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Article 104

The Anniversary of the Death of a Loved One

Lennis G. Echterling, Carol Marvin, and Donna L. Sundre

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For decades, counselors have suggested that survivors experience predictable grief reactions (Maciejewski, Zhang, Block, & Prigerson, 2007), including greater distress on the anniversary of a death of a loved one or other traumatic event (Mintz, 1971). However, most of the evidence for an anniversary effect has been based upon a few case studies of individuals in psychotherapy (Bornstein & Clayton, 1972; Beratis, Gourzis, & Gabiel, 1994; Musaph, 1990). Empirical evidence for an anniversary effect of a trauma or loss is virtually non-existent.

Only three research projects from around the world have provided limited evidence suggesting an anniversary reaction. Studying Gulf War veterans, researchers discovered that 38% of participants reported their worst month of functioning after deployment coincided with the month in which their trauma occurred (Morgan, Hill, Fox, Kingham, & Southwick, 1999). Thai flood survivors were found to have increased levels of psychological distress around the anniversary of the catastrophic event (Assanangkornchai, Tangboonngam, Sam-angsri, & Edwards, 2007). Finally, in a recent study of bereaved young adults in the United States, Holland and Neimeyer (2010) found no support for a stage model of grief, but uncovered some indications of an anniversary reaction, which included greater distress and lower acceptance during the second anniversary of the traumatic event.

The purpose of this research was to test empirically the assumption in the current grief counseling literature regarding the anniversary of the death of a loved one. The study was designed to explore the various grief responses—behaviors, emotions, and physical reactions— that individuals may experience around the anniversary.

Method

The participants in this study were individuals who had experienced the death of a loved one at least one year before the sampling time period. Thirty-three individuals who had received services from the local hospice/bereavement program volunteered to complete a survey regarding their anniversary experiences.

Instrument

The instrument used was an eight-page survey designed by the researchers to explore the experience of the anniversary of the death of a loved one. The survey requested information regarding the demographic characteristics of the survivor, the deceased’s relationship to the survivor, the nature of the death, the months leading up to the anniversary, and five domains of anniversary experience itself (activities, emotions, cognitions, interpersonal interactions, and somatic complaints). Analysis of these data provided a measure of the anniversary effect. Finally, participants were also requested to share their coping strategies and suggestions to others experiencing the loss of a loved one.

Sample

The sample population consisted of 33 participants, 27 of whom were female. Nearly half of the respondents were widowed and over a third were currently married. All were White and ranged from 30 years to 89 years. Many were able to give the exact date the loved one had died and 85% reported being able to recollect the anniversary experience. The largest group of respondents (49%) had lost a spouse and the second largest had lost a child (27%). The most common cause of death was cancer (42%), however, a significant portion of respondents did not specify the cause of death (21%). Over half (61%) of the participants reported that the death was expected.

Anniversary Experience

Most of the participants reported increasing levels of distress for several months leading up to the anniversary of their loss. Over half of the respondents reported that they were usually or almost always preoccupied with the anniversary (57%), made plans for the day (54%), and dreaded its arrival (57%). Almost half were tense (48%) and apprehensive (48%) about the upcoming anniversary.

The biggest changes in behavior at the time of the anniversary were reported increases in reflecting on the event (82%) and crying (70%). Many people also reported talking (61%), praying (51%), and working (34%) more on that day. A significant number of people reported sleeping (39%) and eating less (33%) on or around the anniversary.

The participants also reported increases in grief-related emotions around the time of the anniversary. Over half of the sample noticed an increase in sadness (82%), loneliness (79%), and restlessness (51%). Many also reported feeling more helpless (48%), overwhelmed (45%), exhausted (45%), nervous (42%), and angry (33%). Most of the survivors reported more frequent grief-related thoughts around the anniversary. Survivors experienced an increase in the number of memories (91%) and flashbacks (69%), while also reporting greater difficulty concentrating (51%), more unwanted thoughts (48%), and more dreams (30%) about the death. Many people reported spending more time with their family (42%), friends (33%), and fellow members of their faith-based group (30%) around the anniversary. However, a significant number reported spending less time with a support or counseling group (27%).

