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The experience of grief for surviving friends Martin, Debra Lucille 1996

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THE EXPERIENCE OF. GRIEF FOR SURVIVING FRIENDS by DEBRA LUCILLE MARTIN B.A., Un i v e r s i t y of V i c t o r i a , 1991 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF THE FACULTY OF GRADUATE STUDIES (Department of Counselling Psychology) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA Copyright Debra L u c i l l e Martin, 1996 MASTER OF ARTS i n A p r i l 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada Date DE-6 (2/88) 11 Abstract The expanding body of l i t e r a t u r e i n the f i e l d of bereavement has predominantly focused on the g r i e f reactions of family members. The role of "bereaved", with i t s attendant grieving r i g h t s , has almost e x c l u s i v e l y been accorded to the spouse and kin of the deceased. Despite the intimacy of the r e l a t i o n s h i p often shared between the surviving close f r i e n d and the deceased, minimal research e x i s t s d e f i n i n g the experience of g r i e f for these bereaved. L i t t l e i s known about the meaning the bereaved f r i e n d bestows on his or her experience of g r i e f . The purpose of t h i s study i s to explore the experience of g r i e f i n surviving friends. A phenomenological study based on unstructured interviews was undertaken to explore t h i s experience with four adult women who have survived the death of a close f r i e n d . By making e x p l i c i t the meanings i m p l i c i t i n t h e i r experience of g r i e f , the meaning structure containing the e s s e n t i a l elements of the phenomenon of g r i e f for these bereaved friends was c l a r i f i e d . Ten elements or themes common to the experience of g r i e f for a l l informants were illuminated and described. Implications for research and p r a c t i c e were also discussed. iii TABLE OF CONTENTS PAGE ABSTRACT i i TABLE OF CONTENTS i i i CHAPTER I - INTRODUCTION • 1 CHAPTER II - LITERATURE REVIEW 4 Theories and models of g r i e f 5 Phenomenological examinations of g r i e f 15 Disenfranchised and hidden g r i e f — • 22 Empirical studies of friendship g r i e f 27 CHAPTER III - METHODOLOGY : 33 Foundations of method —- 33 Trustworthiness of the proposed research 34 Participants r 37 Data gathering ; • 38 Data analysis 39 Presuppositions 42 De f i n i t i o n s - 44 CHAPTER IV - RESULTS 45 Situated Structures 45 Anna's experience of loss 45 Natasha's experience of loss • 52 Carla's experience of loss • 60 Diane's experience of loss — ; : 67 General Structure 75 Emotional d i s t r e s s - 75 Exclusion 77 Inclusion 79 Concession • 81 iv TABLE OF CONTENTS PAGE Control 82 Dissonance 84 In t e g r i t y 86 Meaning 87 - R i t u a l 90 Acceptance 92 CHAPTER V - DISCUSSION 96 Results i n r e l a t i o n to current l i t e r a t u r e 96 Limitations and implications for future research 108 Implications for p r a c t i c e 109 REFERENCES 114 APPENDIX A - Pre-screening questions 118 APPENDIX B - Interview protocols 119 APPENDIX C - D e f i n i t i o n s of unique and common themes 120 APPENDIX D - E i d e t i c analysis of Anna's experience 123 APPENDIX E - E i d e t i c analysis of Carla's experience 128 APPENDIX F - E i d e t i c analysis of Diane's experience 133 APPENDIX G - E i d e t i c analysis of Natasha's experience 139 APPENDIX H - Common themes 144 1 CHAPTER 1 Introduction Grief has been widely explored i n recent years, and i s defined as a process of responding to loss which includes an i n t e g r a t i o n of emotional, i n t e l l e c t u a l , s p i r i t u a l and physical reactions eventually leading to res o l u t i o n of the loss (Kubler-Ross, 1969; Lindemann, 1944; Worden, 1991). Theories of g r i e f have v a r i o u s l y described the process of grieving as one i n v o l v i n g phases (Parkes, 1987-88; Bowlby, 1961); stages (Kubler-Ross, 1969) and tasks (Worden, 1991), the completion of which i s considered necessary i n order to adapt to the l o s s . The concomitant process of g r i e f work, or mourning, i s s i m i l a r to the p h y s i o l o g i c a l process of healing, and as such requires s p e c i f i c components to f a c i l i t a t e the res o l u t i o n of that healing (Worden, 1991). An important component of t h i s healing process i s the presence of perceived s o c i a l support. A review of the recent l i t e r a t u r e on g r i e f indicates general agreement on the necessity of t h i s component to the res o l u t i o n of g r i e f . The presence of such support also allows mourners the perception that they have a s o c i a l l y sanctioned role and r i g h t to grieve (Doka, 1989; Sklar & Hartley, 1990). As outlined i n t h e i r reviews of bereavement l i t e r a t u r e , Cowles and Rodgers (1991) and Raphael and Middleton (1987) in d i c a t e the existence of much ambiguity i n the l i t e r a t u r e regarding the concept of g r i e f . Among the many facets of the phenomenon of g r i e f which need to be c l a r i f i e d , these writers suggest there e x i s t s a need to define more comprehensively the experience of g r i e f as i t i s l i v e d and perceived by various categories of bereaved. Q u a l i t a t i v e studies are beginning to address the ambiguities replete i n the l i t e r a t u r e . In so doing, these studies have begun to expand and challenge s p e c i f i c aspects of the leading theories of 2 g r i e f . In exploring the phenomenon of g r i e f as i t i s experienced, Carter (1989) illuminates features of bereavement not addressed by t h e o r e t i c a l perspectives. One such aspect involves the pervasive influence on the grieving experience of personal and s o c i e t a l expectations regarding the correct way to grieve. This and other studies suggest that e x i s t i n g t h e o r e t i c a l perspectives do not provide a comprehensive d e f i n i t i o n of the experience of bereavement. Carter (1989) concludes that i n caring for the bereaved, a "broad range of unique responses from the bereaved" needs to be anticipated (p. 358). Personal as well as universal responses to g r i e f need to be considered i n understanding the experience of that phenomenon. There also appear to be l i m i t a t i o n s i n the l i t e r a t u r e regarding which categories of survivors are e l i g i b l e to grieve. The expanding body of bereavement l i t e r a t u r e appears to focus predominantly on the g r i e f reactions of the spouse and kin of the deceased. Minimal research e x i s t s defining the experience of g r i e f for those survivors, including close friends, who are not r e l a t e d to the deceased. Though the process of g r i e f for surviving friends may be s i m i l a r to that of family members (Sklar & Hartley, 1990), the l o s s and g r i e f reactions of surviving friends are generally neither s o c i a l l y acknowledged nor endorsed (Doka, 1989; Rando, 1992-93; Sklar & Hartley, 1990). Not uncommonly, these surviving friends are further unrecognized, or disenfranchised, i n t h e i r g r i e f by exclusion from active involvement i n other components of the healing process, such as the .funeral and other mourning r i t u a l s (Doka, 1989; Meagher, 1989; Sklar, 1991-92; Sklar & Hartley, 1990). The preceeding research appears to i n d i c a t e that l i t t l e opportunity e x i s t s for such survivors as bereaved friends to l e g i t i m a t e l y enter into and complete the grieving process. Given the r e a l i t y of g r i e f for surviving friends, the question t h i s thesis seeks 3 to answer i s , "What i s the experience of g r i e f for the non-familial survivor who i s grieving the loss through death of a close friend?". The phenomenological research method w i l l be used to address t h i s question. Through unstructured interviews, the meanings of g r i e f for each p a r t i c i p a n t w i l l be uncovered and themes w i l l be illuminated to c l a r i f y the sought question. 4 CHAPTER II Li t e r a t u r e Review This chapter w i l l review a cross-section of the expanding body of l i t e r a t u r e on g r i e f to h i g h l i g h t the various conceptions of t h i s phenomenon. Selected empirical findings, theories, and models of g r i e f w i l l be reviewed to i l l u s t r a t e t h e i r contributions to the current understanding of g r i e f . Selected t h e o r e t i c a l and c l i n i c a l concerns that have arisen from the presence of such multiple conceptualizations of g r i e f w i l l also be highlighted. Several reviews of the f i e l d of bereavement l i t e r a t u r e contend that a coherent and e m p i r i c a l l y supported model of bereavement has yet to evolve. Numerous remedial suggestions are offered to address t h i s concern. Among those suggested i s a need for an increased focus on systematic phenomenological studies i n order to c l a r i f y the e s s e n t i a l aspects of g r i e f as i t i s l i v e d and experienced, an area wherein there currently exists only l i m i t e d empirical data. A sample of phenomenological studies w i l l be reviewed to i l l u s t r a t e the contributions t h i s methodological approach has made to the evolving conceptualization of g r i e f . A review of the l i t e r a t u r e also indicates that the bereavement reactions and g r i e f experiences investigated have p r i m a r i l y been those of family members. Mourning friends and other bereaved non-kin are r a r e l y represented i n academic conceptualizations and empirical i n v e s t i g a t i o n s , including the current phenomenological examinations of g r i e f . To elucidate t h i s gap i n the l i t e r a t u r e , Doka (1989) states, We are involved i n webs of re l a t i o n s h i p s that include not only family...but also lovers, friends, colleagues and caregivers. Though t h i s point seems obvious, i t i s often ignored i n a society that emphasizes the primacy of the dyadic r e l a t i o n s h i p and the nuclear family, extending to those r e l a t i o n s h i p s almost exclusive monopoly to mourn (p. 329). 5 L i t e r a t u r e focused on these disenfranchised and hidden mourners w i l l be reviewed to provide a composite representation of t h i s bereaved population. Despite such conceptual e f f o r t s to recognize bereaved non-kin i n the l i t e r a t u r e , only a l i m i t e d number of empirical studies e x i s t which provide systematic data r e l a t e d to the experience of g r i e f i n t h i s population of bereaved. Fewer empirical studies yet focus on bereavement i n surviving f r i e n d s . The chapter w i l l conclude with a review of those e x i s t i n g empirical studies which focus on bereaved friends, and w i l l point to the fact that few, i f any, phenomenological studies have examined the experience of g r i e f i n t h i s population. In order to address the conceptual gap i n the l i t e r a t u r e r e l a t e d to the experience of g r i e f for surviving friends, t h i s aspect of the review w i l l emphasize the need for more phenomenological studies focused on bereaved friends and the essence of t h e i r g r i e f as i t i s l i v e d and experienced. The Grieving Process Theories and Models of Grief Based on his observations of bereaved survivors of victims who perished i n a Boston nightclub f i r e , Lindemann (1944) was one of the f i r s t thanatological t h e o r i s t s to study normal g r i e f reactions. Amongst the bereaved he noted remarkably s i m i l a r g r i e f reactions which could be aroused by such circumstances as r e c e i v i n g sympathy, v i s i t s by r e l a t i v e s and a l l u s i o n s to the deceased. Although not exhaustive, his compiled l i s t of signs and symptoms o f f e r s a foundation for conceptualizing bereavement as a d i s t i n c t response to c r i s i s i n v o l v i n g a set of c h a r a c t e r i s t i c biopsychosocial responses. According to Lindemann's observations, there appeared to be s i x elements common to the g r i e f reaction. These symptomatic elements 6 included f e e l i n g - r e l a t e d phenomena such as sadness, anger, g u i l t and self-reproach; somatic d i s t r e s s ranging from tightness i n the chest and throat, to a sense of depersonalization; preoccupation with the image of the deceased, and d i s b e l i e f i n the r e a l i t y of the death; h o s t i l e reactions; loss of patterns of conduct, including loss of warmth i n re l a t i o n s h i p s with others; and appearance of t r a i t s of the deceased i n the behavior of the bereaved, notwithstanding other behavioral symptoms such as sleep and appetite disturbances. Although one of the e a r l i e s t studies of g r i e f reactions, the symptamology established by Lindemann (1944) appears to "have proven robust when subjected to t h e o r e t i c a l and empirical scrutiny" (Vargas, Loya, & Hodde-Vargas, 1989, p. 1484). A d d i t i o n a l l y , Lindemann's early work continues today to provide a general guideline for c l i n i c a l diagnosis and p r a c t i c e (Schwartz-Borden, 1986; Worden, 1982). Since the p u b l i c a t i o n of Lindemann's (1944) work, l i t e r a t u r e i n the f i e l d of bereavement and g r i e f has burgeoned. Several models have been developed to address such process-related issues as the time frame within which the g r i e f response occurs, and the f a c i l i t a t i o n of g r i e f r e s o l u t i o n . Although these approaches seem to d i f f e r somewhat i n t h e i r conceptualizations of the phenomenon, the central themes rela t e d to the process of g r i e f appear to be s i m i l a r . Such subsequent conceptualizations of g r i e f have expanded on the symptomalogical approach of Lindemann (1944) to include a component of sequencing. In her theory of death and dying, which, has been adapted to describe the experience of loss and g r i e f i n general, Kubler-Ross (1969) advocates sequencing as a fundamental component i n conceptualizing g r i e f . The phenomenon of g r i e f i s considered a process in v o l v i n g a sequence of f i v e stages which eventually culminate i n r e s o l u t i o n of the g r i e f reaction. The f i r s t of the f i v e stages outlined by Kubler-Ross (1969) i s 7 conceived as denial, a state of d i s b e l i e f i n the r e a l i t y of the l o s s . The stage that follows i s one of anger, which may range from anger with God for taking the l i f e of the deceased, to anger with the deceased for having died and l e f t the bereaved alone to grieve. The d i s s i p a t i n g anger i s succeeded by behaviors and cognitions which in d i c a t e the bereaved are bargaining with themselves or some higher power for the return of l i f e as i t was known before the loved one's death, i n exchange for some other commodity such as f a i t h or good works. When a l l preceeding attempts f a i l to return the status quo, the fourth state suggestive of depression ensues. Eventually the depression w i l l be mediated, f a c i l i t a t i n g the f i n a l stage of acceptance. The sequence of stages appears to be one i n which movement from one stage to the next i s l i n e a r . Once the bereaved i n d i v i d u a l no longer denies the r e a l i t y of the death, a t r a n s i t i o n occurs to the next stage of anger. T r a n s i t i o n through the stages continues at a variable rate u n t i l the f i n a l stage of acceptance of the death i s achieved. As a representative of the stage-based approach, Kubler-Ross' model i s e f f e c t i v e i n demonstrating the dynamic, adaptive nature of g r i e f . In delineating the progressive s h i f t s i n emotional, cognitive and behavioral responses, the model demonstrates the process of movement from i n i t i a l reaction through to re s o l u t i o n and return to steady state. A drawback of the stage-based model appears to e x i s t i n the emphasis on l i n e a r i t y . Resolutibn of one stage appears to be necessary to f a c i l i t a t e movement to the next; an implication which inadvertently may impose on the bereaved the expectation that a l l stages must be experienced and sequentially so i n order for adaptation to occur. Grief has s i m i l a r l y been conceptualized as a process involving a 8 sequence of phases. Based on attachment and object r e l a t i o n s theories, Bowlby (1961) views the g r i e f response to loss as i n s t i n c t u a l l y s i m i l a r to a c h i l d ' s response to the absence of i t s mother. He proposes a model i n which g r i e f i s understood as a process of progression through four phases. As outlined by Bowlby (1961), a f t e r the f i r s t phase of shock and numbness, grieving i n d i v i d u a l s enter a searching phase i n an attempt to reunite with the l o s t object, or deceased i n d i v i d u a l . As does the c h i l d i n response to the absent mother, the grieving adult engaged i n the searching phase c h a r a c t e r i s t i c a l l y e x hibits weeping and angry behaviors during t h i s phase. The weeping i s an e f f o r t to coax the return of the l o s t loved one, while the anger expressing the pain of abandonment may be v a r i o u s l y d i r e c t e d towards the deceased or others involved. As the hope of reunion with the deceased begins to diminish, a sense of despair ensues. At t h i s point, the bereaved i s considered to be engaged i n the t h i r d phase, described as one of disorganization. As awareness evolves of the extent of the losses accompanying the death, the bereaved begins to experience symptoms of depression. The depressive aspect of t h i s phase i s considered adaptive, i n that i t f a c i l i t a t e s the eventual r e l i n q u i s h i n g of the attachment to the deceased. The process of relinquishment heralds the f i n a l stage, i n which the bereaved begins to reorganize and eventually form new goals and new attachments. A subtle d i s t i n c t i o n appears to e x i s t between the process of movement emphasised i n staged-based models and that i n phase-based approaches. Where the former model appears to focus on l i n e a r progression, the phase-based model appears to emphasize overlaps between phases. The overlapping q u a l i t y would seem to indi c a t e l e s s c l e a r l y d i f f e r e n t i a t e d boundaries between phases. Within t h i s system of f l u i d i t y , the bereaved may return to a previous phase as a r e s u l t 9 of t r i g g e r s such as unexpected reminders of the deceased. C r i t i c a l of the implied p a s s i v i t y of phases as a process to which the bereaved must acquiesce, Worden (1982, 1991) proposes that g r i e f i s instead an active process, and one which i s responsive to therapeutic intervention. Adaptation to loss i s here conceived as a process of mourning within which c e r t a i n tasks must be completed i n order to resolve the c r i s i s of l o s s . Worden (1991) poses that one's awareness of the option to take an active part i n the grieving process, "can be a powerful antidote to the feelings of helplessness that most mourners experience" (p. 35). The tasks involved i n grieving can be simultaneously mediated and are outlined as follows. The bereaved must accept the r e a l i t y of the lo s s , a time-consuming task which involves both i n t e l l e c t u a l as well as emotional acceptance. A further task requires that the bereaved acknowledge and negotiate the pain of g r i e f u n t i l that pain i t s e l f i s resolved; i f t h i s task i s avoided, the pain may be expressed i n d i r e c t l y i n behaviours such as i d e a l i z i n g or v i l l a i n i z i n g the deceased. Another c r i t i c a l task involves the adjustment to an environment i n which the deceased i s missing. The nature of t h i s adjustment depends on the nature of the r e l a t i o n s h i p with and the roles played by the deceased. The remaining task involves the emotional r e l o c a t i o n of the deceased, an endeavour which would allow the bereaved to set new d i r e c t i o n s and l i v e f u l l y i n the world. This emotional r e l o c a t i o n i s s i g n a l l e d by an a b i l i t y to r e c a l l the memory of the deceased without the accompanying deluge of intense emotion. Worden (1991) suggests that these tasks may be self-generated by the bereaved i n d i v i d u a l , or may require professional counselling intervention to promote t h e i r completion i f the bereaved i s experiencing d i f f i c u l t y i n entering into the healing process. Raphael and Middleton (1987) o f f e r a d e f i n i t i o n of g r i e f which 10 appears to capture the s i m i l a r themes that weave through a l l of the preceeding models of g r i e f . From t h e i r examination of the f i e l d of bereavement research, Raphael and Middleton characterize g r i e f as, an i n i t i a l shock and numbness giving way to d i s t r e s s , yearning and searching behaviors as well as anger and protest as the bereaved experiences the pain of the separation from the loved person; then gradually and i n c r e a s i n g l y there are sad and even despairing disorganized responses as the f i n a l i t y and i r r e v o c a b i l i t y of the loss become accepted (p. 7). The d e f i n i t i o n appears to synthesize many of the commonly accepted phenomena describing the g r i e f response i n the f i e l d of thanatological l i t e r a t u r e . Factors supporting or hindering the f a c i l i t a t i o n of g r i e f . Regardless of t h e o r e t i c a l standpoint, there appears to be considerable agreement i n the l i t e r a t u r e regarding factors that may either support or hinder the f a c i l i t a t i o n of g r i e f . One such factor i s the role that s o c i a l support plays i n adaptation to bereavement. Worden (1991) and others (Raphael, 1977; Vachon & Stylianos, 1988) note that i t i s the perception of s o c i a l support, rather than the actual support i t s e l f , which a l l e v i a t e s the adverse e f f e c t s of the stress of bereavement. The "goodness of f i t " between the actual support offered and the q u a l i t y of support as i t i s perceived by the bereaved w i l l be determined by several factors, i n c l u d i n g the presence of concurrent stressors, personality factors, and the degree of impact of the loss on the various members of the s o c i a l network (Vachon & Stylianos, 1988) . In her assessment of widows i n the early weeks of t h e i r bereavement, Raphael (1977) noted that one of the most d i s t i n c t predictors of poor adjustment was the widow's perception of inadequate or nonsupport for her g r i e f . Further, the s o c i a l support system may have d e l i t e r i o u s e f f e c t s on adaptation to bereavement i f expectations are placed on the bereaved that adjustment to the l o s s i s not occurring as r a p i d l y as others expect (Lehman, E l l a r d , & Wortman, 11 1986; Vachon & Stylianos, 1988). Raphael and Middleton (1987) conclude that although i t i s d i f f i c u l t to state d e f i n i t i v e l y how adjustment i s f a c i l i t a t e d by s o c i a l support, a review of the l i t e r a t u r e indicates that several factors may be at play. Interaction which i s perceived p o s i t i v e l y by the bereaved not only provides opportunities for support, catharsis, and making meaning of the event, but also appears to help "the bereaved person to hold a sense of s e l f -worth i n his shattered world, where the person perhaps most responsible for giving him a sense of value i s gone" (Raphael & Middleton, 1987, p.12). Another factor a f f e c t i n g adjustment to bereavement i s the q u a l i t y of the r e l a t i o n s h i p between the bereaved and the deceased. A review of the l i t e r a t u r e suggests consistent agreement that the i n t e n s i t y of g r i e f experienced i s p o s i t i v e l y r e l a t e d to the i n t e n s i t y , or closeness, of the r e l a t i o n s h i p with the deceased. Although i t may be assumed that " i t i s impossible to lose someone you have been deeply attached to without experiencing some l e v e l of pain" (Worden, 1991, p. 13), the adjustment to loss may be complicated when there has been a high l e v e l of dependency or ambiguity i n the r e l a t i o n s h i p with the deceased (Parkes & Weiss, 1983; Raphael, 1977; Worden, 1982). Raphael and Nunn (1988) state that i n the case of dependency, the sense of abandonment appears to be much greater, and feelings of anger and protest are subsequently i n t e n s i f i e d . S i m i l a r l y though some ambivalence ex i s t s i n a l l r e l a t i o n s h i p s , i n those r e l a t i o n s h i p s dominated by powerful feel i n g s of ambiguity the bereaved may have d i f f i c u l t y facing " t h i s n e g a t i v i t y because of the g u i l t that would be involved, so denial or exaggerated i d e a l i z a t i o n of the dead person may appear instead" (Raphael & Nunn, 1988, p. 193). Planning and p a r t i c i p a t i o n i n r i t u a l s s i g n i f y i n g the death i s another important component i n adjustment to bereavement. Worden 12 (1991) states the funeral r i t u a l f a c i l i t a t e s adjustment i n several ways. Not only does t h i s formal r i t u a l help to make r e a l the fact of the l o s s , but i t also provides an opportunity for the bereaved to openly express t h e i r g r i e f , and draws the s o c i a l support network close to the bereaved (Worden, 1991) . For those bereaved who are not present at the funeral, adjustment to loss may be complicated i f they f i n d no other external way to v a l i d a t e the r e a l i t y of the death (Worden, 1991; Yoder, 1986). Having a part i n planning the funeral also appears to f a c i l i t a t e adjustment, as i t may provide the opportunity f or the bereaved to express symbolically the personal meaning of t h e i r r e l a t i o n s h i p with the deceased (Hocker, 1990; Reeves, 1989). Even the informal r i t u a l of how news of the death was conveyed may f a c i l i t a t e or hinder adaptation to the l o s s ; adaptation here seems to depend upon whether the announcement was synchronized with the expectations of the bereaved regarding how revelations of t h i s nature should be made (Raphael & Nunn, 1988). Correlated with these factors i s the i n d i v i d u a l ' s p h y s i o l o g i c a l response which may va r i o u s l y a f f e c t adjustment to bereavement. Stanwood (1992) states that during the f i r s t year a f t e r a major l o s s , the immune system i s often lowered, leaving the bereaved more prone to i n f e c t i o n . A causal l i n k between loss and subsequent m o r t a l i t y i n the bereaved i s however cautioned by Raphael and Middleton (1987) who state, "While there i s now substantial evidence l i n k i n g behavior and immunity,...direct l i n k s of loss-bereavement reaction-immune changes-disease have not been established" (p. 14-15). Gendered response to g r i e f . There i s much debate i n the l i t e r a t u r e regarding the e f f e c t s of gender on the experience of and reactions to g r i e f . Much of the debate has centred on widowed i n d i v i d u a l s and which gender, i f either, sustains greater d i f f i c u l t i e s while i n the process of grieving. In 13 t h e i r research on the widowed, Weissman and Klerman (cited i n Sanders, 1988) state that a l i k e l y explanation for the debate i s the d i f f e r e n t i a l reporting of symptoms between males and females. These writers suggest that widowed females only appear to be more severely d i s t r e s s e d than widowed males because males generally report l e s s a f f e c t i v e d i s t r e s s and fewer symptoms than females. This d i f f e r e n t i a l reporting of g r i e f responses i s further supported by Stroebe and Stroebe (1989-90). They assert that sex norms influence coping s t y l e s i n each gender, which consequently a f f e c t s the way i n which males and females report g r i e f reactions. They state that i n our society, "men are expected to control t h e i r emotions, .... [and] tend to t r y to cope alone or seek d i s t r a c t i o n i n t h e i r work...[whereas] women are allowed, perhaps even expected, to show t h e i r feelings....[and] turn to others i n times of s t r e s s " (Stroebe & Stroebe, 1989-90, p. 22) . Such norms about the s e l f -control of emotions generally influence the way i n which each gender expresses g r i e f reactions and receives s o c i a l support for the same. In his review of the l i t e r a t u r e pertaining to grieving males, L i s t e r (1991) also appears to agree with t h i s d i f f e r e n t i a l reporting of g r i e f reactions. He asserts that although the i n t e n s i t y of g r i e f experienced by males may not be ov e r t l y expressed, i t i s nonetheless intensely experienced. Sex norms may also influence the tendency to discuss death and r e l a t e d issues. In t h e i r assessment of gender differences i n reported attitudes towards death. Da S i l v a and Schork (1984-85) found that females appear to be more open to discussing death, including the event of t h e i r own, whereas males appeared to experience more d i f f i c u l t y i n discussing death and death-related issues. Stroebe and Stroebe (cited i n Rapheal, 1987) assert that among other factors, the sex role norms as well as the l i m i t e d a v a i l a b i l i t y 14 of the b u f f e r i n g e f f e c t s of s o c i a l support for men, contribute to greater r i s k s i n bereavement for males than females. They state that mental and physical i l l n e s s , depression, m o r t a l i t y and suicide are experienced to a greater degree by widowed males compared to married men, versus widowed females compared to married women. Given t h i s and the preceding assertions regarding what appear to be c u l t u r a l l y d i c t a t e d sex-norms for the overt expression of g r i e f reactions, g r i e f may well be experienced d i f f e r e n t l y by each gender. If norms d i c t a t e the way i n which each gender expresses g r i e f reactions and receives subsequent support, then the perception and experience of g r i e f for each gender may be q u a l i t a t i v e l y d i f f e r e n t . In essence, g r i e f may be a gendered experience. The state of current research. The e f f e c t of gender on the experience of bereavement i s but one area of contention i n the l i t e r a t u r e . In reviewing the f i e l d of bereavement, Raphael and Middleton (1987) state that despite the expanding body of l i t e r a t u r e , current research has f a i l e d yet to c l a r i f y and provide systematic data re l a t e d to aspects of accepted theories and concepts i n the f i e l d . Among several observations, these writers contend that a coherent and e m p i r i c a l l y supported model of bereavement has yet to evolve. They also suggest that the v a l i d i t y of bereavement stages, as well as the essence of bereavement reactions i n the various categories of mourners (e.g., spouse, parent) need to be addressed. Of several remedial suggestions, Raphael and Middleton (1987) in d i c a t e the need for an increased focus on systematic phenomenological studies which, i n e f f e c t , "would be more representative of the r e a l i t y of the experience of bereaved people" (p. 9)• The c a l l for phenomenological research i s r e i t e r a t e d by Cowles and Rodgers (1991) i n t h e i r review of l i t e r a t u r e concerning g r i e f within 15 the d i s c i p l i n e s of nursing and medicine. These authors note that the lack of a s p e c i f i c conceptualization of g r i e f i n general often leads to disagreement regarding appropriate interventions i n treatment of the bereaved. Cowles and Rodgers (1991) conclude there e x i s t s "a need for a d d i t i o n a l research on g r i e f that u t i l i z e s in-depth interviews as a primary source of data....Such research i s es s e n t i a l to understanding g r i e f as i t i s experienced" (p. 125). Recently, phenomenological studies have begun to populate the bereavement l i t e r a t u r e . The findings appear to c l a r i f y some of those issues r a i s e d i n the Raphael and Middleton (1987) and Cowles and Rodgers (1991) reviews. The following section w i l l discuss the findings i n a sample of phenomenological studies. Phenomenological Examinations of Grief The phenomenological approach examines g r i e f as i t i s perceived and experienced. In an attempt to tap into the l i v e d experience of g r i e f , Carter (1989) conducted open-ended interviews with 30 bereaved adults, 28 of whom were kin and two of whom were friends of deceased i n d i v i d u a l s . Nine themes associated with bereavement were i d e n t i f i e d . These were further delineated into f i v e core themes, three meta-themes, and a contextual theme which was found to a f f e c t the q u a l i t y and meaning of each i n d i v i d u a l ' s bereavement. The f i v e core themes describe common experiences which include Being Stopped, or an interrupted a b i l i t y to f e e l the pain and comprehend the r e a l i t y of the lo s s , and re-enter the usual flow of l i f e ' s d a i l y events. The theme frequently described through metaphors of physi c a l i n j u r y i s that of Hurting, which i s characterized by intensely p a i n f u l emotions such as unrelenting sadness, g u i l t , anger and sorrowful wishing. Though each p a r t i c i p a n t unanimously reported sadness, other emotions such as anger were not reportedly experienced by a l l p a r t i c i p a n t s . A t h i r d theme i s 16 described as Missing, and i s characterized by an acute awareness of the magnitude of the l o s s . The theme characterized by s e l e c t i v e preservation of aspects representing the deceased i s described as Holding, and i s t y p i f i e d by such acts as focusing on facets of the r e l a t i o n s h i p which were p a r t i c u l a r l y meaning laden and generally pleasant. The f i n a l core theme i s described as that of Seeking, which i s characterized by a search both for comfort, and for meaning i n the l o s s . Carter (198 9) also describes the meta-themes about bereavement illuminated i n the interviews. These themes include that of Change, wherein the experience of bereavement i t s e l f changes i n q u a l i t y and softens i n i n t e n s i t y , although acute attacks of p a i n f u l g r i e f could p o t e n t i a l l y be triggered by some event even years a f t e r the death. The experience of bereavement also induced changes i n other aspects of the p a r t i c i p a n t s ' l i v e s such as r e l a t i o n s h i p s , behaviours, career plans, and self-esteem (which was often reported to have increased). The second meta-theme, that of Expectations, describes the p a r t i c i p a n t s perception that there e x i s t s a s o c i a l l y and personally prescribed way to grieve. The perceived expectations, however, often appeared to contradict the way i n which the p a r t i c i p a n t was a c t u a l l y experiencing the g r i e f . The f i n a l meta-theme of I n e x p r e s s i b i l i t y involves the p a r t i c i p a n t s perceived inadequacy i n fin d i n g the words to convey the f