Review scientific article
Received 25 February 2019, accepted 1 July 2019
Ana Štambuk
Widowhood and grieving in old age
Characteristics of widowhood in old age and different reactions to loss are investigated in the first part. In the second part, theoretical approaches to grief are examined. In the process of grieving, the complexity and individuality of each individual are important, and professionals working with the elderly and their family members should recognise the signs of grief and take into account all factors related to the grieving process. Although adaptation to the death of a spouse in old age is considered one of the natural stages of life, it is emphasised that the loss of a spouse is one of life's greatest stressors. The consequences ofwidowhood are discussed, as well as differences in adaptation between men and women, which must be understood if adequate assistance and support is to be provided. Finally, strategies for coping with loneliness as a consequence of widowhood are suggested. The conclusion underlines the importance of social support to all the elderly in bereavement (particularly to those who are severely ill, without family or on a low income and to men) as well as the need to create a social climate in which grieving persons are recognised and accepted in their new role, for which they need time to adapt.
Key words: loss, social gerontology, social support, bereavement, loneliness, death.
Ana Štambuk, PhD, is an associate professor from the Chair of the Department of Social Gerontology at the Faculty of Law, University of Zagreb. She teaches Social Gerontology at undergraduate level and Palliative Care and Social Work with Older People at postgraduate level. Contakt: astambuk@pravo.hr.
Vdovstvo in žalovanje v starosti
V prvem delu so predstavljeni značilnosti vdovstva in različni odzivi na izgubo v starosti, v drugem pa teoretski pristopi k žalosti. V procesu žalovanja sta pomembni kompleksnost in individualnost vsakega posameznika, strokovnjaki in družinski člani pa bi morali upoštevati dejavnike, povezane z žalovanjem. Čeprav velja prilagajanje na smrt zakonca v starosti za eno od naravnih faz življenja, je izguba zakonca eden največjih stresorjev v življenju. Avtorica obravnava posledice vdovstva in razlike v prilagajanju na izgubo med moškimi in ženskami; to je še posebej pomembno upoštevati pri zagotavljanju ustrezne pomoči in podpore. Predlaga tudi strategije za obvladovanje osamljenosti, kije posledica vdovstva. V sklepu je poudarjen pomen socialne podpore za vse stare ljudi v težavnih razmerah (zlastiza tiste, ki so hudo bolni, brez družine ali imajo majhne dohodke, in za moške). Treba je ustvariti družbeno ozračje, v katerem bodo žalujoči priznani in sprejeti v svoji novi vlogi, za katero potrebujejo čas, da se navadijo nanjo.
Ključne besede: izguba, socialna gerontologija, socialna podpora, žalost, osamljenost, smrt.
Dr. Ana Štambuk je izredna profesorica in predstojnica Katedre za socialno gerontologijo Študijskega centra za socialno delo na Pravni fakulteti Univerze v Zagrebu. Dodiplomskim študentom predava Socialno gerontologijo, podiplomskim pa Paliativno oskrbo in Socialno delo s starimi ljudmi. Kontakt: astambuk@pravo.hr.
Introduction	3
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The population of the world, including Europe, is rapidly ageing. Within the	~ European Union, the development of services for the elderly has become one
of the principal objectives of all Member States. Eurostat data (2014) show	;3
that the proportion of residents older than 65 years of age was then 18.2%.	o
Slightly earlier, in 2010, the percentage of women in the European Union in	*
the 65-79 age group stood at 55%, while almost 70% of the 80+ age group	5
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-I were women (Eurostat, 2010). From the above, we can conclude that women | are more likely to encounter the loss of their spouse and are more likely to experience the process of grieving. But, for both women and men alike, the loss of a spouse is a great, and for some even the greatest stressor of life (Beaver & Miller, 1992).
Robert Havighurst (1968) lists several developmental tasks associated with old age (a developmental task is the most important achievement expected from a person in a particular life period): adjustment to the decline in body strength and health, adaptation to retirement and reduced income, adaptation to the death of a spouse, the establishment of a clear sense of belonging to one's own age group, fulfilling social and civic obligations and establishing satisfactory living conditions. It is thus, to some extent, expected of people in old age that they perform successfully the developmental task of adapting to the death of a spouse. However, it should be noted that, given the numerous changes within the family and society over the last few decades (Jedvaj, Stambuk & Rusac, 2014), greater care of the most vulnerable of the elderly is required, and among those in such need are surely persons who have lost their partner.
We can define loss as an event that has prevented our constant access to a person who is significant to us, to whom we are devoted, loyal and emotionally bound so that, owing to separation, the feeling of a loss of security emerges and the process of mourning begins (Salajpal, 2008). Worden (2005) defines grief as a term that is applied to the process through which we pass as we adapt to the loss of a person, while loss is what a person seeks to adapt to. Although each of us is a unique being and passes through the grieving process in his or her own way, there are some general features and patterns of grief. Thus, many authors differentiate a normal, or usual, from difficult grief. In addition, there are some behaviour patterns, feelings and reactions to loss that are considered universal. According to Arambasic (2005), the grieving process is influenced by four factors:
