia the impact of spousal loss on older adults. The hermeneutic
nurse (A.B.), clinical supervisors (A.L.H., E.S., and A.B.), research method developed by Fleming et al. (2003) was
and researchers (A.L.H., E.S., and A.B.). used. The text was read by the first and second authors to
obtain an overall understanding. In addition, a summary of
each interview was performed in which meanings and pos-
Participants sible themes were explored. In this first reading, the partici-
Four men and three women were recruited by the leaders of pants’ statements guided the understanding of spousal loss.
a senior center in a county on the West Coast of Norway. One The second step included an investigation of the sentences
inclusion criterion was having lost their spouse during the to deepen the initial understanding of the text (Fleming et al.,
last 5 years. On several occasions, the first and third author 2003). The first and second authors read the text for a second
(A.L.H. and A.B.) provided information about the project in time, writing codes that described the text in other words in
a senior center. However, after several months, they were an attempt to expand the understanding of what the partici-
still unable to find a sufficient number of participants who pants had said. Several themes emerged that could be repre-
had lost their husband/wife during the last 5 years. A second sentative of the underlying meaning of the sentences in the
inclusion criterion was that that the participants should be summaries.
aged over 65 years. As a result of the difficulty finding a suf- According to Fleming et al. (2003), the third step is impor-
ficient number of participants both of the above-mentioned tant because the researcher returns to the whole text and tries
criteria were excluded (see Table 1). Therefore, the inclusion to deepen the understanding of the inherent meaning. The
criteria were as follows: able to speak and understand the authors thus read the interview text a third time to capture the
Norwegian language, no cognitive deficit, living in a com- underlying meaning of the emerging themes. This step of the
munity in Norway, and over 60 years of age. analysis has also been described as finding the “hidden mean-
ing” of the text (Porter & Robinson, 2011, p. 121).
The fourth step concerned identifying and interpreting the
Interviews theme and sub-themes, followed by reaching consensus on the
This study used in-depth interviews (Polit & Beck, 2017). essential meaning and understanding. This was a time con-
Each interview lasted for 1 to 2 hr and took the form of a suming phase but important for a common understanding of
dialogue with the participant (Gadamer, 2004). The first and the whole text. The themes and sub-themes were then searched
the third author (A.L.H. and A.B.) encouraged the partici- for an abstraction that captured a common understanding.
pants to contribute to the dialogue about their experiences of
bereavement and asked them the following question: “Can
you please tell me how you manage your everyday life since
Trustworthiness
the death of your spouse?” Sometimes the participants found The first and the second authors performed the interpretation
it difficult to describe their experiences and stated that they of the text, while the other authors critically reviewed the
4 SAGE Open

Table 2. Overview of Overall Theme, Themes and Sub-Themes.

Struggling to maintain pride and dignity

Feeling misunderstood in the dialogue

Themes Understanding health decline A lonely painful struggle with others
Sub-themes Difficulty asking for help Striving to avoid feeling sorry for oneself Longing for support to achieve
inclusion
Searching for meaning when life becomes Togetherness is the best medicine
meaningless
Sensing that one’s spouse is present