e l t sense of t h e i r bereavement. The contextual theme of personal history, or the meaning of the l i f e and death of the deceased held by the bereaved, underlies a l l f i v e core themes. Carter (1989) emphasizes that understanding who the deceased was to the survivor i s e s s e n t i a l for understanding the experience of the bereavement i t s e l f . Carter (1989) compared these themes with the t h e o r e t i c a l perspectives on bereavement embodied i n the works of Freud, Kubler-17 Ross, and various e x i s t e n t i a l writers. She states that several features of the bereavement experience as described by the p a r t i c i p a n t s are not apparent i n those theories. Among the features of g r i e f which Carter states are uniquely elucidated by the p a r t i c i p a n t s i n her study are the q u a l i t a t i v e changes i n g r i e f , i ncluding waves of intense pain triggered years a f t e r the death; the i n d i v i d u a l process of holding, or preserving aspects of the existence of the deceased; personal h i s t o r y as a c r i t i c a l factor i n i n f l u e n c i n g the i n d i v i d u a l meaning and features of bereavement; and s o c i a l and personal expectations r e l a t e d to how grieving should be pursued, which included the often burdensome expectation that one should experience stages of g r i e f . Although these features may not be addressed by the theories with which they are compared i n Carter's study, several features are aspects of g r i e f which appear to be touched upon by other workers i n the f i e l d of bereavement. For example, Zysook, Devaul and C l i c k (1982) have described the changing i n t e n s i t y of g r i e f , and noted the p o t e n t i a l for intense emotional reactions to occur upto 10 years a f t e r a l o s s . In r e l a t i o n to the preservation of aspects of the existence of the deceased, Lindemann (1944) described some aspects of the holding process and defined the behavior as preoccupation with the image of the deceased. And f i n a l l y , Parkes and Weiss (cited i n Raphael & Nunn, 1988) have re f e r r e d to the q u a l i t y of r e l a t i o n s h i p , or personal history, as a s i g n i f i c a n t influence determining the q u a l i t y of bereavement. Nevertheless, Carter's (1989) findings support the assertion made by Raphael and Middleton (1987) that no one t h e o r e t i c a l perspective on g r i e f appears to comprehensively capture the phenomenon of bereavement. Her work brings to l i g h t features of the l i v e d experience of g r i e f that diverge from c h a r a c t e r i s t i c s outlined i n 18 p r e v a i l i n g theories of g r i e f . For instance, the meta-theme delineated as Expectations describes the burden shouldered by the bereaved whose experience of g r i e f does not correspond to the socially-accepted t h e o r e t i c a l "stages of grieving". Here Carter seems to allude to the detrimental e f f e c t s on i n d i v i d u a l adjustment i f the bereaved and/or the system of supports r i g i d l y adhere to one t h e o r e t i c a l p r e s c r i p t i o n of adaptation to l o s s . Carter concludes that conversely by using as a guide such phenomenologically-generated themes as were outlined i n her study, a broad range of unique responses can thus be a n t i c i p a t e d to better support the bereaved through t h e i r l o s s . Carter (1989) included i n the group of p a r t i c i p a n t s two friends of deceased persons. Given that t h e i r experience would include a non-f a m i l i a l r e l a t i o n s h i p to the deceased, the question a r i s e s regarding the p o t e n t i a l for q u a l i t a t i v e differences i n t h e i r bereavement experience. Because of t h e i r l i m i t e d representation within the sample, and the fact that by v i r t u e of the methodology t h e i r accounts were collapsed and combined with the common g r i e f experiences of family members, the p o t e n t i a l l y unique features of the experience for surviving friends were most l i k e l y eliminated. A f i n a l note r e l a t e s to the elapsed time of bereavement for her p a r t i c i p a n t s which ranged from three weeks to 23 years. This appears to be too wide a time frame within which to capture the experience of g r i e f as i t i s l i v e d . I t seems l i k e l y that p a r t i c i p a n t s who have been bereaved for three weeks w i l l have a l i m i t e d experience of bereavement, whereas those who experienced loss 23 years e a r l i e r may no longer be l i v i n g the experience of bereavement. Although exact lengths of time for g r i e f r e s o l u t i o n cannot be generalized (Worden, 1991), a time frame of two to three years has been suggested by Freese (cited i n Floerchinger, 1991) to describe the duration i n which g r i e f i s experienced most intensely. This general time frame i s also 19 supported by the research of Zisook, Devaul and C l i c k (1982) who state that g r i e f - r e l a t e d f e e l i n g s , e s p e c i a l l y those r e l a t e d to dysphoria, peak i n i n t e n s i t y within one to two years a f t e r the death, although many symptoms of g r i e f appear for some i n d i v i d u a l s to be present for years. The observations of bereaved c l i e n t s by L. P o l l a r d - E l g e r t (Personal Communication, October 14, 1994) would also suggest t h i s time frame. She suggests that bereavement appears to be experienced most intensely over the f i r s t three years since the death. P o l l a r d -E l g e r t describes the f i r s t year as being consumed by the struggle with the r e a l i t y of the l o s s , whereas the second year i s often characterized by an expanding awareness of the extent of the loss i n a l l aspects of the survivors l i f e . The t h i r d year i s one i n which the survivor begins to envision how a reconnection with l i f e might be possible. Although t h i s process i s generally mediated within the f i r s t three years, i t may take several more years to r e a l i z e the f u l l extent of the los s and to f u l l y immerse i n l i f e again. The findings suggested by these studies seem to ind i c a t e a general time frame within which the experience of g r i e f might be best explored. In order to describe the experience of g r i e f as i t i s l i v e d , the optimal time within which to explore t h i s phenomena may be within the f i r s t three to f i v e years of bereavement. In r e l a t i o n to Carter's (1989) study, s i m i l a r themes were illuminated i n a recent d i s s e r t a t i o n by Douglas (1994). Twelve bereaved adults re l a t e d t h e i r experience of bereavement i n open-ended interviews. From these interviews, f i v e themes evolved based on categories of predominant f e e l i n g s . The commonalities of the experience of loss were integrated and bereavement i s defined as a loss which: permeates through the body and soul of a bereaved i n d i v i d u a l 20 causing profound emotional and physical pain. A loss of d i r e c t i o n , purpose, and i d e n t i t y i s experienced, often accompanied by thoughts of suicide. The bereaved are faced with i r r e v e r s i b l e changes i n themselves that are i n some cases seen as p o s i t i v e . Loss of a loved one brings to most a deeper sense of s p i r i t u a l i t y and understanding of l i f e and death, and many bereaved i n d i v i d u a l s seek to help others who are experiencing pain following the death of a loved one. The bereavement themes elucidated by p a r t i c i p a n t s i n t h i s study coincide with various aspects of the themes i l l u s t r a t e d by Carter (1989). In addition, there are aspects of the bereavement experience which are*! uniquely ou t l i n e d by Douglas (1994). These themes include the occurrence of s u i c i d a l thoughts accompanying a sense of anomie, as well as a deeper sense of s p i r i t u a l i t y , each experienced at some point by most of the p a r t i c i p a n t s . A t h i r d study of g r i e f , b r i e f l y described here, also serves to demonstrate the a b i l i t y with which the phenomenological method illuminates the unique as well as universal themes present i n the experience of g r i e f . In his phenomenological study, Brice (1991) conducts 12 interviews, separated by i n t e r v a l s of one month, with each of three mothers mourning the death of an infant, young or adult c h i l d . While 15 general themes of maternal mourning are delineated, Brice (1991) concludes that the general thematic structure of maternal mourning i s characterized by paradox. For example, each p a r t i c i p a n t describes a sense of emptiness that corresponds to her c h i l d ' s nothingness. Paradoxically, t h i s emptiness i s experienced as a sense of f u l l n e s s , or a bursting with g r i e f . Further, each mother "experiences her c h i l d as a part of her which she t r i e s to r e t a i n but must expel i n order to mourn properly" (Brice, 1991, p. 26); she fears her r e l a t i o n s h i p with the c h i l d w i l l end i f she completes her mourning, yet i n order to evade the torment of l i f e without her c h i l d , she wishes to erase the c h i l d from her memory. Brice (1991) states that eventually the grieving mother comes to accept that she w i l l 21 never f u l l y accept the death, a comforting res o l u t i o n which allows her to maintain some connection to her c h i l d . Her mourning i s structured by "an ambiguity with which there i s no straightforward, non-c o n f l i c t i n g or non self-deceptive way to l i v e " (Brice, 1991, p. 35). In describing the complexity of the phenomenon of g r i e f , Brice (1991) states that since "maternal mourning i s e s s e n t i a l l y ambiguous and p a r a d o x i c a l a n d the findings of any study are l i m i t e d by those p r o f i l e s of the phenomenon which show themselves... no single i n v e s t i g a t o r could hope to f u l l y characterize i t " (p. 35). Brice (1991) here r e l a t e s the complexity of the g r i e f response. In so doing, he suggests the potent a b i l i t y of the phenomenological method to define the essence of a phenomenon given the existence of multiple r e a l i t i e s . In considering the common and unique features of g r i e f brought to the forefront by these studies, one of the hallmarks of the q u a l i t a t i v e method i s i l l u s t r a t e d . In the course of in-depth interviews, a wealth of information i s obtained which i n e v i t a b l y emphasizes both the "universal and inv a r i a n t themes" of l i v e d experienced (Brice, 1991, p.23), as well as the unique dilemnas and meanings generated by the presence of multiple r e a l i t i e s (Krefting, 1991). As i s demonstrated by these studies, i n phenomenological research i t i s not i d e n t i c a l r e p e t i t i o n which i s sought. I t i s rather the c l a r i f i c a t i o n of e s s e n t i a l components of a l i v e d experience, and the r i c h v a r i a t i o n within that experience, which the phenomenological i n v e s t i g a t i o n seeks to define. The research by Brice (1991), Carter (1989) and Douglas (1994) expands and enriches the body of bereavement l i t e r a t u r e by exploring the subjective experience of g r i e f as i t i s l i v e d . Despite t h i s expansion, however, a review of the l i t e r a t u r e would i n d i c a t e that the bereavement reactions and experiences investigated have generally been 22 those of family members and r e l a t e d kin. There appears to be a gap i n the l i t e r a t u r e regarding the essence and s e v e r i t y of bereavement reactions i n the category of grieving i n d i v i d u a l s who are unrelated to the deceased. A composite representation of g r i e f f or these survivors w i l l be described i n the following section. Disenfranchised and Hidden Grief In reference to the expanding body of l i t e r a t u r e concerning g r i e f reactions, Doka (1989) observes that "most of the l i t e r a t u r e has concentrated on g r i e f reactions i n s o c i a l l y recognized and sanctioned r o l e s " of bereaved kin (p.1). Despite some debate i n the l i t e r a t u r e regarding which type of loss p r e c i p i t a t e s the most intense g r i e f reaction, there i s widespread agreement that death of a c h i l d , spouse, parent or s i b l i n g generally activates a protracted grieving response. In contrast, the g r i e f of i n d i v i d u a l s surviving the death of a close f r i e n d i s acknowledged yet minimized, a tendency which i s r e f l e c t e d i n the statement by R. S. Weiss (1988): The death of a spouse or a c h i l d tends to be followed by years of g r i e f ; the death of a f r i e n d or colleague... tends to be followed by d i s t r e s s and sadness but not by severe and p e r s i s t i n g grief....There w i l l not, o r d i n a r i l y , be pain, pining, search, protracted d i s t r e s s and other elements of g r i e f , (p. 37). Weiss provides no empirical data however to support his assertion. Although Raphael (1983) i s more tentative i n her treatment of surviving close friends, the g r i e f response of t h i s population appears to be i n d i r e c t l y minimized by the amount of text devoted to t h e i r experience. In her survey of over 400 published works on bereavement l i t e r a t u r e , Raphael devotes three l i n e s of text to discussing the g r i e f of close friends. Raphael compares friendship g r i e f to that of conjugal g r i e f and suggests that, "Less intimate partnerships of close friends, working mates, and business associates, may have s i m i l a r patterns of g r i e f and mourning, but they are l i k e l y to be attenuated" 23 (p. 227). This minimalization of the g r i e f of close friends i s s i m i l a r l y echoed Worden (1991) who alludes to friendship g r i e f , but p r i m a r i l y as a means of i l l u s t r a t i n g how loss i n general p r e c i p i t a t e s e x i s t e n t i a l angst. There i s a growing body of s c h o l a r l y papers which have recently begun to document the occurrence of g r i e f experienced outside the boundaries of kinship. Doka (1989) and others (Deck & Folta, 1989; Pine, 1989; Kauffman, 1989) argue that the g r i e f of these non-familial survivors i s l a r g e l y unrecognized and unacknowledged. These survivors often experience g r i e f which i s disenfranchised, or without s o c i a l legitimacy. Doka (1989) defines disenfranchised g r i e f as that which "persons experience when they incur a l o s s that i s not or cannot be openly acknowledged, p u b l i c l y mourned, or s o c i a l l y supported" (p. 4). I t i s described as a phenomenon which ex i s t s as a consequence of s o c i e t a l norms that prescribe who, how and for whom grieving should be done (Doka, 1989) ; norms which reserve the d e f i n i t i o n of bereaved for spouses and immediate kin (Deck & Folta, 1989) . While the primary source of disenfranchisement l i e s i n the f a i l u r e of others to l e g i t i m i z e the g r i e f response i n non-kin, disenfranchisement may also occur i n t r a p s y c h i c a l l y , wherein the bereaved i n d i v i d u a l does not recognize his or her own r i g h t to grieve (Kauffman, 1989; Pine, 1989). Kauffman (1989) explains that surviving non-kin may themselves f a i l to acknowledge t h e i r own g r i e f as a means of avoiding the perceived judgement of others who might consider the expressed g r i e f as i l l e g i t i m a t e or inappropriate. The bond of friendship i s frequently e x t o l l e d i n l i t e r a t u r e and i n popular media. Yet, i n spite of the high l e v e l of intimacy among friends as compared to many other s o c i a l r e l a t i o n s h i p s , surviving friends are frequently among those who lack a s o c i a l l y sanctioned 24 r i g h t and role to p a r t i c i p a t e i n the grieving process granted to kin (Deck & Folta, 1989). They are, according to Sklar and Hartley (1990) a "hidden" population. Though loss of a close f r i e n d i s generally acknowledged, Sklar (1991-92) contends that t h i s acknowledgement i s where concern appears to end. Deck and Folta (1989) assert that while g r i e f reactions such as angry outbursts, i m p u l s i v i t y and prolonged sadness are generally perceived as part of the normal grieving process for family, t h i s s o c i e t a l tolerance i s not granted to friends. In a "society lacking any s o c i a l l y recognizable state of g r i e f for friends", such p u b l i c d i s p l a y of emotion and dysphoria i s generally discouraged (Deck & Folta, 1989, p. 85). S i m i l a r l y Doka (1989) states "one may spend twenty-five years working side by side with a colleague for f o r t y hours a week and yet be expected to work the same way i n that colleague's absence... there i s g r i e f , but i t i s often disenfranchised" (p. 32) . Factors which appear to f a c i l i t a t e the grieving process i n general are often unavailable to the grieving f r i e n d . In lacking the recognized role of "bereaved", surviving friends are often i n h i b i t e d from g r i e v i n g openly (Doka, 1989). As a r e s u l t , t h e i r p r i v a t e experience e f f e c t i v e l y precludes t h e i r access to the c r u c i a l component of s o c i a l support (Doka, 1989; Meagher, 1989; Rando, 1992-93; Sklar & Hartley, 1990). The predicament of diminished s o c i a l support e f f e c t i v e l y d i c t a t e s and i s d i c t a t e d by the unacknowledged g r i e f of the surviving f r i e n d . A serious consequence of t h i s perceived lack of s o c i a l support i s the p o t e n t i a l for complicated mourning (Rando, 1992-93). Rando (1992-93) describes t h i s state as a compromised a b i l i t y to engage e f f e c t i v e l y i n the mourning process. Bereaved i n d i v i d u a l s without access to support may tend towards denial of aspects or implications 25 of the l o s s , or may continue to l i v e i n d e f i n a t e l y as i f the deceased were s t i l l a l i v e . As a r e s u l t of t h e i r complicated mourning, Rando states these bereaved experience prolonged mourning, and have continued d i f f i c u l t y reinvesting i n l i f e long a f t e r the death of t h e i r loved one. The funeral r i t u a l i s another important factor i n the f a c i l i t a t i o n of g r i e f . The funeral provides a p u b l i c forum within which the bereaved may openly express t h e i r g r i e f . For the surviving f r i e n d i n p a r t i c u l a r , the funeral may be one of the few opportunities for mutual sharing of the l o s s . The grieving f r i e n d , however, often plays a marginal role i n the funeral as that of a supportive guest; except i n cases where friends may be asked to eulogize the deceased, they are often not included i n planning t h i s therapeutic r i t u a l (Deck & Folta, 1989; Sklar, 1991-92) . The grieving f r i e n d "has no i d e n t i t y , no r o l e recognition, and no function with respect to the deceased. In e f f e c t , the grieving f r i e n d i s i n a state of anomie" (Deck & Folta, 1989, p. 83). As a consequence, the opportunity i s denied to p u b l i c l y express the symbolic meaning of the r e l a t i o n s h i p previously shared with the deceased. A major repercussion of exclusion from the therapeutic benefits of planning or attending the funeral r i t u a l i s the p o t e n t i a l impediment to accepting the r e a l i t y of the loss (Doka, 1989; Deck & Folta, 1989). In considering the grieving tasks outlined by Worden (1989), the i n a b i l i t y to accept the r e a l i t y of the loss p o t e n t i a l l y hinders the r e s o l u t i o n of g r i e f . Without access to the therapeutic aspects of the funeral r i t u a l , the r i s k i s increased for prolonged or complicated g r i e f reactions (Doka, 1989; Meagher, 1989; Rando, 1992-93). Deck and Folta (1989) explore the i n s t i t u t i o n a l p o l i c i e s which l i m i t the role of grieving friends. They indi c a t e that although most places of employment w i l l grant a few hours for funeral attendance, 26 personnel p o l i c i e s r a r e l y recognize extended absenteeism as legitimate i n the event of the death of a close f r i e n d . Hospital p o l i c i e s i n c r i t i c a l and intensive care units often l i m i t v i s i t a t i o n to immediate kin only, and "even the a i r l i n e s have a d e f i n i t i o n of acceptable grievers - exchange or refund granted only for death of spouse, c h i l d , parent or s i b l i n g " (Deck & Folta, 1989, p. 82) . Sklar and Hartley (1990) echo these words i n t h e i r observation suggesting that, "society has almost no i n s t i t u t i o n a l i z e d expectations about the bereavement of close f r i e n d s . Survivor-friends might be allowed to be unhappy for a short period following a death, but that i s a l l " (p. 106). Kamerman (1993) posi t s several factors which might explain the apparent s o c i e t a l and i n s t i t u t i o n a l resistance to enlarging the d e f i n i t i o n of legitimate grievers. He states the threat implied i n widening the domain of grievers i s that i t undermines " e x c l u s i v i t y of the t r a d i t i o n a l r e l a t i o n s h i p and at l e a s t some of the value assumptions on which that r e l a t i o n s h i p i s based" (p. 284) . A d d i t i o n a l l y , the amount and i n t e n s i t y of s o c i a l support afforded to legitimate grievers may be d i l u t e d i f t h i s resource was to be spread amongst a wider body of mourners. Further, the extension of benefits to friends would not be considered c o s t - e f f e c t i v e . And i n considering to whom benefits should be extended, there may be considerable d i f f i c u l t i e s encountered i n gauging the i n t e n s i t y of the r e l a t i o n s h i p and consequent i n t e n s i t y of g r i e f , i n contrast to the l e g a l s i m p l i c i t y that kinship and marriage provides. Sklar (1991-92) augments Kamerman1s l i s t of factors by suggesting that friends are excluded from bereavement rights as a means of preventing t h e i r access to the property of the deceased. He observes that t h i s exclusion allows the family to be unimpeded i n i t s claims to t h i s property. The i n s t i t u t i o n a l negation of the g r i e f experienced by surviving friends does not appear to be un i v e r s a l . Halberg (1986) discusses the 27 attempts that colleges and u n i v e r s i t i e s are making i n an e f f o r t to address deaths on campus. These i n s t i t u t i o n a l e f f o r t s are also evident i n the l i t e r a t u r e on bereaved adolescent friends i n school settings (Balk, 1991; Brent & Perper, 1993; Podell, 1989). In contrast then, there appears to be a greater d e f i c i t i n organizational e f f o r t s to respond to the g r i e f of friends i n the adult population. This d e f i c i t i n the s o c i a l and i n s t i t u t i o n a l recognition of the g r i e f of surviving friends i s r e f l e c t e d i n the l i m i t e d number of empirical studies exploring t h i s problem. There ex i s t s few studies that s p e c i f i c a l l y address the population of adult surviving friends who are grieving the loss through death of a close, p l a t o n i c f r i e n d . Several of the prominent writers i n the f i e l d of thanatology decry t h i s gap (e.g.. Deck & Folta, 1989; Rando, 1992-93; Sklar & Hartley, 1990) . They would appear to agree with Doka (198 9) who contends that extensive studies "of disenfranchised g r i e f are few. In almost each s i t u a t i o n , there i s research that should be done documenting the extent and manifestation of g r i e f , the variables that complicate or f a c i l i t a t e g r i e f , and the strategies that seek to ameliorate g r i e f " (p. 332). Although l i m i t e d i n t h e i r a b i l i t y to address these considerations, the following r e l a t e d study as well as two small-scale exploratory studies provide some i n d i c a t i o n of the grieving patterns of bereaved friends. Empirical studies of friendship g r i e f . Park and Cohen (1993) interviewed 96 undergraduate students about t h e i r r e l i g i o u s and non-religious coping with the recent death of a close f r i e n d . A structured interview as well as f i v e questionnaires were used to measure c h a r a c t e r i s t i c s i n c l u d i n g the p a r t i c i p a n t s ' r e l i g i o u s o r i e n t a t i o n ; use of r e l i g i o u s and non-religious causal appraisals and coping strategies i n response to the death; and outcomes such as l e v e l of dysphoria. As a r e s u l t of several complex 28 findings, the researchers suggest that r e l i g i o s i t y as expressed by the b e l i e f i n a divin e plan, plays an important p o s i t i v e role i n the coping process. R e l i g i o s i t y d i d not, however, appear to mitigate a l l aspects of the impact of the friend's death. Park and Cohen (1993) conclude that while r e l i g i o u s i n d i v i d u a l s may take some refuge i n applying a larger purpose to the death, "the negative emotions springing from the loss of another and the continuance of l i f e without the f r i e n d are nevertheless present and need to be dealt with over a prolonged period of time" (p. 574). Regardless of the meaning friends make of the death, the study appears to indic a t e that g r i e f reactions i n friends are intense and appear to remain intense f o r some period of time. While Park and Cohen (1993) indeed add another piece to the puzzle of the experience of surviving friends, the focus i s l i m i t e d by v i r t u e of the methodology to the role of r e l i g i o n i n coping. L i t t l e can be gleaned from t h i s research regarding how these mourners experienced and expressed t h e i r g r i e f , both i n t r a p s y c h i c a l l y and extrapersonally, or how g r i e f was experienced and expressed for those surviving friends who reported to be nonreligious. Furthermore, Park and Cohen (1993) do not explain t h e i r r a t i o n a l e f o r the sole observation of pa r t i c i p a n t s who were i n the category of bereaved friends. Although i t i s almost c e r t a i n that t h i s category of mourner was not chosen on the basis of sampling convenience, these researchers f a i l to c l e a r l y state any assumptions pertaining to t h e i r s p e c i f i c choice of t h i s p a r t i c i p a n t group. I t i s d i f f i c u l t to assess whether the coping responses of these bereaved friends are unique or rather whether they are responses common to a l l survivors, including spouse and kin. The following exploratory studies p a r t i a l l y address these questions. Sklar and Hartley (1990) describe two small-scale unpublished studies they conducted i n an e f f o r t to explore aspects of the 29 bereavement of close friends. Although the r e l i a b i l i t y and v a l i d i t y of the data cannot be v e r i f i e d due to the unpublished nature of these reports, t h e i r preliminary findings are of i n t e r e s t . In t h e i r f i r s t exploratory study, undertaken i n 1985-86, Sklar and Hartley (1990) conducted a project which involved in-depth interviews and essays by p a r t i c i p a n t s who had survived the death of a close f r i e n d within the previous f i v e years. Participants were students between the ages of eighteen and f o r t y - f i v e . The interview protocol involved questions ranging from the events encompassing the funeral; a f f e c t i v e , behavioral and cognitive responses to the loss of t h e i r f r i e n d ; experiences following the death; and the reactions of others to the p a r t i c i p a n t ' s g r i e f responses. The authors combined the findings from t h i s project with the r e s u l t s of a second project, i n v o l v i n g a mutual support group organized by the authors for surviving f r i e n d s . This l a t t e r project included t h i r t e e n adult p a r t i c i p a n t s who discussed t h e i r experience of bereavement as i t r e l a t e d to t h e i r p o s i t i o n of surviving f r i e n d . The authors state that from these studies, "there emerged i n the group meetings, interviews, and essays a broad range of themes that c l o s e l y p a r a l l e l well-known findings for f a m i l i a l bereavement" (Sklar & Hartley, 1990, p. 108). S p e c i f i c a l l y , the p a r t i c i p a n t s were found to have experienced several constituents associated with f a m i l i a l g r i e f , i ncluding a decreased a b i l i t y to cope, accompanied by a profound sense of loss that lingered for several months and a f f e c t e d t h e i r performance i n d a i l y matters; anger with the deceased and with themselves; dysphoric sensations, and h a l l u c i n a t i o n s i n v o l v i n g the deceased f r i e n d which resulted i n questioning t h e i r own sanity; g u i l t over things l e f t unsaid; and a tendency for anniversary dates, e s p e c i a l l y the anniversary of the death, to p r e c i p i t a t e intense emotional reactions. 30 Sklar and Hartley (1990) assert that although p a r t i c i p a n t s reported many of the same emotions and experiences associated with grieving family members, these same emotions and experiences are r a r e l y a t t r i b u t e d to surviving friends. The findings also indicated that surviving friends often d i d not themselves recognize the legitimacy of t h e i r own g r i e f , and the prevalence of g r i e f amongst surviving friends. In e f f e c t , none r e a l i z e d that "friends as a 'category' could mourn, although each had mourned independently. Survivor-friends, i t seems, are a hidden population even to themselves" (p. 110). In t h e i r concluding remarks, the authors state, we could only f i n d one p a r t i c i p a n t i n our research who f e l t he had been acknowledged by others as t r u l y g r ieving to the same degree that a family member might. By contrast, other p a r t i c i p a n t s who consciously attempted to grieve as might be expected by a family member... discovered they were not "permitted" to do so (p. 110). Sklar and Hartley's (1990) exploratory studies i l l u s t r a t e the assertions of others (e.g., Doka, 1989) that surviving friends experience features of g r i e f commonly a t t r i b u t e d to bereaved family members. Further, t h i s g r i e f i s often disenfranchised i n that i t i s r a r e l y acknowledged to have the p o t e n t i a l i n t e n s i t y of f a m i l i a l g r i e f . Based on t h e i r exploratory findings, the authors suggest the urgent need for more systematic research to examine i n depth the experience of g r i e f for surviving f r i e n d s . The urgent need to address t h i s s i t u a t i o n i s repeated by Rando (1992-93) and Kamerman (1993) . They suggest that the incidence of disenfranchised g r i e f i s increasing as a r e s u l t of such processes as urbanization, d e r i t u a l i z a t i o n and reorganization of the nuclear family i n contemporary society. Rando (1993) concludes, "the more society creates, maintains, or permits i n d i v i d u a l s to be disenfranchised i n t h e i r mourning, the more those i n d i v i d u a l s are at r i s k " (p. 54). Although s o c i e t a l recognition of g r i e f i n the surviving f r i e n d may 31 prove to be a slow process, Kamerman (1993) i s nonetheless o p t i m i s t i c . He states that i n a society so r e l i a n t on p r o f e s sional expertise, those people who work with grievers, who i n e f f e c t are advocates for the disenfranchised griever, "are the only ones i n a good p o s i t i o n to t r y to bring about those changes" (p. 283). A review of the l i t e r a t u r e would indi c a t e widening agreement regarding the r e a l i t y of disenfranchised g r i e f among various populations of bereaved, inc l u d i n g surviving f r i e n d s . Despite the prevalence of these assertions however, l i t t l e i f any empirical evidence e x i s t s describing the l i v e d experience of g r i e f i n surviving friends as they themselves perceive i t . Assertions regarding the experience of g r i e f among surviving friends have not as yet been em p i r i c a l l y v e r i f i e d . The surviving f r i e n d remains the p r o t o t y p i c a l "black box". If the experience of unacknowledged g r i e f i s indeed a r e a l i t y for c e r t a i n mourners, t h e i r r e a l i t y needs to be defined. This review has i l l u s t r a t e d a s e l e c t i v e cross-section of the burgeoning f i e l d of bereavement l i t e r a t u r e . Selected empirical findings, t h e o r e t i c a l assertions and models of g r i e f have been reviewed to h i g h l i g h t t h e i r contribution to current conceptualizations of t h i s phenomenon. It appears however that a coherent and e m p i r i c a l l y supported model of g r i e f has yet to evolve. Among many suggestions for remediation, t h i s evolution requires that several gaps i n the l i t e r a t u r e be addressed. One such gap appears to be the l i m i t e d representation of bereaved non-kin, and more s p e c i f i c a l l y of bereaved friends, i n the l i t e r a t u r e . A second and r e l a t e d area that requires further examination i s the subjective experience of g r i e f i t s e l f . There e x i s t s l i m i t e d empirical data regarding the meaning the bereaved i n d i v i d u a l bestows on the experience of g r i e f as i t i s perceived and l i v e d ; hence there appears to be a need for an increased focus on systematic phenomenological studies i n order to c l a r i f y the 32 es s e n t i a l elements of t h i s phenomenon as i t i s experienced by the bereaved. Through a phenomenological approach, t h i s research seeks to address the essence of g r i e f as i t i s l i v e d and experienced by surviving friends. It w i l l attempt to make e x p l i c i t the meanings bestowed on the experience of g r i e f by surviving friends such that the es s e n t i a l elements of the phenomenon as i t i s experienced by t h i s population can be c l a r i f i e d and described. A major imp l i c a t i o n of t h i s research i s that i t w i l l begin to address the conceptual gap i n terms of the l i v e d experience of g r i e f for surviving friends. In essence, the c i r c l e of l e g i t i m a t e l y bereaved as implied by representation i n the l i t e r a t u r e may be enlarged to include these non-f a m i l i a l bereaved. Furthermore, i f surviving friends indeed experience t h e i r g r i e f as p a r t i a l l y or wholly disenfranchised, research of t h i s nature may begin to r e - e s t a b l i s h t h e i r legitimate r i g h t and role to grieve. 