1.	Who died, or the strength of the emotional bond with the deceased;
2.	How that person died, or the circumstances of death;
3.	Personal factors related to the bereaved (age, gender, personality traits...);
4.	External factors (grieving rituals, the size of the social network...).
The grieving process is as more difficult and lasting according to the emotional strength of the relationship with the deceased or, in other words, the more we are devoted to the deceased person, the harder it will be to endure his or her loss. According to Bowlby (1977), the theory of affection explains attachment as stemming from the need for protection and security; it is developed early in life, is directed at several specific individuals and survives for the larger part of the life cycle. In addition to being devoted to our parents, brothers and sisters, we are most often devoted to our spouse. Therefore, the loss of a spouse (along with the loss of a child) is considered one of the strongest stressors in life (Holmes & Rahe, 1967). If we have been living with a partner for many years, it may seem that he or she complements our thoughts and feelings so that, when that person is lost to us, we feel we
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have lost much of ourselves at the same time (Noel and Blair, 2012). The g loss of a spouse is specific and special because it is often accompanied by | numerous life changes such as loss of identity, loss of mutual friends and/or 0 financial support. Likewise, the position of a widow or widower in society is n contingent to a significant extent on the rules and traditions of the local or g regional environment, so it can be accompanied by a change of social status or even social exclusion.	K
The loss of a spouse in old age carries some specific consequences: a per- K son becomes aware of his or her own mortality, he or she may become lonely $ and experience multiple losses. This is why social support is important at this period of life. There are differences between men and women with respect to the provision of support and its acceptance. Some authors argue that men are less willing to acknowledge the need for support and are less active in seeking it, while women receive more support from family and friends. Older mothers receive more practical, financial and emotional support from adult children than fathers (Suitor, Gilligan, Johnson and Pillemer, 2014). Arber (2004) indicates that men are more dependent on the spouse in the areas of support and engagement in general and can have difficulties in forming a new, lasting relationship. For many men, greater engagement is associated with the work they do, and they do not invest sufficiently in the construction of the social capital that will sustain them through old age, specifically through widowhood. The research conducted by Ha, Carr, Utz and Nesse (2006) has shown that widows give and receive more support, which can be explained by the traditional division of roles in the family - even in stressful moments they take care of the whole family, while widowers retreat and suppress grief.
Widowhood
Like divorce, widowhood involves the termination of a conjugal union, leading to a particular form of post-married life. Although it can be simply and unambiguously defined, it has a number of different aspects. Widowhood is the status of a person who has not remarried after the death of a spouse. Many authors (Cox, 1988; Ha, Carr, Utz and Nesse, 2006) recognise widowhood as one of the typical, natural and expected - normative changes in the aging process. Some consider the adaptation to the death of the spouse as one of the most difficult developmental tasks of an elderly person who has been married (Roberto & Pearson Scott, 1986).
For an individual, widowhood is a deeply traumatic emotional experience (Stokes, 1992) and an irreplaceable loss of the most intimate relationship, owing to the interruption of intimacy with the life partner (Utz, Reidy, Carr, Nesse and Wortman, 2004). That is why it ranks among life events that violate not only personal integrity but also social order (Kafetz, 2002).
Therefore, widowhood is an embedded social category - a state encompassing social position, relationships and roles that involves a widow or widower, the family, close persons and the wider community. At the same time, in social terms, widowhood is a life transition; it is thus a developmental process that
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-I manifests as the transition to a new period of life with the adoption of new | roles. It lasts until the conclusion of a new conjugal union or the individual's death, and involves different ways of coping with, or adapting to, new life circumstances. Specific developmental dynamics of change in the status, roles and behaviour of an individual are a specific experience that is different for every widow and every widower. Therefore, uniqueness is an important dimension of widowhood. It is determined by the interaction of internal and external factors such as the circumstances surrounding a particular widowhood, the personality traits, gender, age, culture, size and structure of the family, the relevant social network, the context of loss, the ability to adapt and previous experience of doing so (Stokes, 1992).
Reactions to loss of a spouse
Loss causes different reactions. Arambasic (2005, p. 84) lists four groups of reactions: emotional, mental, physical and behavioural. The emotional reactions include: sadness, anger, feelings of guilt and self-recrimination, anxiety and fear, feelings of loneliness or abandonment, feelings of emptiness, helplessness, longing for the deceased, feelings of "freedom" and relief. The mental reactions are: shock and disbelief, confusion, the experience of losing control over life, thinking about the dead person, the experience of having a dead person next to us, difficulties with concentrating, remembering and reminiscence, intrusive thoughts and images of the deceased, concern, imagining the deceased, seeking to make sense of the loss and the meaning of life after the loss. The physical reactions include: "emptiness" in the stomach, tightness of the chest and throat, pressure and chest pain, sensitivity to sounds, breathing difficulties, muscular weakness, dry mouth, headache, dizziness, drowsiness, fatigue. The behavioural reactions include: sleeping difficulties, changes in appetite, withdrawal from people, dreams of the deceased, excessive activity, crying, going to places reminiscent of the deceased, obsessive care for things that belonged to the deceased and seeking justice, and to assign blame for death.
Powerful emotional reactions can leave various consequences. It is interesting to explore how men respond to the loss of a wife. Silverman and Thomson (2018) conducted a qualitative study with 33 widowers aged 45 to 89 years, whose average age was 62. The work focused on emotions related to the loss of the wife, ways of coping with the loss and changes that had occurred in their lives. The characteristics of the initial reactions to the loss of the wife depended on several situational factors: the manner of death - whether it was a sudden loss or a prolonged illness that lasted for several months or years, the age of the children who remained and, perhaps, the most important factor - the quality and characteristics of the relationship with the deceased woman.