interpretation, thereby increasing the credibility and con- emerged: Longing for support to achieve inclusion and
firmability of the emerging themes and sub-themes. Togetherness is the best medicine (Table 2).
Trustworthiness is related to confidence in the interpretation
and analysis (Polit & Beck, 2017). Discussion of the themes
and sub-themes was a process aimed at finding the most suit-
Struggling to Maintain Pride and Dignity
able interpretation. The authors attempted to identify mean- Becoming a widow or a widower in old age (aged over 65
ing units that best represented the participants (Denzin & years), seems to involve maintaining one’s pride and dig-
Lincoln, 2008). Using the participants’ own words enables nity to understand a chaotic world. According to our find-
the reader to decide whether or not the interpretation is cred- ings, the meaning of bereavement can be understood as the
ible (Holm et al., 2013). participants’ attempt to maintain both intrapsychic and
A limitation of this study might be the fact that the partici- social aspects. An older person often lacks certain skills and
pants ranged in age from 63 to 89 years. In addition, their has difficulty understanding the value of help in their every-
ability to remember events could be a cause of concern espe- day life. Loneliness and anxiety seem to be a part of the
cially as many of the participants were in their eighties. bereavement process and one can experience that life is no
Another limitation could be related to the time that had longer worth living. One attempts to maintain one’s pride
passed since the death of the spouse (see Table 1). and dignity by not asking for help from children, friends or
professionals. The widowed person struggles to avoid feel-
ing sorry for herself/himself and being perceived as a
Ethical Considerations victim.
The study was approved by the Norwegian Social Science
Data Services (NSD) (No. 5553) and carried out in accor- Understanding Health Decline
dance with the ethical guidelines for nursing research in the
Nordic countries (Northern Nurses Federation, 2003). The Most of the participants stated that they had to force them-
first and third authors conducted the interviews in a sensitive selves to understand their health decline. Many of them
manner to decrease the older persons’ feelings of grief related revealed that they suffer from physical health problems such
to the lived experiences of bereavement (Liamputtong, as high blood pressure, heart disease, and arthritis (Table 1).
2011). The older persons were provided with detailed written All of the widowers and two of widows had undergone sur-
information and signed a consent form. They were assured gery for heart disease after the death of their spouse. One of
that their name and identity would not be disclosed and that the widows stated,
they had the right to withdraw at any time. All data were
stored in a locked and fireproof filing cabinet. I have had several heart attacks after the death of my spouse. I
have also had problems with my knees and shoulders, but I
really want to manage myself and do not want to bother anybody
Results with my health problems.

Struggling to maintain pride and dignity, three themes and six Others mentioned the difficulty of having a big house
sub-themes emerged. The first theme, Understanding health when one is in poor health and two had decided to move to a
decline, included one sub-theme: Difficulty asking for help. smaller apartment, making it easier to manage household
The second theme, A lonely painful struggle, had three sub- tasks.
themes: Striving to avoid feeling sorry for oneself, Searching One of the widowers stated,
for meaning when life becomes meaningless, and Sensing
that one’s spouse is present. In the third theme, Feeling mis- After my wife died I got a heart attack. Both of these two
understood in the dialogue with others, two sub-themes separate experiences have influenced my health condition. I
Holm et al. 5

have had two heart operations. In addition, I had lung cancer and each day or a new health care professional offered to help
had surgery for that too. them with showering or other intimate needs. One stated,

A widow expressed, I have a problem with the healthcare professionals when they
promise to come early in the morning, but do not turn up until
I struggle with arthritis and ankylosing spondylitis. In addition, eleven o’clock. Am I expected to sit around waiting for hours?
I also had cancer and this is something that will never leave me. No, it would be horrible!
I try not to think about it, but it seems to be stuck in my head. So
my physical health is not always good, but I do not give up, I often go to the elderly centre to eat or buy a meal to take home.
because I think of people who suffer more than me. It has Then I have dinner for two days. I do not work anymore so I do
nothing to do with being tough, but rather something you accept not need so much food. And my daughters bring me some food
and have to deal with. occasionally. However, I do the shopping myself. Sometimes I
manage to cook a dinner when I want to eat something else.
The participants did not complain much about their men-
tal health decline. However, some explained that mental The same participant reported that he would like a techni-
health was related to darkness that often comes in the eve- cal device where the health care professional could check on
ning or at night. a monitor to see if he was asleep or not. He explained,
A widower stated,
It would be much worse if someone wakes me up after I fall
I struggle with my mental health, especially in the evening when asleep. I would experience that as an assault. And after such an
I am alone, many thoughts go through my head. I try not to think experience I would never get any sleep.
too much, but sometimes I cannot sleep when I think too much.