33 CHAPTER III Methodology Foundations of Method C o l a i z z i states the phenomenological approach attempts to describe and c l a r i f y i n t e g r a l components of a phenomenon, and as such i s the c r i t i c a l " f i r s t step" i n research. S i m i l a r l y , Karlsson (1993) defines the phenomenological approach as one which aims at describing "what" and "how" something i s , rather than "why" i t i s . He asserts, "the essence of what something i s , i s epistemologically p r i o r to the question of why such and such i s the case" (Karlsson, 1993, p. 14) . Given that the e s s e n t i a l aspects of the experience of g r i e f as i t i s l i v e d and experienced by bereaved friends has not yet been c l a r i f i e d , the phenomenological approach w i l l be used to address t h i s problem. Accordingly, Reeves (1989) asserts that i n an attempt to study what the phenomenon i s , t h i s approach "respects the complexity of a phenomenon, giving i t meditative exploration and a thoughtful d e s c r i p t i o n " (p. 3) . To further c l a r i f y the aim of the phenomenological approach, Karlsson (1993) d i f f e r e n t i a t e s between the phenomenal and phenomenological l e v e l s of observation, both of which are e s s e n t i a l to the process of defining the e s s e n t i a l aspects of a phenomenon. The phenomenal l e v e l encompasses the straightforward recounting of the subject's experience of the phenomena, "whereas a phenomenological l e v e l traces out the structure, or the e s s e n t i a l constituents, e n t a i l e d i n the experience, i . e . , the logos of the phenomenon" (Karlsson, 1993, p. 14). The researcher i s i n t e r e s t e d i n the facts not for t h e i r e x p l i c i t d e t a i l but rather for the meanings which are implied i n the f a c t s . The essence of the phenomenon l i e s i n the meaning with which these facts are imbued. Fundamentally, the phenomenological approach seeks to ill u m i n a t e the meaning the 34 experiencing i n d i v i d u a l bestows on the experience as i t i s perceived and l i v e d . Karlsson (1993) employs the expression " e i d e t i c reduction" (p. 45) to explain the e s s e n t i a l process i n the methodology. He explains the term " e i d e t i c " stems from the greek word "eidos" which means essence or meaning-structure, and hence "by implementing the e i d e t i c reduction we wish to f i n d out the essence or the meaning-structure of that which we study" (Karlsson, 1993, p. 45) . The reduction does not imply that the experience of the phenomenon w i l l be modified i n any way. In fact "the meaning of the reduction i s quite the contrary. I t aims at e x p l i c a t i n g that which was given ( i m p l i c i t l y ) i n the natural attit u d e , but never grasped on a thematic l e v e l " (Karlsson, 1993, p. 50) . By making e x p l i c i t the meanings suffused i n the experience, the essence, or meaning structure, of the phenomenon can be c l a r i f i e d and described. In the process, the themes by which the i n d i v i d u a l structures his or her world become d i s t i n c t . As a consequence of t h i s thematization of the meaning structure imbedded i n experience, a deeper understanding of that experience i s achieved. Trustworthiness of the Proposed Research Since c r i t e r i a of r e l i a b i l i t y and v a l i d i t y are not appropriate strategies for e s t a b l i s h i n g r i g o r i n q u a l i t a t i v e research, Krefting (1991) suggests that every q u a l i t a t i v e research report must e s t a b l i s h i t s trustworthiness based on other c r i t e r i a . Three such strategies for e s t a b l i s h i n g and evaluating the trustworthiness of q u a l i t a t i v e research w i l l be discussed here including c r e d i b i l i t y , t r a n s f e r a b i l i t y and dependability (Krefting, 1991). C r e d i b i l i t y s t r a t e g i e s . According to Krefting (1991) c r e d i b i l i t y can be established i n q u a l i t a t i v e research through the accurate d e s c r i p t i o n of the phenomenon as i t i s perceived and l i v e d by the p a r t i c i p a n t s . In the 35 present study c r e d i b i l i t y w i l l be enhanced through the use of several c r i t e r i a as outlined by Kre f t i n g (1991). The f i r s t of those c r i t e r i a i s described as member checking, wherein p a r t i c i p a n t s are given an opportunity to check the transformed data from t h e i r f i r s t interview to insure that the writer's thematic d e s c r i p t i o n accurately represents t h e i r experience. This process minimizes the r i s k of misrepresentation and insures that the multiple r e a l i t i e s of the par t i c i p a n t s are accurately described. R e f l e x i v i t y w i l l also be employed to e s t a b l i s h c r e d i b i l i t y . Krefing (1991) defines t h i s c r i t e r i o n as the assessment of the researcher's perceptions, i n t e r e s t s and biases on the research process. Reflexive measures w i l l be taken to enhance c r e d i b i l i t y p r i o r to data c o l l e c t i o n and analysis. These measures w i l l include that of s e l f - r e f l e c t i o n and discussion with others regarding my own presuppositions concerning g r i e f , the experience of grieving, and the i d e n t i t y and roles of the bereaved. These presuppositions w i l l be documented i n t h i s chapter. Further, my role as a c l i n i c i a n and health care professional may p o t e n t i a l l y influence the data c o l l e c t i o n and analysis: constant r e f l e c t i o n w i l l be required to insure that t h i s role does not i n t e r f e r e with my role as researcher and the research i t s e l f . C r e d i b i l i t y w i l l also be enhanced through frequent checks of the research process and i t s findings with my research supervisor. This w i l l ensure that I have accurately described the multiple perceptions of the experience of g r i e f . Such checks w i l l also ensure the v a l i d i t y of the coding scheme I have used to i d e n t i f y common e x p e r i e n t i a l themes. A p o t e n t i a l threat to c r e d i b i l i t y according to Kirk and M i l l e r (cited i n Krefting, 1991) occurs when p a r t i c i p a n t s ' responses are based on s o c i a l d e s i r a b i l i t y . To insure against t h i s , I w i l l r e f r a i n 36 from asking s p e c i f i c questions about aspects of the p a r t i c i p a n t ' s experience. The p a r t i c i p a n t w i l l be encouraged throughout the interview by non-verbal and verbal cues to describe her experience as spontaneously and i n as much d e t a i l as possible. T r a n s f e r a b i l i t y s t r a t e g i e s . T r a n s f e r a b i l i t y i s another strategy towards increasing trustworthiness of the study. K r e f t i n g (1991) poses that t r a n s f e r a b i l i t y i s established through such c r i t e r i a as providing dense d e s c r i p t i o n of the data i n order to allow for "others to assess how transferable the f i n d i n g are" (p. 220). Descriptions of p a r t i c i p a n t s , t h e i r backgrounds and the research context i t s e l f w i l l be provided i n t h i s chapter as well as i n chapter V (see L i m i t a t i o n s ) . Numerous d i r e c t quotes from the p a r t i c i p a n t s regarding t h e i r experience of g r i e f w i l l also be provided i n chapter IV to further enhance t r a n s f e r a b i l i t y . Dependability s t r a t e g i e s . Dependability i s also a strategy for e s t a b l i s h i n g and evaluating trustworthiness. Strategies to enhance dependability r e l a t e to the consistency of findings. K r e f t i n g (1991) argues that the q u a l i t a t i v e researcher must describe exact methods of data gathering and analysis. This comprehensive d e s c r i p t i o n of methods "provides information as to how repeatable the study might be or how unique the s i t u a t i o n " (Krefting, 1991, p. 221). In the present study dependability c r i t e r i o n w i l l be established i n t h i s chapter (see Data gathering and Data analysis) as well as i n Appendices D, E, F, and G which w i l l d e t a i l the e i d e t i c analysis of each p a r t i c i p a n t s experience. Dependability of t h i s study w i l l also be enhanced by conducting a code-recode procedure. A f t e r a segment of data i s thematically coded during the analysis, I w i l l return to t h i s data a f t e r a period of 2 months to recode that data and compare the r e s u l t s . 37 Participants Participants w i l l be ref e r r e d to as co-researchers to emphasize the fact that they are in f l u e n c i n g the study; co-researchers w i l l e s s e n t i a l l y generate the data (Reeves, 1989). Co-researchers w i l l have survived the death of a close f r i e n d within the l a s t f i v e years. In the i n t e r e s t of attempting to capture p o t e n t i a l homogeneity of experience, the co-researchers w i l l be of adult age, ranging from young to middle adulthood (approximately 19 to 60 years of age) . The gendered response to bereavement, as suggested i n the l i t e r a t u r e , needs to be taken into account when s e l e c t i n g co-researchers. In the i n t e r e s t of homogeneity of experience, given that women may be more l i k e l y to volunteer for in-depth interviews (Stroebe & Stroebe, 1989-90) and may be more open to discussing t h e i r experience of bereavement as well as death re l a t e d attitudes (DaSilva & Schork, 1984-85), I have chosen to interview female surviving friends about t h e i r experience of g r i e f . Four co-researchers w i l l be interviewed. In consideration of time and given the substantial quantity and q u a l i t y of data which p o t e n t i a l l y w i l l be generated by each protocol, i t i s reasonable to assume that t h i s number of p a r t i c i p a n t s w i l l be s u f f i c i e n t to trace the structure, or essence, of g r i e f as i t i s experienced by these co-researchers . A pre-screening telephone interview w i l l insure that p o t e n t i a l co-researchers f i t the d e s c r i p t i o n of "bereaved close f r i e n d " (see Appendix A) . This r e l a t i o n s h i p w i l l be defined as a non-sexual companionship, wherein the deceased was considered to be one of the pa r t i c i p a n t ' s most intimate frie n d s . I f the respondent answers a f f i r m a t i v e l y to the pre-screening question determining whether she would consider the deceased to have been among her close s t seven or eight friends, she w i l l be considered a co-participant i n the study. 38 Co-researchers w i l l not normally be interviewed within the f i r s t year a f t e r the death, when i t might be expected that t h e i r g r i e f i s most intense. This guideline may help to avoid the p o t e n t i a l exacerbation of dysphoric feelings which may r e s u l t from the p r i m a r i l y research-based, versus supportive, nature of the i n t e r a c t i o n . Further, i n order to avoid the misunderstanding of the purpose of the interview as one within which counselling w i l l be provided, p o t e n t i a l p a r t i c i p a n t s w i l l be advised during the pre-screening contact of the research nature of the study. References for l o c a l g r i e f counselling agencies w i l l be given to i n d i v i d u a l s upon t h e i r request i f t h e i r i n t e n t i o n was to receive counselling to f a c i l i t a t e t h e i r grieving. I f in d i v i d u a l s are currently receiving counselling, and are cognizant of the purpose of the research, they may be included i n the study contingent on discussing the same with t h e i r present counsellor. F i n a l l y i n the event that the interview catalyses or uncovers unresolved or complicated g r i e f , I w i l l inform the p a r t i c i p a n t of counselling resources a v a i l a b l e i n the c i t y which might hopefully address her bereavement needs. Data Gathering Data w i l l be gathered through the use of unstructured interviews, wherein the p a r t i c i p a n t s w i l l be asked to "describe the phenomenon i n question spontaneously and i n as much d e t a i l as poss i b l e " (Karlsson, 1993, p. 94). Each co-researcher w i l l be interviewed twice, at a pre-arranged time. The f i r s t interview w i l l be audio-taped and w i l l l a s t approximately one and one-half hours, contingent upon the co-researcher's i n d i c a t i o n s that she i s s a t i s f i e d with her d e s c r i p t i o n of the experience. Interviews w i l l take place i n an environment which i s agreed upon to be comfortable for the co-researcher, perhaps within her own home. 39 A f t e r the purpose of the study i s explained, the consent form i s signed. As co-researchers may not be f a m i l i a r with the design of an unstructured interview, an explanation of the purpose and format of t h i s type of interview w i l l be offered. When the co-researcher indicates readiness to commence, I w i l l begin the interview by stat i n g , We have talked e a r l i e r about the purpose of t h i s study being an attempt to map or define the process of g r i e f experienced by friends surviving the loss through death of a close f r i e n d . You have mentioned the death of your close f r i e n d and your experience of grieving that l o s s . I wonder i f you would share your story about your l o s s , beginning i f you l i k e with the moment that stands out the most for you. The story i n c l u d i n g cognitions and events experienced w i l l unfold according to the way i n which the co-researcher experienced, and i s experiencing i t . The co-researcher w i l l be encouraged throughout the interview by verbal and non-verbal cues to describe her experience as spontaneously and i n as much d e t a i l as possible (see Appendix B). The second interview w i l l take place i n the same s e t t i n g . I t w i l l be an opportunity to check with the co-researcher to insure that the thematic d e s c r i p t i o n of her story accurately represents her experience (see Appendix B) . This second interview w i l l require approximately one hour, or l e s s , to complete. Data analysis Unless otherwise indicated, the method of analysis employed i n t h i s study w i l l be adapted from that outlined by Karlsson (1993), which proceeds i n a series of f i v e steps. The c o l l e c t i o n and analysis of data w i l l progress simultaneously, such that emerging themes can be compared, revised and refined with the addition of each co-researchers story (Reeves, 1989). Each completed interview w i l l be transcribed, and I w i l l read the drafted protocol u n t i l I have a clear understanding of the content. 40 In t h i s f i r s t step of the analysis, the "researcher i s open to the text and r e f r a i n s from imposing any t h e o r e t i c a l explanatory model upon i t " (Karlsson, 1993, p. 98). Each aspect of the protocol w i l l be r e f l e c t e d upon and understood i n the context of the whole of the experience. When I have a clear understanding of the protocol, I w i l l move onto step two. In the second step of analysis the protocol w i l l be divided into smaller units, each of which s i g n i f i e s a s h i f t i n meaning. Each unit of meaning can be perceived as a d i s t i n c t segment i n the ges t a l t , or contextual whole, of the experience. Karlsson (1993) describes t h i s d i s c r i m i n a t i o n of meaning units as a p r a c t i c a l a i d which helps the researcher to adopt "a concentrated and dwelling a t t i t u d e on each s h i f t of meaning [necessary for] the penetrating analysis i n step 3" (p. 97) . In step three, the analysis proper begins to take place, and i s focused on the meaning imbued i n the fa c t s . E i d e t i c analysis, or analysis of meaning-structure, w i l l be employed to track the meaning of the l i v e d experience each subject describes-, both i m p l i c i t l y and e x p l i c i t l y , i n her protocol. Each unit of meaning i s here transformed i n t o the researcher's language. Keeping i n mind the contextual whole, through the process of dwelling or r e f l e c t i n g on the possible meanings contained i n each unit, the d i s t i n c t aspects of the p a r t i c i p a n t ' s experience w i l l be abstracted and eventually transformed into a general meaning. In short, the co-researcher's d e s c r i p t i o n of p a r t i c u l a r facts w i l l be transformed into "a language of meaning" (Karlsson, 1993, p. 99). In t h i s step of the analysis, Karlsson (1993) emphasizes " i t may turn out that two d i f f e r e n t facts have the same psychological meaning. In addition, one and the same fact may have d i f f e r e n t meanings on d i f f e r e n t occasions and/or f o r d i f f e r e n t people" (p. 97). Upon 41 completing the transformation of units of meaning in t o general meanings, I w i l l proceed to step four i n the analysis. As described by Karlsson (1993), step four " e n t a i l s a synthesizing of the transformed meaning units into a s o - c a l l e d 'situated structure', presented i n the form of a synopsis." (p. 106). Here, the units of meaning may be omitted or s h i f t e d and rearranged to more c l e a r l y define the meaning structure. At t h i s point as suggested by Reeves (1989), I w i l l ask co-researchers to review the transformed units of meaning and the synopsis, or thematic structure, illuminated i n t h e i r story. This second interview w i l l v e r i f y the v a l i d i t y of my int e r p r e t a t i o n s by insuring that the transformed meanings and thematic structure represent the p a r t i c i p a n t ' s experience. The f i n a l step i n the analysis i s to condense the common e i d e t i c constituents from the situated structure of each p a r t i c i p a n t ' s experience into a general structure. As stated by Karlsson (1993), t h i s general or "meaning-structure of a phenomenon i s the invar i a n t 'thread' which runs through a l l diverse manifestations of a phenomenon" (p. 93) . The general structure i s e s s e n t i a l l y a d e f i n i t i o n which describes the e s s e n t i a l aspects of the l i v e d experience of g r i e f for a l l of the co-researchers. Meaning i s herein generalized from "one protocol to a l l protocols i n the study" (Karlsson, 1993, p. I l l ) . The d e f i n i t i o n w i l l e f f e c t i v e l y embody " a l l aspects of the phenomenon's e s s e n t i a l meaning" (Reeves, 1989, p. 41). As a f i n a l note, Karlsson (1993) indicates that the general structure i s the model used when a l l the situated structures can be meaningfully condensed into one configuration. He suggests that i f a study contains more than one structure of the phenomenon, each structure should be preserved as a "ty p o l o g i c a l structure" (p. 93) . Such t y p o l o g i c a l structures are indicated when aspects of divergent meanings are found i n various protocols; and "to omit such t y p o l o g i c a l 42 constituents i n order to condense the data into one general structure would mean that much psychological relevance would be l o s t " (Karlson, 1993, p. 88) . A p i l o t study w i l l be conducted to c l a r i f y the methodology, and insure that the experience of g r i e f for surviving friends can be accessed v i a the proposed method. Meaning units and a thematic synopsis w i l l be illuminated to capture the experience of the co-researcher. I f the methodology proves e f f e c t i v e , and the data from t h i s p i l o t study appears to be able to add to the data c o l l e c t e d i n the study proper, the p i l o t w i l l be included i n the r e s u l t s of the study. Presuppositions As stated by Karlsson (1993), the "researcher's understanding of the data i s not free from presuppositions... Instead, the researcher's understanding arises from a l i n g u i s t i c , c u l t u r a l horizon beyond which one cannot move" (p. 89) . He defines research as a d e l i c a t e balance between the researcher's pre-understanding ( c u l t u r a l and l i n g u i s t i c heritage) and a complimentary a t t i t u d e of attempting to be as presuppositionless and open as possible i n r e l a t i o n to the phenomenon being studied. Consequently, to avoid obtaining r e s u l t s which are merely descriptions of the researcher's own understanding of a phenomenon, the researcher must c l a r i f y her or his own presuppositions (Karlsson, 1993; Reeves, 1989). Through s e l f - r e f l e c t i o n and discussion with others, I am aware of several of my presuppositions regarding the phenomenon of g r i e f . In being aware of these pre-conceived notions, I hope to avoid then imposing my r e a l i t y on the experiences of the co-researchers. Ad d i t i o n a l presuppositions w i l l become cl e a r e r as I encounter the data, and as others f a m i l i a r with the methodology observe my treatment of that data. Throughout the process of the interviews, data 43 analysis and reporting of r e s u l t s , I w i l l c o n t i n u a l l y r e f l e c t on these presuppositions to insure they are not i n f l u e n c i n g the meanings held by the co-researchers. My presuppositions are l i s t e d and described below. Degrees of disenfranchisement amongst grieving friends Disenfranchised g r i e f i s a phenomenon which may accompany, to varying degrees, the grieving process of a surviving f r i e n d . I conceive of g r i e f as being experienced along a continuum of i n t e n s i t y . Several factors influence the i n t e n s i t y of that g r i e f , i n c l u d i n g the degree to which the deceased f u l f i l l e d exclusive functions and roles i n the l i f e of the surviving f r i e n d ; the meanings imbued by the bereaved i n the r e l a t i o n s h i p with the deceased, and i n the l i f e and death of the deceased; and the survivors' own expectations about g r i e f and bereavement, including t h e i r perceived r i g h t to grieve. I f these factors contribute to some i n t e n s i t y of g r i e f i n surviving friends, and i f t h e i r expression of g r i e f i s influenced by assumptions which associate open g r i e f with a healthy g r i e f response but only i n family members, then g r i e f may be a private, disenfranchised experience for surviving friends. The prevalence of disenfranchised g r i e f as stated i n the l i t e r a t u r e appears to be supported by conversations I have had with several i n d i v i d u a l s who have discussed t h e i r personal encounter with the phenomenon. I have recently had an interview with L. P o l l a r d -E l g e r t , a g r i e f counsellor from the L i v i n g Through Loss Society i n Vancouver. She referred to the s i t u a t i o n s of several c l i e n t s who as surviving friends perceived they lacked the s o c i a l sanction and support which would have allowed them to openly and l e g i t i m a t e l y grieve t h e i r l o s s . As a r e s u l t , they sought the support of counselling to a s s i s t them i n resolving t h e i r turmoil and t h e i r g r i e f . 44 One of the implications of the present research may well be that the interview format i t s e l f might be one of the few opportunities for surviving friends to discuss t h e i r experience. T e l l i n g the story of p a i n f u l loss may provide emotional r e l i e f to survivors (Hocker, 1990; S c u r f i e l d , 1985) as well as a s s i s t them i n bringing a greater depth of meaning to t h e i r experience. D e f i n i t i o n s Bereavement. As defined by Rando (1984), i s the state of having endured a l o s s . Complicated mourning. Taking into consideration the amount of time since the death, complicated g r i e f as outlined by Rando (1992-93), occurs when there i s a f a i l u r e , compromise, or d i s t o r t i o n i n the a b i l i t y of the bereaved to engage i n various mourning processes. These denied or d i s t o r t e d processes include avoidance or denial of aspects of the l o s s , of the accompanying pain, and of the f u l l implications of that l o s s . The bereaved may also attempt to avoid r e l i n q u i s h i n g the deceased i n d i v i d u a l , or readjusting to l i f e without the deceased. When any of these d i s t o r t i o n s occur i n the grieving process, reinvestment i n l i f e i s interrupted, and the i n d i v i d u a l i s thought to be experiencing complicated g r i e f . G r i e f . As defined by Rando (1984), i s the process of intrapsychic, s o c i a l and somatic reactions to l o s s . Mourning. As defined by Rando (1984), mourning i s a state characterized by responses to loss which are guided or di r e c t e d by the in d i v i d u a l ' s i n t e r n a l i z e d c u l t u r a l response to g r i e f . 45 CHAPTER IV Results This chapter i s divided into two sections. The f i r s t section w i l l encompass i n d i v i d u a l elements of each co-researcher's experience of the loss of her close f r i e n d . For each co-researcher the situated structure, or synopsis, w i l l be presented f i r s t (see Appendix C for d e f i n i t i o n s of elements or themes; and Appendixes D through G for the e i d e t i c analysis of each p r o t o c o l ) . The second section of the chapter contains an o v e r a l l synthesis of the co-researchers' experience i n the form of a general structure. This generalized d e s c r i p t i o n w i l l describe the e s s e n t i a l elements of the experience of g r i e f common to a l l co-researchers i n the study (see also Appendix H). Situated Structures Anna's Experience of Loss Nearly 3 years ago Anna suffered the loss of her good f r i e n d "N". Anna characterized her r e l a t i o n s h i p with "N" as being s i m i l a r to that of kin, and she noted s i m i l a r i t i e s between her r e l a t i o n s h i p with "N" and that which she had experienced with her father. For Anna, the re l a t i o n s h i p with each of them was characterized by protection. She shielded them from aspects of r e a l i t y which might have caused them offence, and they i n turn d i d the same for her. As such, she wondered i f N's deliberate e f f o r t to hide the truth of h i s i l l n e s s from her was an attempt to protect her from the pain of the r e a l i t y of his impending death. For "N" the diagnosis of AIDS seemed to reduce his self-regard. Anna suspected at times that he believed he deserved to die as a punishment for who he was, a thought which she found very d i f f i c u l t to resolve. In spite of the pain of her losses however, Anna remarked on the fac t that her own i n t e g r i t y remained i n t a c t throughout his 46 i l l n e s s and a f t e r his death, and she had not been diminished by the i n t e n s i t y of her g r i e f . Though she would not describe i t as t y p i c a l of her other close r e l a t i o n s h i p s , Anna made concessions for her dying f r i e n d "N" which required that she r e s t r a i n her open and genuine expression about his imminent death. She impeded h e r s e l f from sharing with him her own sense of loss i n order to respect his autonomy i n how he wished to respond to the r e a l i t y of his i l l n e s s and impending death. She sensed he d i d not want to discuss his terminal condition and i t s implications. Thus even when his i l l n e s s was obvious to her she did not confront him when he denied the r e a l i t y of his condition. A f t e r his death however these concessions l e d to unresolved fee l i n g s for her. The allowances she had made c o n f l i c t e d with her conviction that i n friendship things should not be hidden or pretended. Such concessions also l e d i n part to a sense of exclusion for Anna i n N's ordeal of i l l n e s s and death. Her sadness i n his loss was i n t e n s i f i e d by her awareness that despite her knowledge of his terminal i l l n e s s , she was impeded i n discussing i t with him u n t i l his impending death was imminent. Anna also experienced a physical separation from "N". Before he became i l l they were constant companions. Yet when his i l l n e s s advanced he moved away to l a t e r die at his parents home i n another c i t y , leaving no s p e c i f i c expectations of h i s friends regarding his wishes or needs during his i l l n e s s and a f t e r his death. Anna struggled with whether she would have f e l t more resolved about his loss i f she had i n s i s t e d that "N" d i s c l o s e and openly discuss with her the implications of his i l l n e s s . She resolved however that she could not have i n s i s t e d on t h i s d i s c l o s u r e . In forcing such discussion she believed she would not have f i t with what he needed i n a supportive f r i e n d . 47 Anna believed her response to N's loss was t y p i c a l of what she had expected to experience with g r i e f . She described a sense of anguish, sadness and meaninglessness which were prolonged and intense. And despite many in d i c a t i o n s that her f r i e n d "N" was about to die, she described a continual sense of d i s b e l i e f i n or denial of t h i s end. She found that c e r t a i n objects or circumstances seemed to t r i g g e r her anguish. Immediately a f t e r N's death when her anguish was most intense she could not look at pictures of him i n happier times, or be offered condolences from people who knew how close she and " N " had been. Even two years a f t e r his death she continued to experience sadness and longing when she encountered symbolic reminders of him, such as t u l i p s i n the Spring which he had loved. In order to avoid those thoughts, events or people that she feared would t r i g g e r her anguish and longing, Anna found h e r s e l f seeking d i s t r a c t i o n s or techniques to help her focus her thoughts on the task at hand. She hoped such d i s t r a c t i o n s would "magically" a s s i s t her i n avoiding the pain of her loss and help her to function with her normal l e v e l of competence i n her work. One year ago Anna experienced the loss of " J " , another close f r i e n d who l i k e "N" also died of AIDS. In contrast to her experience with the loss of "N", Anna described a process of being included i n J's experience of i l l n e s s through to his death. Anna and " J " spoke openly to each other about the s i g n i f i c a n c e of his i l l n e s s and impending death. She spent a great amount of time with her dying f r i e n d " J " , and was witness to his gradual decline. Throughout t h i s process, " J " earnestly requested her forthrightness i n expressing her feelin g s about his decline and death. Anna was aware of what was needed and desired by her dying f r i e n d " J " , and stated "there was no second guessing i n that friendship". This c l a r i t y reduced her sense of confusion not only during his dying process but also a f t e r his 48 death. Well before J's death Anna was resolved to his l o s s . She had begun to accept his impending death as an a l t e r n a t i v e to his anguish over his decline, and his discouragement with no longer being who he once was. She believed that " J " had ant i c i p a t e d and was at peace with his death, which made i t easier for others including h e r s e l f to accept i t s i n e v i t a b i l i t y . Though she was saddened by his absence, she was at peace with his death. During his i l l n e s s " J " had made his expectations e x p l i c i t , i ncluding those regarding others' conduct during his funeral. When asked by J's partner to read her choice of poems at the funeral, Anna was unsure of her a b i l i t y to read the poem calmly and completely i n a way that would emulate her friend's courage. She was able to do so despite her fear of l o s i n g composure by reminding h e r s e l f throughout the reading that " J " d i d not want his funeral to be an occasion for dredging out the tragedy of his death. During the time i n which " J " was dying, Anna was aware of the ef f e c t s of i l l n e s s on his i n t e g r i t y . She r e c a l l e d that despite J's awareness of others' discomfort with and disdain for his disease and impending death, his se l f - r e g a r d remained i n t a c t . He remained true to f e e l i n g and expressing what he was genuinely experiencing regardless of others' opinions. With the advancement of his disease however, he became discouraged with the way i n which the q u a l i t y of his l i f e had diminished. He began to look forward to death and the end of his burden. Witnessing J's l i f e dwindle to the point where he no longer wished to l i v e seemed to diminish Anna's discomfort with his death. Rather than experiencing the sadness that she believed others f e l t with his death, Anna described f e e l i n g an i n c r e d i b l e sense of pride i n the way " J " had attempted for so long to adhere to a way of being despite the adversity of his i l l n e s s . 