All the widowers in the study experienced the loss of their wives to be a profound shock. They report experiencing the emotions of sadness, despair, anger, shock, fear and guilt. The combination of these emotions has led to a sense of loss of personal identity and to tense relationships with family and friends. After the initial difficult emotions, the widowers report that they
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felt a need to establish control over their life and, in some cases, a relief that	s
suffering from a severe illness was terminated. Widowhood as an unexpected	|
but also strongly stressful event is more difficult to endure and for the person	g
concerned, especially for the widower, presents an emotional burden and	g
leads to a number of troubled emotions, changes of status and role in society,	s
loneliness, etc. (Britvic, 2010). As for the widows, they also experience many	|
negative emotions when losing their spouse. Of course, in some way it can be	5
assumed that, to women, the death of their spouse is as difficult event as to	5
men, and even more so since women are more dependent on men in general.	e The most common emotions that appear in widows are sadness, longing for the past life as a couple, loneliness and a certain trepidation over life in the future (Vuletic and Stapic, 2013).
Theoretical approaches to grief
There are different definitions of grief, which more or less emphasise that it is a normal and necessary process through which people pass after the loss of someone or something that they have been emotionally attached to, that has occupied an important place in their lives. Since the grieving process is reflected in different areas and aspects of human life, many theories have been devised to explain this complex process from different points of view. Aram-basic (2005) lists two groups of theoretical models: traditional and contemporary. Traditional models emerged earlier and have a great influence on the area of loss and grief, and serve as the basis for, or origin of, modern models. These approaches are based on the phases through which the grieving person passes and tasks that need to be carried out during mourning.
Modern models approach grief in a different way, taking into account the stages of grieving, internal and external factors, and the outcomes of grief. Although the object of this article is not to present the theories of grieving, it should be noted that there is still a considerable degree of prejudice present in relation to this process, so that many of those in mourning report to interviewers the following difficulties during the process of adapting: the lack of understanding of those around them, non-acceptance of their expression of negative feelings or of grieving as a process, which has no predetermined rules or conventions according to which a grieving person should behave. Grief is an individual process in which we, as individuals, learn to live under changed circumstances (without the person we loved). We change from day to day and that in spite of everything, we can develop our life and continue to live in a different way from before the moment of loss of a loved one. Consequently, it is important that we have the support and understanding of the social environment.
One of the newer theories, which has questioned some of the basic assumptions of older ones (especially of traditional models, e.g. Kubller-Ross, 1969) is the theory of continuing bonds developed by Klass, Silverman and Nickman (1996). It emphasises that a healthy grieving process is based on the ability of those in mourning to maintain a lasting relationship with the
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-I deceased person. While earlier theories saw the purpose of grieving to lie in | the final termination of relationships, leaving them behind and creating new ™ relationships, the authors of this theory consider that the purpose of grief is to find a way to maintain a relationship with the deceased person, one compatible with other existing relationships and new ones.
Arambasic (2005, p. 234) asserts that the function of such theoretical approaches is to interpret the numerous and complex reactions to loss, helping to explain individual differences in the outcomes of grief and to shape strategies for providing assistance and support to those grieving. Therefore, it is necessary to mention the signs and forms of complicated mourning that indicate the need to provide professional help to the grieving person.
Signs and forms of complicated grief
The signs of complicated grief include: attacks of anxiety and fear, taking on symptoms of diseases from which the deceased suffered, reckless business ventures, apathy, self-destructive behaviour, agitated depression, excessive activity without sense of loss, etc. Unfortunately, for a large number of people, influenced by culture and family models of expressing emotion, talking about fears and sorrow due to loss is a taboo topic. Although most people pass through the grieving process, as a natural response to loss, without major problems in the functioning of the family or at the workplace, others need help and support of professionals because even for a long time after the loss (e.g. two years or more) the grieving process may not even have started or many have become "entangled" within difficulties. There are a number of factors that can complicate a grieving process: personality traits (e.g. tendency to depression), a personal history of losses (more severe losses occurring at the same time or incomplete grieving for earlier losses), the circumstances of the loss (unexpected, sudden death), and various social factors that do not allow individuals to express their grief and accept it.
Burke and Neimeyer (2013) give the following risk factors: 1. low level of social support, 2. avoiding/anxious/insecure type of attachment, 3. discovering the corpse in cases of violent death or dissatisfaction with the manner of being informed about the death, 4. being a spouse or a parent of the deceased, 5. high level of marital dependence, and 6. high degree of neuroticism.
Different authors state various types of complicated grief. According to William Worden (2005), we distinguish: chronic, delayed, excessive and covert grief. In chronic grief the person himself or herself and those in his or her social environment are aware that there is no progress in the grieving process. This grief is characterised by the inability to accept irreversible loss. Delayed grief can be present in people who normally have problems expressing emotions and occurs in the form of insufficiently pronounced sadness at the time of loss. An individual can also take responsibility for others who are grieving, so his or her own grief is suppressed for some time, while a previous experience of greater loss may impede the expression of current grief. Excessive grief is just the opposite of the above. The person is overwhelmed
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by intense sadness and can exhibit socially unacceptable behaviour that can	i
turn into depression, anxiety disorder or some form of social phobia. Covert	|
grief is characterised by avoidance and suppression, i.e. the person fails to	|
face loss in a direct way and develops replacement "symptoms" different	d
from emotional (e.g. symptoms of a disease that has been manifest in the	i
deceased person).	|
era n l
The specifics of losing a spouse in old age	e
Family law in Croatia defines marriage as the legally-regulated lifetime union of a woman and a man (Obiteljski zakon, 2003, art. 5). Pernar (2010) points out that every marriage "consists" of the wife's and husband's marriage expectations. According to tradition, women are considered the guardians of the relationship, which means that they are responsible for making communication between partners flow easily and for making relations intimate. For women, expressing intimate thoughts and feelings is a very important aspect of marriage, while, for men, the physical expression of intimacy and care is more important.
