Experiences of continued presence: On the practical consequences of 'hallucinations' in bereavement

Perceiving those who are gone: Cultural research on post-bereavement perception or hallucination of the deceased

Experiencing the continued presence of the deceased is common among the bereaved, whether as a sensory perception or as a felt presence. This phenomenon has been researched from psychological and psychiatric perspectives during the last five decades. Such experiences have been also documented in the ethnographic literature but, despite the extensive cross-cultural research in the area, anthropological data has generally not been considered in the psychological literature about this phenomenon. This paper provides an overview aimed at bridging these two areas of knowledge, and approaches the post-bereavement perception or hallucination of the deceased in cultural context. Ongoing debates are addressed from the vantage point of ethnographic and clinical case study research focusing on the cultural repertoires (in constant flux as cultures change) from which these experiences are labelled as desirable and normal, on the one hand, or as dangerous and pathological, on the other.

Description and Impact of Encounters With Deceased Partners or Spouses

This study investigates perceived interactions with the deceased, a phenomenon reported across societies, with 30-34% of individuals likely experiencing at least one ADC in their lifetime. Despite this prevalence, studies examining the impact of ADCs' on those who have lost partners are limited. We present data from 70 individuals reporting partner ADCs via an online survey. Forty percent reported accelerated recovery and 42.9% confirm the ADCs' significant influence in their grieving, with 61% expressing a desire for continued contact. ADCs, interestingly, didn't worsen their pain. The influence on grief-related sadness varied: 41% noted no change, while 40% reported reduced sadness. Forty-seven percent acknowledged ADCs eased their loss acceptance. The data highlight ADCs' substantial, potentially therapeutic role in grief and healing, despite varying effects on sadness and recovery. This study underscores the ADCs' possible positive influence on bereaved partners, advocating for a deeper understanding of this phenomenon in the grieving process.

Very Present and Very Real: A Case Study of Regularly Hearing the Voice of the Deceased Without Distress in Bereavement

Although sensory and quasi-sensory experiences of the deceased (SED) have been the subject of much debate, research on the phenomenology of auditory verbal experiences in the bereaved has been neglected. This case study describes the phenomenology of a regularly occurring voice hearing experience and its meaning for a single bereaved individual. The voice of the deceased can be heard as though in external space, and the experience can feel real, even when the death is fully acknowledged. A bereaved individual can welcome and benefit from the experience even when it is not recognized as a normal part of grieving in the individual's cultural context, when no afterlife belief is present, and when the experience remains unexplained. The case study demonstrates that hearing the voice of the deceased can be a regular occurrence without causing distress or dysfunction and lends support to the idea that SED are a common concomitant of normal bereavement.

The impact of continuing bonds following bereavement: A systematic review

Following bereavement, continuing bonds (CBs) include engaging with memories, illusions, sensory and quasi-sensory perceptions, hallucinations, communication, actions, and belief that evoke an inner relationship with the deceased. To date, the literature has been unable to confirm whether retaining, rather than relinquishing, bonds is helpful. A mixed studies systematic literature search explored how CBs affect grief. Studies on the effect or experience of CBs on adjustment following bereavement were eligible for inclusion. Six computerized databases were searched. A total of 79 of 319 screened studies were included. Three themes were derived from the thematic analysis: (1) comfort and distress, (2) ongoing bonds and relational identity, and (3) uncertainty, conceptualizing, and spirituality. Themes describe the role of CBs for the accommodation of the death story, transformation of the relationship, meaning reconstruction, identity processes, and affirmation of spiritual belief. Results shed light on the adaptive potentials for CBs.

Varieties of felt presence? Three surveys of presence phenomena and their relations to psychopathology

BACKGROUND

Experiences of felt presence (FP) are well documented in neurology, neuropsychology and bereavement research, but systematic research in relation to psychopathology is limited. FP is a feature of sensorimotor disruption in psychosis, hypnagogic experiences, solo pursuits and spiritual encounters, but research comparing these phenomena remains rare. A comparative approach to the phenomenology of FP has the potential to identify shared and unique processes underlying the experience across these contexts, with implications for clinical understanding and intervention.

