Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

An exploration of bereavement intervention in palliative/hospice care programming Dawson, Patricia Shelagh Jean 1990

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1990_A5 D38.pdf [ 10.96MB ]
Metadata
JSON: 831-1.0097997.json
JSON-LD: 831-1.0097997-ld.json
RDF/XML (Pretty): 831-1.0097997-rdf.xml
RDF/JSON: 831-1.0097997-rdf.json
Turtle: 831-1.0097997-turtle.txt
N-Triples: 831-1.0097997-rdf-ntriples.txt
Original Record: 831-1.0097997-source.json
Full Text
831-1.0097997-fulltext.txt
Citation
831-1.0097997.ris

Full Text

AN EXPLORATION OF BEREAVEMENT INTERVENTION In PALLIATIVE/HOSPICE CARE PROGRAMMING By PATRICIA SHELAGH JEAN DAWSON B.A., The University of Alberta, 1980 S.W., The University of B r i t i s h Columbia, 1989 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in THE FACULTY OF GRADUATE STUDIES (School of Social Work) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July 1990 © P a t r i c i a Shelagh Jean Dawson, 1990 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. 1 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 The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT Bereavement i n t e r v e n t i o n i s subsumed w i t h i n p a l l i a t i v e programme p h i l o s o p h y which encompasses the f a m i l y as the u n i t o f care and p r o v i d e s a continuum of care t h a t extends beyond the death of a f a m i l y member. There i s no a v a i l a b l e r e s e a r c h on the e f f e c t o f post-bereavement i n t e r v e n t i o n w i t h i n p a l l i a t i v e programming, and very l i m i t e d r e s e a r c h e x i s t s t h a t e v a l u a t e s the e f f e c t o f i n t e r v e n t i o n on bereavement outcome. T h i s e x p l o r a t o r y study endeavors t o d i f f e r e n t i a t e bereavement outcome between two p o p u l a t i o n s having p a l l i a t i v e / h o s p i c e program support but o n l y one choosing t o p a r t i c i p a t e i n bereavement f o l l o w - u p . A mixed s t r a t e g y o f q u a n t i t a t i v e and grounded th e o r y approaches p r o v i d e d an expanded a n a l y s i s through which meaning s t r u c t u r e s and time/process parameters f o r g r i e v i n g i n d i v i d u a l s were e x p l o r e d . The study extended from i d i o s y n c r a t i c data i n t o the realm of l a r g e r systemic i n t e r a c t i o n s . An important f i n d i n g was t h a t the amount of time f o r p r e p a r a t i o n f o r the death of a f a m i l y member i s c r u c i a l . Other m i t i g a t i n g f a c t o r s i n f l u e n c i n g the g r i e f outcome were s o c i a l support, network v i a b i l i t y , and age. TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i i LIST OF FIGURES x ACKNOWLEDGEMENT x i I Introduction to the Study 1 Background to P a l l i a t i v e Care and Bereavement Intervention 1 Basic Social Processes (BSP) 3 Grief as an Il l n e s s 10 Paradigm S h i f t i n the Medical Model 13 Research Questions 17 Research Objectives 18 Summary 19 II Theoretical Framework 21 Introduction 21 Grief Defined 23 Meaning of Grieving/Mourning 26 Adaptation to Loss 29 Grief Process 29 Stages/Phases/Sequences 31 Tasks of Grieving 32 Bereavement Intervention 35 Rationale 35 Social Support 38 Informal Support Networks 42 Self-Help 43 Formal Support Networks 4 6 Summary 4 9 III Quantitative Analysis and Findings 50 Rationale for Quantitative Approach 50 Methodology 52 Sample Selection 53 Data C o l l e c t i o n Procedures 56 Cameron-Brings Questionnaire 58 Therapeutic Interview 60 Quantitative Data Analysis 62 Cameron and Brings Grief and Adjustment Inventories 62 Interview Coding 63 i i i Wilcoxon Matched-Pairs Signed-Rank Test 65 F i s h e r ' s Exact Test 66 D e s c r i p t i o n o f Method 66 F i n d i n g s o f the Q u a n t i t a t i v e A n a l y s i s 67 C r o s s - t a b u l a t i o n s 68 F i s h e r ' s Exact Test 69 Wilcoxon Matched-Pairs Signed-Ranks Test 72 G r i e f Scores 73 Adjustment Scores 75 C o m p a r a b i l i t y w i t h the Cameron-Brings/ Cameron-Parkes S t u d i e s 7 8 Other F i n d i n g s 81 Summary 84 IV Q u a l i t a t i v e A n a l y s i s and F i n d i n g s 8 6 R a t i o n a l e f o r Q u a l i t a t i v e A n a l y s i s 86 Methodology 89 Sample S e l e c t i o n 8 9 Data C o l l e c t i o n Procedures 91 Coding Paradigm 91 Frame f o r Bereavement A n a l y s i s 92 Time as a Study Parameter 93 C o g n i t i v e B i a s e s 95 Grounded Theory Approach 97 Open Coding 98 A x i a l Coding 99 Core C a t e g o r i e s 99 Memo W r i t i n g 100 I n t e g r a t i v e Diagrams and Charts 100 Report and T h e s i s W r i t i n g 100 Themes 102 Worden's Four Tasks of G r i e v i n g 108 Summary of Methodology 110 F i n d i n g s o f the Q u a l i t a t i v e A n a l y s i s 110 Metaphor as an E x p r e s s i o n o f Meaning I l l R e l a t i o n s h i p o f Metaphor t o Worden's Tasks 112 Metaphor of Process 112 Metaphor of P l a c e 117 i v Metaphor of Person 121 R e l a t i o n s h i p of Time t o Worden's Tasks 126 Four Dimensions of Time 129 Summary 133 V I n t e r p r e t a t i o n of F i n d i n g s 136 I n t e r p r e t a t i o n o f Q u a n t i t a t i v e F i n d i n g s 138 Review of G r i e f and Adjustment S c o r e s . . . . 140 I n t e r p r e t a t i o n o f Q u a l i t a t i v e F i n d i n g s 144 Review o f R e l a t i o n s h i p o f Metaphor t o Worden's Tasks 145 Process Metaphors 145 Plac e Metaphors 14 6 Person Metaphors 146 D i s c u s s i o n 147 Bereavement I n t e r v e n t i o n - C o n c e p t u a l i z i n g the Need 149 S o c i a l Support 150 Informal Support 150 Semi-Formal Support 154 Formal Support 155 R i t u a l and T r a d i t i o n 156 D i s c u s s i o n 160 Role R e d e f i n i t i o n 161 S o c i a l P s y c h o l o g i c a l Process 164 I d i o s y n c r a t i c c o n s i d e r a t i o n s 164 Aggregate c o n s i d e r a t i o n s 165 Models of Assessment f o r Bereavement I n t e r v e n t i o n 167 P s y c h o l o g i c a l D i s t r e s s Model 168 P s y c h o l o g i c a l Growth Model 169 D i s c u s s i o n 171 Assessment 171 Community Assessment 171 I n d i v i d u a l / F a m i l y Assessment 172 P l a n n i n g I n t e r v e n t i o n 174 Summary 175 VI Implications for Practice 178 Section I 179 Implications for Practice 181 Intervention Strategies 182 Integrative Family Therapy 184 Interactional Therapy 186 Problem-determined Systems Analysis 187 Sociocultural Approach 188 Discussion 189 Implications for Integrated Practice 190 Contextual R e a l i t i e s and Relational Processes 194 Boundaries, System F l e x i b i l i t y and Morphostasis 197 Communication 199 Discussion 202 Section II 203 Cha r a c t e r i s t i c s of the Sampled Bereavement Programme 203 Implications Concerning Bereavement Intervention From the Findings 205 Bereavement Intervention Programme Development 209 Philosophy 212 Goals 212 Objectives 212 Program Components 213 Economic Considerations 215 Po l i c y Implications 217 P a l l i a t i v e Care/Hospice Care P o l i c y 217 Advantages 223 Disadvantages 223 Finances 224 Discussion 228 Soci a l Work i n Bereavement Intervention 22 9 Social Worker i n Family Practice 230 Social Worker as Professional 231 Social Worker as Team Member 231 Social Worker as Individual 232 Summary 233 v i VII Summary and Con c l u d i n g Remarks 235 Summary 235 Study Parameters 236 Q u a n t i t a t i v e A n a l y s i s 237 Q u a l i t a t i v e A n a l y s i s 238 F i n d i n g s 239 I n t e r p r e t a t i o n o f the F i n d i n g s 240 Assessment 245 I m p l i c a t i o n s f o r P r a c t i c e 245 I m p l i c a t i o n s f o r F u r t h e r Research 24 C o n c l u s i o n 24 B i b l i o g r a p h y 255 Appendices Appendix I Sampling Frame 270 Appendix I I Q u e s t i o n n a i r e and S e l e c t e d E x c e r p t s 274 Appendix I I I Cameron and B r i n g s G r i e f and Adjustment I n v e n t o r i e s 295 Appendix IV Code Book f o r SPSS:X A n a l y s i s and Raw Data M a t r i x 299 Appendix V A b s t r a c t o f Comments u s i n g Worden's Four Tasks of G r i e v i n g . 302 Appendix VI A b s t r a c t o f Time Connotations . . . 315 L i s t o f Tables Table 1 M a n i f e s t a t i o n s of Normal G r i e f 25 Table 2 Dimensions of S o c i a l Support 40 Table 3 C r o s s - T a b u l a t i o n s of P r e p a r a t i o n Time and Bereavement Group P a r t i c i p a t i o n ... 