In contrast to the numerous reported changes in behavior, affect, cognitions and interpersonal relations, most of the sample responded that there was no change in how they felt physically on or around the anniversary. Respondents reported only one somatic symptom, which was an increase in headaches (30%).

Overall, evidence of the anniversary effect was found in all the five domains—activities, emotions, cognitions, interpersonal interactions, and somatic complaints—that were evaluated in this study. Although evidence of the anniversary effect was stronger in some domains, particularly in the survivors’ thoughts, feelings and behaviors, it nonetheless impacted at least one component of each domain.

Discussion

Limitations

There are several limitations to this study. The first limitation concerns the gender of the participants. Very few males agreed to take part in the study. One reason for this situation may have been that males may be less likely to complete and return surveys that ask them to respond to personal questions. Also, males typically are less likely than women to talk about their emotions or to join support groups.

Another limitation concerns the age of the study’s sample. Of those who volunteered to participate, no one was under the age of 30. Since studies of the grieving process have demonstrated that there are developmental differences based on age (Webb, 2010), the current study’s results may not apply to younger survivors.

Three additional limitations related to other demographic characteristics are evident. First, all participants were White. People from different ethnic populations may differ in their grief reactions based on their culture. Additionally, at the time of the death the participants were all living in a rural area. It is unknown if the reactions would be the same if the subjects were from a large city or an urban area. Further, all of them participated in a Hospice program. People who are willing to participate in a Hospice program may differ in their grief reactions from those who do not. Consequently, generalizability of the results to other populations, such as African American, urban, and those not involved in grief services, is uncertain. Keeping these limitations in mind, the results of this study nevertheless make a contribution to the grief research literature by providing empirical data regarding the anniversary effect.

Anniversary Effect

These results are consistent with the anticipatory bereavement model proposed by Chow (2010), who suggested that the expectation alone can intensify the distress. This study examined the participant’s anticipation of the event several months before the anniversary took place and found that over half of the respondents reported feeling apprehension, experiencing dread, and planning for the event. One respondent acknowledged, “Sometimes the actual day can be somewhat of a let down because you expect all of these emotions, and when the day comes, the emotions aren’t there! I think it is because you experienced it all before the day.” Many people commented that the months leading up to the anniversary were actually much worse than the day itself. As one person wrote, “Preparing for the anniversary was worse than the anniversary itself.”

Although the anticipation involved significant anguish, most participants reported many distressing changes in their thoughts, feelings and behavior around the time of the anniversary. Respondents reported talking, crying, and working more during this time. One widow described the anniversary as a day when you “remember, reflect, cry, talk about the person, laugh about funny things you did together.”

Many reported feeling more lonely, sad, and helpless around the anniversary. “At first,” reported one survivor, “I would want to share some news with my husband that I had heard. As time went on it was easier to deal with this feeling.” Many stated they were prepared to have these emotions, but they were surprised to feel overwhelmed and exhausted. As one participant put it, “My sorrows and remembrances catches (sic.) me at odd moments.” Another said, “I face each anniversary realizing my loss will once again overwhelm me, but I also know he would want me to be strong in my faith.”

Cognitive experiences related to the anniversary experience included more memories, dreams, unwanted thoughts, and difficulty concentrating. Many respondents reported dealing with this by visiting the cemetery on the anniversary, placing flowers in the church, or putting memorials in the newspaper. A few also reported wanting to do something meaningful, but could not find the energy to do it.

Several clinicians have pointed to somatic symptomology as evidence of an anniversary effect (Hull, Lane, & Gibbons, 1993). The results of the present study are not consistent with this earlier observation of a powerful somatic reaction to the anniversary. Although participants reported an increase in the number of headaches around the anniversary, no other somatic complaints were reported. The contrast in results between this study and earlier research may be due to the differences in methodology. The previous researchers were from a medical background and were trained to look for physical symptoms attributable to stress reactions. In addition, the participants used in the earlier study underwent a physical examination. The present study relied only on self-report of general physical complaints, such as headaches, stomachaches, and heart pains. A comprehensive medical examination may have uncovered more physiological reactions.