Marriage in older age acquires some special features. The first change in marital relations is brought by retirement, because it means that the couple will spend a lot more time together than before. Couples in this period feel strong mutual intimacy, men become more dependent on women, less competitive and seek more companionship within the family (Pernar, 2010).
The second big change comes about with the death of the spouse and the process of adaptation to it. Since one loss always involves more losses - along with the loss of a spouse we lose at the same time an intimate partner, a protector from afflictions, a friend, a trustworthy person, a person with whom we have shared responsibility for important decisions, a person who provides for our entertainment, material security, social status, a complete home and joint parent of our children (Arambasic, 2005). The loss of a spouse means therefore the loss we feel in many areas of life.
In this period of life we pass through several stages (Pernar, 2010): 1. Stage of preparation - if we know the health problems of a spouse, we can "prepare" for his or her death, but this does not mean that we will not experience strong emotional pain after the loss of a spouse. 2. Stage of grief - follows the death of a partner, when it is essential to express emotions and thoughts, and help can be found in a supportive social environment. 3. Stage of adaptation - we find some other meaning in life and new values and attitudes appear. There will be more about grief in the following sections.
Noel and Blair (2012) give the following multiple changes that occur along with the loss of a spouse:
1. Loss of identity - considering that we interpret life's ups and downs together with our partner, it often happens that along with the loss of a partner we also lose the foundations of our identity. We have to gradually build a new life in a period when we are both physically and emotionally exhausted;
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-I 2. Loss of mutual friends - mutual friends are often lost because they bring |	back memories of the lost partner, so the widow(er) cannot bear to see
™	them anymore;
3. Memories and images - many widowers or widows see the figure of their
lost partner and feel her or his presence, which can help them recover. Although the grieving process for each individual is specific, Worden (2005) states that grieving in old age, as a result of the loss of a spouse, has some specific characteristics:
1.	Mutual dependence - in each marriage there is mutual dependence, but if the marriage lasts for many years that dependence becomes very pronounced, which leads to a more difficult adjustment to the loss of the person with whom the greater part of life has been spent.
2.	Multiple losses - as a person grows old, his or her friends and family members grow old as well, and this leads to the possibility that an individual experiences a high number of losses in a very short period of time, which can lead that person to feel such devastation that he or she does not grieve at all (the ability to grieve may be reduced). In addition, there is the possibility of the loss of work, of physical strength, the appearance of disability, the weakening of the senses, etc.
3.	Awareness of your own mortality - experiencing the loss of your peers, friends, spouse, brothers and sisters can lead to the increased awareness of your own mortality, which can lead to existential anguish.
4.	Loneliness - after the loss of their spouse, many elderly people live alone, which can lead to a strong sense of loneliness in the physical environment they once shared with their partner.
5.	Adjustment of roles - after the loss of their partner, an individual must face new roles. This more often affects men, who, after they lose their wives, have to face household chores that, until that moment, they had never had to perform.
Differences between men and women in adaptation to widowhood
Differences in the adaptation to widowhood have not yet been sufficiently explored, so in the literature we find conflicting opinions about who it is who finds it more difficult to adapt to widowhood. Arambasic (2005) believes that the problem lies in the fact that men and women show how they feel after loss in different ways and then are "judged" on that basis with regard to who finds it easier or more difficult.
Some research has shown that women adapt better to the widowhood because they have a better developed social network. Stroebe and Schut (1999) assert that women are more focused on loss and men on recovery. Women and men also differ according to the needs they want to address at the meetings of support groups after the loss. Women emphasise the need to share feelings with others while men need to know how others have been coping with a similar situation. Widowers show fewer contacts with friends and relatives 6 months after the death of their wife (Ha, Carr, Utz and Nesse, 2006).
However, the adaptation of women to widowhood depends on the nature of g the husband's death. If death occurred after a long and severe illness, women |
go through a period of anticipation, which later facilitates the adaptation to 0
d
widowhood. The adjustment is more difficult if death occurs abruptly. The n quality of adaptation also depends on the relationship that existed between g partners. If a woman was dependent and passive, she remains completely lost after her husband's death, while independent women become accustomed to K a new state more rapidly, according to Poredos (2001). He claims that men K find it more difficult to adapt to the conditions of solitary life because they $ suppress sadness and retreat into themselves, while women more easily accept single life because they have been taking and performing different social roles throughout their lives. In addition, they are "allowed" to be sad and to weep. However, women often encounter financial problems after the death of their spouse (Angel, Jimenez and Angel, 2007). Poredos (2001) also refers to the financial problems of widowed women who had a slightly lower level of education than their husbands and were mostly housewives, so that their financial status after the husband's death becomes considerably worse. In the course of their lives, widowers have had higher incomes than their wives and retain the same financial resources.