49 In r e c a l l i n g her l a s t v i s i t with " J " , Anna described an image she cherished of " J " wherein he was s i t t i n g up i n bed eating a popsicle. The image seemed to restore his c h a r a c t e r i s t i c v i t a l i t y i n the face of impending death, and was one which helped her adjust to his l o s s . During t h i s l a s t v i s i t with " J " before he died, Anna had an i n t u i t i v e sense that t h i s would be the l a s t time she would see him. I t was a more c e r t a i n or d i s t i n c t sense than she had ever experienced with him before. While away she had a dream of which the content l e d her to wake with the impression that " J " had died during the night, an impression which was l a t e r confirmed to be true. Recognition of her loss and of her status as bereaved was an important aspect i n Anna's experience of l o s i n g both "N" and " J " In recognizing h e r s e l f as bereaved and i n others' recognition of her as such, she f e l t e n t i t l e d to openly expressing her response to her loss and to receiving support. The support of her close group of friends was important e s p e c i a l l y i n her attempt to adjust to the loss of "N". In her anguish she was comforted i n knowing that several others shared a s i m i l a r response to his l o s s , and understood the i n t e n s i t y of her reaction. S i m i l a r l y the recognition by others of the legitimacy of her loss was important. During the ceremony wherein J's ashes were spread, she r e c a l l e d being emotionally moved by the response of the captain of the boat they had chartered who c r i e d while witnessing t h e i r poignant ceremony despite knowing neither them nor " J " . At times Anna struggled with the degree of control or influence she had had i n each friends' i l l n e s s and death. She questioned at times whether she had done enough to support them. She believed she should have had the a b i l i t y to f i x , change or p r e d i c t the course of t h e i r i l l n e s s , and occasionally struggled with her c u l p a b i l i t y and self-reproach i n being unable to do so. She wondered i f t h i s struggle with control was a way of q u e l l i n g the sense of v u l n e r a b i l i t y that 50 arose when she was confronted with the i n e v i t a b i l i t y of mortality i t s e l f . She acknowledged that the loss of someone close to her had taught her that death i s a r e a l i t y to which no one i s immune, and one which can be neither predicted nor co n t r o l l e d . Anna was generally able to t o l e r a t e others' unique responses to the losses of "N" and " J " . She was aware of the differences amongst the bereaved i n t h e i r response to the deaths, and stated though she could accept those differences, " i t wasn't a shared experience". Anna also experienced t h i s sense of tolerance i n other bereaved i n d i v i d u a l s towards hers e l f , e s p e c i a l l y i n terms of the way she responded to N's l o s s . When "N" died, Anna chose not to attend his funeral. Yet despite the fact that i t was assumed everyone i n N's group of friends would attend, Anna remarked that neither her absence nor that of his other female friends at the ceremony was ever questioned by any of the group members. In contrast to such tolerance, Anna at times experienced a sense of dissonance i n her losses. This discord occurred both when her own response to loss d i d not f i t with her self-perception, and when others' response to the loss was d i f f i c u l t for her to condone. A f t e r N's death, Anna found he r s e l f wanting only to cry i n those f i r s t few months and stated that as yet she had not accepted his death. She found these responses inconsistent with a sense of s e l f she described as composed and r e a l i s t i c . Considering h e r s e l f a normally very competent and i n f l u e n t i a l person, she experienced further dissonance i n r e f l e c t i n g on her sense of powerlessness i n being unable to influence the fate of ei t h e r of her friends. At times she experienced discord with others whose responses to the loss of her friends were dissonant with her own. She found i t af f r o n t i n g when one of her friends took pictures at N's funeral and displayed them to the group such that those who were absent from the 51 ceremony could witness h i s experience. And a f t e r the death of " J " , she experienced dissonance with others who i n s i s t e d she was i n denial when they were confronted with the fact that she had already accepted J's death. In contrast to t h e i r anguish she f e l t a sense of peace and pride i n her friend's courage. In her attempt to cope with her losses, Anna found that personally meaningful r i t u a l s were important i n the process. She found such r i t e s meaningful i f they symbolically represented the deceased, her personal r e l a t i o n s h i p with the deceased, or her expectations of what a commemorative ceremony should be. The r i t u a l i n v o l v i n g the s c a t t e r i n g of J's ashes took place i n the company of supportive others and seemed to be a f i t t i n g ceremony to represent his l i f e and l o s s . Conversely, at a wake for "N" which took place i n an atmosphere of tension between p a r t i c i p a n t s , she found i t discomfiting to be expected to view photos of him and discuss him i n happy times. In attending t h i s l a t t e r r i t u a l she was disturbed by her conviction that t h i s ceremony was not something "N" would have wanted. Though she had no unanswered questions regarding J's death, Anna found h e r s e l f searching for a means of making sense e s p e c i a l l y of N's l o s s . She found his loss so d i f f i c u l t to explain i n part because she had considered him the l e a s t l i k e l y to be struck by the terminal i l l n e s s . She hoped for someone to provide an explanation for her that would q u e l l her pain, yet r e a l i z e d the f u t i l i t y of t h i s desire i n l i g h t of her b e l i e f that she could not make sense of N's death because death i t s e l f d i d not make sense. Anna experienced her response to the loss of "N" and to that of " J " as uniquely i n d i v i d u a l . In terms of " J " , to whom she f e l t connected i n his process of dying and death, she believed she was resolved about his death, and d i d not f e e l anguish with his l o s s . She compared t h i s response to her reaction a f t e r the death of "N", i n 52 whose death she has yet to f i n d acceptance and peace. She believed that "N" never accepted his i l l n e s s or impending death, which l e f t her with a continuing f e e l i n g of regret. In l i g h t of the fact that "N" died well before " J " , Anna suggested that for her, acceptance was not s o l e l y a function of time or of f a m i l i a r i t y with death. She continued to be struck by the f i n a l i t y of his death, and was angered by the fact that she would never again have the pleasure of his company. In considering the death of "N" and c e r t a i n other loved ones, she believed that she would never accept t h e i r l o s s , and resolved that death was not something that she would ever become accustomed to. Natasha's Experience of Loss Natasha's f i r s t experience of the loss of a close f r i e n d was characterized predominantly by a sense of exclusion. A f t e r the i l l n e s s and death of her best f r i e n d J. i n childhood, Natasha was denied access to attending her funeral. The s i g n i f i c a n c e of Natasha's loss was not recognized or acknowledged by others, and she was e f f e c t i v e l y excluded from bereavement status. Natasha considered " J " someone with whom she f e l t equal and very close. She believed the circumstances surrounding J's death were very s i g n i f i c a n t i n terms of her present response to l o s s . Though she was aware of extenuating circumstances which may account for the following, Natasha suspected that her exclusion from bereavement status with J's death may have impacted her l i f e to the extent that she developed a pattern of being unable to f u l l y acknowledge and process her feeli n g s r e l a t e d to l o s s . In e f f e c t , the exclusion had attenuated her a b i l i t y to f u l l y grieve. Natasha described an event which some years l a t e r triggered an intense sense of anguish for her. While working as a chaplain i n p a l l i a t i v e care she b r i e f l y met a woman whose death affected her so profoundly that she experienced anguish, confusion and depression with 53 an i n t e n s i t y she had never before encountered. In considering the meaning of her response she stated " i n a l o t of ways I f e l t as though I was r e a l l y grieving for myself. But I also think that she was the tr i g g e r for a l o t of accumulated deaths that I had experienced". Since she had not shared a s i g n i f i c a n t r e l a t i o n s h i p with t h i s woman, the i n t e n s i t y of Natasha's reaction to her loss was i n i t i a l l y bewildering. She wondered i f the woman's death had allowed her through symbolic means to deeply and completely experience the feelings which she had been previously unable to do with her more s i g n i f i c a n t losses. She stated that thereafter she understood the r e l i e v i n g and cleansing e f f e c t that other t r i g g e r s such as movies could have. For Natasha, such t r i g g e r s allow the bereaved to channel t h e i r g r i e f when no other appropriate format e x i s t s for them to otherwise l e g i t i m a t e l y do so. Her sense of exclusion with J's death resurfaced with the recent and unexpected death of J's brother. Natasha had planned to contact him for some time, but was unable to do so before his death. With his death, she was denied access to information that she believed would have a s s i s t e d her i n resolving issues and recovering memories from the part of her l i f e she had shared with " J " . Natasha again described a sense of exclusion with the death of her fr i e n d "L", who died 1 year ago. She had been very close to "L" for most of her school years, and they remained friends u n t i l L's death. There had been times i n t h e i r r e l a t i o n s h i p when there were gaps i n communication due to distance and d i f f e r e n t l i f e phases. Natasha was thus not aware of the recurrence of L's cancer u n t i l i t was very advanced. She experienced a sense of shock upon hearing that her f r i e n d was i l l with recurrent cancer, and had been so for 2-3 years by the time the news was di s c l o s e d to her. In learning further of the t r a g i c circumstances surrounding L's i l l n e s s , she also experienced an 54 overwhelming and simultaneous sense sadness and anger. "L" had been l i v i n g and h o s p i t a l i z e d i n another province. During Natasha's f i n a l v i s i t with "L" before her death, she found i t i n c r e d i b l y f r u s t r a t i n g that by the time she a c t u a l l y saw her f r i e n d she was so close to death that she was no longer present or accessible. For Natasha, i t was as i f her f r i e n d "was already i n another world...and had succumbed to death". She also experienced a f e e l i n g of dissonance with others whose response to the impending loss of V L " was d i f f i c u l t for Natasha to t o l e r a t e . In l i g h t of her need to openly acknowledge the approaching loss of "L" and i t s implications, she experienced great f r u s t r a t i o n with others, in c l u d i n g "L", who continued to deny the r e a l i t y of L's death despite i t s imminency. Through her e f f o r t s to understand the motivation behind t h i s denial, Natasha was eventually able to t o l e r a t e such responses. In recognizing that "L" had fought death for so long i n order to stay a l i v e for her young son, Natasha was able to endure the d e n i a l . During t h i s v i s i t Natasha struggled with her a b i l i t y to influence her friend's p a i n f u l process of dying. She tended to L's phy s i c a l needs and was able to make contact with "L" through the act of massaging her feet. This act symbolized for her the bond of t h e i r friendship, and was empowering for Natasha who believed that regardless of her friend's diminished l e v e l of consciousness the act would be something "L" could sense and appreciate. This f i n a l and only v i s i t with "L" before her death was one of Natasha's most treasured memories. In being present with her f r i e n d and caring for her phy s i c a l needs, Natasha gained a sense of i n c l u s i o n , a sense of being able to p a r t i c i p a t e i n and ease L's dying process. During her l a s t v i s i t with "L", Natasha had been aware of a l e v e l of s u p e r f i c i a l i t y that dominated t h e i r conversations during L's moments of l u c i d i t y . She conceded that the s u p e r f i c i a l i t y of t h i s 55 l a s t contact had a c t u a l l y characterized much of her r e l a t i o n s h i p with "L". Despite her r e q u i s i t e for depth and intimacy i n her r e l a t i o n s h i p s formed i n adulthood, her l o y a l t y remained constant to her dying childhood f r i e n d . Though the depth of t h e i r bond had been circumscribed by extenuating circumstances i n t h e i r youth, she r e a l i z e d t h i s bond had provided her with a sense of belonging and support during those years. She recognized that t h e i r friendship had been sustained throughout by the strength of t h i s bond which remained i n t a c t despite t h e i r physical distance and often very d i f f e r e n t perspectives i n l i f e . In the months before L's death, Natasha had resigned h e r s e l f to the i n e v i t a b i l i t y of her loss and believed she grieved more before L's death than a f t e r . In her attempt to cope with the r e a l i t y of L's impending death, Natasha found expression for her fee l i n g s of loss i n her music and i n her a r t . During t h i s time she was p a r t i c u l a r l y moved by the music of an a r t i s t whose songs seemed to be addressing a loved one who was dying. She learned to play these songs, and repeatedly played the one which most resonated with her own experience of l o s i n g Upon- receiving word that "L" had died, Natasha experienced an i n i t i a l sense of numbness. She described t h i s numbness as i n part a mixture of sadness that L's l i f e had ended, and r e l i e f i n that death was a p o s i t i v e a l t e r n a t i v e to the months and years of s u f f e r i n g her f r i e n d had endured. In r e f l e c t i n g on L's struggle, Natasha was aware of the e f f e c t the i l l n e s s had had on the i n t e g r i t y of her f r i e n d . Amidst the sadness of her loss, Natasha f e l t a sense of pride i n her friend's courage to b a t t l e for her l i f e for so long i n spite of her recurrent i l l n e s s . Natasha questioned whether more could have been done to have saved L's l i f e . Before L's death, she experienced great f r u s t r a t i o n i n 56 learning that "L" had been discouraged by her doctors i n seeking treatment at a centre where Natasha was aware that promising p o s s i b i l i t i e s existed for treatment. In learning of her friend's i l l n e s s too l a t e , Natasha was powerless to influence the s i t u a t i o n . She was angered by the fact that "something could have happened and the circumstances didn't tr a n s p i r e " . She was confronted by the f i n a l i t y of death; an important t i e to her past, that which had sustained her i n her youth, was gone. The sense of exclusion Natasha had experienced during L's i l l n e s s was again heightened by a l e t t e r she received from L's twin s i s t e r , with whom Natasha had also been close for many years. Natasha dis c l o s e d i n a previous l e t t e r to L's s i s t e r the issues that she had been struggling with since L's death. In response, she received a l e t t e r which for Natasha had the e f f e c t of i n v a l i d a t i n g her pain and los s . I t was a response which indicated to Natasha that she would be impeded i n further discussing her loss with t h i s f r i e n d . A f t e r working through the pain of her loss within her own support group, Natasha was able to to l e r a t e the disenfranchisement she had endured with L's s i s t e r . She recognized that her f r i e n d had not yet begun to grieve the loss of her own s i s t e r , and had continued to deny to he r s e l f the s i g n i f i c a n c e of her l o s s . When her pain was discounted by L's s i s t e r , Natasha sought other avenues through which she could openly explore and c l a r i f y the meaning of L's l o s s . She gained a sense of i n c l u s i o n i n terms of being enabled to openly discuss her experience of loss through her own support group. There she was given the l a t i t u d e to struggle with her pain and the issues surrounding her l o s s . Her sense of i n c l u s i o n was also heightened by the development of her friendship with "K", L's daughter. A f t e r L's death, Natasha contacted K. to o f f e r her support and acknowledge her l o s s . Through t h e i r open discussion of L's loss 57 and i t s implications, Natasha had the experience of connecting at a deeper l e v e l with "K". I t i s a connection that continues to gain depth as they resolve t h e i r experience of l o s s . Natasha found the freedom i n her support group to f u l l y express what the loss of "L" had meant for her. She described her experience s t a t i n g , "only when I was able to f e e l the f u l l n e s s of what I needed to f e e l , and to go to the depths of the despair that was there and to acknowledge that, and to be i n that r e a l l y lonely place was I able to then l e t i t go and emerge i n a new form". In so doing, she recognized that through her friendship with "L", she had obtained i n her youth that which for her symbolized support, family and belonging. She began to r e a l i z e that her experience of the loss of "L" may have potentiated a p a r a l l e l need to grieve the absence of her own natural family i n her l i f e . She had considered "L" and L's family to be her re a l family, and wondered i f i n grieving for "L" she was also grieving the loss of the b i r t h family she never had. Through t h i s process of acknowledging the meaning of her r e l a t i o n s h i p with "L", she further confirmed the extent of her loss and the legitimacy of her bereavement status. Natasha searched not only for a means of making sense of her losses, but also f o r a way to grieve the death of her friends that would honor the meaning t h e i r l i v e s had embodied. Natasha was conscious of a long established pattern wherein she found h e r s e l f unable to immediately and f u l l y acknowledge and experience her feelings r e l a t e d to the l o s s . Two years a f t e r L's death, Natasha questioned whether she had grieved for her f r i e n d as completely as she believed she should. She r e c a l l e d a character i n a f i l m whose response to the loss of a close f r i e n d moved her so deeply that she has since wished to emulate t h i s i d e a l i n her own experience of l o s s . She stated that i n her response to loss she would wish to "grieve the 58 loss at the time i t happened... and acknowledge the meaning of the deceased ••• [in order to] honor them by carrying that and channelling what was s p e c i a l about them i n your own l i f e " . In her attempt to meaningfully resolve the l o s s of her friends, Natasha r e f l e c t e d on the ways i n which she had adapted to other losses. She i d e n t i f i e d meaningful r i t u a l s as important factors i n her a b i l i t y to resolve those losses. A f t e r being impeded as a c h i l d i n attending J's funeral, Natasha watched the ceremony from the school yard fence. She believed that at l e a s t having witnessed the ceremony was s i g n i f i c a n t i n l e g i t i m i z i n g her experience of J's l o s s . She r e c a l l e d having created a funeral r i t u a l for a dead b i r d some time a f t e r J's death, and wondered i f t h i s was an attempt i n her childhood to symbolically commemorate J's l i f e and put her death i n t o perspective. Years l a t e r as an adult she returned to her childhood home and went to places that had been s i g n i f i c a n t . She believed that having taken a picture of J's tombstone was an important step towards resolut i o n . She stated that creating a r i t u a l enabled her to honor the meaning of the deceased. In so doing i t allowed her to " l e t go of whatever [she seemed] to be hanging onto about that person's death". Natasha recognized that aspects of L's l o s s remained unresolved for her, and she needed to create a r i t u a l that would allow her to commemorate the meaning "L" had embodied. She r e a l i z e d however that at present she was not yet ready to do t h i s . In conjunction with r i t u a l , she also described the creation of artwork as an avenue which i n her adulthood enabled her to access the feelings that she had d i f f i c u l t y acknowledging and f u l l y experiencing i n her l o s s . The process of writing was another way i n which she commemorated the l i f e and meaning of the deceased. I t was through t h i s l a t t e r process that she was able to begin to work through the 59 loss of "L". When "L" died Natasha could not j u s t i f y another long journey to attend the funeral. Instead she took pains to compile for the service and L's family a multi-page card which acknowledged a l l that "L" had meant to Natasha over the many years of t h e i r friendship. Natasha questioned whether her response to loss i t s e l f was unique i n r e l a t i o n to the way i n which other bereaved i n d i v i d u a l s respond. Though she believed her a b i l i t y to grieve was c h a r a c t e r i s t i c a l l y attenuated, she resolved past losses i n part through such acknowledgements as r i t u a l , w r i t i ng and d i s p l a y i n g pieces of artwork which capture the meaning of that p a r t i c u l a r deceased i n d i v i d u a l . She was uncertain whether such acknowledgements would be made by others i n t h e i r experience of l o s s , but believed such had been h e l p f u l i n her own process of attempting to resolve her losses. S i m i l a r l y , she questioned whether her response to L's loss would be unique i n r e l a t i o n to her response to losses she may suff e r i n the future. She compared the l e s s e r degree of i n t e n s i t y attained i n her friendship with "L" to her more recent r e l a t i o n s h i p s through which she has "connected at deeper l e v e l s with people". In considering her growing a b i l i t y to a t t a i n greater depth i n these r e l a t i o n s h i p s , she speculated that her response to these losses i n r e l a t i o n to her present experience with the loss of "L" would be unique, and one i n which the depth and f u l l n e s s of her g r i e f would correspond to the depth of connection she had thus established. In considering the way i n which she has grieved for "L", Natasha stated that i n some respects she has been able to grieve i n the way she believed she should for her f r i e n d . Through such means as the memorial card she composed and sent to L's family a f t e r her death, she believed she had begun to acknowledge and channel the meaning of her friend's l i f e . In considering such, she wondered i f she was more completed i n her grieving and i n accepting L's loss than what she had 60 thus f ar r e a l i z e d . Though she believed she needed to bring some f i n a l closure to the process, she questioned i f she had not already experienced the depth of g r i e f for "L" that she believed she e s s e n t i a l l y would experience. In reviewing her experience of L's lo s s , Natasha concluded that the emotional impact of death on the bereaved may be recognized to some degree by others. She believed however that the s i g n i f i c a n c e of the death i s soon l o s t i n the intensive, f r e n e t i c l i f e s t y l e of a culture that honors performance and denies g r i e f . She suggested t h i s denial e x i s t s for a l l loss i n c l u d i n g that of a family member, but i s i n t e n s i f i e d when the loss i s that of a f r i e n d . Carla's Experience of Loss Carla described a long h i s t o r y with "S", a close f r i e n d who took her own l i f e nearly 2 years ago. They had known each other since they were babies, and had l i v e d next door to each other for much of t h e i r l i v e s sharing most a l l of t h e i r childhood and youth experiences. As young women t h e i r friendship continued, although t h e i r closeness fluctuated with the waxing and waning of S's struggle with p s y c h i a t r i c i l l n e s s i n early adulthood. Before the onset of i l l n e s s , Carla believed "S" had the p o t e n t i a l to s u c c e s s f u l l y do whatever she aspired to i n l i f e . I n i t i a l l y during the 6 years of S's i l l n e s s Carla maintained hope that "S" would recover, encouraged by her b e l i e f i n her friend's t a l e n t and p o t e n t i a l . When "S" became i l l , Carla spent time during her friend's i n c r e a s i n g l y unstable periods o f f e r i n g support and hope for her recovery. However as S's disease advanced and she watched her f r i e n d become diminished and d e s t a b i l i z e d Carla began to believe she was witnessing the decline of terminal i l l n e s s . Her hope began to diminish as she resigned h e r s e l f to the i n e v i t a b i l i t y of S's fate. She found h e r s e l f beginning to accept her impending loss well before S's actual 61 death. She believed the i l l n e s s had not only begun to erode S's character but also the i n t e g r i t y they had shared i n t h e i r friendship. She often found he r s e l f exhausted a f t e r t h e i r v i s i t s and f e l t she was getting l i t t l e i n return for the energy she was putting into t h e i r friendship. I t had become obvious to her that i n the f i n a l years of t h e i r r e l a t i o n s h i p "S" was determined p r i m a r i l y to end her own anguished l i f e . Aware of t h e i r diminished intimacy, Carla attempted to maintain the friendship's i n t e g r i t y by avoiding the use of her p s y c h i a t r i c knowledge to influence "S" during t h e i r time together. During v i s i t s with "S", she maintained what she described as the role of a fri e n d , and focused on happy or neutral topics i n order to remind "S" of the j o y f u l aspects of l i f e . Though Carla often worked extra s h i f t s on the p s y c h i a t r i c unit, i n order to avoid further discouragement and sadness i n seeing her f r i e n d there, she refused to work s h i f t s on that unit when "S" was admitted. Carla maintained her support for "S" i n the face of an i l l n e s s that others found disturbing, and i n sp i t e of S's diminished a b i l i t y to be an equal partner i n t h e i r friendship. She believed she was able to make such concessions as a r e s u l t of the bond she shared with "S". She believed that her professional knowledge also helped her to better understand S's p l i g h t and found h e r s e l f experiencing dissonance with others whose approach to S's i l l n e s s seemed to i n t e r f e r e with her recovery. She was fr u s t r a t e d with the seemingly counterproductive attempts of others to augment S's therapy, and angered by those who took advantage of S's v u l n e r a b i l i t y by r e c r u i t i n g her during her i l l n e s s into an unfamiliar f a i t h . While Carla was away on holidays, "S" took her own l i f e . Without knowing the reason for her sense of urgency, Carla had a strong sense that she and her family should return home ea r l y from t h e i r holidays. 62 Upon t h e i r a r r i v a l she was informed that her f r i e n d had died and the funeral was scheduled for l a t e r that day. I t was a memorial she considered important to attend yet would have missed had she not heeded her i n t u i t i v e sense. Though she found the i n t u i t i o n unnerving, she believed that the close bond she shared with "S" had i n e x p l i c a b l y drawn her home for the funeral. During S's open casket funeral, Carla refused to view her f r i e n d l y i n g i n state. She instead chose to remember "S" i n her v i t a l i t y and companionship. An image which continued to stand out for Carla was that of her f r i e n d transformed as an angel at the moment of her death. This image was comforting for Carla. I t symbolized for her that her f r i e n d had f i n a l l y found the peace which she had been long struggling for. The formal r i t u a l of S's funeral was an u n s e t t l i n g experience for her. I t f a i l e d to acknowledge the p o s i t i v e e f f e c t "S" had had on the l i v e s of Carla and others. Its proceedings were extremely unfamiliar to her, further f r u s t r a t i n g her expectations for a ceremony that would meet her needs for closure. In contrast, the evening spent with bereaved friends immediately a f t e r the funeral was for Carla a more f i t t i n g r i t u a l . I t commemorated S's l i f e through the mutual sharing of personal remembrances of her. This l a t t e r r i t u a l and that of the funeral (despite i t s shortcomings) took place i n the company of supportive others, and Carla recognized such r i t u a l s as important opportunities for her to share her g r i e f and have i t acknowledged by others. She believed that had she missed these gatherings, she would have f e l t more i s o l a t e d i n her l o s s . Rather than experiencing shock with the news of S's death, her sense of shock and d i s b e l i e f were rel a t e d more to the strength of her own i n t u i t i o n that urged her early return from holidays i n time to attend her friend's funeral. Carla recognized that despite having 63 been prepared for her friend's i n e v i t a b l e death, she nonetheless experienced a sense of numbness as a r e s u l t of having had l i t t l e time to absorb the news before the actual funeral. She f e l t unprepared for the memorial and recounted the day of the funeral as one of the worst i n her l i f e . She described a sense of being on "automatic p i l o t " for some time a f t e r the funeral. When the numbness' d i s s i p a t e d i t was replaced by a sense of anguish and longing which seemed to be triggered e s p e c i a l l y during times when she was alone or engaged i n tasks which did not require her t o t a l concentration. Later i n her bereavement she found that anniversary dates such as S's birthday and the date of her death also triggered her anguish. In the f i r s t several months following the death of her f r i e n d , Carla experienced a sense of exclusion or i s o l a t i o n i n her bereavement experience. This exclusion was generated p r i m a r i l y by her b e l i e f that the meaning and extent of her loss would not be understood by those who d i d not know "S" when she was healthy. She believed few would comprehend the l e v e l of intimacy t h e i r friendship had reached, and resolved i n i t i a l l y that she could speak with no one about her l o s s . She experienced her r e s t r a i n t as a burden and stated "I kept i t a l l to myself....I r e a l l y didn't think I had permission to t a l k about my g r i e f " . Her close friends who were also grieving the loss of "S" l i v e d f a r away and were not always accessible, which further exacerbated her sense of i s o l a t i o n . Carla also experienced a sense of dissonance i n r e s t r a i n i n g h e r s e l f from openly discussing her experience of loss a f t e r S's death. She perceived he r s e l f to be very f o r t h r i g h t i n discussing and resolving her issues, yet i n t h i s s i t u a t i o n of loss she f e l t impeded i n her a b i l i t y to resolve i t . This f e e l i n g of disc o r d was heightened by her sense of being torn between longing for the return of her f r i e n d and admitting that i t was only i n death that "S" found the 64 peace she had wanted. When Carla r e a l i z e d that her f r i e n d would never again be there to share birthdays and other s p e c i a l times, she was struck by the f i n a l i t y of death i t s e l f . She experienced lo n e l i n e s s and longed for someone with whom she could share her sadness. Though she had friends who met other needs, she r e a l i z e d that the unique h i s t o r y and c h a r a c t e r i s t i c s that t y p i f i e d her bond with "S" were i r r e p l a c e a b l y gone. Amidst her anguish a f t e r S's death Carla also experienced anger with her f r i e n d . Given the i n t e g r i t y she believed her f r i e n d had possessed i n her health, she found i t d i f f i c u l t not only to t o l e r a t e the means by which S. had chosen to end her l i f e , but also the way i n which others i n the community had sensationalized that choice. I t was d i f f i c u l t to accept that given S's i n t e l l i g e n c e , and despite such i n t e l l i g e n c e , "S" must have c l e a r l y known that i t would be her parents who would make the p a i n f u l discovery of her l i f e l e s s body i n t h e i r own home. Carla was eventually able to make sense of S's act and accept i t by a t t r i b u t i n g her motive to desperation rather than s e l f i s h n e s s . In adapting to her l o s s , Carla found h e l p f u l the creation of her own private r i t u a l s . Though she assumed i t customary to wear black to the funeral she chose to wear c o l o u r f u l c l o t h i n g instead because she believed i t better represented her vibrant friendship with "S". And l a t e r i n her bereavement when she found h e r s e l f constantly dwelling on S's death and struggle with l i f e , she created another r i t u a l to honor the joy her friend's l i f e had also embodied. She resolved to engage i n a r i t u a l each January, the month of S's b i r t h , wherein she would set aside time to purposefully focus on the p o s i t i v e and happy memories of S's l i f e . Recognition of the extent of her loss and of her status as bereaved was also an important factor i n Carla's adaptation to her 65 l o s s . The support of those close friends who had known WS" when she was healthy was paramount f o r Carla. She d i d not expect support from those who d i d not know S. well but cherished such support when i t was received. She was impressed by the generosity of the wife of a f r i e n d whose h o s p i t a l i t y made i t possible for Carla and other bereaved friends to gather and o f f e r each other support i n t h e i r l o s s . In the i n i t i a l months a f t e r S's death Carla struggled with recognizing h e r s e l f as l e g i t i m a t e l y bereaved. She attempted to q u e l l her pain by diminishing the importance of her l o s s . She found h e r s e l f i n times of anguish repeatedly attempting to convince h e r s e l f she had "only l o s t a f r i e n d " . Only a f t e r agreeing to be interviewed about her experience of loss d i d she give h e r s e l f permission to acknowledge to he r s e l f and others the f u l l extent of her loss rather than deny i t s legitimacy. She experienced r e l i e f i n allowing h e r s e l f to do so, and stated "now I know that friends are allowed to grieve and w i l l grieve". Upon acknowledging the legitimacy of her own loss, Carla r e a l i z e d that her close friends, separated from her and each other by distance, were l i k e l y f e e l i n g as i s o l a t e d i n t h e i r g r i e f as she had been i n hers. She resolved to share her feelings about her loss of "S" with them, and i n v i t e d them to share the same. She made the o f f e r as a means of l e g i t i m i z i n g both t h e i r experience of loss and t h e i r entitlement to support. In so doing, Carla. found that her previous sense of i s o l a t i o n began to d i s s i p a t e . Though she found a f f r o n t i n g some responses of others to S's death, Carla was generally able to t o l e r a t e i n d i v i d u a l autonomy i n terms of others bereavement responses. She described the response of a mutual f r i e n d who rescinded her support of "S" well before the l a t t e r ' s death. Though she d i d not condone i t , Carla accepted t h i s f r i e n d ' s response by resolving that by v i r t u e of her upbringing t h i s f r i e n d 66 could not have been expected to respond d i f f e r e n t l y to S's behaviour. Carla described as uncanny the occurrence of c e r t a i n u n l i k e l y events which helped her adapt to her l o s s . She described the f i r s t such event as occurring during S's funeral where i n the midst of her anguish she was able to experience the unexpected support of a close mutual f r i e n d of he r s e l f and "S" who uncannily happened to be i n town at the time of S's death and funeral. Several months l a t e r Carla experienced another event which helped her further adapt to her loss and to resolve aspects of the loss with which she had been struggling. Some time a f t e r S's death, Carla was the sole person to intervene i n the attempted suicide of one of the patients on the ward. Later that night she had a dream which connected t h i s patient's attempt at suicide with the death of S. In attempting to make sense of the dream she concluded that despite never having taken conscious r e s p o n s i b i l i t y for S's outcome, she believed that at some l e v e l she was struggling with her c u l p a b i l i t y i n i t . She was unnerved by the a b i l i t y of her unconscious to force her to make meaning of aspects of the loss which she had previously avoided addressing. The dream helped her to recognize that aspects of S's death, such as her r e s p o n s i b i l i t y to intervene, had remained unresolved and she needed thus to t a l k about her experience of loss i n order to resolve such issues. She found the dream comforting i n that a f t e r making sense of i t , she became more resolved i n b e l i e v i n g she and others had done everything they could to save S. Her friend's death was ul t i m a