Another widower commented, A Lonely Painful Struggle

Several of the older adults described the initial period of wid-
Mental health, what is that? I know nothing about that. It has owhood as a lonely struggle where they felt sad and isolated.
something to do with the mental and not the physical. I have no
One of the widows stated,
problem with it.
It was like being inside a bubble where everything outside was
Difficulty asking for help. Being too proud to ask for help was foggy. It was a tough time. I ask myself why he died before me.
described as a problem when one’s health was poor. Most of Why him and not me?
the participants revealed how difficult it is to admit that one
needs help from significant others, friends, or health care This widow was prescribed medication by her general
professionals. One participant expressed, practitioner. She felt agitated and nervous. The agitation was
physical. Another widow stated,
Many people asked if I needed help. But I never said yes, I
answered that I could manage myself. It is so stupid. I do not mean you don’t have to grieve. However, I need to go
through the grieving process alone. And it is how you go through
Most of the participants did not want help from the health it alone that is important for the future. Who can I complain to?
care services. Health care professionals were described as Many people experience grieving the same way as I do. If I
working in accordance with the law and procedures, but not complain to someone who has not had the same experience, she/
always using their head. One participant had experienced he will not understand what I am complaining about. Only by
health care professionals who refused to assist older patients having the same experience can a person discover the truth
in their home. This participant was denied help because the about grieving. My struggle to manage everyday life involved
homecare professionals did not approve a decision about her becoming aware of my responsibility for the new situation of
being alone in the world. A struggle to survive and try to manage
or his need for help and stated,
my everyday life.
The healthcare professionals told me why they cannot help me
with this or that based on law and procedures. This refusal does This struggle was described as a long process where one
not help me to makes me wonder what view the healthcare gradually achieves a sort of self-awareness.
services have of human beings.
Striving to avoid feeling sorry for oneself. Most of the older
The participants experienced themselves as independent adults reported that they did not want to be seen as someone
persons. However, they had problems with the routines, who complains and feels sorry for themselves. They had to
when for example, a different health care professional came pull themselves together. When feeling sad they explained
6 SAGE Open

that they forced themselves to stay at home. One of the par- Sometimes when I am watching TV I fall asleep for a while and
ticipants stated, then I hear her calling my name and I wake up. So I feel as if she
is with me all the time.
I have to stay at home when I suffer too much. Sometimes I feel
that I do not want to live anymore. I want to give up, I admit that. The other participant explained,

Some mentioned that they do not expect nor want signifi- I keep having the same dream that he is back. He is coming and
cant others to take care of them, but wish to manage their life suddenly I wake up thinking “oh dear now you are going crazy.”
themselves. One of the participants explained, I see him clearly on the road where we lived, but the children are
small. At other times I feel as if he is sitting in the chair looking
at me, but the worst thing is when I feel him at my back when I
I want to be responsible for myself. I do not want others to take
am in bed.
over. I tell myself that living life like this is my destiny. I do not
want to be “poor dad.” And my daughters understood me.
This participant did not feel that this was positive. She
was not scared, but explained that such feelings could be
Searching for meaning when life becomes meaningless. The par-
related to the fact that her late husband was very demanding
ticipants related that when one is alone there is nothing that
and extremely ill before he died.
can be done about it. One has to be thankful for previous
experiences and memories. Voluntary work was described as
something that gives meaning to life and allows one to help Feeling Misunderstood in the Dialogue With
other people. One participant stated, Others
I can help and as it is voluntary work I get no money, but it gives
Most of the participants stated that they sometimes felt mis-
me a feeling that my life is meaningful. understood in the communication and dialogue with other
people. They felt stigmatized and experienced discrimina-
Others revealed all the positive things that happened in tion after the loss of their spouse. One of the widows related
their voluntary work and explained how meaningful such that she was invited to join a so-called grief group. She had
work is. One participant commented, no interest in joining such a group and found the advice
given by the professional moderator inappropriate:
Since my husband died suddenly several years ago I have been
involved in a children’s home in eastern Europe. He told me that I was lucky to have a grave to go to. He told me
to think about others who do not have a grave such as divorced
people. I lost my temper and answered him like this: Do you
The participants revealed how they searched for hope and
really compare the death of my spouse with a divorce? I then
continued with daily life. One of the women used the follow-
added that he must never say things like that to anyone.
ing words to describe what she meant:
Others stated that people avoid talking to them when, for
You have to find the light yourself, find moments that light up
your everyday life and do something you find positive.
example, they meet on the street. They do not experience
empathy from others. One of the participants said,
Many of the participants stated that they sometimes feel
People behaved very strangely as if I had done something
that life is meaninglessness and not worth living. One of the
wrong. Some even asked me: “Are you here?” I remember
widowers expressed, “Why should I go on living?” but most answering: “Do I not have the right to be here?” Others said
of the participants believed in God or that fate had decided things such as: “Oh, it looks as if you are coping well” as if that
that this is their life. One of the widowers stated:, was surprising.