70 Table 4 D i f f e r e n c e s i n G r i e f Scores between I n d i v i d u a l s With and Without Bereavement I n t e r v e n t i o n u s i n g the Wilcoxon Matched-P a i r s Signed-Ranks Test 73 Table 5 Computer /Analysis of G r i e f Scores u s i n g the Wilcoxon Matched-Pairs Signed-Ranks Test 74 Table 6 D i f f e r e n c e s i n Adjustment Scores between I n d i v i d u a l s With and Without Bereavement I n t e r v e n t i o n u s i n g the Wilcoxon Matched-P a i r s Signed-Ranks Test 75 Table 7 Computer A n a l y s i s of Adjustment Scores u s i n g the Wilcoxon Matched-Pairs Signed-Ranks Test 7 6 Table 8 Examples of Theme Assessment u t i l i z i n g the Coding Paradigm Components of C o n d i t i o n , I n t e r a c t i o n , S t r a t e g i e s and Consequences 105 Table 9 M a t r i x of Process Metaphors w i t h Worden's Four Tasks o f G r i e v i n g r e l a t e d t o Bereavement Group P a r t i c i p a t i o n 115 Table 10 M a t r i x of P l a c e Metaphors w i t h Worden's Four Tasks of G r i e v i n g r e l a t e d t o Bereavement Group P a r t i c i p a t i o n 120 v i i i i x L i s t of F i g u r e s F i g u r e 1 Bereavement Process 28 F i g u r e 2 Non-Linear R e p r e s e n t a t i o n o f the Bereavement Process 2 9 F i g u r e 3 F a c t o r s I n t e r v e n i n g w i t h the R e p o r t i n g o f Events 94 F i g u r e 4 Dimensional R e p r e s e n t a t i o n o f "Meaning" i n the Bereavement Process 107 F i g u r e 5 Context M a t r i x of Temporal Dimensions i n the Bereavement Process 133 x ACKNOWLEDGEMENT I wish t o express my g r a t i t u d e t o Ms. Susan Hogman, M.S.W., P a l l i a t i v e Care Program C o o r d i n a t o r , Department of S o c i a l Work, L i o n s Gate H o s p i t a l and t o the M e d i c a l Research Committee, L i o n s Gate H o s p i t a l , f o r very k i n d l y c o n s e n t i n g t o t h i s study. I am deeply i n d e b t e d t o those i n d i v i d u a l s who very generously shared w i t h me an extremely d i f f i c u l t and p e r s o n a l time i n t h e i r l i v e s , and f o r the encouragement and support o f Ms. Hogman. i x 1 CHAPTER 1 INTRODUCTION TO THE STUDY Background "We are a l l v u l n e r a b l e t o the profound f e e l i n g s t h a t accompany l o s s ... whether t h a t be our own impending death or l o s s o f h e a l t h ; the death or l o s s o f h e a l t h of someone we l o v e ; the l o s s of r e l a t i o n s h i p s , o f f u n c t i o n , o f dreams; the l o s s of p o s s e s s i o n s " (Ajemian and Mount, 1980, p.422). The p a s t twenty years have seen a phenomenal s h i f t i n awareness of i s s u e s surrounding death and d y i n g i n Western s o c i e t y . The r e s u l t has been a p r o l i f e r a t i o n o f p o p u l a r l i t e r a t u r e and s e l f - h e l p o r g a n i z a t i o n s ; the e s t a b l i s h m e n t of p r o f e s s i o n a l s t u d i e s , s p e c i a l i z a t i o n s , j o u r n a l s ; and the development of p a l l i a t i v e c a r e / h o s p i c e o r g a n i z a t i o n s and treatment c e n t r e s throughout North America. Governments have e s t a b l i s h e d p o l i c i e s and procedures c o v e r i n g standards of c a r e and r e s u l t i n g f u n d i n g parameters (Hospice Development and T e c h n i c a l A s s i s t a n c e Group, Bethesda MD. 1978; Government of Canada, M i n i s t e r of N a t i o n a l H e a l t h and Welfare, 1982). Vachon (1988) notes t h a t "a b a s i c t e n e t of 2 h o s p i c e / p a l l i a t i v e c a r e i s the p r o v i s i o n of emotional support f o r the p a t i e n t / f a m i l y u n i t ... [and] t h a t t h i s care w i l l c o n t i n u e i n t o the bereavement p r o c e s s " (Medicare Reimbursement P o l i c i e s i n the U n i t e d S t a t e s , Vachon, 1988, p. 36) . Research r e l a t e d t o g r i e f and bereavement i n c r e a s e d s i g n i f i c a n t l y w i t h the i n c e p t i o n of h o s p i c e care and w i t h St. C h r i s t o p h e r ' s Hospice i n 1965 i n England. S t u d i e s by Hinton (1967) and Parkes (1972) i n d i c a t e d need f o r h e l p i n g and s u p p o r t i n g bereaved i n d i v i d u a l s , and demonstrated r e l a t i o n s h i p s between bereavement d i f f i c u l t i e s and decreased job performance and/or i n c r e a s e d p h y s i c a l / m e n t a l h e a l t h problems. R e d e f i n i t i o n of "normal" bereavement, of what c o n s t i t u t e s "at r i s k p o p u l a t i o n s " and e f f i c a c y of a m e l i o r a t i o n l e n d v i t a l i t y — and c h a l l e n g e — t o an ever changing, ever growing area of i n q u i r y (Rando 1984, 1986; Raphael, 1980, 1982; Schoenberg, 1975; Vachon 1982, 1988; Worden, 1982). These s t u d i e s c o n t a i n a d e s i r e f o r knowledge t h a t can be d i r e c t l y a p p l i e d t o a l l e v i a t e the p a i n and s u f f e r i n g of d y i n g i n d i v i d u a l s and t h e i r f a m i l i e s -- to t u r n the p o t e n t i a l l y most p a i n f u l l i f e e xperience i n t o a p e r i o d of growth and change. I t i s f e l t t h a t P a l l i a t i v e Care reduces bereavement r i s k through i t s i n c o r p o r a t i o n of the 3 family as the unit of care. Basic S o c i a l Process (BSP) Glaser (1978) describes a BSP as a process containing "two or more clear emergent stages, requires that the stages should d i f f e r e n t i a t e and account f o r the problematic pattern of behaviour. ... A process i s something which occurs over time and involves change over time" (p.97). Consideration of change over time i s forced upon an e x p l i c a t i o n of bereavement programming as i t i s subsumed within the evolution of h o s p i c e / p a l l i a t i v e care that r e f l e c t s s o c i e t a l change i n p r i o r i t i e s . Reference i s made on the previous page to "an ever changing, ever growing area of inquiry". With bereavement care, a consideration of the BSP would look at multiple linkages between the i n d i v i d u a l and s o c i e t a l structures and the multiple l e v e l s i n which t h i s i s played out. There are two leve l s of analysis therefore — the basic s o c i a l psychological process (BSPP) that "refers to s o c i a l psychological processes such as becoming, h i g h l i g h t i n g , personalizing, health optimizing, awe i n s p i r i n g and so forth", and the basic s o c i a l s t r u c t u r a l process (BSSP) that would include "bureaucratization, 4 c e n t r a l i z a t i o n , o r g a n i z a t i o n a l growth". ... " U s u a l l y one r e q u i r e s a BSPP to understand the focus on a BSSP" (Glaser, p.102) . When c o n s i d e r i n g the s t r u c t u r e of h e a l t h d i s t r i b u t i o n through programming of p a l l i a t i v e care, h e a l t h p r e v e n t i o n through bereavement support, and a v a i l a b i l i t y and access through government f u n d i n g p r i o r i t i e s , the focus i s on s o c i a l s t r u c t u r a l p r o c e s s . T h i s a l s o i n c l u d e s s o c i e t a l norms t h a t may change over time thus impinging upon r o l e d e f i n i t i o n and s o c i a l e x p e c t a t i o n s of bereaved i n d i v i d u a l s . At t h i s l e v e l of a n a l y s i s , the s o c i a l s t r u c t u r e s are " c o n d i t i o n s t h a t a f f e c t the n a t u r e " of the s o c i a l p s y c h o l o g i c a l p r o c e s s e s ( I b i d , p.103). "The v a l u e systems and normative m i l i e u s of the l a r g e r s o c i a l s t r u c t u r e t y p i c a l l y i n f l u e n c e the b ehaviours of i n d i v i d u a l s through t r a n s m i s s i o n and enforcement ... mediated through i n d i v i d u a l human a c t i o n . T h i s i n v o l v e s , f i r s t , s o c i a l - p s y c h o l o g i c a l theory, which d e a l s with the i n d i v i d u a l ' s response to a x g i v e n ' s o c i a l s i t u a t i o n , and, second, th e o r y at the s t r u c t u r a l l e v e l , which d e a l s w i t h the d e t e r m i n a t i o n of t h a t g i v e n s o c i a l s i t u a t i o n by c h a r a c t e r i s t i c s of the l a r g e r s o c i a l system" ( L a z a r s f e l d et a l , 1972, p .291). 5 I t i s not p o s s i b l e t o d i v o r c e the observed p r o c e s s e s of change f o r bereaved i n d i v i d u a l s from the dynamics of s o c i e t a l change. As i n d i v i d u a l s seek r e d e f i n i t i o n , r e f o r m u l a t i o n and r e i n t e g r a t i o n of meaning and s e l f , they do so w i t h i n a dynamic s o c i e t y under-going continuous i n f r a -s t r u c t u r a l change. For g r i e v i n g i n d i v i d u a l s , the p r o c e s s of change may appear t o be i n phases or stages, which can, p a r t i c u l a r l y i n r e t r o s p e c t , be seen as t u r n i n g p o i n t s w i t h i n the p r o c e s s . These are viewed as " c r i t i c a l j u n c t u r e s ... when the occurance or non-occurrence of a p a r t i c u l a r c r i t i c a l event (or whatever) w i l l determine whether a new stage has been e n t e r e d ; ... or may not be as c l e a r ...