t e l y her own choice. Though she acknowledged that thoughts about her r e s p o n s i b i l i t y may recur i n the future, she was comforted i n knowing that everything that could have been done was done to save her f r i e n d . In r e f l e c t i n g on her experience of lo s s , Carla suggested that for her the loss of a close f r i e n d was p r i m a r i l y a uniquely personal experience. She believed that i n contrast to the loss of a family 67 member wherein there are some commonly accepted meanings associated with the loss, the death of a close f r i e n d i s d i f f i c u l t for the non-bereaved to r e l a t e to s p e c i f i c a l l y because the p a r t i c u l a r l e v e l of intimacy attained i s not a given. She stated that others are generally unaware of the l e v e l of intimacy a p a r t i c u l a r friendship has attained. She concluded that the meaning of the loss of a close f r i e n d was one which could only be c l a r i f i e d p r i v a t e l y or through the assistance of someone who could allow the bereaved to explore the experience without interference. Though p a i n f u l memories of S's years of struggle had i n i t i a l l y predominated Carla's thoughts, she was eventually able to manage an increasing a b i l i t y to focus on memories of "S" i n happier h e a l t h i e r times. Carla stated that two years a f t e r S's death she d i d not have to deny the p a i n f u l memories but could choose more w i l f u l l y not to focus on them. She no longer f e l t anguish but simply missed her friend's presence. She believed she had completed what she considered stages of l o s s , and was f i n a l l y at peace with her friend's death. She was g r a t e f u l that S's struggle with the pain i n her l i f e had ended. Her f r i e n d had f i n a l l y found i n death the peace that had evaded her i n l i f e . Diane's Experience of Loss Diane discussed the loss of four close friends who had died over a span of several years i n her adult l i f e . With each death she gained a greater depth of meaning i n the l o s s . During these years she was also intensely involved with her a i l i n g mother who died when Diane was 26, and her dying grandmother whom she l o s t 14 years l a t e r . Her experiences with them i n t h e i r processes of dying and death l a r g e l y enhanced her a b i l i t y to cope and f i n d meaning i n the deaths of her friends. Since aspects of her experience with her dying family members have informed her perception of loss, such aspects w i l l be 68 included i n describing her experience of grieving the deaths of her close friends. Diane's f i r s t experience with death was with the sudden loss of her f r i e n d "A", 21 years ago. During the b r i e f d i s a b l i n g i l l n e s s that culminated i n his death, she was emotionally overwhelmed by his de t e r i o r a t i o n . She found h e r s e l f unable to be with him before his death, and long a f t e r experienced disappointment i n hers e l f for t h i s self-imposed exclusion. For some time a f t e r his lo s s , Diane denied the r e a l i t y of the fact that he would never return. She experienced a sense of dissonance i n t h i s confrontation with death and could f i n d no meaning i n i t . At t h i s e a r l y point i n her l i f e she was unfamiliar with death and had not yet acknowledged the r e a l i t y of i t s existence. She remained unable to make sense of his death u n t i l a f t e r experiencing the loss of her own mother. Her intense involvement with her mother's process of dying helped her to accept the r e a l i t y of death and f i n d meaning i n i t . Whereas her exclusion from A's process of dying had denied her access to such meaning, she witnessed i n her a i l i n g mother a sense of s p i r i t u a l i l l u m i n a t i o n or transcendence i n the midst of her d e t e r i o r a t i o n . Through her i n c l u s i o n i n her mother's experience of dying she resolved there existed peace i n death, and the dying welcome i t as an end to t h e i r s u f f e r i n g . She began to perceive of death as an awe i n s p i r i n g mystery. And since t h i s experience she has looked for and sensed t h i s s p i r i t u a l aspect of death i n a l l the losses she has endured. Through her experience with her dying mother, Diane developed a pervasive desire to understand the experience of death and dying. Her need to understand and support t h i s process allowed her a sense of i n c l u s i o n some years l a t e r i n her f r i e n d J's experience of dying. While being treated for a l i f e - l o n g chronic i l l n e s s her f r i e n d had contracted a disease which was terminal. Her a b i l i t y to support him 69 i n his struggle allowed Diane and J. to openly and con t i n u a l l y discuss his i l l n e s s and impending death, and the implications i t held for each of them. As a r e s u l t of t h i s i n c l u s i o n , the closeness i n t h e i r friendship deepened during h i s lengthy i l l n e s s u n t i l his death, nearly 9 years ago. , Diane was i n s p i r e d by the adherence to a purpose of being that characterized her friend's l i f e throughout his struggle with chronic and terminal i l l n e s s e s . He confided to her that i n having l i v e d with a chronic i l l n e s s which involved frequent h o s p i t a l i z a t i o n s , he had grown up with the r e a l i t y of dying. He believed t h i s perspective helped him to bear and accept the present r e a l i t y of his terminal i l l n e s s . His resignation to death and longstanding courage i n the face of i t s i n e v i t a b i l i t y helped to f a c i l i t a t e her own acceptance of his impending death. " J " died a f t e r a night of agonizing pain, and had cut his wrists seemingly i n the midst of his agony. As with her f r i e n d "A", Diane again experienced a sense of dissonance with her l o s s . Her discord was associated not with the r e a l i t y of h i s death i t s e l f but rather with the way i n which his l i f e may have ended. In l i g h t of the stoicism she f e l t he had possessed, she had great d i f f i c u l t y resolving the fact that he may have taken his own l i f e and struggled to make sense of t h i s for some time a f t e r his death. Her sense of dissonance was i n t e n s i f i e d by learning a f t e r his death both of the unnecessary s u f f e r i n g he had endured i n his family throughout his childhood, and the f i g h t i n g that had ensued between his family members over his assets a f t e r his death. She f e l t confronted by what she described as the unfairness of l i f e . Diane struggled with issues of control e s p e c i a l l y around J's sudden l o s s . Though she had been resolved to J's i n e v i t a b l e death, she found h e r s e l f unprepared for how suddenly his death a c t u a l l y 70 occurred. Her sense of v u l n e r a b i l i t y was heightened by her struggle to cope at the time of J's death with the f a i l i n g health of her father and grandmother, and the impending death of the l a t t e r . Challenged by the v u l n e r a b i l i t y of t h e i r mortality, she found h e r s e l f overwhelmed and stated "I didn't go and scatter J's ashes because I didn't think I could face i t . . . i t was ju s t too much". Several years l a t e r Diane was again confronted by t h i s v u l n e r a b i l i t y with the loss of her f r i e n d "D", who died 4 years ago suddenly and without warning. She described having experienced a sense of great shock and d i s b e l i e f i n his death which l a s t e d long a f t e r h i s funeral. She struggled for some time with the seeming meaninglessness of his death, and recognized that her t r i a l was due i n part to being completely unprepared for his l o s s . Her experience of D's loss was further shaped by events which l e d her to f e e l intense dissonance. Amidst the pain and confusion of her los s , she was enraged by another mourner whose e x p l o i t a t i v e actions impinged on the a b i l i t i e s of Diane and other bereaved to openly and f u l l y experience and share t h e i r g r i e f . She f e l t offended that t h i s mourner would advance her own needs at the expense of other bereaved who wanted only to honour and acknowledge t h e i r l o s s . Diane's sense of discord was heightened further yet by an image of D's young daughter whose l a s t memory of her father was that of him f i g h t i n g with her mother. She was saddened i n knowing that t h i s c o n f l i c t would be his daughter's f i n a l memory of him. She believed his sudden death had robbed "D" and those close to him of the chance to say and do what was needed to bring a sense of resolu t i o n to his l i f e . She was l e f t with a sense of being excluded from his dying and death. With his death she recognized she lacked the s p i r i t u a l feedback that she had received through her i n c l u s i o n i n her mother and J's processes of dying; feedback which she believed was 71 an important factor i n find i n g meaning i n and accepting the l o s s . Her sadness and i n a b i l i t y to f i n d meaning i n his death seemed prolonged to her, and she found that an intense sense of these appeared to be triggered by various circumstances such as encountering strangers who resembled her deceased f r i e n d . In her struggle to make sense of his death she sought the advice of "J.H", another close f r i e n d who himself was dying of a terminal i l l n e s s . In his responding l e t t e r "J.H" discussed the degradation he experienced through his physical d e t e r i o r a t i o n , his fear of t o t a l i n c a p a c i t a t i o n and dependence, and his impossible challenge to make sense of his approaching death. He suggested that because "D" had not expected his own impending death he was enabled to l i v e his l i f e f u l l y and without such struggle u n t i l the moment of h i s death. In reviewing the l e t t e r , Diane believed that i t more than anything helped her to cope with D's death. Recognition of her loss and of her status as bereaved was an important factor i n Diane's adjustment to her losses, i n c l u d i n g D's. With each death, she c l a r i f i e d the extent and s i g n i f i c a n c e of the loss through the act of reviewing who her f r i e n d had been i n l i f e and what he had meaint to her. With each loss she considered h e r s e l f l e g i t i m a t e l y bereaved. However with D's death she was aware that the f u l l extent of the loss suffered by he r s e l f and others could not be acknowledged because many of the bereaved were simply unaware of the depths of each other's connections to "D". In order to address the si t u a t i o n , Diane made e f f o r t s during and a f t e r his funeral to seek out such bereaved and acknowledge the mutual l o s s . In her attempt to adapt to his loss and further r e c t i f y the disenfranchisement she witnessed, Diane found h e l p f u l the creation of a personally meaningful r i t u a l . She supported the creation of a memorial fund which would support a workshop offered annually i n h i s 72 area of s p e c i a l i t y . She then encouraged those l e s s recognized bereaved i n d i v i d u a l s to a s s i s t i n i t s co-creation. She conceived of the memorial not only as a means of honouring "D", but also as an avenue through which the disenfranchised bereaved could receive support and invest the energy from the pain of t h e i r loss into something p o s i t i v e . One year ago Diane l o s t a fourth close f r i e n d , "J.H", who died a f t e r enduring a terminal i l l n e s s for several years. Her i n i t i a l experience of his impending loss was characterized by a sense of exclusion. She had been aware of his terminal i l l n e s s well before he dis c l o s e d i t to her and during t h i s i nterim she f e l t impeded i n her need to openly discuss with him his impending death and i t s implications. She found he r s e l f p a i n f u l l y r e s t r a i n i n g her anguish i n his presence. A f t e r his dis c l o s u r e of his i l l n e s s , she gained a sense of i n c l u s i o n i n his experience of dying. She was intensely involved i n his care to the very end of his l i f e . Throughout t h i s time together they openly discussed h i s i l l n e s s and the s i g n i f i c a n c e of his l o s s . Her involvement i n his experience deepened t h e i r friendship, and a s s i s t e d her sense of acceptance i n his l o s s . Although Diane was intensely dedicated to a s s i s t i n g "J.H" i n his dying process, she allowed others autonomy i n t h e i r own response to his i l l n e s s and approaching death. She encountered several mutual friends who for various reasons could not o f f e r him t h e i r support and t o l e r a t e d t h e i r i n a b i l i t y to be involved despite her own compelling commitment to him. She witnessed i n her f r i e n d "J.H." an i n t e g r i t y that remained i n t a c t despite the adversity of his d e b i l i t a t i n g i l l n e s s . He had confided to her that his mounting i n c a p a c i t a t i o n challenged h i s a b i l i t y to continue to f i g h t for l i f e , yet he adhered to the purpose 73 of l i v i n g the remainder of his l i f e with d i g n i t y and accepting his death with that same di g n i t y . And though the loss of her f r i e n d was extremely p a i n f u l , her own i n t e g r i t y remained i n t a c t throughout his dying process. She f e l t proud of her a b i l i t y to commit to his care and o f f e r support i n spite of her own sorrow. Before departing on a holiday, Diane experienced i n her l a s t v i s i t with "J.H." a strong sense that his death was imminent. Her i n t u i t i o n was confirmed by his partner. In having t h i s r e a l i t y confirmed, Diane and "J.H." were given the opportunity to say a f i n a l goodbye and assure each other of t h e i r love for one another. She believed they were able to l e t go with peace and resolve. While she was away she experienced a sensation wherein her long-standing anxiety about "J.H." was suddenly diminished, and was replaced by a f e e l i n g of peacefulness. She sensed that "J.H" had f i n a l l y l e t go of l i f e . Her i n s t i n c t was l a t e r affirmed when she learned that her f r i e n d had died at the same moment i n which she had f e l t a sense of peace. In the weeks surrounding his death Diane f e l t she needed to do something p o s i t i v e with the energy from her anguish. Again she found the mechanism of r i t u a l important i n helping her adjust to J.H's death. A f t e r his funeral i n the company of other bereaved who were also close to "J.H.", she p a r t i c i p a t e d i n a ceremony wherein his ashes were scattered over the ocean. She and other mutual close friends also donated a bench i n his honour to a l o c a l park. A f t e r his death, she recognized that through her intense involvement i n his dying process she had impeded h e r s e l f from enjoying her own l i f e . She had f e l t that while he was s u f f e r i n g she could not h e r s e l f continue to l i v e f u l l y . During his i l l n e s s she d i d not want to burden him with her own sorrow, and made a further concession of resolving not to cry while i n his presence. A f t e r each v i s i t she 74 would allow her sorrow to surface and c r i e d while alone i n her car on her way home. Though she d i d not regret her concessions she believed she paid a t o l l for her intense support i n having blocked her own experience of joy before his death. She was aware that a f t e r his death, she f e l t the r e l i e f of being able to continue to l i v e f u l l y again. Diane described her experience with the loss of her grandmother several years e a r l i e r and that of "J.H." as s i m i l a r i n terms of "the long term and the preparedness and the deep t a l k s , and the acceptance". She believed her experience with the dying and death of her grandmother had most influenced her a b i l i t y to f i n d meaning i n the death of "J.H.". She described an experience a f t e r the loss of her grandmother which immensely affected her perception of death. A f t e r her grandmother's death Diane won i n a l o t t e r y two consecutive f i r s t p r i z e s , each of which was a b o t t l e of "Joy" perfume. She believed her grandmother had somehow sent t h i s message i n an attempt to ease Diane's pain by describing the joy she had found i n death. Several years a f t e r her grandmother's death she was able to bring t h i s meaning to the loss of her f r i e n d "J.H.". Despite her anguish she f e l t c e r t a i n that i n death "J.H." had found joy. He had been freed from his p a i n f u l struggle with l i f e and had gone on i n peace to a better place. J.H's i l l n e s s had been long-term, and i n watching him deteriorate she had accepted that i t was terminal. She had experienced intense and continual anguish i n the months before his death, and stated she had done "most of the work of g r i e f " before his death. Although a year a f t e r his death she believed she had come to terms with much of his loss, she found that c e r t a i n symbolic reminders, such as passing by the bench dedicated to his memory, triggered her sadness. She conceded that although she was s t i l l mourning, the triggered sadness 75 was not i n d i c a t i v e of a lack of acceptance of J.H's lo s s , but rather of the depth of her feeli n g s for him. In considering a l l of her experiences of l o s s , she resolved that " g r i e f i s about mourning our own mo r t a l i t y as much as mourning the loss of the other person". She believed that her losses, e s p e c i a l l y those that were sudden, had taught her to make the most of each moment with others. And i n witnessing such courage i n her friends, she acknowledged she was he r s e l f i n s p i r e d towards greater courage, wisdom and purpose i n her own l i f e and work. General Structure The Meaning of Grief for a l l Co-researchers Despite the d i v e r s i t y of t h e i r experience of lo s s , there appeared to be an invar i a n t thread which ran through each co-researcher's story of g r i eving the death of her close f r i e n d . This thread was constructed of 10 themes common to a l l the experiences. Though each survivor's story contained some themes not found i n the other experiences of lo s s , the meaning of g r i e f for a l l co-researchers seemed to embody the following themes or elements: Emotional Distress, Exclusion, Inclusion, Concession, Control, Dissonance, Integrity, Meaning, R i t u a l , and Acceptance. These elements d i d not appear to be experienced i n a l i n e a r pattern within the experiences. As the s t o r i e s of loss were t o l d by the co-researchers, i t would appear that some elements were experienced simultaneously and at several points throughout the experience of l o s s . For the sake of the following presentation, however, the elements w i l l be presented i n a l i n e a r manner with the caveat that no one element appeared to supercede another i n terms of influence i n the co-researchers' experience of g r i e f . The f i r s t element, or theme, to be presented i s that of Emotional d i s t r e s s . Emotional d i s t r e s s . 76 With the death of her fri e n d , the co-researcher described a sense of emotional d i s t r e s s which may have included such facets as anguish, confusion, d i s b e l i e f , longing, and a sense of being overwhelmed. These feel i n g s appeared to be experienced to varying degrees regardless of her preparation for the death of her f r i e n d . This reaction seemed to be i n t e n s i f i e d when the death was sudden or multiple stressors existed. Throughout her bereavement these feelings tended to be triggered by various factors for the co-researcher, including symbolic reminders of the deceased, or the acknowledgement by others of the legitimacy of her l o s s . Other t r i g g e r s were also reported such as dreams and moments of quiet or solitud e . In response to the loss of her f r i e n d "N", Anna experienced the anguish, sadness and sense of meaninglessness which she believed were t y p i c a l aspects of bereavement. She stated that when "N" died, the experience was so intensely p a i n f u l and so t y p i c a l of what people think of that enormous sense of sadness and wanting to cry and not wanting i t to happen.... a l l I wanted to do was to know how to get through the days....A couple of people at work knew "N", and that we had a very close r e l a t i o n s h i p and I just didn't want them to say anything ...I [didn't] want to cry...and I was a f r a i d something would t r i g g e r . . . S i m i l a r l y , with the loss of her f r i e n d "S", Carla experienced an intense sense of anguish which was often and unexpectedly triggered. She stated, She'd been doing r e a l l y good so i t was a r e a l shock....my sadness and pain came up at funny times, during dreams and while d r i v i n g or doing other tasks....I think of her at d i f f e r e n t times and i t ' s now just sad. I t ' s not an ache or a shock anymore, I just miss her. With the deaths of her close friends, Diane also experienced a sense of anguish and longing, and at times f e l t overwhelmed by her 77 l o s s . She described an i n t e n s i f i e d sense of these e s p e c i a l l y during the i l l n e s s and a f t e r the death of her f r i e n d "J.H", and stated With "J.H." i n p a r t i c u l a r the loss was so apparent and so long term, you know [I was] con t i n u a l l y grieving...I was always conscious about not crying i n front of him and so I'd see him and then drive home i n my car bawling my eyes out. That was an ongoing part of i t . So when he a c t u a l l y died there was a l o t of that work that had already been done...A couple months ago I walked by the apartment that he used to l i v e i n and I started crying... i t ' s not a lack of acceptance. I t ' s more ju s t how deeply you f e e l about i t and how close the r e l a t i o n s h i p got through the process of l o s s . A f t e r the loss of her l i f e - l o n g f r i e n d "L", Natasha described a sense of shock followed by an overwhelming sense of sadness and anger, st a t i n g The cancer was i n her bones by the time I had found out about i t , and so a l o t obviously of that meeting I was i n shock.... I f e l t sad, and shocked and angry....And i t was February before she a c t u a l l y died but i t was l i k e when I f i r s t found out - i t was kind of l i k e I was numb. I heard the news but I guess part of i t was r e l i e f mixed with sadness. Exclusion. The co-researchers also described a sense of exclusion i n t h e i r experience of l o s s . Such exclusion was experienced i n several forms, including p h y s i c a l exclusion wherein the bereaved f r i e n d was impeded i n being p h y s i c a l l y present with the dying f r i e n d or during the friend's funeral. S i m i l a r l y exclusion was experienced when the bereaved f r i e n d was impeded, or impeded he r s e l f , i n openly discussing aspects of the impending or actual l o s s . Some co-researchers experienced exclusion i n terms of t h e i r own bereavement status i t s e l f , wherein others or they themselves denied the legitimacy of t h e i r loss thereby l i m i t i n g t h e i r access to support. For Anna, a f t e r her close f r i e n d "N" became i l l , she experienced both emotional and physical separation from him. Believing he d i d not 78 want to t a l k about his i l l n e s s , she f e l t impeded i n openly exploring and resolving with N. the meaning and implications of his l o s s . When his i l l n e s s progressed, he moved to his home town to die. She f e l t e f f e c t i v e l y excluded from his dying process, which may have influenced her continued d i f f i c u l t y i n accepting his l o s s . She stated, "N", who was so close to me, kept the knowledge of his i l l n e s s and the fact that he was going to die from me u n t i l i t was completely obvious....my g r i e f i n his death was that we r e a l l y didn't t a l k about i t . . . a n d so that I think heightened the more t y p i c a l sadness.... If he had an idea of how he wanted things to happen, he c e r t a i n l y never said to anyone. He went home [to another c i t y ] to die. Carla also experienced a sense of exclusion i n her bereavement experience. Her sense of exclusion was generated p r i m a r i l y by her uncertainty regarding the legitimacy of her bereavement status. She not only believed that others were generally unaware of the meaning and extent of her lo s s , but at times also questioned whether she her s e l f had r e a l l y suffered a legitimate l o s s . Such uncertainty seems to have l e d to her self-imposed exclusion from bereavement status, i n h i b i t i n g her a b i l i t y to openly grieve and seek support. She stated, I didn't r e a l l y f e e l there was anyone who understood where I was at, so I just sort of kept i t a l l to myself. I r e a l l y didn't think I had permission to t a l k about my grief....Nobody knows what you're missing because they don't know what l e v e l of friendship you had.... i t was lonely, but then I kept thinking "Oh well, get on with i t , j u s t get on with i t . She was ju s t a f r i e n d . " With the deaths of 3 of her friends, Diane also described a varying experience of exclusion i n the loss of each. She describes here her experience of exclusion with the loss of her f r i e n d "D". Aft e r D's unexpected death, Diane experienced an intense sense of exclusion from his dying process. His sudden death e f f e c t i v e l y prevented her from exploring and resolving with him the meaning that his l i f e had held for her. Diane believed such exclusion created 79 great d i f f i c u l t y for her i n resolving his loss and stated, His death was so sudden....I didn't get the s p i r i t u a l feedback that was important with the other people that died, that would have helped me to accept i t . . . . I didn't get a sense back that there was meaning i n i t . Natasha also described a sense of exclusion with the deaths of her 2 friend s . Her f i r s t experience of the loss of her best f r i e n d i n childhood was characterized predominantly by the experience of exclusion from bereavement status. I t was an experience which she believed greatly affected the way i n she grieved l a t e r losses. She stated, Nobody seemed to understand the s i g n i f i c a n c e of J's death to me, and I was not allowed to go to the funeral. I f e l t r e a l l y l e f t out. . . .The fact that I was denied access - denied value - i n wanting to grieve her death formally I think has also been another pattern i n my l i f e . . . . I do have t h i s pattern of not being able to r e a l l y process my feeli n g s and to grieve....I don't even remember crying at my father's funeral. Inclusion. At other times i n t h e i r experience of lo s s , the co-researchers described f e e l i n g a sense of i n c l u s i o n . Such i n c l u s i o n was experienced when open discussion of the loss and i t s implications was encouraged by the dying f r i e n d , or by others who recognized the legitimacy of the lo s s . Inclusion was also experienced through such acts as care-taking for the dying f r i e n d , or carrying out his or her s p e c i f i c wishes. The co-researcher's sense of i n c l u s i o n was further enhanced when the legitimacy of her loss and of her status as bereaved was recognized by the bereaved h e r s e l f or by others who were aware of her l o s s . Anna described a sense of i n c l u s i o n i n J's experience of i l l n e s s and dying' through to his death, explaining, " J " and I talked about him being i l l , we talked very openly about how he f e l t . . . . a n d what [dying of AIDS] meant to him...we talked 80 about the regret that we would not get old together...."J" would force me, would almost say "you t e l l me what i t i s you r e a l l y think"....To the very end I was a part of his experience. While her f r i e n d "S" was i l l Carla also experienced a sense of i n c l u s i o n i n S's care, o f f e r i n g support and hope for her recovery. Jn the i n i t i a l months a f t e r S's death, Carla struggled with her own po s i t i o n as l e g i t i m a t e l y bereaved. But eventually a f t e r acknowledging the v a l i d i t y of her lo s s , she again experienced a sense of i n c l u s i o n as she began to openly acknowledge and explore the meaning of her los s , while encouraging other mutually bereaved friends to do the same. She stated, A f t e r agreeing to do t h i s interview, I l e t myself explore my fe e l i n g s . . . . I r e a l i z e d that i f there was a study being done on t h i s , that maybe I wasn't the only f r i e n d who was grieving the loss of a f r i e n d . I t was l i k e discovering I was allowed to f e e l t h i s way...I've r e a l i z e d i t i s acceptable to grieve l i k e t h i s for a fr i e n d . . . . I wrote [a mutual f r i e n d also grieving the loss of "S"] to l e t her know that she could c a l l me to t a l k and that i t ' s okay to grieve "S", to reach out.... Diane also had a sense of i n c l u s i o n i n her experience of bereavement with both " J " and "J.H." E s p e c i a l l y with her f r i e n d "J.H.", open discussion of his impending death was ongoing, and she was intensely involved i n his care to the very end of his dying process. She described her sense of i n c l u s i o n , s t a t i n g We were close [and] we got closer a f t e r he got AIDS.... there were a group of us who were a support group who sat with him and d i d a round the clock watch....the experience of that was the connection we [J.H. and I] had....it meant that I could t a l k to him about how I f e l t about him going, and that I could t e l l him that I loved him and that he could t e l l me he loved me. Natasha also described a sense of i n c l u s i o n i n her experience of the death of her f r i e n d "L". Though she believed her a b i l i t y to openly discuss the loss with L's family was discouraged, she gained a 81 sense of i n c l u s i o n with her own support group where she found the freedom to f u l l y express what the loss of "L" had meant f or her. She stated that i t was "only there that I was able to f e e l and go to the depths of despair... and to acknowledge that...and then l e t i t go". Her f i n a l and only v i s i t with "L" before she died also allowed Natasha a sense of i n c l u s i o n . She f e l t she had been given an opportunity to p a r t i c i p a t e i n and ease L's dying process, and stated One of my best memories was I got that peppermint foot cream and I massaged her feet - i t probably symbolized an awful l o t but i t f e l t good to be able to do something that I thought no matter what stage she was at i n her consciousness, she could probably f e e l and appreciate that. Concession. Each co-researcher also found h e r s e l f making concessions for her dying f r i e n d . In order to support the needs of the i l l f r i e n d i n his or her dying process, the bereaved f r i e n d allowed i n her r e l a t i o n s h i p with the dying f r i e n d what she normally would not otherwise condone i n her friendships. Anna made concessions for her dying f r i e n d "N" which required that she constrain open and genuine expression about his impending loss i n order to allow him autonomy i n how he wished to cope with his fate. Such concessions may have contributed to her continued d i f f i c u l t y i n resolving his death. In describing her concessions, she stated Rightly or wrongly I sensed i t was something he p a r t i c u l a r l y d i d not want to share. . . . [yet] friendship means for me a ce r t a i n i n t e n s i t y , a b e l i e f that you don't have to hide things.... I f e e l l i k e I missed something....Why didn't I do what I genuinely wanted? - so i t ' s regret.... should I have said "Now don't l i e to me. You t e l l me how you f e e l " . But I couldn't because I wanted to be his version of the perfect f r i e n d . . .my guess was that he didn't want to say anything. Carla too made concessions for her f r i e n d "S". She maintained her support for "S" i n sp i t e of the l a t t e r ' s a b i l i t y to be a contributing 82 partner i n t h e i r friendship. Carla explained, I spent a l o t of time with "S" during her rough times.... Because "S" had decompensated for so many years we'd l o s t that closeness... i t was so draining, l i k e I was t r y i n g to put so much energy into her to t r y and get her out of t h i s depression and she wasn't giving anything back to me...I psyched myself up quite a b i t to go out and see her but I'm glad I did. Diane also made concessions during her experience of loss e s p e c i a l l y for her f r i e n d "J.H.". She consciously impeded h e r s e l f from f u l l y enjoying her own l i f e during J.H.'s long struggle with i l l n e s s and death. Though she d i d not regret her concessions she believed she paid a t o l l for her intense support and explained, I wasn't r e a l l y l e t t i n g myself enjoy myself to the max, because I f e l t I couldn't r e a l l y have so much fun i f my f r i e n d i s dying and su f f e r i n g . I couldn't r e a l l y go on and l i v e . Natasha also made a concession for her f r i e n d "L". She recognized that the s u p e r f i c i a l i t y of t h e i r l a s t contact a c t u a l l y characterized much of her re l a t i o n s h i p with "L", "I mean we d i d have some conversations, but i t was always very s u p e r f i c i a l . . . and so that r e a l i z a t i o n went into that contact I had with her i n those days when she was dying". Despite the lack of depth i n t h e i r r e l a t i o n s h i p however, her l o y a l t y remained constant to her dying f r i e n d over the months before L's death. She stated she f u l l y recognized, i n spite of the s u p e r f i c i a l i t y , "what L had meant to me over the years, and how we had managed to sustain the friendship i n sp i t e of the distance and our d i f f e r e n t avenues i n l i f e " . Control. During her experience of lo s s , the co-researcher often needed to address her own sense of powerlessness i n being able to control or somehow influence the course of events leading up to and surrounding 83 the l o s s . At times she questioned whether she had done enough or whether enough had been done for her dying f r i e n d . When confronted with her actual a b i l i t y to p r e dict or influence the outcome, several co-researchers o s c i l l a t e d between a sense of powerlessness and that of s a t i s f a c t i o n i n t h e i r a b i l i t y to have done so. For most co-researchers the death challenged them not only to cope with the loss of the f r i e n d but also with t h e i r own v u l n e r a b i l i t y i n terms of mortality i t s e l f ; the death of her f r i e n d often challenged the co-researcher to address the r e a l i t y of her own i n e v i t a b l e death. Anna found h e r s e l f struggling with the degree of control or influence she had had i n the course of both the i l l n e s s e