The changes in interpersonal interactions indicate that relationships during this time were especially helpful in reducing the impact of the anniversary effect. One participant stated that it was “very important to build relationships with new people. I found people that have been through [the] same experiences to be very helpful.” Another participant said, “I think if I wouldn’t have had my friends, husband [and] the strength God gave me, I would not have been able to deal with my loss.”

Implications for Counselors

Questions at the conclusion of the survey requested participants to share what they found helpful, describe activities they participated in to commemorate the anniversary, and offer suggestions they might give to others who are experiencing the same event. The subjects responded with great detail, explaining what they did, offering what was helpful, and vividly pouring out their emotions. They also expressed gratitude for this survey because its content provided affirmation of their anniversary experience and provided them with an opportunity to share it with others. Based on these comments, several implications for counselors have been developed.

The first, and perhaps most crucial, implication for grief counselors and support group facilitators is that they must begin early to prepare survivors for the anniversary of a death. With about half of the survivors feeling tense and apprehensive, dreading the arrival of the day, and being preoccupied with the anniversary, it is essential that grief counselors begin early to prepare survivors for this experience. Counselors can engage both individuals and families in creative interventions that promote social support, meaning-making, emotional regulation and adaptive coping (Echterling & Stewart, 2008).

Second, the anniversary effect needs to be normalized. The educational content of grief support groups can acknowledge that the majority of survivors are likely to engage in more reflecting, crying, talking, and praying, while sleeping and eating less, around the anniversary. Survivors are also apt to feel particularly lonely, sad, and restless during this time. Such information can alleviate the common concerns of people that what they are experiencing is abnormal or unusual.

Many friends and relatives may encourage survivors to put the past behind them and to move on with their lives. To counter these misguided attempts to be helpful, counselors can give survivors permission to reflect more on the past as the time of an anniversary approaches. One survivor explained, “When you lose your mate, who was also your dearest friend, you miss them every day. When I hear news about someone we both know, I want to tell him….Then reality hits. After you get through the numbness of the first six months, you suddenly realize that this is what it is for the rest of your life….That is when I shed tears more freely.” When survivors welcome and cherish these memories during the anniversary, they are engaging in the normal, natural bereavement process. Counselors should encourage others, such as friends and family members, to offer understanding, emotional support and practical assistance as the survivor faces the anniversary (Echterling, Presbury, & McKee, 2005). One survivor suggested, “Don’t try to handle all of it by yourself—let others help you through this time.”

In spite of the fact that they were experiencing greater grief reactions during the time of the anniversary, over a fourth of this study’s participants reported spending significantly less time seeing a counselor or attending a grief support group. One reason for failing to connect with these services during this crucial time could be due to social expectations that bereavement is a short-term process. For example, the DSM-IV-TR (American Psychiatric Association, 2000) stated that normal bereavement takes approximately 2 months for the majority of the population. It is the counselor’s responsibility to advocate, through public education and outreach, for survivors as they experience the many complex and long-term challenges of the grieving process, including the anniversary of the death. In community education programs and public announcements in the media, counselors can remind survivors that they do not have to carry their burdens alone.

Questions for Further Research

Given the many deaths of members of the U.S. armed services and the lethality of natural disasters, further research needs to be conducted to explore possible gender, cultural, situational, and developmental differences in the anniversary reaction. Additionally, research should be done with populations from suburban and metropolitan areas. Future studies could also explore how the dynamics of the anniversary effect may differ on each subsequent year. Such findings would provide counselors with helpful guidelines for designing and timing their interventions to enhance the well-being of survivors.

Conclusion

The results of this study demonstrated that there is a predictable, psychological reaction to the anniversary of a death. While the data can only be generalized with caution to other populations, there is sufficient evidence to prompt counselors to recognize and address the anniversary effect as an opportunity to promote the resilience of survivors as they seek meaning in their grief.