You are tired of living. Such thoughts come when I am tired. It

is not too serious. It has something to do with being tired of life. Longing for support to achieve inclusion. Most of the partici-
I do not think I could have shot myself.
pants described how they were longing for support to achieve
inclusion. Some mentioned membership in various organiza-
This statement revealed that the widower felt that life is
tions as playing an important role in their self-management
meaningless sometimes.
in the initial period after their bereavement. One of the older
men stated,
Sensing that one’s spouse is present. Two of the participants
related that they often have a feeling that their spouse is still The care I perceived was extremely important. People supported
with them. One of them found this comforting: me in many ways.
Holm et al. 7

They described the value of meeting people and attending walk for instance. My daughter phones me every day to hear
lectures, stating that they have a responsibility to do some- how I am managing.
thing themselves to regain meaning in life. Although most of
the participants reported positive experiences, it was not the The participants spoke about how they missed their
case for all of them. One of the men related: spouse, especially in relation to the events of daily life and
having someone to talk to. Someone who meets you at/when
I wish that the people in the organization of which I am a you open the door who is interested in you and asks how you
member would make a greater effort to include me. I feel like a feel and how your day has been. One of the widowers stated:
stranger and do not perceive any contact. I experienced sitting
alone at a table all the time. I told my wife things that went on in the meeting for instance.
What the people talked about. But also small things such as what
Some told about friends who did not remain in contact my day was like. The worst thing about being alone is that you
after the bereavement. This mainly concerned couples with have no one to talk to.
whom they and their late spouse had spent time occasionally.
One of the participants explained, One of the widows commented,

There were some couples who we did things together with now I can tell about one episode three months after my husband died.
and then, but they disappeared after my husband died and I no I went to a meeting where there were a lot of people I knew.
longer have any contact with them. They looked at me as I had done something wrong. One came up
to me and asked: “Are you here? It seems as if you are coping
Others mentioned that meeting people is more difficult well” ‘Yes I am here I replied. Do I not have the right to be
here?’ I have met such attitudes several times. People behave in
when you grow old. In the past, they knew many people in
strange ways. There are twenty four hours in a day and at other
the city. Nowadays they could walk through the city and
times where I do not go outside the door, so no one knows how
nobody knew them and they knew nobody. One of the men I struggle.
stated,
The results revealed that spousal loss is an on-going
Most of the people you knew are gone when you are old.
struggle even several years after the bereavement. The emo-
tional problems as well as the longing for inclusion high-
Togetherness is the best medicine. In contrast to the quotations lighted the social aspects of bereavement. The participants
presented above, some of the participants told themselves to did not report that no bereavement groups were available.
think positively and tried to socialize. Most of them com-
mented that the best thing is meeting other people with the
same attitude or values and finding a way of giving some- Discussion
thing to others. One stated, The attempt to gain an understanding of the meaning of
bereavement for older adults by means of interviews
I really do not want to be a burden to anyone. revealed one overall theme: Struggling to maintain pride
and dignity. It seems to be a lonely struggle as the partici-
They wanted to be a resource. Some of the participants pants appeared to lack adequate words to describe their
went to church on Sundays. They explained that the care they environment and emotions. Their world is shattered and the
receive in the church is helpful because they no longer func- future appears uncertain and difficult to understand. They
tion as well as when they were younger. Some use a rollator appear to lack the necessary skills to handle both emotional
and have joined a physical training group. One of the widow- and health problems. The older adults seem to perceive
ers stated, themselves as stigmatized and discriminated against because
they are no longer productive and active agents of society.
Afterwards we go to a café where some eat dinner and others Not being considered an active and productive member of
have a cup of coffee. The socializing and chatting after the
the community can be understood as ageism, where the
training is good and can last for two or three hours. This is
helpful.
where older people are seen as unproductive and useless
(Officer & de la Fuente-Núñez, 2018). Ageism tends to be
Another widower expressed, socially accepted and unchallenged because of its implicit
and unconscious nature (Cuddy et al., 2005; Levy & Banaji,
I decided to sell my house because I do not want to be a burden 2002). Ageism can thus be understood as the need to main-
for my children. This house in the middle of the town has a lift tain pride in an environment where one feels excluded by
and everything is on the same floor, so I have no stairs to climb. other people. Pride has been described as an emotion and a
The future seems brighter because of this. I do not want to be a way of being more conscious of oneself with intrapersonal
burden to my family if I get problems with my legs and cannot characteristics (Tracy & Robins, 2004, 2007; van Osch
8 SAGE Open