s and deaths of "N" and " J " , and stated What g r i e f as well means for me i s a sense of r e s p o n s i b i l i t y ; a c h i l d i s h sense that I had enough control to f i x i t . . . t h a t I could have changed things... I even have t h i s i r r a t i o n a l thought that I should have been more supportive and said "well you don't have to die, you can be the one person [who beats t h i s disease] "... I suppose I didn't say that because I didn't think that....but everyone once i n a while I ' l l think "what else could I have done?" Carla also struggled with the degree of r e s p o n s i b i l i t y she had i n i n f l u e n c i n g S's fate, and found h e r s e l f asking why she "wasn't able to stop "S" from hanging h e r s e l f " . A f t e r considering the number of people, including h e r s e l f , who had t r i e d to intervene she resolved that she and others had done everything they could to prevent S' s su i c i d e . She explained, There, was nothing I could do, or anybody else. I f a l l these strong and caring people couldn't help her through i t , then maybe i t j ust wasn't meant to b e . . . . i t was her choice. Diane's experience of the loss of her friends " J " and then "D" was also characterized by a struggle with her sense of c o n t r o l . Though 84 she was resolved to J's impending death, she found h e r s e l f confronted by the fact that he may have ended his l i f e e a rly through suicide. She was unprepared for the suddenness of his l o s s , and also found her s e l f overwhelmed by the fact that at the same time the health of both her father and grandmother was s e r i o u s l y f a i l i n g . She stated "people's mortality was r e a l l y i n my face at the time, i n a big way. I think I r e a l l y had to do some sorting out". She was again confronted by a sense of powerlessness when she found h e r s e l f unable to make sense of the sudden loss of another f r i e n d , "D". She began to recognize that resolving his loss meant acknowledging her own v u l n e r a b i l i t y . She stated. The other part [about g r i e f ] i s coming to terms with my own mortality. What I've gotten from a l l of these experiences i s the l i v i n g to the moment... people can leave r e a l l y suddenly, so no matter what age they are we need to cherish the time we have. Natasha also struggled with her sense of powerlessness i n f i n d i n g out too l a t e that her f r i e n d had been discouraged from seeking treatment at a centre where Natasha was aware that promising p o s s i b i l i t i e s existed for treatment. She questioned whether more could have been done to have saved her friend's l i f e and stated " i t ' s kindof that s i t u a t i o n where you think that something could have happened and the circumstances didn't t r a n s p i r e . . . that was r e a l l y d i f f i c u l t for me." Dissonance. The co-researcher experienced a sense of dissonance when her b e l i e f s about the deceased or about g r i e f reactions were i n c o n f l i c t with her own overt behaviors or the overt behaviors of others. This sense of discord was experienced as anger, f r u s t r a t i o n or revulsion i n response to other persons whose reactions were d i f f i c u l t for the bereaved f r i e n d to accept. Such discord may have also occurred i n 85 terms of her own response to the loss which was at times experienced as dissonant with or contrary to the way she believed she would or should have coped with such a l o s s ; t h i s dissonance was often experienced by the bereaved as f r u s t r a t i o n or reproach with h e r s e l f . Anna experienced a sense of discord e s p e c i a l l y a f t e r the death of her f r i e n d "N". She experienced an i n t e n s i t y of anguish a f t e r his death which f e l t completely foreign and d i s d a i n f u l to her. To avoid becoming emotionally overwhelmed and crying i n front of others, Anna i s o l a t e d h e r s e l f and explained to a concerned f r i e n d , " i t ' s not part of my character to be a blubbering kind of i d i o t " . Dissonance was also a part of Carla's experience of l o s s . Constraining h e r s e l f from speaking to others about the los s of "S" was experienced as dissonant for Carla, who perceived h e r s e l f to be otherwise instrumental i n f o r t h r i g h t l y discussing and resolving issues. She explained, " I t was r e a l l y a burden keeping i t [S's loss] to myself... everything else i n my l i f e I always deal with - I'm quite an assertive person". She also experienced a sense of dissonance with others, including "S", i n t h e i r response to S's death, s t a t i n g I was angry at the gossip i n the town a f t e r she died. And I was angry about how she chose to do i t [suicide by hanging] - I was very angry about that. How could people be so unkind? Diane experienced a sense of dissonance with the los s of several of her frie n d s . She described an intense sense of discord e s p e c i a l l y with the death of her f r i e n d " J " . She had been i n s p i r e d by J's courage and determination i n the face of his chronic and terminal i l l n e s s e s , and i n l i g h t of t h i s s t o i c i s m she had d i f f i c u l t y resolving that he may have taken his own l i f e , and stated I think I've always questioned that too i f he d i d take his l i f e . . . that part i s s t i l l hard for me to come to terms with...maybe because i t was incongruent with the s t o i c nature of 86 his character.... there was also some b a t t l i n g going on i n his family about his assets, so there's that kind of negative side...I remember coming back from the funeral service, I f e l t a l o t of anger. Natasha also experienced a sense of dissonance, and discussed how she experienced t h i s with the death of her f r i e n d "L". In l i g h t of her need to openly acknowledge the impending loss of her f r i e n d and what that meant to her, she experienced great f r u s t r a t i o n with others, sta t i n g , "I went back home to v i s i t her [but] at the point where I saw her she had r e a l l y succumbed to death. I found i t i n c r e d i b l y f r u s t r a t i n g , and on top of that everybody seemed to be denying that she was a c t u a l l y dying". I n t e g r i t y . In her experience of lo s s , each co-researcher seemed to become aware of the e f f e c t that impending death had on her friend's i n t e g r i t y , or adherence to a code of values. The co-researcher noted with pride the way i n which her friend's i n t e g r i t y remained i n t a c t despite the adversity of i l l n e s s . Or conversely, she r e c a l l e d with sadness how such i n t e g r i t y had been threatened or diminished by the i l l n e s s . Several co-researchers were also aware of the e f f e c t of the impending or actual death on t h e i r own sense of i n t e g r i t y and t h e i r a b i l i t y to l i v e with conviction and meaning. Some co-researchers described a s p e c i f i c image of t h e i r deceased f r i e n d which symbolized that friend's serenity or v i t a l i t y i n the face of death. This image seemed to restore or uphold t h e i r friend's i n t e g r i t y , and appeared to a s s i s t the bereaved i n managing her anguish. Anna rel a t e d that although both her friends had died of AIDS, the i l l n e s s had very d i f f e r e n t e f f e c t s on t h e i r i n t e g r i t y . She stated that " J " had "acknowledged how he f e l t about that, but he never denied who he was...he didn't f e e l l i k e i t was a punishment...! f e l t so proud 87 of him, so i n c r e d i b l y proud of him". Whereas with "N" she explained he " r e a l l y d i d believe that i n some way he deserved to die, that i t was a punishment". Carla was also aware of the e f f e c t of i l l n e s s on S's i n t e g r i t y . She was saddened i n watching her f r i e n d become diminished and d e s t a b i l i z e d by her disease, s t a t i n g "S" had the looks, the brains, the t a l e n t . So when you knew the p o t e n t i a l , to slowly watch i t crumble away was so painf u l . . . and knowing how smart she was I was saddened that that was the way.that she f i n a l l y succeeded i n k i l l i n g h e r s e l f . Amidst t h e i r i l l n e s s e s , Diane also recognized the courage and i n t e g r i t y possessed e s p e c i a l l y by her friends " J " , and "J.H." Discussing her sense of t h i s as i t r e l a t e d to " J " , she stated "the impact of his l i f e on me was the courage... when you see someone who i s so r e s i l i e n t , s u f f e r i n g with more than almost anybody can deal with, I mean how could we not make a courageous e f f o r t about our own l i v e s " . And though her losses were extremely p a i n f u l , her own i n t e g r i t y remained i n t a c t throughout t h e i r dying processes. She recounted, I'm r e a l l y proud of myself for being able to be t h e r e . . . i t ' s r e a l l y about being aware of what you can give and what you can't, and what yo u r ' l i m i t s are, and t r y to be true to yourself and the other person i n that way. Natasha was also aware of the e f f e c t of i l l n e s s on the i n t e g r i t y of her dying f r i e n d . She r e f l e c t e d on the number of years "L" had suffered with her recurring i l l n e s s , and stated "I thought she had just r e a l l y fought a brave b a t t l e over a very long period of time...[the cancer] had reoccurred and then reoccurred a t h i r d time, and that was her f i n a l b a t t l e . " Meaning. 88 It i s important here to d i f f e r e n t i a t e between the two l e v e l s of meaning observed i n the experience of g r i e f . The f i r s t l e v e l of meaning i s that which i s addressed i n a l l the elements of the co-researchers' experience of l o s s . The elements are i n fact the extracted or e x p l i c i t meanings which the bereaved i m p l i c i t l y bestowed on her experience of g r i e f . Through the phenomenological l e v e l of observation , the meanings i m p l i c i t i n the l i v e d experience of g r i e f are made e x p l i c i t , allowing the e s s e n t i a l elements of the phenomenon to be illuminated. The second l e v e l of meaning observed i s i n the form of an element of g r i e f i t s e l f . Meaning as an element i s the co-researchers' active process of consciously s t r i v i n g to a t t r i b u t e cause or reason to the l o s s . The element of Meaning was also experienced by the bereaved as an active process of fin d i n g concrete ways to grieve the loss i n a way which most honored what the deceased had meant to the bereaved. The second l e v e l of meaning experienced as an element i n i t s e l f w i l l be discussed as follows. Though Anna had no unanswered questions about J's death, which occurred some time a f t e r N's, she found h e r s e l f s t i l l searching for a means of making sense of the e a r l i e r loss of N. She stated "there wasn't even a l o g i c a l explanation as to why he got i l l . " She hoped for someone to provide an explanation for her that would q u e l l her pain yet resolved, "there's nothing that's going to sort t h i s out for me that w i l l make sense. Because death doesn't make sense." Carla also struggled to make sense of the death of her f r i e n d "S", and the means by which "S" had attained that end. She was able to make sense of her friend's act a f t e r resolving that for "S", death was the only option which offered peace and an end to her struggle. She explained "I guess that's how desperate she was...her dad said she looked very peaceful when he found her, so I guess that's what she 89 wanted". This search for meaning was compelling, and seemed to be driven at times at an unconscious l e v e l . Carla described having had a dream several months a f t e r the loss which helped her to make sense of aspects of S's death which had remained unresolved, such as the degree of r e s p o n s i b i l i t y Carla h e r s e l f had i n preventing i t . She stated " i t ' s weird how strong your subconscious i s , and i t ' s important to deal with things, you can't just keep brushing them away ...obviously somewhere insi d e of me there was some pretty strong f e e l i n g s . " For Diane, e s p e c i a l l y i n her f i r s t experience with the loss of a close f r i e n d , there ensued a struggle to make sense of A's death. She stated, I r e a l l y wasn't i n touch with the fact that people would a c t u a l l y d i e . . . i t was a very sad part of my l i f e but not something I was mature enough or emotionally able to deal with other than i n just being overwhelmed. She was unable to make sense of her experience u n t i l a f t e r the death of her own mother, 1 year l a t e r , with whom she spent time exploring the meaning of the impending l o s s . She stated "I think t h i s turned i t around for me...since then I've always sensed the r e a l l y s p i r i t u a l part and looked for the s p i r i t u a l part of death." Her most recent loss of her f r i e n d "J.H." was one with which despite her anguish she struggled l e s s to f i n d meaning i n the death. She had spent a great deal of time during his i l l n e s s administering to his needs and exploring with him the meaning of his l o s s . A f t e r witnessing his long and agonizing struggle with i l l n e s s , Diane found meaning i n J.H.'s los s , s t a t i n g that for him "there [was] joy with death." In her attempt to cope with her losses, Natasha searched not only for a means of making sense of those losses, but also for a way to grieve the death of her friends that would honour the unique meaning t h e i r l i v e s had embodied. She explained, 90 I'm t r y i n g to f i n d a way for me to grieve... I've created writings or poetry or sayings or whatever seems to be appropriate and meaningful...the meaning of the person that has been important to you l i v e s within you and i n a l o t of ways you honour them by carrying that and channelling what was s p e c i a l about them i n your own l i f e . R i t u a l . R i t u a l i s here defined as a commemorative act which symbolically and/or metaphorically condenses into a dramatic moment one or more es s e n t i a l aspects of the r e l a t i o n s h i p shared with the deceased. As described by Imber-Black (1988) r i t u a l s "make p o t e n t i a l l y d i s r u p t i v e l i f e - c y c l e t r a n s i t i o n s more manageable and le s s threatening by enclosing them i n a web of prescribed a c t i v i t i e s ...they provide a safe context for the expression of intense emotion" (p. 60). This d e f i n i t i o n appears to f i t the experience of the bereaved i n the present study. In an attempt to adapt to the loss of her f r i e n d , each co-researcher engaged i n a p r i v a t e or p u b l i c ceremony or act which both commemorated the l i f e of her friend, and l e g i t i m i z e d her l o s s . She described the r i t u a l e f f e c t i v e i n f a c i l i t a t i n g her adjustment to the loss i f i t symbolized the value of the deceased or her r e l a t i o n s h i p with the deceased. Further, the r i t u a l was h e l p f u l i f i t f i t the expectations of the bereaved f r i e n d , and took place i n the company of supportive others when the r i t u a l was of a shared nature. For Anna, who was asked to read her choice of 2 poems at J's funeral, the reading of a personally selected poem was a r i t u a l that helped her symbolically honour the meaning of J's l i f e . She recounted "The one I wanted to read i s The Road Not Taken, but I didn't know i f I could get through i t . . . I thought to respect my f r i e n d I'm going to get through t h i s , I'm not going to cry, I'm just going to read t h i s . " Further, she found r i t u a l h e l p f u l when i t met her expectations of what a commemorative ceremony should be. Describing the d i s p o s i t i o n of J's 91 ashes, a ceremony which took place with a few close friends, she stated " i t was the way things are supposed to be." Conversely, she found di s t u r b i n g a ceremony planned for her f r i e n d N. which she believed neither representative of his wishes nor f i t t i n g i n terms of her own needs, and r e c a l l e d thinking to h e r s e l f "what am I going to do now. I can't bear to look at these p i c t u r e s . . . t h i s i s unreal... I don't think N. would have wanted any of i t . " Carla also found u n s e t t l i n g the experience of r i t u a l that d i d not r e f l e c t her expectations or the value of the deceased. She found the formal r i t u a l of S's funeral disturbing as i t f a i l e d to eulogize and thus represent the p o s i t i v e e f f e c t s "S" had had on the l i v e s of Carla and others. She explained that she believed at a funeral, they should t a l k about the person and t h e i r l i f e , and how they touched people, and [the church] just didn't do that...so whereas at some funerals you experience closure because you can s i t and think about t h e i r l i f e , hers was just long and so b i z a r r e . In contrast the evening spent with bereaved friends a f t e r the funeral was a more f i t t i n g r i t u a l for Carla who f e l t her friend's l i f e had there been honoured through personal remembrances the group had shared about S. She recounts "that day with those old friends was r e a l l y important... that to me was more of the funeral because we reminisced about S." Carla also created p r i v a t e r i t u a l s to honour the l i f e of her f r i e n d s t a t i n g , "I chose not to wear black to the funeral...our l i v e s together were colors, so I wore a very c o l o r f u l dress... I thought I ' l l be mourning on the outside but i n s i d e colors i s what she i s . " In her attempt to adapt to her losses, Diane also found important the creation of personally meaningful r i t u a l s . Encouraged by her a i l i n g f r i e n d "J.H." to do something p o s i t i v e with the energy from her pain and create a " f i t t i n g , l i v i n g , contributing memorial" for her 92 deceased f r i e n d "D", she helped to e s t a b l i s h a memorial fund which would a s s i s t i n the administration of an annual workshop offered i n D's area of s p e c i a l i t y . She stated "the memorial was r e a l l y how I di r e c t e d some of my energy. It was a way to honour him." She found such p u b l i c commemoration h e l p f u l also i n adjusting to the death of several other important people, in c l u d i n g the l a t e r death of her f r i e n d "J.H." She stated what's helped me i n the grieving has been to do that kind of memorial thing that "J.H." talked about...and with "J.H." we went out and scattered his ashes near lighthouse park and that was r e a l l y b e a u t i f u l . . . those things are r e a l l y important i n the acknowledgement [of the l o s s ] . Natasha also believed the creation of a meaningful r i t u a l enabled her to honour the meaning of her deceased frie n d s . A f t e r being denied access to the funeral of her childhood f r i e n d " J " , she described the r i t u a l s she created, s t a t i n g I remember standing out on the fence of the schoolyard watching [J's] funeral... somehow i t seemed very s i g n i f i c a n t that I had at l e a s t seen i t . . . I remember a b i r d dying and I buried i t and put a cross on the grave. Whether that was a way of channelling J's death I'm not sure... [And l a t e r as an adult] I took a p i c t u r e of J's tombstone and that seemed to have been something r e a l l y important to do. In describing the importance of r i t u a l s i n her experience of bereavement, Natasha explained further, "I'm a very s p i r i t u a l person and I need to create r i t u a l s that honour the value and the l i f e that i s sacred and has meaning to me. And through doing that I'm able to l e t i t go." Acceptance. The f i n a l element to be discussed i n the co-researcher's experience of loss i s that of Acceptance. The co-researcher indicated that i n adapting to her l o s s , she eventually began to experience 93 acceptance of that loss as a r e s u l t of an active process that took place over an extended period of time. Acceptance, for each co-researcher, seemed to be f a c i l i t a t e d by a b e l i e f which gained c l a r i t y over time that her f r i e n d had found a sense of peace or joy i n death. Acceptance of her friend's death seemed to be accompanied by a sense of r e s o l u t i o n that the bereaved h e r s e l f was at peace with the l o s s . Anna described a sense of acceptance i n J's l o s s . She found h e r s e l f resigned to the i n e v i t a b i l i t y of his death, which helped her prepare for and begin to accept his l o s s . She had supported him through his lengthy experience of i l l n e s s and dying, and began to accept his impending death as a p o s i t i v e a l t e r n a t i v e to the anguish and pain he experienced with his decline. Believing " J " ant i c i p a t e d and found peace i n impending death, she explained, I had watched him become a person that he didn't want to be... I didn't want him to l i v e that way anymore, and I knew that he didn't want to live...There were no other options. And he was r e l a t i v e l y ok with [dying], as ok as anybody could be...The best thing about J's death i s he made i t awfully easy for his frie n d s . . . I have a quite peaceful f e e l i n g about that death...It i s something that i s sad but not something you have to keep t r y i n g to sort out... oddly enough i t f e e l s l i k e he died a long time ago, although i t ' s j u s t a year. In contrast, though N's death had occurred almost 2 years before J's, Anna found she had not yet accepted N's lo s s , s t a t i n g Not that I had a closer friendship with "N" than I had with "J"...[but] the other thing i t goes back to i s i f you believe people get what they want when they die, that helps. In a sense " J " got what he wanted, and then there's the other sense that "N" didn't get what he wanted. And so there's that element missing. So there's that regret... I don't know that I ' l l ever f e e l i t ' s okay that "N" d i e d . . . i t frightens me to say that there wouldn't be acceptance. Carla's anguish over her friend's struggle with i l l n e s s also brought her to a point where she began to resign to S's fate well 94 before the actual death. Recalling a conversation with a mutual f r i e n d of S's before the suicide she stated, "we both acknowledged that one day we were going to get the c a l l that she had taken her l i f e . . .we were just sortof preparing ourselves... she was so tormented those l a s t couple of years." Two years a f t e r S's death, through a process of allowing h e r s e l f to acknowledge the extent of her loss and experience the concomitant anguish, Carla believed she had f i n a l l y accepted S's death, explaining That's what she wanted and i n the end i t was her choice... She i s at peace f i n a l l y a f t e r struggling so long...I'm just happy that she's not struggling l i k e she was, and now I'm able to just enjoy the good memories... I' ve had so much time to think about i t and I've l e t myself think about i t . Now I can t a l k about i t without r e a l l y getting emotional because I'm at peace with i t now. For Diane, p a r t i c i p a t i n g i n her mother and grandmother's experiences of i l l n e s s and death helped f a c i l i t a t e her acceptance of the deaths of her friends, e s p e c i a l l y "A", " J " , and "J.H.". In the deaths of her family members, she witnessed what she described as an awe i n s p i r i n g sense of s p i r i t u a l i t y , wherein death for the deceased was accompanied by a sense of peace or joy. She sensed t h i s mystery e s p e c i a l l y i n the death of her f r i e n d "J.H.", i n whose dying process she was most intensely involved, and with whose death she was most immediately resolved. She stated His loss was so long term, we were grieving continually... so when he a c t u a l l y died, there was a l o t of that work that had already been done...what I got from death is...someone whose body i s d e t e r i o r a t i n g and who i s r e a l l y i l l , r e a l l y welcomes death... there i s peace i n i t . . . t h e r e i s joy with death...and he was going to a r e a l l y nice p l a c e . . . A l l that s t u f f has helped me with the acceptance. With the unexpected death of her f r i e n d "D" however she stated "the suddenness of i t . . . I didn't have the a b i l i t y to process i t l i k e I 95 did with the others." Her acceptance of his loss was f a c i l i t a t e d by another dying f r i e n d who suggested to her that "D" had had a f u l l l i f e , and that his sudden and unexpected death "allowed him to l i v e u n t i l the end. That i s a p o s i t i v e , that he d i d not become incapacitated... or have to cope with the knowledge of impending death. " And for Natasha, i n the months before the death of her f r i e n d L., she had also resigned h e r s e l f to the i n e v i t a b i l i t y of her l o s s . When the news of L's death a r r i v e d Natasha experienced sadness, but also r e l i e f i n that death was a p o s i t i v e a l t e r n a t i v e to the months and years of s u f f e r i n g that L. had endured. To experience acceptance i n L's l o s s , she believed she needed to bring some f i n a l closure to the process of grieving that l o s s , but stated I've grieved for her i n a l o t of the ways that I've needed to [but] I may need to bring some f i n a l closure to i t and acknowledge that...with friends, I don't know what r e a l l y l e t t i n g them go i s l i k e . I only know the way that I've done i t . 96 CHAPTER V Discussion The purpose of t h i s study was to define the e s s e n t i a l elements of the l i v e d experience of g r i e f for surviving f r i e n d s . In examining the experience of los s as described by each of the four co-researchers interviewed i n t h i s study, there appeared to be a common thread of shared meaning or experience that embodied 10 e s s e n t i a l elements. Although an element may have been manifested i n d i f f e r e n t forms across each of the experiences of loss, i t s e s s e n t i a l meaning remained the same. For the bereaved friends i n t h i s study, the experience of g r i e f was constructed of the following elements, in c l u d i n g that of Acceptance, Concession, Control, Dissonance, Emotional Distress, Exclusion, Inclusion, I n t e g r i t y , Meaning, and R i t u a l . Results i n Relation to Current L i t e r a t u r e Lindemann (1944) characterized g r i e f as a reaction to c r i s i s i n v o l v i n g a set of s i x c h a r a c t e r i s t i c biopsychosocial symptoms or elements. The co-researchers i n the present study appear to have experienced several of these elements i n t h e i r bereavement, although not a l l of the following responses as outlined by Lindemann were con s i s t e n t l y experienced. The f i r s t of Lindemann's symptomatic elements was described as f e e l i n g - r e l a t e d phenomena such as sadness, anger, g u i l t and self-reproach. These phenomena appeared to be v a r i a b l y experienced by the bereaved i n t h i s study. A l l co-researchers experienced sadness i n t h e i r l o s s , an element which was thematically defined i n the present study as "Emotional D i s t r e s s . " Anger also seemed to be an aspect of experience for the bereaved i n t h i s study, and was defined here as the element or theme of "Dissonance", wherein the co-researcher experienced a sense of discord e i t h e r with others or with her own reaction to the l o s s . Co-researchers also appeared to experience g u i l t or self-reproach. 97 although they described t h e i r experience more as a struggle with issues of control and powerlessness rather than that of g u i l t . D i s b e l i e f i n the r e a l i t y of the death, another d i s t i n c t element of the g r i e f reaction described i n Lindemann's study, was also i l l u s t r a t e d i n the present study e s p e c i a l l y i n Diane's experience of l o s s . Her f i r s t experience with death was with the loss of her f r i e n d "A", and for some time a f t e r his loss she denied the r e a l i t y of the fact that he would never return. At t h i s point i n her l i f e she was unfamiliar with death and had not yet acknowledged the r e a l i t y of i t s existence. H o s t i l e reactions, also a symptom described by Lindemann as c h a r a c t e r i s t i c of the g r i e f response, was v a r i a b l y experienced by three of the co-researchers i n the study. Anna, Diane and Carla each described what may be defined as h o s t i l e reactions during t h e i r experiences of bereavement. These h o s t i l e reactions are defined as the experience of "Dissonance" i n the present study. Anna experienced dissonance when confronted by another bereaved who openly i n v a l i d a t e d Anna's feeli n g s of anger with the loss of her f r i e n d "N". Diane also experienced dissonance amidst the pain of her loss of "D" and found h e r s e l f enraged by another mourner whose e x p l o i t a t i v e actions impinged on the a b i l i t i e s of Diane and other bereaved to openly and f u l l y experience t h e i r g r i e f . Carla s i m i l a r l y experienced dissonance when confronted by the gossip of non-bereaved i n d i v i d u a l s whose actions appeared to her to be s e n s a t i o n a l i z i n g her friend's suicide. Lindemann also described the loss of patterns of conduct as a c h a r a c t e r i s t i c symptom of g r i e f . Such loss was experienced more as a di s r u p t i o n i n the present study. With the death of her f r i e n d "N", Anna described an i n i t i a l d i s r u p t i o n i n her pattern of conduct, and experienced t h i s i n her work as well as i n her s o c i a l l i f e . Carla, Diane and Natasha also experienced some form of d i s r u p t i o n i n t h e i r 6 98 patterns of conduct a f t e r the loss of t h e i r respective friends. The f i n a l c h a r a c t e r i s t i c to be i l l u s t r a t e d here regarding Lindemann's symptomology i s that of behavioral symptoms, incl u d i n g sleep and appetite disturbances. Co-researchers i n the present study also appeared to experience a v a r i e t y of such disturbances, including v i v i d and sleep-disrupting dreams, and changes i n appetite and energy. The r e s u l t s of the present study can also be discussed i n r e l a t i o n to aspects of the models of g r i e f proposed by Bowlby (1961) and Kubler-Ross (1969). In contrast to t h e i r findings regarding the phases (Bowlby, 1961) or stages (Kubler-Ross, 1969) of g r i e f , a l i n e a r or sequential aspect i n the experience of g r i e f generally d i d not appear to emerge i n t h i s study. Only one co-researcher spoke of her experience of loss as i f i t occurred i n stages. Before the death of her f r i e n d , Carla had been f a m i l i a r with a model o u t l i n i n g the stages of g r i e f , and l a t e r found he r s e l f comparing her own experience to t h i s model. I t i s d i f f i c u l t to assess the extent to which her experience was affected by such a p r i o r i knowledge. For the other bereaved i n t h i s study, the elements of t h e i r g r i e f d i d not seem to be experienced i n a l i n e a r form. Most elements seemed to overlap and were re-experienced at various times throughout the co-researchers' experience of l o s s . For example the element of Acceptance may have been experienced by the co-researcher well before the death, yet v a r i a b l y waxed and waned i n c l a r i t y and d e f i n i t i o n as the surviving f r i e n d mediated other elements of her experience, such as that of Control or Meaning. The l i m i t e d emergence i n the present study of such aspects of g r i e f as phases or stages may well be explained by the p a r t i c u l a r methodology chosen. Each co-researcher i n t h i s study was asked to describe her experience of loss by commencing her story at a point i n her experience which seemed most important or f i t t i n g as a place to 99 begin. The intent of t h i s approach was to allow the co-researcher to focus on aspects of her experience which she h e r s e l f deemed to be most meaningful and/or problematic, thereby allowing the essence of her experience i t s e l f to d i c t a t e the emergent structure of g r i e f . Had the co-researcher been in s t r u c t e d instead to describe her experience by beginning at a point i n her experience as determined by the researcher, i t i s possible that a chronological or sequential form may have emerged i n terms of her experience of the elements of her g r i e f . Despite the fact that co-researchers d i d not describe the presence of stages or phases i n t h e i r experience, other aspects of the models of g r i e f proposed by Kubler-Ross (1969) and Bowlby (1961) appear to be illuminated i n the experiences of g r i e f described i n the present study. D i s b e l i e f , anger, depressive-like symptoms and acceptance were experienced to varying degrees by most of the bereaved i n t h i s study. Bowlby (1961) also described the d i s r u p t i v e phenomenon of t r i g g e r s , such as unexpected reminders of the deceased. He suggested that such t r i g g e r s p r e c i p i t a t e d a regression towards an e a r l i e r phase of bereavement." Several of the bereaved i n the present study also described having encountered unexpected phenomena which often triggered intense emotional or behavioral responses. Co-researchers di d not seem however to perceive such experiences as regressive but rather as events which helped them further adapt to, and often f i n d greater meaning i n , t h e i r l o s s . To i l l u s t r a t e t h i s dynamic, an aspect of Carla's experience w i l l be discussed. Several months a f t e r the suicide of her close f r i e n d , Carla unexpectedly found h e r s e l f intervening i n the suicide attempt of one of her patients. She spent several days attempting to make sense of t h i s event and the v i v i d , d i s t u r b i n g dream which had ensued. In l i g h t of these events Carla began to recognize that at some l e v e l she had been struggling since her friend's suicide with her own p o t e n t i a l c u l p a b i l i t y i n i t , a 100 disturbing issue which u n t i l the second suicide had remained unacknowledged and unresolved. Witnessing t h i s second suicide attempt had been a t r i g g e r which helped her further adapt to her loss and bring greater c l a r i t y of meaning to i t . The experience of g r i e f appeared to be an active process for the bereaved friends i n t h i s study. This f i n d i n g seems to be i n keeping with Worden's (1982, 1991) assertion that g r i e f i s a dynamic process. Worden describes the act of acknowledging and negotiating the pain of g r i e f as a task which leads for the bereaved towards the eventual r e s o l u t i o n of l o s s . The dynamic aspect of t h i s acknowledgement and negotiation of pain was also evident i n the experience of g r i e f for the bereaved i n t h i s study. In describing her experience of the elements of i n