[but] may be obvious l a t e r a f t e r a s h o r t p e r i o d of time, through g r a d u a l occurrence and c l a r i t y of a set of i n d i c a t o r s " (Glaser, 1978, pp.99-100). Turning p o i n t s can a l s o apply t o s o c i e t a l change. The major i n f l u e n c e on c u r r e n t P a l l i a t i v e Care development can be t r a c e d back t o the 1960s, when a booming economy accommodated broad s o c i a l d i v e r s i t y . Combined w i t h s o c i e t a l i n t r o s p e c t i o n , t h i s produced a m u l t i p l i c i t y of s o c i a l movement e x p r e s s i o n s which spoke t o a l i e n a t i o n , m a t e r i a l i s m , t e c h n o l o g i c a l advances and dehumanizing s t r u c t u r e s . These 6 were i n c o r p o r a t e d w i t h i n a paradigm s h i f t which r e s t r u c t u r e d C a r t e s i a n "thoughts, p e r c e p t i o n s and v a l u e s t h a t formed a p a r t i c u l a r v i s i o n of r e a l i t y " (Capra, 1982, p.30) Capra p l a c e s t h i s s h i f t i n a broad p e r s p e c t i v e o f c u l t u r a l r e v o l u t i o n encompassing a movement from the s c i e n t i f i c method t o a r e f o r m a t i v e e v o l u t i o n of "most s o c i a l r e l a t i o n s h i p s and forms of s o c i a l o r g a n i z a t i o n s " ( I b i d , p.31). T h i s i s expressed i n h o l i s t i c terms of e t h i c a l v a l u e s and human "standards of j u s t i c e , t r u t h and beauty" (Ibid) . The l a t e 1970s and e a r l y 1980s saw tremendous s o c i a l change i n f l u e n c e d by the downturn of the economy -- h i g h unemployment, h i g h i n t e r e s t r a t e s , i n c r e a s e d p r e s s u r e on government spending, i n c r e a s e d t e c h n o l o g i c a l advance w i t h i n h e r e n t c o s t i n c r e a s e , thus p l a c i n g a d d i t i o n a l p r e s s u r e s on h e a l t h care d o l l a r s . The s h i f t i n government p o l i c i e s and h e a l t h care f u n d i n g parameters toward c o s t s a v i n g p r e v e n t i v e and h e a l t h promotion programming, b e n e f i t t e d the implementation of P a l l i a t i v e Care and community based support s t r u c t u r e s . The need t o i n c o r p o r a t e a sense of s o c i a l j u s t i c e i n t h i s p r o c e s s i s a l s o apparent. "In a time when h e a l t h care e x p e n d i t u r e s are i n c r e a s i n g l y s c r u t i n i z e d t o maximize the b e n e f i t s f o r 7 the community at l a r g e , the needs of the bereaved s h o u l d be g i v e n a h i g h p r i o r i t y i n an attempt t o reduce t h e i r p o t e n t i a l long-term burden on the h e a l t h care system" (Bereza, 1988, p.1097). W i t h i n the m e d i c a l model, the impact of h o l i s m i s s l o w l y e r o d i n g entrenched power s t r u c t u r e s — p a r t i c u l a r l y i n P a l l i a t i v e Care programming — s u p p o r t i n g and v a l i d a t i n g i n d i v i d u a l s through p e r s o n a l empowerment. I t i s a l s o a f f e c t i n g medical t r a i n i n g , course content and p h y s i c i a n s p e c i a l t y c h o i c e s — w i t h a l a r g e r number of new d o c t o r s o p t i n g f o r h o l i s t i c f a m i l y medicine (St. L o u i s U n i v e r s i t y School of Medicine, 1984; D e B e l l i s et a l . 1988). The r o l e s and s o c i e t a l e x p e c t a t i o n s of women have changed d r a m a t i c a l l y , which i n i t s e l f impacts r o l e r e d e f i n i t i o n and meaning d u r i n g the bereavement p r o c e s s . Capra c o n s i d e r s the f e m i n i s t movement as "one of the s t r o n g e s t c u l t u r a l c u r r e n t s of our time ... having a profound e f f e c t on our f u r t h e r e v o l u t i o n " (Capra, 1982, p.30) F e m i n i s t v a l u e s of c o o p e r a t i o n , c o l l a b o r a t i o n and consensus, have been a s s i m i l a t e d i n t o environmental movements, h o l i s t i c h e a l t h and h e a l t h y community movements, and community p l a n n i n g and s o c i a l o r g a n i z a t i o n models. I t i s w i t h i n t h i s context t h a t i n d i v i d u a l s have matured, 8 developed attachment bonds, r e l a t i o n s h i p d i f f e r e n t i a t i o n and r o l e behaviour s t r a t e g i e s i n the home and community. With the death of a f a m i l y member, the bereaved are b e r e f t o f r e l a t i o n a l r o l e s and s e l f d e f i n i t i o n . F or some, depending upon the l i f e c y c l e stage, t h e r e i s l i t t l e or no understanding o f r o l e e x p e c t a t i o n s i n s o c i e t y , r e s u l t i n g i n a f e e l i n g of d i s c o n t i n u i t y . T h e r e f o r e , w h ile focus may be on the i n d i v i d u a l g r i e v i n g p r o c e s s and i t s a m e l i o r a t i o n through bereavement support programming, we are i n f a c t i n c o r p o r a t i n g the g r i e v i n g p r o c e s s of a v a r i e t y of i n d i v i d u a l s encountered i n a v a r i e t y of m i l i e u x ; "these m i l i e u x , i n t u r n , are l o c a t e d i n l a r g e r h i s t o r i c a l and s o c i a l s t r u c t u r e s " ( M i l l s , 1961, p.129). T h i s suggests t h a t as g r i e f and bereavement concepts are embedded w i t h i n complex systems, we need t o "move toward a complex, mu t u a l l y c a u s a l , and s e l f -t r a n s c e n d i n g [understanding o f the] s t r u c t u r e o f change ... t h a t k n i t s t o g e t h e r those a p p a r e n t l y d i s p a r a t e a s p e c t s of our emergent maps of r e a l i t y " (Schwartz and O g i l v y , p.57) In t h i s way Schwartz and O g i l v y suggest t h a t w h i l e p r o c e s s may have r u l e s — phases or stages — "they are r u l e s f o r engagement r a t h e r than f o r o b j e c t i f y i n g " , t h a t w i l l be i n n o v a t i v e — " h e t e r a r c h i c a l , d e c e n t r a l i z e d and many-9 d i m e n s i o n a l " , and w i l l c o n s i d e r m u l t i p l e sources and m u t u a l i t y of e x p e r i e n c e . G l a s e r would i d e n t i f y a B a s i c S o c i a l S t r u c t u r a l Process as the s o c i a l s t r u c t u r e w i t h i n which the s o c i a l - p s y c h o l o g i c a l p r o c e s s e s are f a c i l i t a t e d ( G laser, 1978, p.102). The s o c i a l p s y c h o l o g i c a l p r o c e s s e s of g r i e f and bereavement are bounded by the c u l t u r e of the s o c i e t y , and meaning i s d e r i v e d from the connections of p e r s o n a l w i t h s o c i a l p r o c e s s e s . Parkes (1971) m a i n t a i n s t h a t an i n d i v i d u a l ' s "assumptive world" model i n c o r p o r a t e s both the i d e a l i z e d world and the a c t u a l , p e r c e i v e d world. When the a f f e c t i o n a l bonds are severed through g r i e f , the i n i t i a l response i s r e s i s t a n c e t o change. Lack of f i t r e q u i r e s i n d i v i d u a l s t o change t h e i r map of r e a l i t y , g i v i n g up one s e l f - v i e w and the assumptive world-view, w h i l e b u i l d i n g up new assumptions about the world and s e l f . One way i n which t o frame the death event and t o reframe l i v i n g i n the new c o n f i g u r a t i o n i s through r i t u a l a c t s and behaviours c o n t a i n e d w i t h i n mourning customs of a s o c i e t y . Of major concern i n our s o c i e t y i s the l o s s of r i t u a l s u r r o u n d i n g death and bereavement. As r e l i g i o s i t y d e c l i n e s , so too do the wakes, the f u n e r a l p r o c e s s i o n s , the b l a c k arm bands, the " s h i v a h " — the o p p o r t u n i t i e s f o r the 10 community to draw together to support the bereaved. While cultures use r i t u a l to l e g i t i m i z e s o c i a l arrangements — for example the current trend to elaborate wedding r i t e s — a r e f l e c t i o n of our death-denying society i s found i n i t s lack of legitimation of the death. Gri e f as an I l l n e s s Since World War II, care f o r the terminally i l l has been progressively focussed i n the h o s p i t a l s e t t i n g thus defining t h i s component of care. Modern h o s p i c e / p a l l i a t i v e care was f i r s t put f o r t h by physicians — Drs. Ceci l y Saunders i n England and Elizabeth Kubler-Ross i n the United States — who spoke to the need for better care of the terminally i l l and t h e i r f a m i l i e s . It was presented as "a new and challenging opportunity to refocus on the patient as a human being, to include him i n dialogues, to learn from him the strengths and weaknesses of our h o s p i t a l