According to Umberson, Wortman and Kessler (1992), the differences in adaptation to widowhood are associated with differences in marital role; men and women experience marriage in a different way and therefore their experience of the loss of a spouse is also different. The primary benefit for married women (according to traditional approaches) is financial certainty, so by losing their husbands they face loss of financial s ecurity. Men, on the other hand, by entering into marriage, increase their social network and have someone who helps them with their household chores. For them, therefore, losing a wife means a narrowing of their social network and having to navigate their household chores. Bennett, Smith and Hughes (2005), by contrast, found differences to lie in the expression of feelings after the death of a spouse: men are more depressed and express negative emotions, while women express more anger. In addition, men use physical activity to expel negative emotions associated with loss, while women are more inclined to do so through conversation.
Differences in adaptation between men and women can also be seen through the willingness to receive support from, or give support to, other family members. Widows have been shown to receive more support from children than married women, while male widowers receive the same amount of support as married men (Kalmijn, 2007). As far as women are concerned, they look for more help concerning financial and legal issues because they often lack experience in dealing with these things (this is often a part of the role of a husband). On the other hand, they are better at providing emotional and instrumental support because they are accustomed to take care of other family members in moments of stress. In general, widows receive and give more help than widowers (Ha, Carr, Utz and Nesse, 2006). However, the level of education affects the willingness to receive or give support. Women
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-I with a higher degree of education are less dependent on children in terms of | finances, just as better educated men are more prepared to provide children ™ with emotional support.
The quality of marital relations is likewise a very significant factor in adjusting to the death of a spouse. Widowers and widows who had a high degree of conflict in their marital relations (Parkes and Weiss, 1983) showed relatively low discomfort and high social participation six weeks after the death of their partners. In a repeat study, 13 months after the death of the partner, the same respondents claimed a significantly lower level of conflict in marriage compared with their first statements (which is not a rare occurrence, as the deceased is described often in better terms than she or he usually was). After 24-48 months, the same respondents showed a high degree of anxiety, guilt and depression in comparison with respondents with fewer conflicts in marriage. The investigation of Carr, House, Kesser, Nesse, Sonnega and Wortman (2000) showed that more anxiety is expressed by those spouses who were more dependent in marriage in comparison with those who were more independent. The level of longing for the deceased was lower in people whose relationships were characterised by conflict in relation to those who had a high degree of marital intimacy and dependence on the spouse. Also, women who received instrumental support (various types of help that others may provide) from their husbands showed a higher level of longing for the deceased.
We can conclude that in adapting to widowhood there are some differences between men and women, but given that the loss of a spouse is an extremely difficult, emotional experience, we cannot talk about who adapts better but just of the different parameters that affect adaptation in women and men. Nevertheless, it is certainly important to observe, in an individual approach, what a person can do on his or her own in reorganising his or her life, and how she or he can be helped and supported by family members, friends and neighbours during the process of adaptation.
Consequences of widowhood
The consequences of widowhood are numerous and complex and regularly include a number of negative, personal and social changes. For each person they mean a unique combination of loss and difficulties whose impact on living can continue long after the death of a partner, and often for life. In general, evidence suggests that widows or widowers have reduced morale and lower spirits after losing their partner. However, some authors point out that confronting widowhood is hardest during the first six months after the death of a partner. The reasons for this are emotional suffering due to loss, difficulty in adopting to new roles and skills and the perception of support received being less than anticipated (Besser and Priel, 2007).
Over time (an average of eighteen months after the loss) most widows and widowers come to a successful recovery and adaptation to a new lifestyle. Often, widowers and widows feel sad, but nonetheless perform their daily duties and find satisfaction in them. Most authors agree that widowhood in
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the social context primarily causes the loss of an important relationship and i support, with changes in social position, roles and patterns of social partici- | pation. There is an unwanted disharmony between the relationships that a | person has and the relationships that she or he would like to have (Dykstra, d van Tilburg and de Jong Gierveld, 2005). His or her limitation or decline often i leads to an underlying loneliness - emotional (experience of abandonment) or | social (experience of social exclusion). Changing the social network can cause 5 a considerable degree of social disintegration, including that of social identity. Specifically, for many married people, being married and part of a couple e constitutes a central part of their identity. Once the partner is dead, society regards the survivor as widowed or single. But the widower still sees him or herself as a husband or wife and remains connected to the deceased. They need some time to reconstruct a new identity (Klass, Silverman and Nickman, 1996). From a personal perspective, widowhood for most elderly people means far more than the emotional loss of a wife or a husband. It usually means a profound change in life that has not been freely chosen or desired, the loss of everyday intimacy and interaction, the loss of the future they have jointly planned, proximity to the end of life or loss of the meaning of life.
Widows or widowers often feel themselves to be in seclusion (Bondevik and Skogstad, 1998), with deteriorating health, especially depression, and the risk of early death (Manzoli, Villari, Pirone and Boccia, 2007), sometimes accompanied by difficulty in grieving. However, individual experiences show that widowhood can be preceded by very different circumstances, which, if unpleasant, promote the alleviation of stress and the heaviness of loss: low level of emotional closeness, poor marital quality, violence in the marital relationship or disease affecting the partner and requiring long-term care with great psychological and physical effort on the carer's part (Cicak, 2010).