c l u s i o n i n her bereavement, Natasha states i t was only when she was "able to f e e l and go to the depths of despair... and acknowledge that" that she was able to begin to resolve her anguish over her l o s s . For Natasha as well as the other co-researchers, such acknowledgement of the pain and the implications of the loss was an active process evolving over a period of time which seemed to impact t h e i r eventual adaptation to l o s s . S i m i l a r l y , other elements appeared to have a dynamic aspect i n the co-researchers' experience of g r i e f . For example each co-researcher a c t i v e l y searched for meaning i n her l o s s , and created concessions as well as personal r i t u a l s as a means of honouring her friendship, each of which appeared to have ei t h e r hindered or enhanced her a b i l i t y to adapt to her l o s s . There appears to be considerable agreement i n the l i t e r a t u r e i n terms of the importance of the role played by s o c i a l support i n e i t h e r a l l e v i a t i n g or exacerbating the adverse e f f e c t s of the stress of bereavement. In t h e i r research on bereaved kin Worden (1991) and others (Raphael, 1977; Vachon & Stalianos, 1988) observe that i t i s the goodness of f i t between the actual support offered and the q u a l i t y 101 of support as i t i s perceived that appears to be one of the strongest predictors of adaptation to bereavement. In t h e i r research on bereaved non-kin, Kauffman (1989) and Pine (1989) also observe the e f f e c t of perceived s o c i a l support on the experience of g r i e f . According to t h e i r observations, bereaved non-kin often f a i l to acknowledge and/or recognize t h e i r own g r i e f , and may do so as a means of avoiding the perceived judgement of others who may consider t h e i r overt expression of g r i e f as i l l e g i t i m a t e . This perception of l i m i t e d s o c i a l support appears to contribute to an intense sense of i s o l a t i o n (Pine, 198 9) which may prolong adaption to the loss for the bereaved. Doka (1989) and others (Deck & Folta, 1989) argue that for non-kin, i t i s the actual s o c i a l support which plays a primary role i n the experience of g r i e f . These writers assert that as a consequence of s o c i e t a l norms which reserve the d e f i n i t i o n of bereaved for surviving spouses and immediate kin, bereaved non-kin are excluded from receiving support and acknowledgement for t h e i r l o s s . Such attenuated support subsequently exacerbates the stress of bereavement for non-kin . The findings i n t h i s research appear to i l l u s t r a t e each of these assertions regarding perceived and actual s o c i a l support. While Anna and Diane indicated' the l e v e l of support received during t h e i r bereavement was adequate, the experience of loss for both Carla and Natasha was at times described as that of exclusion from such s o c i a l support. Both perceived that the support received i n t h e i r bereavement was inadequate. Carla's experience of exclusion from support appears to have been influenced by her i n i t i a l perception that she d i d not have a legitimate r i g h t to openly grieve the death of her f r i e n d and subsequently receive support. She questioned her role as bereaved, s t a t i n g "Why should I get to have someone to t a l k to about my g r i e f , when [the deceased] has parents and two b e a u t i f u l c h i l d r e n 102 who are grieving her l o s s ? " Carla i n d i c a t e d that such perceptions i n i t i a l l y excluded her from accessing the support that was a c t u a l l y a v a i l a b l e . When she eventually acknowledged the legitimacy of her loss and of her pain, she found the support from others that she i n i t i a l l y believed she d i d not have a ri g h t to access. Conversely for Natasha, her sense of exclusion i n her experience of bereavement appeared to be rela t e d to the lack of actual s o c i a l support and acknowledgement for both her loss as well as her role as bereaved. E s p e c i a l l y with her f i r s t experience of lo s s , Natasha r e c a l l e d that she received l i t t l e or no recognition and support f o r the loss of her close f r i e n d i n childhood. Her experience of exclusion from actual s o c i a l support during t h i s i n i t i a l loss appears to have l a r g e l y affected her perception of av a i l a b l e support during l a t e r losses, including those suffered i n adulthood. She states "I question whether there i s support out there for anybody who has suffered a l o s s . Our culture just does not honour the g r i e f process... i f i t i s l i k e that for a family member, i t i s multitudes that that denies the g r i e f of a f r i e n d . " Given the focus of t h i s paper on subjective experience and meaning making, i t i s beyond the scope of t h i s study to determine whether i n fact i t i s the perception of or the actual s o c i a l support that has the greater e f f e c t on the experience of g r i e f . Nonetheless, i t would seem that depending on the unique aspects of the surviving friend's current and h i s t o r i c a l experiences, both the actual as well as the perceived l e v e l of ava i l a b l e support are s i g n i f i c a n t factors i n eit h e r exacerbating or a l l e v i a t i n g the stress of bereavement. Parkes and Weiss (1983) and others (Raphael & Nunn, 1988; Worden, 1982) suggest that another factor a f f e c t i n g adjustment to loss i s the qu a l i t y of the r e l a t i o n s h i p between the bereaved and the deceased. Among other factors a high l e v e l of ambiguity i n the r e l a t i o n s h i p with 103 the deceased may complicate adjustment to l o s s . Such complications may be i l l u s t r a t e d i n the present study i n the g r i e f experiences of Anna and Natasha whose concessions for t h e i r dying friends may have adversely affected t h e i r adjustment to the l o s s . The concessions that Anna made for her f r i e n d "N" required that she constrain her open and genuine expression about his impending l o s s , which l e f t her with many unanswered and unresolved questions a f t e r his death. Such concessions may have contributed to her continued d i f f i c u l t y i n resolving h i s death. For Natasha, despite her awareness of the lack of depth i n her re l a t i o n s h i p with her dying f r i e n d "L", her l o y a l t y remained constant over the months leading up to L's i n e v i t a b l e death. She was unable to address her concerns with her fr i e n d , and long a f t e r L's death Natasha continued to question whether she and f u l l y grieved and resolved her lo s s . There appears to be considerable reference i n the l i t e r a t u r e regarding the importance of r i t u a l i n the experience of g r i e f . Worden (1991) maintains that the r i t u a l of the funeral provides the bereaved with an opportunity to openly express t h e i r anguish and receive support i n t h e i r l o s s . I f the bereaved i s not present at the funeral, Worden (1991) and Yoder (1986) observe that adjustment to loss may be complicated i f no other means i s found to v a l i d a t e the meaning of the re l a t i o n s h i p and the r e a l i t y of the death. The creation of a personally meaningful r i t u a l has been suggested as a vi a b l e means of so doing (Reeves, 1989). Co-researchers i n t h i s study also found r i t u a l to be an important factor i n t h e i r bereavement. In her experience of g r i e f , Natasha was denied access to the funeral of her f r i e n d i n childhood, and maintained that i n being denied such access she was denied an opportunity to express her g r i e f and receive support. She believes that i n order to adjust to her loss, she created private r i t u a l s at various times i n her l i f e to both v a l i d a t e 104 and commemorate her friend's l i f e and death. Such personal and often private r i t u a l s seemed e s p e c i a l l y important i n the co-researchers' adjustment to loss when the p u b l i c r i t u a l was representative neither of the meaning of the deceased (or of the r e l a t i o n s h i p shared with the deceased) nor of the expectations held by the bereaved f r i e n d of what a commemorative ceremony should be. For example, when the formal r i t u a l of the funeral f a i l e d to eulogize and thus represent the meaning of her friend's l i f e , Carla created p r i v a t e r i t u a l s which would e f f e c t i v e l y honour the meaning her friend's l i f e had embodied. The r e s u l t s of t h i s study i l l u s t r a t e only i n part the observations of Doka (1989) and others (Deck & Folta, 1989; Pine, 1989; Kauffman, 1989) who assert that the g r i e f of non-related survivors i s l a r g e l y unrecognized and disenfranchised. C e r t a i n l y aspects of each co-researcher's experience of g r i e f was characterized by a sense of exclusion. However, the co-researchers also experienced an element of i n c l u s i o n i n t h e i r experiences of l o s s , which included a component of s o c i a l recognition for and acknowledgement of t h e i r l o s s . Even Natasha, who experienced what appeared to be an actual lack of support and recognition for her loss, found support within her own therapy group which allowed her a sense of i n c l u s i o n i n her bereavement experience. I t would seem that within the group of co-researchers i n t h i s study, though exclusion was an important element i n the meaning of g r i e f , disenf ranchisement was not as dominant an element as was indicated i n the aforementioned l i t e r a t u r e . In my review of the l i t e r a t u r e , I had been quite influenced by the l i t e r a t u r e related to the phenomenon of disenfranchised g r i e f . I made a conscious attempt not to l e t t h i s information bias my perception of the protocols as I was reading them. However I also expected to f i n d evidence of such disenf ranchisement and was surprised when I d i d not f i n d extensive evidence of t h i s phenomenon i n the protocols at hand. 105 Several factor may explain the minimal influence of t h i s phenomenon on the experience of the co-researchers interviewed i n the present study. F i r s t l y since few i f any empirical studies, in c l u d i n g phenomenological inv e s t i g a t i o n s , appear to have focused on the experience of friendship g r i e f , i t may be that disenf ranchisement i s not as common and potent an element of experience as has been suggested. Conversely, the experience of disenfranchisement may well have been i l l u s t r a t e d as an element of g r i e f i f a d i f f e r e n t group of co-researchers had been interviewed. The element of disenfranchisement may have emerged i f the co-researchers were of the opposite gender than that of the present informants. The co-researchers i n the present study were a l l female, and according to Stroebe and Stroebe (1989-1990) females report and ex h i b i t g r i e f reactions more openly and more frequently than males; subsequently females report having experienced s o c i a l support to a greater degree than t h e i r male counterparts. L i s t e r (1991) has also observed that despite the i n t e n s i t y of g r i e f experienced by males, g r i e f reactions are not overt l y expressed by t h i s gender. S i m i l a r l y DaSilva and Schork (1984-1985) report that males may be r e t i c e n t to discuss t h e i r attitudes about death. Given that such reported tendencies may minimize access to s o c i a l support, i f males had been interviewed i n the present study i t i s possible that an element of disenf ranchisement might have been illuminated. Further, co-researchers were a l l employed i n some aspect of the mental health f i e l d . As a mental health professional I have made the assumption that these co-researchers l i k e myself have had to address some aspect of the phenomenon of g r i e f i n t h e i r work, and through t h e i r work experiences may well have developed to varying degrees a deepened a b i l i t y to discuss, explore and define t h e i r experience of g r i e f as i t i s l i v e d and perceived. I t may also be assumed that these 106 bereaved could p o t e n t i a l l y have had greater access to sources of s o c i a l support than those bereaved whose vocations are not r e l a t e d to some aspect of mental health. Had the informants been employed i n other vocations, or unemployed, an element of disenfranchisement may well have been illuminated. The r e s u l t s of t h i s study appear to i l l u s t r a t e Krefting's argument (1991) regarding the a b i l i t y of the phenomenological approach to c l a r i f y both the inva r i a n t themes and unique meanings of l i v e d experience. In the present study, 10 i n v a r i a n t themes appeared to weave through the l i v e d experience of g r i e f for each bereaved f r i e n d . Such inva r i a n t or universal aspects of g r i e f also appear to be illuminated when comparing the elements found i n t h i s study to that i n Douglas' phenomenological study (1994). In the l a t t e r study, an e s s e n t i a l element i n the experience of g r i e f was found to be the development i n each of the bereaved p a r t i c i p a n t s of a deeper sense of s p i r i t u a l i t y and understanding of l i f e and death. This s p i r i t u a l i t y and deeper understanding also appear to be aspects of the experience of g r i e f for the co-researchers i n the present study. For the co-researchers t h i s deeper sense of s p i r i t u a l i t y appeared to be an aspect of t h e i r experience of the element of acceptance, wherein each of the surviving friends developed a conviction which gained c l a r i t y over time that her f r i e n d had found a sense of peace or joy i n death. A greater understanding of l i f e and death seemed to be an aspect of t h e i r experience of the element of meaning, where the struggle to make sense of the loss often resulted i n a greater depth of meaning i n the co-researcher's own l i f e and i n e v i t a b l e death. In r e l a t i o n to the elements found i n Carter's phenomenological study of g r i e f (1989), such themes were also observed i n the present study. Carter observed the theme of "Seeking", which was characterized by a search for meaning i n the l o s s . The search for 107 meaning i n loss was also an element of the experience of g r i e f for the co-researchers i n the present study. Carter also observed such themes as "Hurting", characterized by intensely p a i n f u l emotions, and "Missing", characterized by an acute awareness of the magnitude of the l o s s . In the present study, such elements of g r i e f were also experienced by each co-researcher, and were defined as the theme or element of "Emotional Distress". The r i c h v a r i a t i o n i n l i v e d experience amongst the bereaved i s also illuminated through the use of the phenomenological approach. This v a r i a t i o n i s illuminated both within the present study, and i n comparing t h i s study to the other phenomenological studies reviewed i n t h i s paper. The r i c h v a r i a t i o n i n experience w i l l be discussed f i r s t l y as i t r e l a t e s to the findings within the present study. A theme which permeated Anna's experience of the loss of her f r i e n d "N" was that of being unresolved. Despite the fact that she had suffered and then resolved another loss of a very close f r i e n d since N's death, she s t i l l could not make sense of N's death and believed i t would remain unresolved and unaccepted. None of the other co-researchers experienced a loss which had remained yet unresolved at the time of the interview despite the s i m i l a r i t y i n time elapsed since t h e i r losses had occurred. S i m i l a r l y , the element of i n t u i t i o n was an aspect of experience for several but not a l l co-researchers. In reference to the loss of a p a r t i c u l a r close f r i e n d , Diane, Carla and Anna each described a sense of knowing without external evidence that there had been a change i n her friend's status; Natasha did not experience t h i s sense of i n t u i t i o n , nor d i d Diane and Anna i n t h e i r experience of loss of other close friends. In comparing the unique elements of g r i e f found i n t h i s study with those found i n other phenomenological studies of g r i e f , such elements as that of " I n t e g r i t y " and "Concession" which were important themes 108 i n the experience of bereaved friends i n t h i s study, do not appear to be illuminated i n the other phenomenological studies discussed i n t h i s paper. Given the existence of multiple r e a l i t i e s , the phenomenological method appears to be a highly e f f e c t i v e means towards de f i n i n g and i l l u m i n a t i n g both the essence of the phenomenon of g r i e f , as well as the unique aspects of i t s l i v e d experience for each bereaved. This writer agrees with Brice (1991) i n his assertions that "the findings of any study are l i m i t e d by those p r o f i l e s that show themselves" (p. 35) . Subsequently i f no sin g l e i n v e s t i g a t o r i s able to r e a l i s t i c a l l y capture the e n t i r e essence of the phenomenon of g r i e f i t appears that further phenomenological research i s required to more f u l l y conceptualize the essence and p o t e n t i a l typologies of g r i e f . Further areas of inqui r y are suggested i n the following section. Limitations of the Present Study and Implications for Future Research The focus of t h i s study was to observe the experience of g r i e f for surviving friends. I t was beyond the scope of t h i s study to draw conclusions about the p o t e n t i a l differences i n the experience of g r i e f which may e x i s t between bereaved friends and bereaved kin. Such d i s t i n c t i o n s may or may not prove u s e f u l . Further phenomenological studies which include p a r t i c i p a n t s from both camps would be required to h i g h l i g h t any d i s t i n c t i o n s . A l l co-researchers i n the present study were female. I t i s possible that a d i f f e r e n t structure of g r i e f would emerge i f co-researchers had been male, of i f the study included bereaved i n d i v i d u a l s of both genders. S i m i l a r l y , a l l co-researchers had some l e v e l of post-secondary education and were employed e i t h e r d i r e c t l y or i n d i r e c t l y i n occupations which focused on the area of mental health. Future research focusing on the experience of g r i e f for the bereaved i n other work and education re l a t e d occupations may prove useful to 109 better understand the essence of g r i e f . A l l co-researchers i n t h i s study were aware of the impending loss p r i o r to the deaths of t h e i r friends. Only one co-researcher, who had suffered several expected losses of close friends, experienced one of her losses as sudden and unexpected. A d i f f e r e n t structure of g r i e f may have emerged i f sudden loss was a factor i n the experience of g r i e f for a l l co-researchers i n t h i s study. A d d i t i o n a l research may prove useful i n determining the existence of such a typology of g r i e f . The structure of the phenomenon of g r i e f may well be dependent on such factors as the context of the death (ie long term terminal i l l n e s s vs. sudden death), the context of the r e l a t i o n s h i p (ie kin vs. non-kin) , or the p r o f i l e of the bereaved (ie gender) . I t may be impossible to condense a l l such situated structures into one configuration or general t y p o l o g i c a l structure of g r i e f without l o s i n g e s s e n t i a l meaning. I t seems that more phenomenological studies both within and between such p o t e n t i a l l y unique contexts are necessary i n order to determine whether various t y p o l o g i c a l structures of g r i e f e x i s t . Further, given that no two investigators using the phenomenological method may choose exactly the same thematic heading to describe an element of l i v e d experience, i t would be necessary to cross-reference a l l such studies to i d e n t i f y i n v a r i a n t but v a r i o u s l y l a b e l l e d themes. Implications for Practice Hocker (1990) and S c u r f i e l d (1985) suggest that i n t e l l i n g the story of p a i n f u l l o s s , the survivor may experience emotional r e l i e f as well as gain a greater depth of meaning i n his or her l o s s . The r e s u l t s of the present study seem to support t h e i r assertions. For several of the co-researchers i n the present study, the interview i t s e l f was one of the few opportunities they had had to t e l l t h e i r story i n a way that seemed most relevant and meaningful. They 110 described experiencing r e l i e f i n the knowledge that they were able to do so without fear of in t e r r u p t i o n . I t seemed that i n being encouraged to discuss the aspects of her experience which seemed most personally meaningful, and i n simply being l i s t e n e d to, the co-researcher experienced emotional r e l i e f and gained a greater depth of meaning i n her l o s s . Three of the four bereaved i n the present study reported such e f f e c t s at our follow-up meeting. In terms of the implications for p r a c t i t i o n e r s , such feedback seems to indic a t e the therapeutic influence at l e a s t i n the i n i t i a l stages of simply l i s t e n i n g without attempts at intervention to the c l i e n t ' s experience of l o s s . The themes by which the co-researchers structured t h e i r experience are also important c l i n i c a l considerations. By using as a guide such phenomenologically-generated themes as those outlined i n the present study, the p r a c t i t i o n e r can an t i c i p a t e and explore with the c l i e n t a broad range of responses i n order to support the c l i e n t i n his or her lo s s . In terms of the element of concession, i t may be useful to explore with a bereaved c l i e n t the allowances which were made for the dying or deceased f r i e n d , and the impact such concessions had and continue to have on the c l i e n t ' s adjustment to l o s s . In the present study, the concessions Carla made for her dying f r i e n d appeared to reassure her of the fac t that she had remained l o y a l to the friendship and subsequently had done a l l she could to save her f r i e n d . Such concessions appeared to f a c i l i t a t e her adaptation to her l o s s . On the other hand, the concessions that Anna made for her f r i e n d "N" may have hindered her adjustment to his lo s s , since these concessions negated her a b i l i t y to openly discuss with him his impending death. Several years a f t e r his death she continues to f e e l unresolved about his lo s s , and wonders i f t h i s lack of acceptance i s the cost of concessions which were made out of l o y a l t y for her f r i e n d . I l l The element of control appears important to address with the bereaved c l i e n t . For the bereaved i n the present study, control was often manifested as a sense of powerlessness, and perhaps g u i l t , i n being unable to e i t h e r influence or predict the friend's demise. I t may prove empowering for the c l i e n t to a s s i s t him or her i n exploring areas wherein he or she was able to r e a l i s t i c a l l y support the f r i e n d . Further to t h i s , several co-researchers i n the present study described the influence of loss i n forcing them to address t h e i r own mortality. Such an e x i s t e n t i a l dilemma may well be a shared experience of g r i e f for many bereaved c l i e n t s , and may prove b e n e f i c i a l for the c l i e n t to explore. It may also be useful to explore the sense of dissonance a bereaved c l i e n t may be experiencing. If the c l i e n t ' s actual response to loss i s experienced as contrary to his or her b e l i e f i n the way a loss should be coped with, such discord may attenuate the c l i e n t ' s a b i l i t y to f u l l y grieve and subsequently resolve the l o s s . The survivor's sense both of exclusion and i n c l u s i o n i n the experience of loss appear to be very important factors i n e i t h e r a l l e v i a t i n g or exacerbating the stress of bereavement. The element of exclusion was manifested i n various forms for the co-researchers i n the present study and appeared to increase the survivor's sense of emotional d i s t r e s s and hinder her adjustment to l o s s . Conversely, the element of i n c l u s i o n i n i t s various forms appeared to f a c i l i t a t e adjustment. It may prove useful to examine with the c l i e n t his or her experience of the element of exclusion. Several factors should be assessed, including the c l i e n t ' s own perception of his or her r i g h t to l e g i t i m a t e l y grieve the loss and receive support. The p r a c t i t i o n e r should also assess with the c l i e n t the a v a i l a b i l i t y and v i a b i l i t y of support systems, with the c l i e n t being encouraged to access those that 112 e x i s t . For the co-researchers i n the present study, the experience of being included i n the friend's process of dying appeared to f a c i l i t a t e adjustment to the l o s s . Such experiences of i n c l u s i o n should be addressed with the bereaved c l i e n t . I f none e x i s t , or i f the death of the f r i e n d was sudden, psychodrama exercises could be suggested by the p r a c t i t i o n e r to encourage the c l i e n t to re-create the story of death. In re-creating the time frame before the actual death, the c l i e n t w i l l have the opportunity to explore the meaning and implications of the loss with the deceased f r i e n d himself, or with other important r i n d i v i d u a l s i n the story, p o t e n t i a l l y f a c i l i t a t i n g adaptation to the lo s s . Such exercises may be contra-indicated i f the c l i e n t i s experiencing some degree of psychosis wherein r e a l i t y t e s t i n g i s compromised. It may prove b e n e f i c i a l to the c l i e n t ' s adjustment to explore his or her awareness of how the dying process and/or death a f f e c t e d the friend's, as well as his or her own, l e v e l of i n t e g r i t y . The c l i e n t should be as s i s t e d i n developing a r e a l i s t i c and meaningful version of the e f f e c t that i l l n e s s or death had on the i n t e g r i t y of those i n question. For the bereaved i n the present study, the search f o r meaning i n the loss was an important element i n t h e i r experience of g r i e f . Although the a b i l i t y to f i n d meaning i n the loss appeared to f a c i l i t a t e adjustment to the friend's death, there was often an aspect of struggle i n the search for such meaning. Accordingly, bereaved c l i e n t s may also require assistance i n t h e i r attempt to make sense of the death. The co-researchers appeared to f i n d the element of r i t u a l e f f e c t i v e , under s p e c i f i c conditions, i n f a c i l i t a t i n g t h e i r adjustment to l o s s . I t i s important to explore with the c l i e n t the degree to 113 which formal or pri v a t e r i t u a l s e f f e c t i v e l y symbolized the meaning of the deceased or the r e l a t i o n s h i p shared with the deceased, and i f those r i t u a l s f i t the c l i e n t ' s expectations. I f r i t u a l f a i l e d to f i t the needs of the bereaved, or i f he or she d i d not p a r t i c i p a t e i n such commemorative ceremonies, the p r a c t i t i o n e r may at an appropriate time a s s i s t the c l i e n t i n creating a personal r i t u a l to f i t those unmet needs. 114 References Balk, D. E. (1991). Death and adolescent bereavement: Current research and future d i r e c t i o n s . Journal of Adolescent Research, 6(1), 7-27. Bowlby, J. (1961). Processes of Mourning. 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Journal of Religion and Health, 25(2), 149-159. 118 Appendix A Pre-screening Questions Name Age Sex Was the person who died a f r i e n d with whom you were involved i n a non-sexual friendship? Would you describe t h i s f r i e n d among your clo s e s t seven or eight friends? How long ago did your f r i e n d die? Are you presently i n counselling to help you adjust to the loss of your friend? (If the person responds a f f i r m a t i v e l y to t h i s , i t w i l l be suggested that she discuss the p o s s i b i l i t y of involvement i n the study with her counsellor, such that her p a r t i c i p a t i o n i n the study w i l l not i n t e r f e r e with the work she i s doing i n therapy). Do you f e e l you require counselling to help you f a c i l i t a t e your grieving process? ( i f the person responds a f f i r m a t i v e l y , the research purpose of the study w i l l again be explained, and the respondent w i l l be asked i f she would l i k e to be provided with references for l o c a l g r i e f counsellors and agencies). 119 Appendix B Interview Protocol For F i r s t Interview Primary Interview Question We have talked e a r l i e r about the purpose of t h i s study being an attempt to map or define the process of g r i e f experienced by friends surviving the loss through death of a close f r i e n d . You have mentioned the death of your close f r i e n d and your experience of grieving that l o s s . I wonder i f you would share your story about your l o s s , beginning i f you l i k e with the moment that stands out the most for you. Interview Protocol for Second Interview As we discussed e a r l i e r , your account of your experience of grieving for your f r i e n d has been transformed i n t o a thematic structure. I t i s hoped that the themes capture the straightforward as well as the underlying ( e x p l i c i t and i m p l i c i t ) meanings that compose experience of g r i e f . Would you please read over t h i s structure to insure that i t represents your experience of grieving for your f r i e n d . Please take as much time as you need; your candid feedback w i l l be very important i n helping us to accurately describe what the experience of friendship g r i e f i s l i k e . 120 Appendix C D e f i n i t i o n s of Unique and Common Themes The following themes were found i n the experiences of l o s s . While 14 themes are i d e n t i f i e d below) only 10 themes were illu m i n a t e d i n the general structure because they were found i n a l l four protocols. 1. A c c e p t a n c e . The co-researcher indicated that accepting the loss of her f r i e n d was an active process. In the s i t u a t i o n s where i l l n e s s preceeded death, acceptance seemed to be f a c i l i t a t e d by a b e l i e f which gained c l a r i t y over time that her f r i e n d had found a sense of peace or joy i n death. There was only one.situation where a co-researcher experienced the loss of a f r i e n d through sudden death. Her acceptance of t h i s loss was f a c i l i t a t e d by her r e s o l u t i o n that i n being unaware of his own impending death her f r i e n d was enabled to l i v e his l i f e f u l l y and without s u f f e r i n g . For a l l co-researchers, acceptance of her friend's death seemed to be accompanied by a sense of r e s o l u t i o n that she h e r s e l f was at peace with the l o s s . 2. C o n c e s s i o n . As a r e s u l t of her bond, the co-researcher found h e r s e l f making concessions for her dying f r i e n d . In order to support the needs of the i l l f r i e n d i n his or her dying process, the bereaved f r i e n d allowed' i n her r e l a t i o n s h i p with the dying f r i e n d what she normally would not otherwise condone i n her friendships. 3. C o n t r o l . During her experience of loss the co-researcher often needed to address her own sense of powerlessness i n being unable to control or somehow influence the course of events leading up to and surrounding the l o s s . At times she questioned whether she had done enough or whether enough had been done for her f r i e n d . When confronted with her actual a b i l i t y to p r e d i c t and/or influence the outcome, several co-researchers o s c i l l a t e d between a sense of powerlessness and that of s a t i s f a c t i o n i n t h e i r a b i l i t y to have done so. For most co-researchers, the death challenged them not only to cope with the loss of the f r i e n d but also with t h e i r own v u l n e r a b i l i t y i n terms of mortality i t s e l f ; the death of her f r i e n d often challenged her to address the r e a l i t y of her own i n e v i t a b l e death. 4. E m o t i o n a l D i s t r e s s . With the death of her f r i e n d the co-researcher experienced such f e e l i n g - r e l a t e d phenomena as denial, anguish, longing, crying, confusion, and a sense of being overwhelmed. These feelings appeared to be experienced to varying degrees regardless of preparation for or resignation to the death of the f r i e n d . This reaction seemed to be i n t e n s i f i e d when the death was sudden or multiple stressors existed. Throughout her bereavement these fee l i n g s tended to be triggered by various factors for the co-researcher, in c l u d i n g symbolic reminders of the deceased, or the acknowledgement by others of the legitimacy of her l o s s . Other t r i g g e r s were also reported, such as dreams and moments of quiet or solitu d e . Several co-researchers reported that through various means an attempt was made to avoid those thoughts, events or people that would t r i g g e r such reactions. 5. D i s s o n a n c e . The co-researcher experienced a sense of dissonance when her b e l i e f s about the deceased or about g r i e f reactions were i n c o n f l i c t with her own overt behaviors or the overt behaviors of others. This sense of discord was at times experienced as anger, f r u s t r a t i o n or revulsion i n response to other persons whose reactions 121 were d i f f i c u l t for the bereaved f r i e n d to accept or t o l e r a t e . For some co-researchers such discord also occurred i n terms of t h e i r personal response to the loss which was experienced as dissonant with or contrary to the way they believed they would or should have coped with such a l o s s ; such dissonance was often experienced by the bereaved as f r u s t r a t i o n or reproach with h e r s e l f . 6. E x c l u s i o n . The co-researcher described a sense of exclusion i n the experience of her friend's l o s s . Such exclusion was experienced i n several ways, incl u d i n g physical exclusion wherein the bereaved f r i e n d was impeded i n being p h y s i c a l l y present with the dying f r i e n d , or during the friend's funeral. S i m i l a r l y exclusion was experienced when the bereaved f r i e n d was impeded, or impeded hers e l f , i n openly discussing aspects of the impending or actual l o s s . Some co-researchers experienced exclusion i n terms of t h e i r bereavement status i t s e l f , wherein others or they themselves denied the legitimacy of t h e i r l o s s , thereby l i m i t i n g t h e i r access to s o c i a l support. 7. F i n a l i t y . The co-researcher was struck by the f i n a l i t y of death, and the fact that c e r t a i n aspects of her r e l a t i o n s h i p with the deceased could never be replaced. 