et al., 2018). But it has also been characterized as a social realization of one’s existential aloneness becomes visible and
emotion that revolves around about one’s relationship with alienates the older person from herself/himself (Holm et al.,
others (van Osch et al., 2018, p. 404). The emotional mean- 2013). In this estrangement, there seems to be a sort of invis-
ing of pride seems to vary across cultures and has been asso- ible blanket between the world and the individual and loneli-
ciated with positive valence and potency (van Osch et al., ness can be a step up from a sense of estrangement. Such
2013, 2018). Most studies ignore the social context in which persons strive to avoid feeling like a “fifth wheel” in social
emotional experiences take place (Fischer & Van Kleef, situations, a phenomenon that is not related to age. Research
2010). Maintaining pride cannot be seen as something that has revealed that the pain of despair and bereavement can be
only happens once, as every day seems to be a battle to a state where one attempts to control one’s emotions. Grief
maintain one’s status (Tracy & Robins, 2007). In this strug- and social withdrawal can increase the stress caused by
gle, pride and dignity can be of the utmost importance. bereavement that can be seen as representing social deficits
Dignity can be related to pride, as it is understood as feeling (Thoits, 2010). The findings of this study revealed that the
valuable in relation to others (Haddock, 1996). Thus, the participants were striving to avoid feeling sorry for them-
social aspects of dignity seem obvious. However, the find- selves. Feeling sorry for oneself can be a part of self-pity that
ings in our study revealed that dignity is a feeling of being is often perceived negatively by other people. Self-pity is fre-
valuable in relation to oneself. This meaning of dignity can quently understood as being controlled by powerful others
be related to self-respect, which is dependent on a sense of (Stöber, 2003). In this study, the participants tried to avoid
importance both in relation to self and others (Nordenfelt, being seen as a victim. Self-pity has been described as a
2004). As in our study, the older adults in Nordenfelt’s response to stressful events such as personal failure, loss, or
(2004) study perceived themselves as dignified persons who illness (Stöber, 2003). To avoid feeling sorry for oneself can
appear to do their best to act according to their own moral be a protection against the sense that one’s world is shattered
law to increase their self-respect. In our study, the findings and there is different forms of emotional pain (Holm &
revealed that dignity can be understood and interpreted as an Severinsson, 2012). Searching for meaning when life become
inner feeling of self-respect. Older adults can exhibit a meaningless can be an effort to find, create, or reconstruct
behavior they consider right for being deemed valuable in meaning, which is an important aspect of understanding
the eyes of self and others (Nordenfelt, 2004). bereavement. This study revealed that the older adults
Understanding health decline, may be exacerbated by the searched for meaning, despite the fact that life became mean-
fact that older adults find it difficult to ask for help. Although ingless after the death of their spouse. Research supports this
their health decline was obvious they were unwilling to finding, suggesting that people engage in three major activi-
admit to themselves and others that they needed help. They ties by which they reconstruct meaning in response to
seemed to be exhausted and stated that it was best to remain bereavement: sense making, benefit finding, and identity
alone. Health decline as described in the present study has change (Gillies & Neimeyer, 2006). A reconstruction of
often been associated with bereavement and loss (Aniruddha, meaning can be seen as an adaptation to bereavement where
2013). Loneliness and lack of energy increase the need for people construct a new identity that changes them forever
help and the individuals involved struggle to understand (Holm & Severinsson, 2012; O’Connor, 2002). Constructivist
what to do. Stress can increase health problems due to nega- theories suggest that the process by which bereaved persons
tive behaviors such as smoking (Klungsøyr et al., 2006), question and make sense of their bereavement is central to the
alcohol use (Davis et al., 2008), poor sleep and physical inac- experience of grief (Neimeyer, 2001). By reconstructing
tivity (Berger et al., 2009). Stressors may trigger a broad pro- meaning in life in response to a loss, one reconstructs oneself.
cess involving social relationships, poor health and biological Changes that occur can be termed “posttraumatic growth,” in
problems (Geronimus et al., 2006). Research has demon- which persons respond to the loss in adaptive ways (Tedeschi
strated that experiencing loneliness after a loss decreases & Calhoun, 2004). This was also highlighted in our study.
opportunities for self-management, although not all social People who experience such growth have reported a changed
relationships seem to satisfy emotional needs (Holm & sense of self, stating that they became more resilient, inde-
Severinsson, 2012; Janke et al., 2008). pendent, and confident. They took on a new role, developed
A lonely and painful struggle seems to be a state in which an awareness of life, and became more sensitive to other peo-
the participants were isolated, strove to avoid feeling sorry for ples’ losses. In this way, their social relationships seem to
themselves, searched for meaning and sensed the presence of change in terms of their increased capacity for empathy and
their spouse by which they hoped to prevent the development becoming emotionally closers to others (Gillies & Neimeyer,
of mental health problems. Pretending that the pain does not 2006; Holm & Severinsson, 2012). As the findings in this
exist may be dysfunctional in certain situations, but can also study and also in Neimeyer (2001) revealed, continuing bonds
be a way to survive bereavement. Estrangement can be as resources for enriched functioning can increase the under-
described as an existential lack of self-management and standing of bereavement. Thus, bereavement can be seen as a
understood as emotional pain and suffering, where the process of reconstructing a world of meaning that has been
Holm et al. 9