management of the patient" (Kubler-Ross, 1969, Preface). Recognition was given to the r o l e of the family i n the patient's perception of and reaction to i l l n e s s , and to the concomitant family changes/disruptions that occur i n response to the i l l n e s s t r a j e c t o r y . Grief was acknowledged as a d i s o r i e n t i n g process, and subsequently thought to be something that required professional intervention i n order to minimize or avoid c e r t a i n reactions. " I m p l i c i t i n t h i s approach are the notions that (1) a spontaneous healing process w i l l occur i f the mourner has s u f f i c i e n t psychological health, (2) the mourner should grieve i n a c e r t a i n way, and (3) the mourner should seek professional person's p r i v i l e g e d knowledge about how to grieve" (Silverman, 1986, p.6). As a r e s u l t , ' g r i e f was incorporated into medical nomenclature, with cer t a i n aspects l a b e l l e d a "functional p s y c h i a t r i c disorder" (Parkes, 1972, p.6), and couched i n terms of 'healing' or 'recovery' with an implied 'cure'. The d e l i n e a t i o n of r i s k variables inherent i n the bereavement process, and t h e i r p o t e n t i a l i t y for expression, has occurred within a medical paradigm. Manifestation of "symptoms" or pain has been considered pathological, hence g r i e f treated as an i l l n e s s . Expertise was located i n the physician or psychoanalyst and the i n d i v i d u a l required intervention i n order to give up, or "decathect" the deceased. With these parameters, i t i s d i f f i c u l t f o r g r i e v i n g i n d i v i d u a l s to r e a l i z e that the pain and discomfort associated with g r i e f and bereavement i s normal, not pathological, that i t i s a process, a t r a n s i t i o n a l period while the individual/family adjusts and adapts to l i f e without the deceased. The o b j e c t i f i c a t i o n of ^ g r i e f as i l l n e s s created a metaphor i n which symptoms equate pathology and ind i v i d u a l s "take up residence i n the kingdom of the i l l prejudiced by the l u r i d metaphors with which i t has been landscaped" (Sontag, 1977, p.4). While the impetus for change i n caring for the terminally i l l and t h e i r families arose within the medical community, i t was noted e a r l i e r that the s o c i a l community of the 1960s engaged i n extensive s e l f - a p p r a i s a l and discerned a need for empowerment and e x p e r i e n t i a l v a l i d a t i o n . Subsequent s o c i e t a l transformations enabled the expression of the pervasive fear, i s o l a t i o n and impotency of terminal i l l n e s s and the need for support of the bereaved. This resulted i n an almost evangelical attachment to values inherent i n a P a l l i a t i v e Care paradigm perceived to be based upon a h o l i s t i c philosophy of care. Holism appears to be contradictory to the medical paradigm, yet i s contained within i t . This creates a source of tension f o r professionals and c l i e n t s a l i k e . S h i f t i n g of attitudes within the h o s p i t a l and health care systems i s r e f l e c t i v e of changing attitudes and p r i o r i t i e s within the larger society. 13 Paradigm S h i f t i n the M e d i c a l Model A C a r t e s i a n conceptual framework upon which the s c i e n t i f i c r e d u c t i o n i s t method i s based has been a p p l i e d t o the concepts of h e a l t h , i l l n e s s and pathology. In t h i s view, the body i s a machine which can be a n a l y z e d i n i t s component p a r t s . Thus ' g r i e f , as we have observed, has been framed i n symptomatology based upon concerns about r i s k , r e c o v e r y and time-boundedness. I t i s important t o r e c o g n i z e the c u l t u r e of the r e d u c t i o n i s t approach which s t r u c t u r e s the o p e r a t i o n a l paradigm of m e d i c a l c a r e g i v e r s / r e s e a r c h e r s throughout t h e i r e d u c a t i o n and p r a c t i c e . Under t h i s c o n d i t i o n , i t i s n a t u r a l t o d e l i n e a t e bereavement r i s k s i n a symptomatic manner. However, c r o s s - d i s c i p l i n a r y c o n f l i c t s can a r i s e from a l a c k of v a l u e congruence. Roberts (1989) m a i n t a i n s t h a t s o c i a l work and m e d i c a l value d i f f e r e n c e s "can c a t a l y z e s u c c e s s f u l c o l l a b o r a t i o n between the two p r o f e s s i o n s , which w i l l u l t i m a t e l y b e n e f i t p a t i e n t s [and c l i e n t s ] who r e c e i v e c a r e " (p.211). Rossman (1977), however, c a u t i o n s t h a t p r o f e s s i o n a l i n t r a n s i g e n c e i s not e a s i l y overcome and t h a t entrenched f u n d i n g p r i o r i t i e s and cure m o t i v a t i o n p r e c l u d e s f u n d i n g f o r "compassion and empathy" (p.192). He a s s e r t s t h a t h o s p i c e s are i n " h o s t i l e t e r r i t o r y " competing f o r l i m i t e d resources, and o f f e r i n g nothing but anecdotal evidence of success. There are reasons therefore, for amassing a body of knowledge that should not escape p r a c t i t i o n e r s of any d i s c i p l i n e . Legitimation precludes marginalization — an occurrence prevalent with alternate health care (ie. homeopathy, naturopathy) — and ensures incorporation/acceptance into the medical community. Another impetus for data formulation i s l e g i t i m i z i n g claims for funding which would conceivably save health d o l l a r s . Lamers (1988) c i t e s lack of h o s p i c e / p a l l i a t i v e care funding as a constraint on hospice research but emphasizes that the value of research cannot be underestimated as benefits to patients and families and dissemination of knowledge le g i t i m i z e s concerns and needs. Dush (1988) notes that while there i s an increase of a r t i c l e s (approximately 2000 i n the period 1980 - 1985) pertaining to the hospice concept, death and dying theory, pain and symptom control, only seven per cent (7%) c i t e d g r i e f as the primary area of focus, and none c i t e d bereavement. He fe e l s large gaps are to be found i n the areas of prevention, hospice family psychology, " s p e c i f i c i t y i n defining measurable aspects of what we are t r y i n g to accomplish by our e f f o r t s " , and program research (Dush, 1988, p.26). Yalom and Vinogradov (1988) found "only f o u r e m p i r i c a l s t u d i e s i n the p r o f e s s i o n a l l i t e r a t u r e which attempt t o examine the e f f i c a c y o f bereavement groups" (p.420). C o n s i d e r a t i o n may a l s o be g i v e n t o the need f o r renewed d i r e c t i o n i n a medi c a l community t h a t has avoided the i s s u e of death and has s u b l i m i n a l l y promoted death d e n i a l i n i t s a l l out war on d i s e a s e . "The m e d i c a l i z a t i o n o f s o c i e t y has brought about the epoch of n a t u r a l death t o an end. Western man has l o s t the r i g h t t o p r e s i d e at h i s act of d y i n g . H e a l t h , or autonomous power t o cope, has been e x p r o p r i a t e d down t o the l a s t b r e a t h . T e c h n i c a l death has won i t s v i c t o r y over d y i n g . Mechanical death has conquered and d e s t r o y e d a l l o t h e r deaths" ( I l l i c h , 1976, p.210). Paradigms are p e r c e i v e d t o be "a p a t t e r n of metaphors which l e a d s t o an i n t e r n a l i z a t i o n of a "map" of r e a l i t y or a b e l i e f system" (Schwartz and O g i l v y , 1979, p.2). A paradigm s h i f t w i t h i n the medi c a l model r e s u l t s i n some s u b t l e , yet p e r v a s i v e changes i n the focus o f care throughout the system. A ' s h i f t ' r e q u i r e s i n t r o s p e c t i o n and acknowledgement of a d i f f e r e n t world view. The C a r t e s i a n model i s based upon an o b j e c t i v e world having n e u t r a l i n s t r u m e n t a l i t y . Shannon (1989) a s s e r t s t h a t the b i o m e d i c a l model of d i s e a s e i s becoming o b s o l e t e . " I n c r e a s e d focus on promotion and i l l n e s s p r e v e n t i o n have c r e a t e d new demands ... [ i n which] boundaries between h e a l t h care p r o v i d e r s and p a t i e n t s w i l l undergo dramatic change" (p.32). P a t i e n t s now have acknowledged r i g h t s w i t h i n the h e a l t h care system — however p e r v a s i v e the p r e s s u r e s of l o y a l t y and o b l i g a t i o n t o a p h y s i c i a n may be. P a t i e n t - c e n t e r e d care i s becoming a c a t c h phrase. But the s h i f t i s g r e a t e r than "cosmetic" changes. The model i t s e l f s h i f t s i n P a l l i a t i v e Care — and with i t