8. I n c l u s i o n . The co-researcher described a sense of i n c l u s i o n i n her experience of coping with the loss of her f r i e n d . Such i n c l u s i o n was experienced when open discussion of the impending or actual death and i t s implications was encouraged by the dying f r i e n d , or by others who recognized the legitimacy of the l o s s . For some bereaved, a sense of i n c l u s i o n was also experienced by p a r t i c i p a t i n g i n the friend's dying process i t s e l f , through such acts as care-taking or carrying out the dying friend's s p e c i f i c wishes. In coping with the death of her fri e n d , the co-researcher's sense of i n c l u s i o n was further enhanced when the legitimacy of her loss and of her status as bereaved was recognized by the bereaved h e r s e l f and/or by others. The co-researcher also attempted to increase the sense of i n c l u s i o n for other bereaved by recognizing and acknowledging the legitimacy of t h e i r mutual l o s s . 9. I n t e g r i t y . In reviewing the dying friend's response to his or her i l l n e s s , the co-researcher gained awareness of the e f f e c t of such i l l n e s s on her friend's i n t e g r i t y or adherence to a code of values. The co-researcher noted with pride the way i n which her friend's i n t e g r i t y remained i n t a c t despite the adversity of i l l n e s s . Or conversely, she r e c a l l e d with sadness how such i n t e g r i t y had been threatened or diminished by the i l l n e s s . Several co-researchers were also aware of the e f f e c t of the impending or actual death on t h e i r own i n t e g r i t y and t h e i r a b i l i t y to l i v e with conviction and meaning. Some co-researchers described a s p e c i f i c image of t h e i r deceased f r i e n d which symbolized that friend's serenity or v i t a l i t y i n the face of death. This image seemed to restore or uphold t h e i r friend's i n t e g r i t y , and appeared to help the bereaved manage t h e i r anguish. 10. I n t u i t i o n . The co-researcher described a sense of knowing without external evidence that there had been a change i n her friend's status or that her f r i e n d had died. 11. K i n - l i k e B o n d . The co-researcher used metaphorical or actual comparisons to family or kin as a means of describing the type of bond shared with the deceased f r i e n d . 122 12. M e a n i n g ( s e a r c h f o r ) . The co-researchers were engaged i n an active process of consciously s t r i v i n g to a t t r i b u t e cause or reason to the l o s s . Several informants were also engaged i n an active process of f i n d i n g concrete ways to grieve the loss i n a way that would most honor what the deceased had meant to them. Some co-researchers believed they could not f u l l y accept or make sense of t h e i r l o s s . Despite t h e i r e f f o r t s to f i n d meaning i n the death, aspects of the loss remained i n s e n s i b l e . 13. R i t u a l . R i t u a l i s here defined /as a commemorative act which symbolically and/or metaphorically condenses into a dramatic moment one or more e s s e n t i a l aspects of the r e l a t i o n s h i p shared with the deceased. As described by Imber-Black (1988) r i t u a l s "make p o t e n t i a l l y d i s r u p t i v e l i f e - c y c l e t r a n s i t i o n s more manageable and le s s threatening by enclosing them i n a web of prescribed activities...they provide a safe context for the expression of intense emotion" (p. 60). This d e f i n i t i o n appears to f i t the experience of the bereaved i n the present study. In an attempt to adapt to the loss of her f r i e n d , the co-researcher engaged i n a private or p u b l i c ceremony which both commemorated the l i f e of her deceased f r i e n d and l e g i t i m i z e d the l o s s . The co-researcher described the r i t u a l e f f e c t i v e i n f a c i l i t a t i n g her adjustment to the loss i f i t symbolized the value of the deceased or her r e l a t i o n s h i p with the deceased. Further, the r i t u a l was h e l p f u l i f i t f i t the expectations of the bereaved f r i e n d , and took place i n the company of supportive others when the r i t u a l was of a shared nature. 14. U n i q u e l y I n d i v i d u a l R e s p o n s e . The co-researcher was aware that aspects of her response to the loss were unique i n r e l a t i o n to that of other bereaved or that described i n models of bereavement with which she was f a m i l i a r . Some co-researchers acknowledged that t h e i r response to the loss i n question was i n i t s e l f unique compared to other losses they had suffered because of the nature of the r e l a t i o n s h i p they had shared with that friend, and the circumstances of the death. The co-researcher also seemed to allow others, i n c l u d i n g the dying fr i e n d , autonomy i n terms of t h e i r own unique response to the impending or actual l o s s . Although she may not have understood t h e i r unique response, the bereaved f r i e n d was generally able to t o l e r a t e i t . 123 Appendix D E i d e t i c Analysis of Anna's Experience Thematic Cluster Thematic Description of Meaning Units 1. Acceptance In reference to J. , with (MU #11, 14, 17, 18, 37, whom she had been a part of 47, 49, 60, 62, 65, his experience of dying, 67) Anna described a sense of acceptance i n his l o s s . She began to accept his impending death as an al t e r n a t i v e to his anguish over his decline. She believed J. ant i c i p a t e d and was at peace with his death, which made i t easier for others including h e r s e l f to accept the i n e v i t a b i l i t y of the same. 2. Concession (MU #6, 13, 22, 26, 27, 28) Anna made concessions e s p e c i a l l y for her dying f r i e n d N. which required that she constrain open and genuine expression about his i l l n e s s and death i n order to allow him autonomy i n how he wished to respond to the same. She would not describe t h i s constraint t y p i c a l however of her other close r e l a t i o n s h i p s . 3. Control (MU #48, 50, 51, 52, 59, 63, 69) Anna struggled with the degree of control or influence she had i n the course of each of her friend's i l l n e s s and death. She questioned at times whether she d i d enough to support them. She wondered i f her struggle with, and b e l i e f i n , personal r e s p o n s i b i l i t y was a way of qu e l l i n g her sense of v u l n e r a b i l i t y that arose when confronted with the i n e v i t a b i l i t y of mortality i t s e l f . 124 4. Emotional Distress (MU #4, 40, 44, 46, 55, 56, 68, 69) Anna considered various aspects of her response to the loss of her friends to be what she perceived as common g r i e f responses. S p e c i f i c a l l y i n response to the loss of N., she experienced the anguish, sadness and sense of meaninglessness which she believed were t y p i c a l aspects of bereavement. Several months a f t e r her los s , she found that c e r t a i n objects or circumstances continued to t r i g g e r her anguish, e s p e c i a l l y r e l a t e d to the loss of N. She attempted to avoid such t r i g g e r s by seeking d i s t r a c t i o n s which she hoped would "magically" a s s i s t her i n avoiding the pain of her l o s s . 5. Dissonance (MU #35, 38, 41, 43, 56, 61, 63) Anna experienced a sense of dissonance i n her losses. This occurred both when her own response to the loss d i d not f i t with her s e l f perception, and when others' response to each loss was d i f f i c u l t for her to to l e r a t e . 6. Exclusion (MU #5, 7, 16, 24, 26, 29, 39) Anna described a sense of exclusion from N's experience of i l l n e s s and death. Her sadness was i n t e n s i f i e d by her awareness that despite her knowledge of his terminal i l l n e s s , they d i d not discuss i t or i t s implications u n t i l his impending death was obvious. She also experienced a physi c a l separation from him. As his i l l n e s s advanced, N. chose to move away to l a t e r die at his parents home i n another c i t y , leaving no s p e c i f i c expectations of his friends regarding h i s wishes or needs during h i s i l l n e s s and 125 7. F i n a l i t y (MU #41, 59) 8. Inclusion (MU #8, 9, 10, 17, 19, 20, 29, 30, 31, 33, 37, 44, 54, 57) 9. I n t e g r i t y (MU# 17, 29, 31, 36, 37,-53, 66) 10. I n t u i t i o n (MU #65, 67) a f t e r his death. Anna was confronted by the f i n a l i t y or i r r e v e r s i b i l i t y of death. Anna described a sense of i n c l u s i o n i n J's experience of i l l n e s s and dying through to his death. Through t h e i r open discussions, she was aware of what was expected and desired by her dying f r i e n d J., a factor which appeared to minimize her confusion i n terms of her response to his l o s s . Recognition of her loss and of her status as bereaved was an important factor i n Anna's experience. In recognizing h e r s e l f as bereaved and i n other's recognition of her as such, her sense of i n c l u s i o n was greatly enhanced. She f e l t e n t i t l e d to recieve support for as well as openly express her response to the loss of both N. and J. Anna was aware of the e f f e c t of i l l n e s s on the i n t e g r i t y of her dying frie n d s . Their sense of s e l f and adherence to a way of being ei t h e r remained i n t a c t despite the adversity of i l l n e s s , or conversely was diminished by i t . She was also aware of the e f f e c t of her losses on her own i n t e g r i t y . She believed that despite her pain the i n t e n s i t y of her g r i e f would neither damage nor diminish her. Anna had an i n t u i t i v e sense that her f r i e n d J. would die before her next v i s i t with him. I t was a more c e r t a i n 126 or d i s t i n c t sense than she had ever before experienced with him. 11. K i n - l i k e Bond (MU #2, 25, 27 41) 12. Meaning (MU #12, 42, 44, 46, 57, 58, 60, 64) Anna described a k i n - l i k e r e l a t i o n s h i p with her f r i e n d N., with whom she was so close that she and others described the two of them as twins. Though she had no unanswered questions about J's death, she found h e r s e l f searching for a means of making sense of the loss of N. She hoped for someone to provide an explanation for her that would q u e l l her pain, yet r e a l i z e d the f u t i l i t y of t h i s desire i n l i g h t of her b e l i e f that she could not make sense of N's death because death i t s e l f d i d not make sense. 13. R i t u a l (MU# 23, 31, 32, 34, 39, 40, 41) In her attempt to cope with the loss of her friends, Anna found that personally meaningful r i t u a l s were important i n the process. She found the r i t e meaningful i f i t symbolically represented the deceased, her personal r e l a t i o n s h i p with the deceased, or her of what a expectations commemorative should be. ceremony 14. Uniquely Individual Response (MU #3, 11, 15, 21, 23, 36, 41, 43, 45, 57, 63, 70) Anna experienced her response to the loss of N. and that of J. a uniquely i n d i v i d u a l . She also experienced t h i s i n d i v i d u a l i t y of response i n r e l a t i o n to others who were also grieving the loss of her f r i e n d s . Anna was generally able to t o l e r a t e others' unique responses to the losses of her frie n d s . She also 127 experienced t h i s tolerance from other bereaved i n d i v i d u a l s , e s p e c i a l l y i n terms of the way she responded to the loss of N. 128 Appendix E E i d e t i c Analysis of Carla's Experience Thematic Cluster Thematic Description of Meaning Units 1. Acceptance Carla described her loss of (MU #20, 23, 26, 38, 47, S. as a gradual process of 48, 58, 60, 64, 66) d e t e r i o r a t i o n wherein S. f i n a l l y achieved her own death. Though Carla d i d not i n d i s c r i m i n a n t l y d i s c l o s e her resignation to the i n e v i t a b i l i t y of S's death, her anguish over t h i s loss brought her to a place where she began to accept S's fate well before her actual death. Two years a f t e r her friend's death, Carla believed she was f i n a l l y at peace with S's l o s s , and could speak about her loss without anguish. Concession (MU #14, 25, 51, 64, 67, 68, 71) Carla maintained her support for S. i n the face of an i l l n e s s that others found disturbing, and i n s p i t e of S's diminished a b i l i t y to be an equal partner i n t h e i r friendship. She believed she was able to do so both as a r e s u l t of her knowledge of psychiatry and the bond that she had shared with S. Further, despite her i n a b i l i t y to condone S' s f i n a l choice of means by which to end her l i f e , Carla was eventually able to accept S's act by a t t r i b u t i n g her motive to desperation rather that to s e l f i s h n e s s . 3. Control (MU #39, 42, 44, 46) Carla struggled at times with her actual a b i l i t y , and c u l p a b i l i t y , i n terms of in f l u e n c i n g her friend's fate. Though she acknowledged that thoughts 129 about her r e s p o n s i b i l i t y may recur, she was comforted i n knowing that everything that could have been done was done to save S. Emotional Distress (MU #3, 10, 11, 21, 22 29, 30, 34, 50, 57, 58, 59, 64, 79) Carla recognized s i m i l a r i t i e s between aspects of her own response to loss and that outlined i n a conventional model of g r i e f with which she was f a m i l i a r . In r e f l e c t i n g on her response to S's lo s s , she described having experienced i n her bereavement a sense of shock and d i s b e l i e f , and an intense sense of anguish and longing. I n i t i a l l y uncertain of the legitimacy of her anguish, Carla attempted to diminish her pain by diminishing the importance of her l o s s . In the f i r s t several months a f t e r her friend's death she found that thoughts of S's p a i n f u l struggle with l i f e dominated her memory of her f r i e n d . She also found that her sense of anguish had a tendency to be triggered unexpectedly during times when she was alone or engaged i n tasks which d i d not require her t o t a l concentration. Dissonance (MU #17, 24, 26, 35, 36, 55, 68, 71) Constraining h e r s e l f from speaking to others about her loss was experienced as dissonant for Carla, who perceived h e r s e l f to be otherwise instrumental i n f o r t h r i g h t l y discussing and resolving issues. She also experienced discord with others, i n c l u d i n g S. her s e l f , i n t h e i r response to S's i l l n e s s and death. Exclusion (MU #8, 9, 27, 33, 34, 36, 37, 40, 45, 62, 69, 80) In the f i r s t several months following the death of her fr i e n d , Carla described a sense of exclusion of 130 i s o l a t i o n i n her bereavement experience. This exclusion was generated p r i m a r i l y by her b e l i e f that the meaning and extent of her loss would not be understood by others. As a r e s u l t , she i n i t i a l l y spoke with no one about her response to the death of her good f r i e n d . 7. F i n a l i t y (MU #36, 49, 82) When Carla recognized that her f r i e n d would never again be there to share birthdays and other s p e c i a l times, she experienced loneliness and longed for someone with whom she could share her sadness about the f i n a l i t y of her l o s s . Though she had friends who met other needs, she r e a l i z e d that the unique h i s t o r y and c h a r a c t e r i s t i c s that t y p i f i e d her bond with S. were i r r e p l a c e a b l y gone. Inclusion (MU #6, 7, 9, 28, 32, 40, 41, 47, 56, 59, 61, 69, 75, 77, 81) Carla f e l t included i n S's experience of i l l n e s s . She spent much time with S. during her unstable periods, o f f e r i n g support and hope for her recovery. Though infrequent, she also had the opportunity to discuss with her own parents and another mutually close f r i e n d to S. her experience of S's i l l n e s s and death. In the i n i t i a l months a f t e r S's death, Carla struggled with recognizing h e r s e l f as l e g i t i m a t e l y bereaved. Upon acknowledging the legitimacy of her l o s s , she made a to l e g i t i m i z e of loss of 2 also grieving of S., t h e i r marked e f f o r t the experience other friends the loss acknowledging entitlement to support. This recognition of the extent of her loss and of her status as bereaved was an important factor i n Carla's experience of l o s s . She believed that those who di d not know S. while she 131 was healthy would not understand the meaning of her l o s s . Consequently, receiving support from such i n d i v i d u a l s was unexpected but cherished. I n t e g r i t y (MU #5, 15, 16, 18, 19, 23, 24, 26, 48, 64, 65) Carla was saddened i n watching her f r i e n d become diminished and d e s t a b i l i z e d by her disease. • She was angered by S's f i n a l choice of means by which to end her l i f e and found i t d i f f i c u l t to condone given the i n t e g r i t y she believed S. had at one time possessed. During S's open casket funeral Carla refused to view her f r i e n d l y i n g i n state, choosing instead to remember S. for her v i t a l i t y and companionship. She believed the i l l n e s s had also diminished the i n t e g r i t y of t h e i r friendship. As such she attempted to maintain friendship's avoiding the professional knowledge to the by her i n t e g r i t y use of p s y c h i a t r i c influence S. during t h e i r time together. 10. I n t u i t i o n (MU #1, 2, 12, 53) Before r e c e i v i n g news of S's death, Carla had a strong sense that she and her family should return home early from t h e i r holidays. Though she found i t unnerving, she believed the close bond that they had shared i n e x p l i c a b l y drew her home for the funeral. 11. Meaning (MU #6, 25, 26, 42, 43, 44, 45) Carla struggled to make sense of S's death and the means by which S. had attained that end. This search for meaning was compelling, and seemed to be driven at times at an unconscious l e v e l . She also described the occurrence pf 132 c e r t a i n u n l i k e l y events which she believed helped her to make sense of aspects of the loss with which she had been struggling. 12. R i t u a l (MU #4, 29, 31, 54, 70, 72, 74, 76, 78) Carla found the formal r i t u a l of S's funeral u n s e t t l i n g as i t f a i l e d to eulogize and thus represent the p o s i t i v e e f f e c t s S. had had on the l i v e s of Carla and others. In contrast, the evening spent with bereaved friends a f t e r the funeral was for Carla a more f i t t i n g r i t u a l because i t involved personal remembrances of S., and took place i n the company of supportive others. This l a t t e r r i t u a l was an important opportunity for Carla to openly share her pain and have i t acknowledged. She also created private r i t u a l s i n order to further a s s i s t her adjustment to her loss and to honor the l i f e of her f r i e n d . 13. Uniquely Individual Response (MU #52, 53, 61, 62, 63, 67, 73) Carla was aware that some aspects of her response to S's loss were unique i n r e l a t i o n to a conventional model of loss with which she was f a m i l i a r . Because she had resigned h e r s e l f to the loss well before S's death, she believed her experience of such responses as shock and d i s b e l i e f were a t y p i c a l when compared to t h e i r conventional d e s c r i p t i o n . She also recognized and t o l e r a t e d the i n d i v i d u a l i t y of other bereaved i n terms of t h e i r response to the loss of S. 133 Appendix F E i d e t i c Analysis of Diane's Experience Thematic Cluster of Meaning Units Thematic Description 1. Acceptance (MU #8, 9, 15, 25, 61, 62, 65, 68, 69, 71, 74) • J's l i f e was ended by a terminal i l l n e s s which was contracted while being treated for a l i f e - l o n g chronic i l l n e s s . His resignation to death and long-standing courage i n the face of i t s i n e v i t a b i l i t y f a c i l i t a t e d Diane's acceptance of h i s impending death. With the deaths of her mother and e s p e c i a l l y her grandmother, she witnessed what she described as an awe i n s p i r i n g sense of s p i r i t u a l i t y incorporating a sense of peace or joy i n death. She sensed t h i s mystery e s p e c i a l l y i n the death of her f r i e n d J.H., i n whose dying process she was most intensely involved and with whose death she was most immediately resolved. Concession In her intense involvement (MU #57, 65) with the dying process of J.H., her most recent l o s s , Diane impeded h e r s e l f from enjoying her own l i f e . She f e l t that amidst his s u f f e r i n g she could not continue to enjoy l i f e and l i v e f u l l y . Because she d i d not want to burden him with her own sorrow she made a further concession and resolved not to cry i n his presence. Though she d i d not regret her concessions she believed she paid a t o l l for her intense support i n having impeded her own experience of joy before his death. 134 3. Control (MU #18, 22, 37, 46, 51, 54, 75, 77) Diane struggled with issues of control e s p e c i a l l y around the sudden losses of her friends J. and D. Though she was resolved to J's in e v i t a b l e death, she found h e r s e l f unprepared for how suddenly his death a c t u a l l y occurred. Her sense of v u l n e r a b i l i t y was i n t e n s i f i e d by her struggle to cope with the f a i l i n g health of her father and grandmother, and the impending death of the l a t t e r . Some years l a t e r she i s again confronted with such v u l n e r a b i l i t y i n terms of mort a l i t y by the sudden death of her f r i e n d D. 4. Emotional Distress (MU #3, 5, 6, 22, 37, 52, 65, 66) Diane described her response to the loss of A. as one i n which she f e l t overwhelmed by the unfamiliar confrontation with death. She remained i n a state of denial for an extended period of time a f t e r his death. With the death of her fr i e n d J. she again experienced a sense of being overwhelmed as his death had coincided with the f a i l i n g health of both her grandmother and father. Several years l a t e r , a f t e r the sudden death of her f r i e n d D., Diane described having experienced p r i m a r i l y a sense of shock and d i s b e l i e f with his l o s s . She struggled for some time with the seeming meaninglessness of his death, and recognized that her struggle was due i n part to being completely unprepared for his death. And with the most recent loss of her f r i e n d J. H. she described an intense and continual sense of anguish, much of which she experienced while caring for 135 him i n the months before his death. 5. Dissonance (MU #1, 17, 21, 38, 40, 42, 44, 49) Diane's experience of the loss of her f r i e n d A. was characterized i n part by dissonance. At that early part i n her l i f e she was unfamiliar with death and had not yet acknowledged the r e a l i t y of mortality. Later, with the death of her f r i e n d J. she again experienced dissonance, not with the r e a l i t y of death i t s e l f but rather with the way i n which his l i f e may have ended. She had been i n s p i r e d by J's courage and determination i n the face of his chronic and terminal i l l n e s s e s , and i n l i g h t of t h i s s t o i c i s m she had great d i f f i c u l t y resolving the fact that he may have taken his own l i f e . With the death of her f r i e n d D., her experience of sudden loss i s shaped by her intense rage with another mourner whose e x p l o i t a t i v e actions impinged on the a b i l i t i e s of Diane and other bereaved to openly and f u l l y experience and share t h e i r g r i e f . 6. Exclusion Diane described a sense of (MU #2, 36, 48, 50, 56) exclusion i n her experience of the loss of A. She f e l t unable to be with him during the acute i l l n e s s that l e d to his death, and experienced disappointment i n h e r s e l f for t h i s s e l f -imposed exclusion for a long period of time a f t e r his death. She again experienced a sense of exclusion with the sudden death of her f r i e n d D. In having had no time to prepare for his loss she believed she was prevented from accessing the s p i r i t u a l feedback that was necessary 136 for her to resolve his l o s s . Her i n i t i a l experience with the impending loss of J.H. was characterized by exclusion. She had been aware of his terminal i l l n e s s well before he dis c l o s e d i t to her and during t h i s i nterim she f e l t impeded i n her need to openly discuss with him his impending death and i t s implications. Inclusion (MU #14, 16, 20, 39, 43, 51, 55, 57, 58, 60, 66) Diane experienced a sense of i n c l u s i o n i n J's process of dying. They openly discussed his impending death and what i t meant for each of them. Her experience of the loss of J.H. was also one of i n c l u s i o n . Open discussion of h i s i l l n e s s and impending death was ongoing between them, and she was intensely involved i n his care to the very end of his dying process. Recognition of her loss and of her status as bereaved was an important factor i n Diane's adjustment to each of her losses. With each death she acknowledged the extent and s i g n i f i c a n c e of the los s through the act of reviewing who her f r i e n d had been i n l i f e and what he had meant to her. With each of her losses she considered h e r s e l f bereaved. l e g i t i m a t e l y I n t e g r i t y (MU #15, 19, 23, 51, 55, 58, 64, 67, 70, 74, 76) Despite the l i f e - l o n g chronic and terminal i l l n e s s e s that ended J's l i f e , she was i n s p i r e d by his courage and adherence to a purpose of being. She again witnessed i n the i l l n e s s and death of her f r i e n d J.H. t h i s same i n t e g r i t y which remained 137 i n t a c t despite the adversity of a d e b i l i t a t i n g i l l n e s s . And though his loss was extremely p a i n f u l , her own i n t e g r i t y remained i n t a c t throughout his dying process. She experienced pride i n her a b i l i t y to be there for him and o f f e r support i n spite of her own pain. 9. I n t u i t i o n (MU # 59, 62) Before departing on a holiday, Diane experienced with J.H. a strong sense of his imminent death, and believed he would die while she was away. Her i n t u i t i o n was l a t e r confirmed. 10. Meaning (MU #7, 8, 17, 20, 46, 50, 51, 68, 69, 72) E s p e c i a l l y i n her f i r s t experiences with the loss of a close f r i e n d , Diane struggled to make sense of t h e i r deaths. With the death of her f r i e n d A. she was emotionally overwhelmed by h i s loss and was unable to make sense of her experience u n t i l a f t e r the death of her own mother. Later with the deaths of her friends J. and then D. she struggled to f i n d meaning more i n the way i n which these friends died rather than i n the deaths themselves. Her most recent loss of her close f r i e n d J.H. has been one with which despite her anguish she has struggled less to f i n d meaning i n the death. A f t e r a long and agonizing struggle with i l l n e s s , Diane r e a l i z e d that i n death J.H. had found joy. 11. Ri t u a l (MU #41, 43, 51, 73) In her attempt to adapt to her losses, Diane found important the creation of personally meaningful r i t u a l s . As a means of doing something p o s i t i v e 138 with her anguish re l a t e d to the loss of D., she helped to create a memorial fund which would a s s i s t i n the administration of an annual workshop offered i n his area of s p e c i a l i t y . She found such p u b l i c commemoration h e l p f u l also i n adjusting to the deaths of her f r i e n d J.H. and her grandmother, and donated g i f t s to the community i n honor of t h e i r memory. 139 Appendix G E i d e t i c Analysis of Natasha's Experience Thematic Cluster Thematic Description of Meaning Units 1. Acceptance In the months before L's (MU # 7, 10, 11, 41, 46) death, Natasha had resigned h e r s e l f to the i n e v i t a b i l i t y of her l o s s . When the news of L's death a r r i v e d Natasha experienced sadness, but also r e l i e f i n that death was a p o s i t i v e a l t e r n a t i v e to the months and years of s u f f e r i n g that L. had endured. Though she asserted a need to bring some f i n a l closure to the process of grieving L's l o s s , Natasha wondered i f she had not already experienced the depth of g r i e f for L. that she believed she e s s e n t i a l l y would experience. Concession Natasha conceded that the (MU #9, 13) s u p e r f i c i a l i t y of t h e i r l a s t contact a c t u a l l y characterized much of her r e l a t i o n s h i p with L. Yet her l o y a l t y remained constant to her dying f r i e n d . Natasha r e a l i z e d that her friendship with L. had been sustained throughout t h e i r l i v e s by a bond which remained i n t a c t despite t h e i r physical distance and often very d i f f e r e n t perspectives i n l i f e . 3. Control Natasha questioned whether (MU #4, 8) more could have been done to have saved L's l i f e . She also struggled with her own a b i l i t y to have influenced the course of her friend's i l l n e s s and her p a i n f u l process of dying. 140 4. Emotional Distress (MU #3, 5, 10, 38, 39) Natasha experienced a sense of shock upon hearing that her f r i e n d L. was i l l with recurrent cancer, and had been so for 2-3 years by the time the news was di s c l o s e d to her. With t h i s d isclosure she also experienced an overwhelming and simultaneous sense of sadness and anger. Upon receiving word that L. had died, Natasha described a sense of numbness, part of which was a mixture of sadness that L's l i f e had ended, and r e l i e f that her struggle with i l l n e s s was f i n a l l y over. Dissonance (MU #7,16) Exclusion (MU #3, 6, 16, 23, 26, 28, 29, 36) Natasha experienced a sense of dissonance with others whose response to the loss of L. was d i f f i c u l t for her to t o l e r a t e , her need acknowledge loss of L. meant to experienced f r u s t r a t i o n i n c l u d i n g L., In l i g h t of to openly the impending and what that her, she great with others, who continued to deny the r e a l i t y of L's death despite i t s imminency. Natasha's f i r s t experience of the loss of a close f r i e n d i s characterized predominantly by a sense of exclusion. A f t e r the i l l n e s s and death of her best f r i e n d i n childhood, Natasha was denied access to attending the funeral. The si g n i f i c a n c e of her loss was not recognized by others, and she was excluded from status. She again sense of exclusion i n adulthood with the death of her f r i e n d L. Natasha was unaware of the recurrence of e f f e c t i v e l y bereavement describes a 141 her friend's cancer u n t i l i t was very advanced. By the time Natasha saw L., her f r i e n d was so close to death that she was no longer present or accessible to Natasha. Her sense of exclusion i s heightened a f t e r L's death when she attempts to di s c l o s e her struggle over L's loss to L's s i s t e r , with whom Natasha had also been close. The s i s t e r ' s response to Natasha' s pain had the e f f e c t of i n v a l i d a t i n g i t , i n d i c a t i n g to Natasha that she would be impeded i n further discussing her loss with L's s i s t e r . 7. F i n a l i t y In acknowledging aspects of (MU #14) the meaning of L's lo s s , Natasha was confronted by the f i n a l i t y of death. Inclusion (MU #8, 14, 15, 17, 18, 44, 47) Natasha's most treasured memory of her f i n a l v i s i t with L. was that of massaging L's feet. This f i n a l and only v i s i t with L. before her death allowed Natasha a sense of i n c l u s i o n . She gained a sense of being able to p a r t i c i p a t e i n and ease L's dying process. Her sense of i n c l u s i o n i n terms of being enabled to openly discuss her experience of loss was l a t e r influenced by her p a r t i c i p a t i o n i n her support group, as well as the development of her re l a t i o n s h i p with L's daughter K. Natasha found the freedom i n her support group to f u l l y express what the loss of L. had meant for her. In so doing, she came to recognize the extent of her los s and the legitimacy of her bereavement status. 142 9. I n t e g r i t y (MU #13) 10. K i n - l i k e Bond (MU #44) 11. Meaning (MU #12, 21, 22, 30, 35, 40, 42, 45, 46) 12. R i t u a l (MU #13, 22, 24, 25, 27, 31, 33) 13. Uniquely Individual Response (MU #7, 20, 30, 46) Natasha was aware of the e f f e c t of i l l n e s s on the i n t e g r i t y of her dying f r i e n d L. She r e f l e c t e d on the number of years her f r i e n d had suffered with her recurring i l l n e s s , and was struck by L's courage to b a t t l e for her l i f e for so long. Natasha r e a l i z e d that her experience of the loss of L. may have been intertwined with grieving the loss of the i d e a l natural family which she f e l t she never had. In her attempt to cope with her losses, Natasha searched not only for a means of making sense of those losses, but also for a way to grieve the death of her friends that would honor the meaning t h e i r l i v e s had embodied. Aspects of L's death, inc l u d i n g the meaning of her l o s s , s t i l l remain unresolved for Natasha. Natasha believed the creation of a meaningful r i t u a l enabled her to honor the meaning of the deceased. The development of such r i t u a l s was also accompanied by the creation of artworks and writings related to the deceased, which allowed her to further resolve her feeli n g s r e l a t e d to her losses. Natasha questioned whether her response to loss i t s e l f was unique i n r e l a t i o n to the way i n which other bereaved i n d i v i d u a l s respond to such l o s s . Further, based on the depth of her 143 r e l a t i o n s h i p with L., she questioned whether her response to the loss of L. would be unique i n r e l a t i o n to her response to losses which she may s u f f e r i n the future. 144 Appendix H Themes Common to the Experience of a l l Co-Researchers Theme Anna Carla Diane Natasha 1. Acceptance MU#11,14, 17,18,37, 47,49,60 62,65, 67 MU#20,23, 26,38,47, 48,58,60, 64, 66 MU#8,9, 15,25,61, 62, 65,68, 69,71,74 MU#7,10, 11,41,46 2. Concession MU#6,13, 22,26,27 28 MU#14,25, 51,64,67, 68,71 MU#57, 65 MU#9,13 3. Control MU#48,50, 51,52,59, 63, 69 MU#39,42, 44,46 MU#18,22 37,46,51 54,75,77 MU#4,8 4 . Emotional Distress MU#4,40 44,46,55 56,68,69 MU#3,10 11,21,22 29,30,34 50,57,58 59,64,79 MU#3,5,6 22,37,52 65, 66 MU#3,5 10,38,39 5. Dissonance MU#35,38 41,43,56 61, 63 MU#17,24 26,35,36 55,68,71 MU#1,17 21,38,40 42,44,49 MU#7,16 6. Exclusion MU#5,7 16,24,26 29, 39 MU#8,9 27,33,34 36,37,40 45,62,69 80 MU#2,36 48,50,56 MU#3,6 16,23,26 28,29,36 7. Inclusion MU#8,9 10,17,19 20,29,30 31,33,37 44,54,57 MU#6,7 9,28,32 40,41,47 56,59,61 69,75,77 81 MU#14,16 20,39,43 51,55,57 58,60,66 MU#8,14 15,17,18 44, 47 8 . In t e g r i t y MU#17,29 31,36,37 53, 66 MU#5,15 16,18,19 23,24,26 48, 64, 65 MU#15,19 23,51,55 58,64,67 70,74,76 MU#13 9. Meaning MU#12,42 44,46,57 58,60,64 MU#6,25 26,42,43 44,45 MU#7,8 17,20,46 50,51,68 69,72 MU#12,21 22,30,35 40,42,45 46 10. Ri t u a l MU#23,31 32,34,39 40,41 MU#4,29 31,54,70 72,74,76 MU#41,43 51,73 MU#13,22 24,25,27 31, 33 

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