shattered by the spouse’s death. In contrast, bereavement can Implications can be related to ageism and how the loss
represent a decrease in self-management when there is no and bereavement are understood by widows and widowers in
hope or optimism for the future (Holm & Severinsson, 2012; the community. Some can exhibit resilient reactions after
Valdimarsdóttir et al., 2003). An alternative approach to the spousal loss, while others are dependent on help from other
idea that successful grieving requires “letting go” is presented people. Most people are able to adjust to spousal loss without
by Hall (2014), who suggests that after a death the bonds with long-term difficulties (Van Der Houwen et al., 2010).
the deceased do not necessarily have to be severed and that it However, a minority can be prone to long-term grief reac-
can be positive to maintain such bonds. This idea represents tions (Bonanno & Mancini, 2008). Early identification of
recognition of the fact that death ends a life, not a relation- those at risk of suffering health consequences makes it pos-
ship, while the participants in the present study revealed that sible to intervene and prevent negative outcomes (Van Der
the deceased can be both present and absent. Such bonds can Houwen et al., 2010). Sometimes professional help is needed.
be understood as conscious, dynamic, and changing (Hall, Stroebe et al. (2007) found several factors that can reduce
2014). One can experience the deceased in dreams, by visit- risks, while Powers and Bisconti (2014) demonstrated that
ing her or his grave and feeling her or his presence. A sense of social support can be the most important factor after the loss
the deceased being present may be much higher than revealed of a spouse. However, widows and widowers should receive
by the literature, as people may be unwilling to disclose this social support that is not associated with the health care sys-
phenomenon due to fear of being considered ridiculous or as tem such as a local bereavement support group.
in the present study, thoughts of going “crazy.”
Despite the fact that being with others was described as
the best medicine, one can feel misunderstood in the dia-
Conclusion
logue with others. The participants described themselves as In this painful struggle, the participants strived to avoid feel-
angry and confused, which can be interpreted as a feeling of ing sorry for themselves, searched for meaning when life
stigma that increases the experiences of loneliness and being became meaningless, and sensed that their spouse was pres-
misunderstood. This can weaken the feeling of support, ent. They often felt misunderstood in the dialogue with oth-
implying that some older persons are at risk of developing ers and longed for support to achieve inclusion as well as
trauma symptoms (Holm & Severinsson, 2012). Social sup- togetherness. Thus, this study provides a valuable insight
port has been described as one way to alleviate the painful into the meaning of bereavement following spousal loss. We
influence of bereavement (Bisconti et al., 2006). Many stud- recommend that the implications be developed and
ies have investigated resilience in widowhood and found that evaluated.
older adults can be resilient to survive bereavement (Holm &
Severinsson, 2012). Social support can be a way of describ- Acknowledgment
ing the size of the social network, while functional support The authors wish to thank Monique Federsel for reviewing the
includes various types of emotional support as well as the English language.
perceptions of and judgments about support (Powers &