METHODS

We present a mixed-methods analysis from three online surveys comparing FP across three diverse contexts: a population sample which included people with experience of psychosis and voice-hearing (study 1, N = 75), people with spiritual and spiritualist beliefs (study 2, N = 47) and practitioners of endurance/solo pursuits (study 3, N = 84). Participants were asked to provide descriptions of their FP experiences and completed questionnaires on FP frequency, hallucinatory experiences, dissociation, paranoia, social inner speech and sleep. Data and code for the study are available via OSF.

RESULTS

Hierarchical linear regression analysis indicated that FP frequency was predicted by a general tendency to experience hallucinations in all three studies, although paranoia and gender (female > male) were also significant predictors in sample 1. Qualitative analysis highlighted shared and diverging phenomenology of FP experiences across the three studies, including a role for immersive states in FP.

CONCLUSIONS

These data combine to provide the first picture of the potential shared mechanisms underlying different accounts of FP, supporting a unitary model of the experience.

The felt-presence experience: from cognition to the clinic

The felt presence experience is the basic feeling that someone else is present in the immediate environment, without clear sensory evidence. Ranging from benevolent to distressing, personified to ambiguous, felt presence has been observed in neurological case studies and within psychosis and paranoia, associated with sleep paralysis and anxiety, and recorded within endurance sports and spiritualist communities. In this Review, we summarise the philosophical, phenomenological, clinical, and non-clinical correlates of felt presence, as well as current approaches that use psychometric, cognitive, and neurophysiological methods. We present current mechanistic explanations for felt presence, suggest a unifying cognitive framework for the phenomenon, and discuss outstanding questions for the field. Felt presence offers a sublime opportunity to understand the cognitive neuroscience of own-body awareness and social agency detection, as an intuitive, but poorly understood, experience in health and disorder.

Restorative Retelling for Processing Psychedelic Experiences: Rationale and Case Study of Complicated Grief

Rationale

Many psychedelic experiences are meaningful, but ineffable. Engaging in meaning-making regarding emerging symbolic content and changing previous schemas have been proposed as mechanisms of change in psychedelic therapy.

Objective

Firstly, we suggest the implementation of a Restorative Retelling (RR) technique to process and integrate the psychedelic experience into autobiographical memory, in a way that fosters meaning-making. We also show how ayahuasca has the potential to evoke key psychological content in survivors, during the process of grief adjustment following the death of a loved one.

Methods

The rationale for the implementation of RR to process psychedelic experiences and a case study of a woman suffering from Complicated Grief (CG) after her mother's suicide are presented.

Results

Evaluations conducted before the ayahuasca experience and after RR suggest the effectiveness of ayahuasca and RR in reducing symptoms of CG and psychopathology.

Conclusion

This case report illustrates an effective adaptation of the RR technique for processing the psychedelic experience. The significance of the study and its limitations are discussed.

Are Sensory Experiences of One's Deceased Spouse Associated with Bereavement-Related Distress?

Following late-life spousal bereavement, sensory and quasi-sensory experiences of the deceased (SED) are commonly reported. This longitudinal study examined SED among 310 older widowed adults 6-10 (T1) and 18-20 (T2) months post loss. Reports of SED in the first 6-10 months after loss were associated with higher symptom levels of prolonged grief, post-traumatic stress, and loneliness at T1. Experiencers of SED were more likely to experience symptoms of prolonged grief and post-traumatic stress above cut-off scores at T1. Importantly, only a minority of the experiencers of SED displayed these elevated levels of bereavement-related distress. In addition, employing multi-level-modeling, a similar trajectory of decreasing bereavement-related distress over time was found for both experiencers and non-experiencers of SED. We argue that SED may be one of several potential reactions to bereavement, which should not be seen as an indicator of grief complications per se.