Strategies for coping with loneliness in widowhood
Loneliness is an integral part of life for every human being. All people, regardless of gender, age, race, religion, marital or socio-economic status, at some point in their lives experience loneliness. In the last two decades, many authors have started to focus more intensively on the issue of loneliness. This has resulted, among other things, in a variety of answers to the question: "What, in fact, is loneliness?" The existing definitions of loneliness can be classified in 3 groups (Klarin, 2003). The first group approaches loneliness as a deficit in social relations, the second regards loneliness as a subjective experience that is occasionally inherent in people, and the last group characterises loneliness as a painful and unpleasant experience. Other authors warn that, owing to its personal and subjective nature, loneliness is very difficult to define precisely. Klarin (2003) defines loneliness as "a subjective, unpleasant emotional state arising from unfulfilled needs for intimacy, belonging and love."
Concepts of loneliness, solitude and living alone are often considered synonyms. Although these are three different concepts, they are linked and are the dimensions of loneliness (Graneheim and Lundman, 2009). First of
-I all, we must differentiate loneliness from being alone. People can be alone | without feeling lonely. Loneliness implies a subjective sense of loneliness and ™ separation from others. Being alone means spending time alone, and living alone means having a single household. These concepts do not have to be associated with the experience of loneliness. Similarly, a person experiencing loneliness can be alone, live alone or live with others (Graneheim and Lundman, 2009). Loneliness does not have to be understood negatively. It is usually described as a significant developmental experience in the process of self-knowledge.
It is possible to distinguish between two types of loneliness: social and emotional. Emotional loneliness arises as a consequence of lack of intimacy, romantic connection, or as a consequence of an unmet need for emotional intimacy and intimacy in relationship with others, often accompanied by anxiety, unrest and a feeling of emptiness. Social loneliness, on the other hand, arises as a result of a lack of meaningful friendships or community and as a consequence of one's own perceived inability to integrate socially, i.e. insufficient social inclusion in social networks. It is accompanied by boredom and a sense of social marginality (Soric, Lackovic-Grgin and Penezic, 2001).
How a person will experience loneliness depends on different correlative factors. However, age is a variable that is, for good reason, most often perceived as significant in relation to loneliness. As people grow old and move towards retirement age, they experience different types of loss. Age-related loss includes not only the loss of physical, cognitive and functional abilities, but also the loss of friends and family members. In addition, ageing can prevent or complicate the acquisition and maintenance of new social relations. Any of these types of loss or barriers can contribute to a feeling of loneliness among the elderly. It can be said that most of the research on the relationship between age and loneliness was triggered by a stereotype that prevails in everyday life, which is that older people are more alone than the young. The results of such research show that the percentage of people experiencing loneliness increases after the age of 75 years (Wagner & Burholt, 2004).
Although inherent to all people, as claimed at the very beginning of this article, loneliness, by nature a subjective experience that varies from person to person, appears as a result of numerous causes and has various consequences (Rokach, 2001). Brajkovic (2010) gives the death of spouses, siblings and friends, sickness, retirement, disability, income reduction and greater dependence as risk factors for various negative life changes, including the experience of loneliness. Reduction in the number of friendships, loss of a role in life and reduced activity of an individual in various areas of life, chosen willingly or imposed by the circumstances, can all initiate social isolation and loneliness for an elderly person. Loneliness is associated with the lack of happiness, self-esteem and general satisfaction with life, which often leads to the development of a number of bodily illnesses that can have tragic consequences for the elderly (Brajkovic, 2010).
Widowhood is associated with a higher level of loneliness, as it is a loss for which it is difficult to compensate. Bennett and Victor (2012) conducted research
to determine what loneliness means to people who are widowed. The survey i was conducted on 125 widowers and widows aged 55 to 98 years. Almost half | of the respondents spontaneously described themselves as lonely. More than | half of respondents (61%), described loneliness in terms of the absence of their d spouse ("I've been feeling the absence..."). One third of respondents (34%) con- i nected loneliness with a certain time and place: at night, at the weekend and at | home ("I am lonely at night...", "Time during the night is the worst time", "Satur- ™ days and Sundays are a bit dead for me"), and 4% of respondents described the emotional impact of loneliness ("I've never been so alone in my life... It broke e my heart"). Thus, the results showed that people who are widowed relate the feeling of loneliness to the concept of emotional loneliness, which is the result of the loss of significant social and emotional connection.
From everyday experience, but also professional literature, it is evident that persons who are lonely for whatever reason strive to overcome this unpleasant state by using different coping strategies. Confronting is usually defined as a "cognitive or behavioural action which seeks to overcome, reduce or tolerate between the person and his or her environment" (Lackovic--Grgin, 2008, p. 139). Many researchers have tried to describe and classify the diversity of ways of coping with loneliness. However, the classification of Rokach (2001) can be considered the most relevant, because she investigated the group of old people. According to Rokach, there are six basic types of coping with loneliness: acceptance and reflection, religion and faith, social support network, increased activity, self-development and understanding and distancing or denial.
The first factor, acceptance and reflection, refers to the possibility for people to be directed towards their inner selves and to become aware of their fears, desires and needs. It enables a person, by accepting his or her own feelings of loneliness, to make the process of cognitively reconfiguring the situation easier by discovering and updating his or her own capabilities. For a person to accept loss, it is necessary that he or she should confront it, which includes: becoming aware of emotions that arise and are associated with loss and sharing the experience of loss with someone (family members, friends), sometimes with experts.