has s h i f t s the power of the p r o f e s s i o n a l ( i n c l u d i n g the p h y s i c i a n ) t o the p a t i e n t and the f a m i l y / s i g n i f i c a n t o t h e r . With t h i s s h i f t has come the r e a l i z a t i o n t h a t while g r i e f e x h i b i t s many of the ^symptoms', g r i e f i s not an i l l n e s s i n i t s e l f , but r a t h e r a pro c e s s o f t r a n s i t i o n , of change. R e c o g n i t i o n i s a l s o made of s o c i e t a l f a c t o r s t h a t "have an impact on the circumstances of death and the course o f bereavement" which may n e c e s s i t a t e i n t e r v e n t i o n t o " f a c i l i t a t e the g r i e v i n g p r o c e s s [to] prevent or a l l e v i a t e d e t r i m e n t a l consequences of bereavement" (Osterweiss, 1984, p.240). I n c o r p o r a t i n g the h o l i s t i c h e a l t h paradigm t h e r e f o r e r e q u i r e s a t o t a l r e s t r u c t u r i n g of v a l u e s , i n which r e c o g n i t i o n i s giv e n t o " i n d i v i d u a l p o t e n t i a l and q u a l i t y of 17 l i f e through p a t i e n t and f a m i l y p a r t i c i p a t i o n i n the d e c i s i o n - m a k i n g and care p r o c e s s e s " (Reidy, Levesque, and Payette, 1987, p.131). The h o l i s t i c v a l u e s of s e l f -d e t e r m i n a t i o n are f a r - r e a c h i n g and complex, and "cannot h e l p but have an impact on the i n s t i t u t i o n a l system, and even perhaps on the g l o b a l h e a l t h system" ( I b i d , p.146). Research Questions I t i s h y p o t h e s i z e d t h a t P a l l i a t i v e Care reduces bereavement r i s k through i t s i n c o r p o r a t i o n of the f a m i l y as the u n i t of c a r e . In t h i s way the f a m i l y u n i t i s empowered and g a i n s c o n t r o l over treatment and i n t e r v e n t i o n i s s u e s . I t i s noted i n the l i t e r a t u r e t h a t while many f a m i l y members with p a l l i a t i v e c a r e e x p e r i e n c e choose not p a r t i c i p a t e i n bereavement support groups, o t h e r f a m i l i e s do (Vachon, 1988; 0'Toole, 1987; Roy and Sumpter, 1983). T h i s o b s e r v a t i o n begs the q u e s t i o n s : • " f o r whom i s bereavement care e f f e c t i v e ? " (Osterweiss, 1988), • what needs are met f o r those who p a r t i c i p a t e ? • why do some i n d i v i d u a l s choose not t o p a r t i c i p a t e ? • what p e r s o n a l / s o c i a l b a r r i e r s e x i s t t o p a r t i c i p a t i o n i n bereavement support a c t i v i t i e s ? 18 Research O b j e c t i v e s The e x p l o r a t i o n i n t o the e f f i c a c y o f bereavement f o l l o w - u p began with a m o d i f i e d r e p l i c a t i o n o f a q u a n t i t a t i v e study c a r r i e d out by Cameron and B r i n g s , at the Royal V i c t o r i a H o s p i t a l P a l l i a t i v e Care U n i t i n 1976. R e a l i z i n g t h a t t h e r e are l i m i t a t i o n s i n r e p l i c a t i o n , a f u r t h e r e x p l i c a t i o n of the g r i e v i n g p r o c e s s i n c o r p o r a t i n g a q u a l i t a t i v e a n a l y s i s u t i l i z i n g W i l l i a m Worden's " t a s k s of g r i e v i n g " was a l s o i n c l u d e d i n the e x p l o r a t o r y d e s i g n . T h i s q u a l i t a t i v e framework c l a r i f i e d meaning s t r u c t u r e s and the bereavement process over time, which enabled e v a l u a t i o n of the e f f e c t of bereavement i n t e r v e n t i o n and p r o v i d e d support f o r i t s u t i l i t y as a p r e v e n t i v e h e a l t h i n t e r v e n t i o n . The o r i g i n a l Cameron study was c a r r i e d out i n 197 6 --i n the i n f a n c y of p a l l i a t i v e care i n b o t h Canada and the U n i t e d S t a t e s . While p e r s o n a l l o s s and g r i e f response does not change, the s t r u c t u r e s w i t h i n which i t i s framed, hence the p e r s o n a l framing, have done so. P a l l i a t i v e Care programming, which encompasses a bereavement f o l l o w - u p component w i t h i n i t s mandate f o r c o n t i n u i t y of care, now has i t s own h i s t o r y , i t s own t r a d i t i o n , and i t s own c u l t u r e . I t was d e f i n e d w i t h i n the medical model, however i t s u b s c r i b e s t o v a l u e s , g o a l s and o b j e c t i v e s t h a t impose a paradigm s h i f t 1 9 toward h o l i s t i c p a t i e n t - d i r e c t e d c a r e . The e v o l u t i o n of p a l l i a t i v e care has c r e a t e d a s u b t l e s h i f t i n the approach t o t o t a l care which i s m i r r o r e d by e x p e c t a t i o n s of the people w i t h i n the pr o c e s s — both c l i e n t s and p r o f e s s i o n a l s . Through the m o d i f i e d r e p l i c a t i o n o f the Cameron-Brings study and, more i m p o r t a n t l y , the f u r t h e r a n a l y s i s through a p p l i c a t i o n o f Worden's Four Tasks of G r i e v i n g , t h i s t h e s i s w i l l endeavour t o c l a r i f y t he e f f i c a c y of bereavement i n t e r v e n t i o n by e x p l o r i n g : • the need f o r bereavement i n t e r v e n t i o n , i m p l i c a t i o n s f o r p r a c t i c e which w i l l address f a m i l y r e s o u r c e e v a l u a t i o n through c o n t e x t u a l a n a l y s i s , and w i l l speak t o s o c i a l s t r u c t u r e s which impinge upon or a m e l i o r a t e the g r i e v i n g p r o c e s s , • p o l i c y i m p l i c a t i o n s f o r p r o v i s i o n of bereavement i n t e r v e n t i o n programming. Summary Th i s c hapter has p r o v i d e d an i n t r o d u c t i o n t o t h i s r e s e a r c h p r o j e c t by a d d r e s s i n g : the h i s t o r i c a l development of bereavement care through the p a l l i a t i v e care movement, 20 v a l u e s i n h e r e n t i n s o c i a l s t r u c t u r a l changes which may a f f e c t bereavement outcome, the l a c k o f r e s e a r c h i n the s p e c i f i c area o f bereavement i n t e r v e n t i o n . Encompassed w i t h i n an a n a l y s i s o f bereavement r e s o l u t i o n i s an interwoven t a p e s t r y o f time and i n t e r p r e t a t i o n w i t h which i n d i v i d u a l s frame t h e i r g r i e v i n g e x p e r i e n c e and t h e i r p e r c e i v e d need f o r bereavement support. The c o v e r t shadow of s t r u c t u r a l change (both i n s o c i e t y and i n the m e d i c a l model i t s e l f ) has l e d t o a broader a n a l y s i s of bereavement care and p r o c e s s . A g r e a t e r s t r e n g t h o f the f u l l i n q u i r y i s found i n the e l u c i d a t i o n of c o n c e p t u a l and p h i l o s o p h i c a l growth, which has broader i m p l i c a t i o n s f o r P a l l i a t i v e Care and c l i e n t empowerment. 21 CHAPTER 2 THEORETICAL FRAMEWORK Th i s chapter p r o v i d e s a s u b s t a n t i v e i n v e n t o r y o f bereavement r i s k f a c t o r s , the d e f i n i t i o n of g r i e f , and f a c t o r s which a m e l i o r a t e the bereavement p r o c e s s . R a t i o n a l e i s e x p l o r e d f o r p r o v i s i o n of bereavement i n t e r v e n t i o n from t h r e e p e r s p e c t i v e s : s o c i a l c o s t , i n f o r m a l and formal support networks. I n t r o d u c t i o n I t i s known t h a t bereavement i s a powerful s t r e s s o r t h a t can r e s u l t i n f a m i l y breakdown, i l l h e a l t h (mental and p h y s i c a l ) , i n a b i l i t y t o work or to cope wi t h s c h o o l , and s u i c i d e . T h i s i s exacerbated by d i s r u p t i o n of s o c i a l t i e s and c o i n c i d e n t i s o l a t i o n and l o n e l i n e s s , and occurs c o n c u r r e n t l y w i t h changing r o l e s , e s t a b l i s h i n g a new i d e n t i t y , and f i n d i n g meaning i n l i f e (Vachon, 1982). The proc e s s can take up t o f o u r years or lon g e r and depends upon many f a c t o r s , among which a r e : the age of the deceased, the q u a l i t y o f the r e l a t i o n s h i p w i t h the deceased and w i t h i n the f a m i l y network, and the s t r e n g t h of the support network. I t w i l l p a r t i c u l a r l y e f f e c t c h i l d r e n and those w i t h dependent c h i l d r e n , young marrieds, e l d e r l y men over seventy y e a r s of age, and i n d i v i d u a l s i n poor p h y s i c a l or mental h e a l t h . Symptoms of g r i e f i n c l u d e : somatic d i s t r e s s , p r e o c c u p a t i o n w i t h the image of the deceased, g u i l t , h o s t i l e r e a c t i o n s , i m p a i r e d judgement, and appearance of t r a i t s of the deceased (Lindemann, 1944; Vachon, 1982). S e p a r a t i o n and i n d i v i d u a t i o n — the movement from acknowledging the l o