Sensory experiences of one's deceased spouse in older adults: An analysis of predisposing factors

Objectives This study focuses on pre-disposing factors associated with sensory experiences of the deceased (SED), also called bereavement hallucinations. Even though SED are common among older widowed adults, our knowledge of these experiences is still limited.Method Survey responses were obtained from 310 older widowed participants (M = 70.05 ± 8.39), complemented with data from Danish national registers.Results Hierarchical logistic regression analysis revealed four significant pre-disposing factors: prior experiences of SED in the context of previous significant bereavements (OR = 4.72), a history of interpersonal trauma (OR = 5.8), high pre-death relationship closeness (OR = 2.76) and stronger religious/spiritual worldview (OR = 1.12). No association to registered mental health diagnosis was identified.Conclusion: SED may be considered an interpersonal experience, which may be more likely to occur if the pre-death relationship is described as very close and if the bereaved has previously experienced interpersonal trauma. We argue that SED should not necessarily be considered an indication of neurodegenerative or psychiatric diseases.

The phenomenology and impact of hallucinations concerning the deceased

Background

People who have suffered the loss of a loved one may subsequently report sensory experiences of the deceased (termed ‘after-death communications’, or ADCs). Such encounters are common and can be a source of comfort to the bereaved. Nevertheless, there has been limited empirical investigation of this phenomenon, and consequently mental health professionals feel ill-equipped to support those who disclose them.

Aims

To map the phenomenology of ADCs, and identify covariates and effects upon the recipient.

Method

We conducted an online mixed-methods survey comprising 194 items about all aspects of ADCs. A purposive sample of 1004 respondents across three language groups (English, French and Spanish) completed the survey.

Results

The most common form of ADC was during sleep, but large numbers of cases involved sensory modalities of touch, sight, hearing, smell and sense of presence that externalised the phenomenon for the recipient. Variations in incidence with participant gender and language group suggest a psychosocial component. ADCs were typically regarded by the participant as deeply meaningful and comforting. Respondents reported significant increases in their sense of spirituality, but not religiosity.

Conclusions

ADCs are a common feature of bereavement that occur unexpectedly, and are independent of any underlying pathology or psychological need. For the person experiencing the hallucination, they are important and meaningful events that they interpret in terms of continuing bonds with the deceased. This adaptive outcome may be stymied where mental health professionals trivialise or pathologise disclosures about ADCs.

Prevalence and Phenomenology of Sensory Experiences of a Deceased Spouse: A Survey of Bereaved Older Adults

Sensory and quasi-sensory experiences of the deceased (SED), also called bereavement hallucinations, are common in bereavement, but research detailing these experiences is limited. Methods: An in-depth survey of SED was developed based on existing research, and 310 older adults from the general Danish population participated in the study 6-10 months after their spouse died. Results: SED were reported by 42% of the participants with wide-ranging phenomenological features across sensory-modalities. In particular, seeing and hearing the deceased spouse was experienced as very similar to the couple's everyday contacts before death. SED were endorsed as positive by a majority of experiencers, and the experiences were often shared with family and friends. Discussion: SED are conceptualized as social and relational phenomena, which may comfort the surviving spouse in late-life bereavement, but also provide tangible help to some experiencers. In clinical practice, SED may be considered a potential resource for the therapeutic grief process.

When experiences of presence go awry: A survey on psychotherapy practice with the ambivalent-to-distressing 'hallucination' of the deceased

OBJECTIVES

Experiences of presence, involving the sensory perception or felt presence of the deceased, are common amongst the bereaved (30-60%). Despite them being predominantly comforting and reassuring, a minority (approximately 25%) report ambivalent or distressing experiences. The study's aim was to explore how psychotherapy is practised with this subset.

METHOD

A mixed-method approach, involving both quantitative analysis and thematic analysis, was used to analyse data from an online survey, conducted in English and Spanish, amongst mental health therapists (i.e., psychologists, psychotherapists, and counsellors). Seventy responded to the survey and four of them were further interviewed.