Bisconti, 2014). The first 2 years of widowhood have been Author Contributions
described as characterized by an increased need for emo- A.L.H. contributed to the study design; A.L.H. and A.B. contrib-
tional and instrumental support, which decreased after 2.5 uted towards data collection; and data analysis, discussion, and
years (Bisconti et al., 2006). Longing for inclusion was preparation were done by A.L.H., E.S., and A.B.
understood as an experience of loneliness as the participants
longed to be included in social dialogue. Research has Declaration of Conflicting Interests
revealed that social inclusion can be one way to survive
The author(s) declared no potential conflicts of interest with respect
bereavement (Holm & Severinsson, 2012). Togetherness is to the research, authorship, and/or publication of this article.
described as the best medicine, as it provides a sense of well-
being in times of stress and constitutes a form of support that Funding
endows life with meaning, even if it does not solve their
problem(s) (Holm et al., 2013). The experience seems to be The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
“beyond words” and metaphors helped them to express the
inexpressible (Buchanan-Barker & Barker, 2005). In real
life, there is an “absolute inseparability of the living body ORCID iD
and life itself” (Gadamer, 2004, p. 71). Mutual respect arises Anne Lise Holm https://orcid.org/0000-0003-2043-8547
from the reality that one is fundamentally related to the other.
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Author Biographies
mortality in older couples. American Journal of Public Health, Anne Lise Holm work as a professor of Western Norway University
103(6), 1140–1145. of Applied Sciences, Department of Health and Caring Science.
Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, Her research interest is systematic reviews, qualitative research,
N., . . .Keshaviah, A. (2011). Complicated grief and related public health, nursing and suicide prevention of older adults.
bereavement issues for DSM-5. Depression & Anxiety, 28,
Elisabeth Severinsson work as a senior clinical professor at the
103–117. http://dx.doi.org/10.1002/da.20780
Nursing and Healthcare Research Group, Stavanger University
Shor, E., Roelfs, D. J., Curreli, M., Clemow, L., Burg, M. M., &
Hospital. She has contributed substantially to the national and inter-
Schwartz, J. E. (2012). Widowhood and mortality: A meta-
national recognition of the department in the field of Health and
analysis and meta-regression. Demography, 49, 575–606.
Social Sciences, most especially in the area of childbirth; consumer,
http://dx.doi.org/10.1007/s13524-012-0096-x
gender and public health issues such as maternal services, normal and
Stimpson, J. P., Kuo, Y.-F., Ray, L. A., Raji, M. A., & Peek,
compromised pregnancy and infancy; mental health, health and well-
M. K. (2007). Risk of mortality related to widowhood in
being, patient safety in healthcare education and practice, as well as
older Mexican Americans. Annals of Epidemiology, 17,
quality in healthcare education and professional development.
313–319.
Stöber, J. (2003). Self-pity: Exploring the links to personality, Astrid Karin Berland is a professor of Western Norway University
control beliefs, and anger. Journal of Personality, 71(2), of Applied Sciences, Department of Health and Caring Science.
183–220. Her research interest is qualitative research, nursing, patient safety
Stroebe, M. S., Schut, H., & Stroebe, W. (2007). Health outcomes in hospital and municipalities. In addition her research interest is
of bereavement. The Lancet, 370, 1960–1973. older adults that wish to die.