Another factor is interpreted as religion and faith. Through affiliation with religious groups and through the practice of prayer, a solitary person can feel strength, inner peace, and a sense of communion and belonging, which can also be a good way to overcome the feeling of loneliness. Mhaske's work (2014) deals with the role of spirituality and religion after the loss of a spouse and indicates the connection between religion and facing difficult life situations. The results indicate that older widowers show more frequent participation in religious practice after they have experienced the loss of their wife, interpreted by Mhaske to be the result of poor support from family and friends, which is therefore replaced by the support of religion. Other researchers, among other things, found that although men in some respect turn more often to religion, widows also use religious practice, spiritual beliefs and behaviour in order to adapt to the loss of their spouse. One study shows
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-I that individuals who process their grief through their spiritual beliefs pass I through grief more completely and faster than those who do not have such ™ beliefs (Walsh, King, Jones, Tookman and Blizard, 2002).
The third factor is the social support network, which refers to the re-establishment of the social network, connecting with other people and use of their support in solving the issue of loneliness or other difficulties in life. Despite the widespread belief that widowhood, compared to other life events, is the most stressful experience (Holmes and Rahe, 1967), most studies agree that only 15-30% of the widowed experience clinically significant depression in the years following the death of the spouse (Stroebe, Stroebe and Hanson, 1993; Zisook and Schuchter, 1991; Wortman and Silver, 1989).
In addition to the initial strong emotional reactions, an interesting aspect of losing a partner is coping with the loss after the passage of a certain period of time, i.e. overcoming the situation of losing a partner. Bharathi, Sridevi and Kumar (2015) have questioned sexual differences in loneliness, depression and participation in social networks following the loss of a spouse. The survey included 30 widows and 30 widowers from rural and urban areas of Hyderabad (India) and the results of the survey showed that men experienced greater loneliness than women in the period from 6 to 24 months after a severe loss, and also, that they more often encountered difficulties in achieving social interactions and seeking assistance from others.
However, the passage of time establishes certain coping mechanisms with the newly-established situation. Coping strategies enable the establishment of control over your life, i.e. overcoming the difficult situation in which a person is put. As activities that helped them cope with loss and the changes caused by the wife's death, the widowers cited a wide range of activities and relationships. In fact, the support by family and friends plays a great role in this respect, as does the support given by the groups on the internet where widowers gather. One group of the widowers questioned said they received great help from professionals and counselling. This research indicates the need to recognise and accept individual ways of coping with loss, noting that the family represents the greatest support provider, but the support groups in which people share the same or similar experiences are also important.
Many studies point to reconfiguration of the existing social networks and the establishment of new close relationships as the most effective way of coping with loneliness. Although in widowhood general social support is expected within the family, and many older people receive it, some still feel the need to make new marriages to alleviate the feeling of losing a spouse and provide themselves with continued support in grief.
Hauksdottir, Valdimarsdottir, Fürst and Steineck (2013) conducted a quantitative research study with widowers and concluded that, after the loss of their wives, husbands are exposed to greater psychological and physical morbidity and that for some their distress meets the criteria of depressive disorders, while some widowers even suffer from post-traumatic stress disorder in the year of the loss of their wife. They also found that widowers who, after 4 or 5 years of widowhood, are not in a new relationship, often report
that they feel anxious and/or depressed, have difficulty in finding meaning in i life, have sleeping disorders and often report psychological problems. Enter- | ing a relationship or marriage after the loss of a wife increases the survival | rate of grieving widowers, and the results show that, where social support d from friends is relatively weak, the new relationship is an important source i of social support. Furthermore, the authors claim that widowers benefit | more from re-connection or new marriage than women, and are more often 5 prepared for and more interested in re-connection.	5
In support of this claim, the research of Indrian (2013) has shown that e more than 60% of widowers had a desire to marry again, while only 20% of widows expressed the same desire. In the survey by Osmani, Matlabi and Rezaei (2018), 48 widows and widowers participated. The results showed that the desire to re-enter into marriage or a romantic relationship depends on a number of factors, mostly concerned with the opinion of the neighbours and the wider social environment. Older widows (over 60 years of age) stated that the re-entry into a romantic relationship or marriage made no sense considering their age. They said that they were unable to fulfil all aspects of a new relationship or marriage because of their age. In connection with this, some widows said that re-entry into the marriage state is immoral, and that no woman could allow herself such a thing. This statement of opinion confirms the finding that widows still feel affection and devotion to their late husband and, moreover, some of the widows questioned had promised their deceased spouse not to take another partner after his death. Regarding family and children, widows more often than widowers state that they feel ashamed and uneasy discussing with their children the possibility of a new relationship or marriage. Some widows believed that such an act would adversely affect their children, i.e. would represent a family disgrace (Osmani, Matlabi and Rezaei, 2018).
In a survey conducted in Finland (Pettay, Rotkirch, Courtiol, Jokela and Lummaa, 2013), the results indicated that widowers tend to form a new conjugal union more often than widows. In some circumstances, the family can have a negative impact on a widow or widower and exert strong social pressure. This happens if there is no relationship of affection in the family, due to an earlier conflict and misunderstanding, a feeling of debt and obligation for the aid provided by the family, or an expectation that the widow or widower behaves as the family desires. A more pronounced situation of hostility or lack of support in the family relationship associated with widow/ widower remarriage often occurs because the offspring of the first marriage do not want the parent to remarry as this puts the family property in question (Cicak, 2010).