s s t o r e i n v e s t i n g energy i n t o l i f e and l i v i n g — i s the long-term p r o c e s s o f g r i e f (Worden, 1982; K i v o w i t z , 1988). G r i e v i n g i s a h i g h l y i n d i v i d u a l p r o c e s s and i t s r e s o l u t i o n assumes v a r i o u s c h a r a c t e r i s t i c s which encompass i n d i v i d u a l e f f e c t i v e n e s s i n meeting p e r s o n a l needs, p e r c e i v e d on-going s o c i a l network support over time, r e a d i l y a v a i l a b l e p r o f e s s i o n a l a s s i s t a n c e , and a r e p e r t o i r e o f copi n g s k i l l s . Bereavement support i s p e r c e i v e d as a means of enhancing s o c i a l networks and d e c r e a s i n g p e r s o n a l d i s t r e s s . A n t i c i p a t o r y bereavement, the o p p o r t u n i t y t o contemplate the l o s s of a l o v e d one i n the s u p p o r t i v e and c a r i n g environment of a P a l l i a t i v e Care Program, can a l s o 23 augment the bereavement p r o c e s s (Rando, 1986; Schoenberg, 1974; Wasow and Coons, 1988). I t i s f e l t t h a t P a l l i a t i v e Care reduces bereavement r i s k through i t s i n c o r p o r a t i o n o f the f a m i l y as the u n i t of c a r e . G r i e f D e f i n e d G r i e f i s d e f i n e d as the p e r s o n a l e x p e r i e n c e of the l o s s , and g r i e v i n g -- or mourning — as the p r o c e s s of a d a p t a t i o n t o the l o s s (Worden, 1982, p.31). While much i s w r i t t e n about the needs of the bereaved, l i t t l e i s known about the meaning of the death event t o the bereaved and how i t s t r u c t u r e s t h e i r mourning. There does not seem t o be agreement on the d e f i n i t i o n o f the g r i e v i n g p r o c e s s . I t has been d e f i n e d v a r i o u s l y as "a p r o c e s s of p s y c h o l o g i c a l r e i n t e g r a t i o n " (Marris, 1986, v i i ) , "a process of ' r e a l i z a t i o n ' by means of which a f f e c t i o n a l bonds are severed and o l d models of the worl d and s e l f g i v e n up" (Parkes, 1971, p.101), "a p e r i o d o f t r a n s i t i o n . . . the proc e s s of going from one s i t u a t i o n t o another" (Silverman, 1986, p.8), a " d i s e q u i l i b r a t i n g " event t h a t r e s u l t s i n r o l e change over time ( I b i d ) . Worden (1982) suggests t h a t "uncomplicated g r i e f encompasses a broad range of f e e l i n g s and b e h a v i o u r s " t h a t f a l l i n t o f o u r g e n e r a l c a t e g o r i e s (p.19). These c a t e g o r i e s are groupings of data d e r i v e d from years of r e s e a r c h s t i m u l a t e d by Lindemann's watershed study of 1944. One m a n i f e s t a t i o n encompasses p h y s i c a l s e n s a t i o n s t h a t are most commonly r e p o r t e d by g r i e v i n g i n d i v i d u a l s : "1. Hollowness i n the stomach 2. T i g h t n e s s i n the chest and/or t h r o a t 3. O v e r s e n s i t i v i t y t o n o i s e 4. A sense of d e p e r s o n a l i z a t i o n 5. B r e a t h l e s s n e s s , s h o r t n e s s of b r e a t h 6. Muscles weakness and/or l a c k of energy 7. Dry mouth" (Worden, 1982, p.23). For s i m p l i f i c a t i o n , Table 1 o u t l i n e s the remaining t h r e e of Worden's f o u r c a t e g o r i e s of g r i e f m a n i f e s t a t i o n which i n c l u d e the f e e l i n g s , c o g n i t i o n s and behaviours observed i n v a r i o u s uncomplicated g r i e f r e a c t i o n s . 25 Table 1: M a n i f e s t a t i o n s of Normal G r i e f (Worden, 1982). F e e l i n q s C o g n i t i o n s Behaviours sadness d i s b e l i e f s l e e p d i s t u r b a n c e anger c o n f u s i o n a p p e t i t e g u i l t p r e o c c u p a t i o n d i s t u r b a n c e a n x i e t y sense of absent-mindedness l o n e l i n e s s presence s o c i a l withdrawal f a t i g u e h a l l u c i n a t i o n s dreams o f the h e l p l e s s n e s s deceased shock a v o i d i n g reminders y e a r n i n g s e a r c h i n g emancipation r e s t l e s s n e s s r e l i e f c r y i n g numbness v i s i t i n g p l a c e s t r e a s u r i n g o b j e c t s As bereavement denotes a profound l o s s , i t i s suggested t h a t r e c o n c i l i n g the l o s s i n v o l v e s v a r i o u s t a s k s of r e s o l u t i o n and phases of a d a p t a t i o n (Worden, 1982; Rando, 1984). Worden p o s i t s f o u r t a s k s of r e s o l u t i o n i m p l i c i t w i t h i n the g r i e v i n g p r o c e s s — a c c e p t i n g the r e a l i t y of the l o s s , e x p e r i e n c i n g the p a i n of g r i e f , a d j u s t i n g t o the l o s s of the i n d i v i d u a l and r e i n v e s t i n g energy i n new r e l a t i o n s h i p s and a c t i v i t i e s (Worden, 1982, pp. 11-15). T h i s p r o c e s s i s exacerbated by the "unique, i n d i v i d u a l i s t i c p e r c e p t i o n of l o s s by the g r i e v e r " , and i s f u r t h e r compounded by the s o c i a l and c u l t u r a l s t r u c t u r e s w i t h i n 26 which the i n d i v i d u a l s t r u c t u r e s meaning (Rando, 1984, p.15), thus i n f l u e n c i n g the p e r c e p t i o n of need f o r s u p p o r t i v e i n t e r v e n t i o n . The Meaning of G r i e f G r i e f has been summarily d e f i n e d above. Whatever the d e f i n i t i o n , the u l t i m a t e meaning f o r the bereaved i n d i v i d u a l i s embodied w i t h i n the r e l a t i o n s h i p between f e e l i n g s , purpose and a c t i o n , and t h e i r c o n c e p t u a l o r g a n i z a t i o n . Bereavement undermines the t r u s t i n attachment and r e s u l t s i n ambivalence or d i s r u p t i o n o f meaning. Throughout an i n d i v i d u a l ' s growth and development, the melding of attachment and e x p e r i e n c e l e a d s t o the for m a t i o n of b e h a v i o r a l s t r a t e g i e s . Through these schemata, r e l a t i o n s h i p s are developed t h a t e n t a i l the s t r u c t u r i n g o f meaning. Bowlby ( c i t e d i n M a r r i s , 1986) suggests t h a t bereavement i s a p r o c e s s of p s y c h o l o g i c a l r e i n t e g r a t i o n whereby ^meaning' i s r e l a t e d t o c o n c e p t u a l r e o r g a n i z a t i o n , through emotional and p u r p o s i v e o r g a n i z a t i o n of r e l a t i o n s h i p s . The assessment of bereavement i n t e r v e n t i o n r e l i e s upon r e c o g n i z i n g the i n d i v i d u a l ' s framing of the death event and the a b i l i t y t o e v a l u a t e the b e h a v i o u r a l s t r a t e g i e s embodied w i t h i n t h e i r p a r t i c u l a r bereavement p r o c e s s . Obershaw (1977) d e s c r i b e s g r i e f as an a l l encompassing " p s y c h o l o g i c a l , p h y s i o l o g i c a l and s o c i o l o g i c a l r e a c t i o n t o l o s s " (p.72) — F i g u r e 1. The process i n c o r p o r a t e s : p r o t e s t — numbness and d i s b e l i e f ; d e s p a i r — c o n f i r m a t i o n of l o s s and c a t a l y s t f o r g r i e f e x p r e s s i o n ; detachment — p u l l i n g back from the deceased person; and, r e o r g a n i z a t i o n — decreased emotional upheaval when d i s c u s s i n g the deceased. When t h i s p r o c e s s i s a m e l i o r a t e d or aggravated by s o c i a l support networks, f a m i l y s t r u c t u r e , f l e x i b i l i t y and r e s o u r c e s , the meaning of the g r i e f p r o c e s s becomes more apparent. 28 F i g u r e 1: Bereavement Process (Obershaw, 1977 p.72) "Meaning [ i s seen] as a c r u c i a l o r g a n i z i n g p r i n c i p l e of human behaviour [as i t ] r e l a t e s purposes t o e x p e c t a t i o n s so as t o o r g a n i z e a c t i o n s , [with] the c o m p e l l i n g reasons t o a c t c o n s t i t u t i n g the trauma of l o s s " (Marris, 1986, v i i ) . i The c r i t i c a l i n t e r a c t i o n of c o g n i t i v e , emotional and e v a l u a t i v e framing i s incumbent upon the meanings d e r i v e d by the i n d i v i d u a l from on-going attachments and support. As can be seen i n F i g u r e 1, Obershaw p r e s e n t e d the g r i e f p r o c e s s i n b a s i c a l l y a l i n e a r p r o g r e s s i o n . I t s h o u l d be noted however t h a t a p r o c e s s occurs over time, and i s not 29 l i n e a r . F i e f e l (1987) contends t h a t "the route o f g r i e f appears t o be one of t a n g l e d and complex pathways, w i t h t r a i l s l o o p i n g back and f o r t h " (p.15). The Obershaw model c o u l d t h e r e f o r e be adapted t o r e f l e c t t h i s n o n - l i n e a r p r o g r e s s i o n i n the f o l l o w i n g manner: F i g u r e 2: N o n - l i n e a r R e p r e s e n t a t i o n of the Bereavement Process OBJECT REORGANIZATION Thus the e