RESULTS

The participants primarily framed interventions for ambivalent-to-distressing experiences of presence as grief therapy, with the severity of the presentation as the main factor influencing their clinical decision-making, but several perspectives co-existed regarding how to intervene. These discourses were categorized into two themes: 'A normalising and exploratory psychotherapy' and 'A grief stages psychotherapy'. The main sources of patient's distress, as understood by the sample, were located in the bereaved-departed relationship, in pre-existing mental health issues, and in a societal taboo or stigma.

CONCLUSION

After comparing and contrasting the participants' working hypotheses with existing knowledge on experiences of presence, and contemporary theories in the research area, guidelines are presented on how to intervene with people disturbed by their experiences of presence.

PRACTITIONER POINTS

Perceiving the deceased person, or feeling their presence, is common and normal amongst bereaved people. When these experiences are distressing or ambivalent, therapists' share that psychological suffering may originate from the departed-bereaved relationship, pre-existing mental health issues, or the effect of societal taboo or stigma. Psychotherapy is frequently aimed at normalizing, accepting, supporting, and exploring patient's experience.

Sensory and Quasi-Sensory Experiences of the Deceased in Bereavement: An Interdisciplinary and Integrative Review

Bereaved people often report having sensory and quasi-sensory experiences of the deceased (SED), and there is an ongoing debate over whether SED are associated with pathology, such as grief complications. Research into these experiences has been conducted in various disciplines, including psychiatry, psychology, and anthropology, without much crossover. This review brings these areas of research together, drawing on the expertise of an interdisciplinary working group formed as part of the International Consortium for Hallucination Research (ICHR). It examines existing evidence on the phenomenology, associated factors, and impact of SED, including the role of culture, and discusses the main theories on SED and how these phenomena compare with unusual experiences in other contexts. The review concludes that the vast majority of these experiences are benign and that they should be considered in light of their biographical, relational, and sociocultural contexts.

Hallucinations in Older Adults: A Practical Review

Older adults experience hallucinations in a variety of social, physical, and mental health contexts. Not everyone is open about these experiences, as hallucinations are surrounded with stigma. Hence, hallucinatory experiences in older individuals are often under-recognized. They are also commonly misunderstood by service providers, suggesting that there is significant scope for improvement in the training and practice of professionals working with this age group. The aim of the present article is to increase knowledge about hallucinations in older adults and provide a practical resource for the health and aged-care workforce. Specifically, we provide a concise narrative review and critique of (1) workforce competency and training issues, (2) assessment tools, and (3) current treatments and management guidelines. We conclude with a brief summary including suggestions for service and training providers and future research.

How many bereaved people hallucinate about their loved one? A systematic review and meta-analysis of bereavement hallucinations

BACKGROUND

Bereavement hallucinations (BHs) entail a perception of a deceased in any sense modality or as a quasi-sensory sense of presence. BHs are an associated feature of the proposed Persistent Complex Bereavement Disorder (PCBD) in DSM-5. The goals of this review are to estimate the prevalence of BHs, identify possible moderators, and review the methodological status of this research field.

METHODS

A systematic literature search was conducted through the databases PubMed, PsycINFO, and CINAHL. Studies systematically assessing the prevalence of BHs of a relative or friend were included.

RESULTS

Twenty-one eligible studies were identified and 8 meta-analyses of BHs in different sense modalities were conducted. The prevalence of having one or more BHs was estimated to be 56.6% (95% CI 49.9-63.2), and the estimated prevalence of BHs in specific sense modalities ranged within 7.0-39.7%. Meta-regression analyses revealed associations to age and conjugal bereavement, but results are tentative and dependent on the type of BH in question.

LIMITATIONS

The included studies were methodologically heterogeneous. Limitations included the lack of a valid measure of BHs and low sample generalizability.

CONCLUSION

This first systematic review and meta-analysis of BHs suggests that more than half of the bereaved people experience some kind of BH. However, there are considerable methodological limitations in the research of BHs, which is of pertinent interest as BHs have been linked to the development of a future diagnosis of clinically impairing grief. A valid measure of BHs needs to be developed and used in high-quality epidemiological research using population-based designs.