The fourth factor is interpreted as increased activity, and refers to an active search for everyday responsibilities as well as other group activities that increase one's social contacts. This factor is explained by Rokach (2001) as a reaction to the fact that loneliness is often perceived as a paralysing helplessness. An effective way of coping with such immobilisation is to increase activity, which increases the feeling of personal control and overcomes any
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accompanying sadness and depression. Increased activity can be an indication 1 of an escape from confronting the strong emotions that accompany mourning. ™ It is certainly necessary to distinguish between healthy and moderate activity < as a way of coping with loss compared with pathological, unreasonable and exaggerated activity as a sign of complicated, disguised or delayed grief.
The fifth factor is called self-development and understanding, and refers to participation in various organised seminars and courses, but also to trusting one's own feelings and attempting to understand one's own thoughts by keeping a diary, which is a good way to achieve personal development and an understanding of one's own problems. After losing their spouse, regardless of the severity of the event, many elderly people find peace and tranquillity through the writing of their autobiography or a review of their life while continuing life in new circumstances. The loss is a challenge for them to test their own abilities and to provide a testimony for their children and grandchildren on how to bear and accept loss.
Finally, the sixth factor is called distancing and denial and is often associated with dependence on alcohol, drugs, as well as other deviant behaviour. People differ in their willingness to recognise or acknowledge loneliness. Fear of stigmatisation can lead them to deny their loneliness through various forms of destructive and deviant behaviour. In much of the Western world, despite its variety, it is still more acceptable to talk about all kinds of physical illnesses and to undergo treatment for such illnesses for years, while the problems of psychological health or those of spiritual nature are very much neglected and unrecognised. Although we witness numerous deaths where "signs of warning" of a psychological or spiritual nature have not been recognised or not taken seriously, it seems that accepting grief as an individual process for which we need time and help, is delayed to a later time in the future.
According to Acharyya (2012), the psychological condition of older people is not good. There is a growing likelihood of depression, and the suicide rate among these of this age group is greater than ever, consistent with the decline in their physical and psychological health. Official statistics identify older people as a high risk group for committing suicide. Miller (2001) gives the attempted suicide rate among the elderly as from 2 to 4 attempts for each successful suicide. However, the rate of suicide committed is itself 50% higher than in the overall population. Thus, older people have a higher suicide rate than any other age group and tend to be more decisive and expeditious (Acharyya, 2012).
Some authors suggest that the suicide rate is on the rise in people who grieve in comparison with other population groups (Agerbo, 2005; Erlagsen, Jeune, Bille-Brahe and Vaupel, 2004). Depression is the most commonly diagnosed mental health problem in elderly individuals who have attempted suicide. However, there are obstacles to the detection of depression in old age. Compared with young people, the elderly rarely exhibit symptoms of depression and are prone to denial of sadness, anxiety and depression. For this very reason, symptoms of depression in old age remain unrecognised and untreated for a longer time.
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In conclusion we can say that widowhood and loneliness have consequences that can lead to serious health problems. Loneliness is one of the	° three main factors that lead to depression, and the prevalence of depressive	h symptoms with age rises (Kennedy, 1996). Also, depression is considered an	n important cause of suicide and suicide attempts among the elderly.	r
e <
n
Conclusion	I
Losing a spouse is considered one of the greatest stressors in life. It is parti- e cularly difficult in old age because of the strong interconnectedness between
partners, and loneliness sometimes follows such a loss. In social terms, widowhood is a developmental process that takes place as a transition to a new period of life and a new role. Widowhood is more often the status of females because wives are usually younger than husbands, live longer and rarely make a new marriage.
In the literature we find opposing opinions on who better adapts to widowhood - men or women. Some authors claim that widows receive and give more help than widowers, but on the other hand, more educated men also provide more support to their family than the uneducated. Also, men are more likely to make new marriages than women. The consequences of widowhood are numerous, and most often they are reflected in physical and psychological ill health, reduced incomes (especially for women), loneliness, greater mortality and suicidal growth (especially in men).
The strategies of coping with loneliness in widowhood are presented: acceptance and reflection, religion and faith, social support network, increased activity, self-development and understanding, distancing or denial. We can conclude that older people use all these strategies, sometimes combining several of them at the same time, and that the majority accomplish their life task of grieving successfully. However, it should be emphasised that social support network is extremely important during the first six months of mourning, but also later, while the elderly, a group vulnerable because of the frequent occurrence of loss and multimorbidity, can be extremely sensitive in coping with a new loss. Special attention should be paid to widowers without a developed social network, with poor health status and low income, who require provision of psychological support as well as help with housekeeping.
Professional help should always be provided (to both men and women) when sudden and/or violent death is involved. It is necessary to educate not only professionals working with the elderly about the signs and forms of complicated grief, but also family members and the wider community in order to ensure that they seek the timely intervention of professional assistance. It is equally important to work on the removal of taboos surrounding death and grief, and on the creation of a social environment (family and community) that will accept the consequences of loss and the necessary recovery time as an important life experience, specific to each individual, just as every life is unique and unrepeatable.
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