v a l u a t i v e framing over time i n d i c a t e s t h e r e are two major components t o g r i e f r e s o l u t i o n — meaning and time. A d a p t a t i o n t o Loss G r i e f P r o c e s s Throughout the l i t e r a t u r e t h e r e i s d i s c u s s i o n r e g a r d i n g bereavement r e s o l u t i o n and the mourning 30 p r o c e s s e s by which t h i s i s achieved. C o n s i d e r a t i o n s of phases, stages, sequences and t a s k s s t r u c t u r e t h i s p r o c e s s d e l i n e a t i o n . Much of the d i s c u s s i o n r e l a t e s t o F r eud and h i s concept of " g r i e f work" i n which the "bereaved g r a d u a l l y undoes the p s y c h o l o g i c a l bonds t h a t bound him t o the deceased" (Raphael, 1982, p.33). Under the s e c o n d i t i o n s the m u l t i d i m e n s i o n a l l a y e r s of the r e l a t i o n s h i p w i t h the deceased t h a t were b u i l t up and i n t e r n a l i z e d over the years, are s l o w l y reviewed and s o r t e d through. As we have d i s c u s s e d p r e v i o u s l y , t h i s i s a p a i n f u l p r o c e s s encompassing not o n l y the p h y s i c a l r e a c t i o n s t o the l o s s , but a l s o the p r o c e s s o f undoing the i n t r i c a t e webs o f bonding t h a t went i n t o b u i l d i n g the r e l a t i o n s h i p . T h i s p r o c e s s i s a i d e d and a b e t t e d by the q u a l i t y of t h a t r e l a t i o n s h i p , and i n normal g r i e v i n g — where t h e r e i s l i t t l e / n o ambivalence toward the r e l a t i o n s h i p — i t i s common t o f i n d f e e l i n g s of anger and g u i l t , sadness, c r y i n g and d e s p a i r , r e l i e f and emancipation. In h i s c o n c e p t u a l i z a t i o n of the g r i e v i n g p r o c e s s i n 1944, Lindemann r e i t e r a t e d Freud's r e f e r e n c e t o " g r i e f work" i n h i s approach t o g r i e f r e s o l u t i o n , i n which the i n d i v i d u a l : • reviews the r e l a t i o n s h i p w i t h the deceased; 31 • becomes aware of the a l t e r a t i o n s i n h i s environment without the deceased; • expresses h i s l o s s and sorrow; and, • seeks new r e l a t i o n s h i p s / a c t i v i t i e s from which he can a c q u i r e new p a t t e r n s of conduct (Lindemann, 1944, p.9). While t h i s p r o c e s s may appear t o be step-wise, i n a c t u a l i t y i t i s c y c l i c a l and goes forward, then back and then forward again as i t g r a d u a l l y changes i n shape and complexity over time. Stages/Phases/Sequences Sequencing (or stages) c o n t a i n s an i n h e r e n t s t r u c t u r a l p rocess — with v a r i o u s r e s e a r c h e r s o u t l i n i n g f o u r t o twelve stages. T h i s type of approach i m p l i e s an i n v a r i a n t , or s e q u e n t i a l , movement through g r i e v i n g , and p a s s i v e p a r t i c i p a t i o n i n the g r i e f r e s o l u t i o n by the bereaved. I t can a l s o l e a d t o c a r e g i v e r s f i t t i n g i n d i v i d u a l s t o the stages r a t h e r than s e e k i n g a b e t t e r u n d e r s t a n d i n g of the i n d i v i d u a l and t h e i r i n t e r p r e t a t i o n of the p r o c e s s . Rando (1984) i d e n t i f i e d i n v e s t i g a t o r s who have i n c o r p o r a t e d phases/stages/sequencing i n t h e i r approach t o 32 mourning. Bowlby (1961) o u t l i n e d t h r e e phases which e n t a i l : "the urge t o r e c o v e r the l o s t o b j e c t ; d i s o r g a n i z a t i o n and d e s p a i r ; and r e o r g a n i z a t i o n " . Parkes (1974) expanded these i n t o f o u r phases by adding "the phase of numbness" at the b e g i n n i n g . Engel (1964) expressed s i x sequences: shock and d i s b e l i e f , d e v e l o p i n g awareness, r e s t i t u t i o n , r e s o l v i n g the l o s s , i d e a l i z a t i o n , and outcome. Kubler-Ross's (1967) f i v e stages of d y i n g are a l s o a p p l i e d to the g r i e v i n g p r o c e s s : d e n i a l and i s o l a t i o n , anger, b a r g a i n i n g , d e p r e s s i o n , and acceptance. Rando (1984) suggests t h r e e r e a c t i o n s , r a t h e r than phases, which f a c i l i t a t e movement of the g r i e v i n g i n d i v i d u a l back and f o r t h among them: avoidance, c o n f r o n t a t i o n and r e - e s t a b l i s h m e n t . Stage or phase a n a l y s i s of the g r i e v i n g p r o c e s s i s c o n s i s t e n t w i t h viewing g r i e f as an i l l n e s s , where an i n d i v i d u a l e x h i b i t s c e r t a i n ^symptoms' depending upon how w e l l they are c o p i n g / a d j u s t i n g t o the death of t h e i r f a m i l y member. G r i e v i n g i n d i v i d u a l s are thus seen t o p a s s i v e l y proceed through a phase or stage ^process' u n t i l the symptoms d i s s i p a t e . Tasks of G r i e v i n g Worden's approach i s t a s k o r i e n t e d 33 and i n v o l v e s a c t i v e engagement of an i n d i v i d u a l i n c e r t a i n t a s k s or b e h a v i o u r s t o f a c i l i t a t e h i s / h e r g r i e f r e s o l u t i o n . T h i s a c t i v e v e r s u s p a s s i v e p a r t i c i p a t i o n i n the p r o c e s s — where one i s "doing" r a t h e r than having something "done t o " , thus enhancing p e r s o n a l c o n t r o l and competency — i s the r a t i o n a l e b e h i n d i n c o r p o r a t i n g t a s k - o r i e n t e d a n a l y s i s i n t h i s study. Mourning i s the work of g r i e f . Task d e l i n e a t i o n i m p l i e s work t h a t needs t o be done, t h a t s p e c i f i c " t h i n g s " need t o be accomplished i n order to move through the g r i e v i n g p r o c e s s . An e x p l i c a t i o n of t a s k s by Parkes and Weiss (1983) o u t l i n e d t h r e e a c t i v i t i e s needing t o be r e s o l v e d i n the r e c o v e r y p r o c e s s : i n t e l l e c t u a l r e c o g n i t i o n and e x p l a n a t i o n of the l o s s , emotional acceptance of the l o s s , assumption of a new i d e n t i t y (Rando, 1984). W i l l i a m Worden combined the t a s k s of Parkes and Weiss with those of Lindemann (from which they were derived) t o e l u c i d a t e the f o u r t a s k s of mourning b r i e f l y o u t l i n e d above — a c c e p t i n g the r e a l i t y of the l o s s , e x p e r i e n c i n g the p a i n of the g r i e f , a d j u s t i n g t o the l o s s of the i n d i v i d u a l and r e i n v e s t i n g energy i n new r e l a t i o n s h i p s and a c t i v i t i e s (Worden, 1982) -34 - which are f u r t h e r i n c o r p o r a t e d i n t o a schema f o r g r i e f c o u n s e l l i n g (see Chapter 6). "The t a s k s approach g i v e s the mourner some sense of l e v e r a g e and hope t h a t t h e r e i s something t h a t he or she can a c t i v e l y do" ( I b i d , p.32) which a l l e v i a t e s f e e l i n g s of h e l p l e s s n e s s and p r o v i d e s a means f o r assessment and i n t e r v e n t i o n i n bereavement r e s o l u t i o n . I t i s f e l t t h a t g r i e v i n g i s not complete u n t i l a l l the t a s k s have been accomplished, which i n d i c a t e s an end p o i n t — but not t o t a l c l o s u r e , as "we f i n d a p l a c e f o r what we l o s e . No matter what may f i l l t he gap, even i f i t be f i l l e d c ompletely, i t n e v e r t h e l e s s remains something e l s e " (Freud, c i t e d i n Worden, p.16). Worden maintains t h a t while t h e r e i s not a step-wise p r o g r e s s i o n through the t a s k s , a l l the t a s k s r e q u i r e completion i n order t o f a c i l i t a t e f u r t h e r growth and development. T h i s approach i s r e m i n i s c e n t of c h i l d development framing by P i a g e t (1954) where i n c o m p l e t i o n of a t a s k at a c e r t a i n l e v e l w i l l impair the a b i l i t y t o master t a s k s at h i g h e r l e v e l s . U n f i n i s h e d t a s k s of g r i e v i n g are l i k e n e d t o unhealed wounds. 35 Bereavement I n t e r v e n t i o n  R a t i o n a l e "There i s a t r a d i t i o n a l Jewish proverb t h a t x t o g r i e v e alone i s t o s u f f e r most'. G r i e f may be s i l e n t f o r some but i t asks f o r community. We are becoming aware t h a t s u p p r e s s i n g or m i n i m i z i n g g r i e f and f a i l u r e t o comprehend i t s h e a l i n g power are maladaptive not j u s t f o r the i n d i v i d u a l and immediate f a m i l y but f o r the l a r g e r community" ( F i e f e l c i t e d i n Morgan, 1987, p.17). I t i s known t h a t v a r i o u s p o p u l a t i o n s are at g r e a t r i s k f o r abnormal g r i e v i n g or p r o l o n g e d g r i e f r e a c t i o n s . These p o p u l a t i o n s i n c l u d e : • the e l d e r l y , p a r t i c u l a r l y men over seventy years o f age, • young m a r r i e d i n d i v i d u a l s , • c h i l d r e n , s i b l i n g s and a d o l e s c e n t s , • those w i t h p r i o r h i s t o r y o f mental or e x t e n s i v e p h y s i c a l i l l n e s s , • i n d i v i d u a l s w i t h m u l t i p l e , and p o s s i b l y u n r e s o l v e d , l o s s e s (Rando, 1984) . 