Bereavement hallucinations after the loss of a spouse: Associations with psychopathological measures, personality and coping style

Bereavement hallucinations (BHs) were assessed in 175 conjugally bereaved participants 4 years post loss, to explore whether BHs were: (a) associated with psychological distress and (b) predicted by sociodemographic variables, personality and/or coping style. Participants with BHs scored significantly higher than those without BHs on prolonged grief, post-traumatic stress, depression symptoms, and emotional loneliness. Hierarchical logistic regression analysis showed avoidant coping, openness to experience, and length of marriage to significantly predict BHs, while detached coping was negatively associated with BHs. This study suggests that BHs may be an indicator of psychological distress in bereavement.

A Qualitative Examination of Continuing Bonds through Spiritual Experiences in Individuals Bereaved by Suicide

Introduction: Suicide is a public health problem worldwide, and spiritual experiences may be important positive experiences or coping mechanisms for difficulties associated with surviving a suicide loss. Studies have found that continuing bonds through spiritual experiences are common among individuals bereaved by suicide. However, the literature lacks depth in understanding these experiences, such as sense of presence. Aims: The aim of this study was to qualitatively examine descriptions of continuing bonds through spiritual experiences after death by suicide. Method: A total of 1301 individuals bereaved by suicide provided 2443 free responses about their spiritual experiences based on four different prompts, which were analyzed using an inductive approach. Results: Nine common themes were identified, selected for interest, and reported: (1) a helpful sense of comfort; (2) a helpful sense of connection with the deceased; (3) intense sadness evoked by the spiritual experiences; (4) confusion regarding the spiritual experiences; (5) negative reminders of the deceased or negative meanings of spiritual experiences; (6) evidence of an afterlife; (7) general importance of the spiritual experiences’ meaning; (8) impact of and on religious beliefs; and (9) others’ responses to disclosure of suicide or spiritual experiences. Conclusion: For the overwhelming majority of participants, spiritual experiences such as a sense of presence have deep meaning and are often regarded as a positive source of healing and transformation after a suicide death.

Hallucinations in Healthy Older Adults: An Overview of the Literature and Perspectives for Future Research

KEY POINTS

➢ Studies suggest a substantial minority of healthy older adults have hallucinatory experiences, in line with existing evidence on hallucinations in other age groups, though it is still unclear if hallucination prevalence increases or declines with age in older cohorts.

➢ Stigma attached to both hallucinations and ageing leads to considerable under-reporting of these experiences in healthy older adults and may negatively bias how professionals, family members, and the public respond.

➢ Why and when hallucinations in healthy older adults remit, persist, or progress to other clinical disorders remains poorly understood.

➢ Current evidence points to a range of factors associated with hallucinations in older adults including decline in sensory or cognitive functioning, poor sleep, and psychosocial stressors (e.g., social isolation, loneliness, and bereavement), highlighting the need for accurate assessment and tailored interventions.

Hallucinations, though common in youth and younger adults, are not the preserve of these age groups. Accumulating evidence shows that hallucinatory experiences are also present at surprisingly high rates in healthy older adults in the general community. Furthermore, stigma and misunderstanding of hallucinations, together with ageism, may lead to under-reporting of these experiences by older adults, and misdiagnosis or mismanagement by health and mental health practitioners. Consequently, improved public and professional knowledge is needed about the nature and significance of hallucinations with advancing age. The purpose of this review is to provide a comprehensive overview, and critical analysis, of research on the prevalence, psychosocial, and neurobiological factors associated with hallucinations in people aged 60 years and over. To the best of our knowledge, this is the first review of its kind in the literature. The evidence supports a dynamic conceptualization of hallucinations, in which the emergence of hallucinations is viewed as a balance between the sensory, cognitive, or social impairments accompanying advancing age and the degree to which compensatory processes elicited by these impairments are successful. We briefly summarize the implications of the literature for aged care services and interventions, and stress that far more studies are needed in this important field of research.