36 The r i s k s i n c l u d e : • a 15% r i s k o f p s y c h i a t r i c admission f o r bereaved i n d i v i d u a l s (Barnes, 1987; McHorney and Mor, 1988) , • h i g h r a t e s o f f a m i l y breakdown with a death of a c h i l d , some c i t e an i n c i d e n c e o f 50% - 80% p o s s i b i l i t y o f d i v o r c e f o r bereaved p a r e n t s (Lauer e t a l , 1988; Rando, 1986), • i n c r e a s e d m o r b i d i t y of the e l d e r l y i n the f i r s t year of bereavement: • i n d i c a t e d by an i n c r e a s e of s i x v i s i t s t o a do c t o r , • r e s u l t i n g i n t h r e e times the r a t e o f h o s p i t a l i z a t i o n s than the normal p o p u l a t i o n , • a 40% m o r t a l i t y r i s k f o r e l d e r l y men w i t h i n the f i r s t s i x months post bereavement, (Conway, 1988; F r e d e r i c k and F r e d e r i c k , 1985; Gass and Chang, 1989; McHorney and Mor, 1988; VandeCreek, 1988; Walton, 1987; Wasow and Coons, 1987), • 4% of a l l c h i l d r e n w i l l l o s e a parent p r i o r t o the age o f e i g h t e e n (Masterman and Reams, 1988) . 37 These c h i l d r e n are at r i s k of • a t h r e e year d e l a y e d r e a c t i o n f o r elementary school-aged c h i l d r e n w i t h a 2:1 r a t i o of admission t o c h i l d p s y c h i a t r i c programs, • i n c r e a s e d d e p r e s s i o n i n the f i r s t year f o l l o w e d by decreased d e p r e s s i o n and i n c r e a s e d behaviour problems (Sandler e t a l , 1988), and • drug and a l c o h o l abuse, and s u i c i d e i f the c h i l d r e n are a d o l e s c e n t s (Ney, 1987) . The l i t e r a t u r e s u b s t a n t i a t e s these and many other r i s k s t o bereaved p o p u l a t i o n s . In h e a l t h care c o s t s alone, c o n s i d e r a t i o n can be g i v e n t o the numbers of bereavement-r e l a t e d p h y s i c i a n v i s i t s which add t o the h e a l t h care burden i n terms of p h y s i c i a n u t i l i z a t i o n as w e l l as a t h r e e f o l d h o s p i t a l i z a t i o n p o t e n t i a l . Other c o s t s i n c l u d e l e g a l c o n s i d e r a t i o n s of f a m i l y breakdown, s c h o o l c o u n s e l l i n g needs f o r c h i l d r e n , i n c r e a s e i n the support requirement from Family S e r v i c e Agencies and the M i n i s t r y of S o c i a l S e r v i c e s and Housing, C h i l d W elfare. Thus p r e v e n t i v e i m p l i c a t i o n s of bereavement i n t e r v e n t i o n 38 f o r s u r v i v o r s must not be underestimated — r i s k f a c t o r s , as mentioned above, can l e a d t o m u l t i p l e g r i e f e x p r e s s i o n , some having d e t r i m e n t a l e f f e c t . Bereavement f o l l o w - u p has l o n g -term s i g n i f i c a n c e and can circumvent these t r a g i c events and t h e i r concomitant anguish. The P a l l i a t i v e Care focus on t o t a l f a m i l y care ensures the c o n t i n u i t y o f care throughout bereavement. I t i s r e c o g n i z e d t h a t bereavement p a t t e r n s are systemic, e f f e c t i n g the t o t a l family-community h e a l t h and support network. I t was noted p r e v i o u s l y i n the R a t i o n a l e above, t h a t t h e r e are many r i s k s a s s o c i a t e d w i t h the g r i e v i n g p r o c e s s . These are g e n e r a l l y r e l a t e d t o i n d i v i d u a l s h a v i n g low s o c i a l support networks — e l d e r l y males, c h i l d r e n , s i n g l e p a r e n t s . S o c i a l support networks can t h e r e f o r e be seen as p r o t e c t i v e mechanisms. S o c i a l Support S o c i a l support p r o v i d e s the means by which i n d i v i d u a l s r e c e i v e a f f i r m a t i o n o f t h e i r p a i n and sustenance d u r i n g the g r i e v i n g p r o c e s s . T h i s i s r e f l e c t e d i n v a r i o u s d e f i n i t i o n s : an e x p e r i e n c e i n human s o l i d a r i t y which s t r e n g t h e n s bonds between and among people (Wasserman and Danforth, 39 1988), "enduring p a t t e r n s or i n t e r m i t t e n t t i e s t h a t p l a y a s i g n i f i c a n t p a r t i n m a i n t a i n i n g p s y c h o l o g i c a l / p h y s i c a l i n t e g r i t y over time" (Caplan c i t e d i n Wasserman and Danforth, 1988), and, a f f i r m a t i o n t h a t an i n d i v i d u a l i s c a r e d f o r , loved, esteemed and a member of a network of r e c i p r o c a l mutual o b l i g a t i o n s (Cobb c i t e d i n Wasserman and Danforth, 1988) . Wasserman and Dan f o r t h contend t h a t through s o c i a l support networks, "one's own and othe r p e o p l e s ' p a i n become moral r e f e r e n c e p o i n t s t o human c o n n e c t i o n " ( I b i d , x ) . There are s i g n i f i c a n t components or dimensions t o s o c i a l support networks t h a t are c r i t i c a l c o n t r i b u t o r s t o p o s i t i v e bereavement support and outcome. Caplan suggests t h a t s o c i a l support p r o v i d e s o t h e r s who m o b i l i z e p s y c h o l o g i c a l r e s o u r c e s , share t a s k s ; and p r o v i d e m a t e r i a l , s k i l l s , or t o o l r e s o u r c e s , and c o g n i t i v e guidance ( c i t e d i n Wasserman and Danforth, 1988, p.7). Bloom, ( c i t e d i n Wasserman and Danforth, 1988, p.9) d e l i n e a t e s f i v e dimensions of s o c i a l support t h a t are echoed by G o t t l i e b 40 ( c i t e d i n M i t c h e l l , 1986). These are p r e s e n t e d below i n Table 2. Table 2: Dimensions of S o c i a l Support Bloom G o t t l i e b • m a i n t a i n s o c i a l i d e n t i t y • macro - degree i n t e g r a t e d i n t o l a r g e r s o c i e t y • micro - s o c i a l t i e s g i v e s o c i a l i d e n t i t y feedback • emotional support • s u s t a i n s i n d i v i d u a l • l o v e d and v a l u e d as e m o t i o n a l l y • environmental support - a l l o w s e x p r e s s i o n of a n x i e t y , concerns, problems i n an a c c e p t i n g , non-t h r e a t e n i n g environment • i n f o r m a t i o n and new ideas enhance p e r s o n a l problem s o l v i n g c a p a b i l i t y a person • s o c i a l a f f i l i a t i o n • need f o r attachment, c o n n e c t i o n , and bonding. • u n c o n d i t i o n a l access or a v a i l a b l e network members who can p r o v i d e advocacy The importance of these components of s o c i a l support s h o u l d not be underestimated i n m a i n t a i n i n g both p h y s i c a l and mental w e l l - b e i n g of bereaved i n d i v i d u a l s . The types of support o u t l i n e d above would a l l e v i a t e the impact of l i f e s t r e s s e s , decrease dependency on chemical substances, l i q u o r and tobacco, and a s s i s t w i t h r e c o v e r y through enhancing c o p i n g s k i l l s . There appears t o be two types of support networks — i n f o r m a l and f o r m a l . However,upon c l o s e r s c r u t i n y i t seems t h e r e i s a continuum t h a t extends from 'most i n f o r m a l ' ( k i t h and kin) t o 'most form a l ' (government s o c i a l programmes) wit h a broad range of 'semi-formal' support c o n f i g u r a t i o n s i n between. T h i s i n f o r m a l / s e m i - f o r m a l s e c t o r i s the focus f o r " s e l f - c a r e " and "mutual a i d " i n i t i a t i v e s by governments (Epp, 1986; Fykes e t a l , 1988) which r e s u l t i n much of the programming found along the continuum. These support groups are r e p r e s e n t a t i v e of p e r s o n a l i n i t i a t i v e s t h a t may or may not have p r o f e s s i o n a l impetus and guidance but g e n e r a l l y come t o g e t h e r at s p e c i f i c times and l o c a t i o n s and i n v o l v e p a r t i c u l a r p o p u l a t i o n s — Compassionate F r i e n d s (bereaved p a r e n t s ) , Widow-to-Widow, e t c . Funding may be through p e r s o n a l c o n t r i b u t i o n , government grants ( i e . New Horizons f o r o u t r e a c h programming), government grants t o v o l u n t a r y 42 agencies or through f o r m a l i z e d arrangements w i t h n o n - p r o f i t o r g a n i z a t i o n s ( h o s p i t a l s ) or government departments ( i e . Community H e a l t h ) . Informal support networks Informal support g e n e r a l l y d e f i n e s a s s i s t a n c e p r o v i d e d by f a m i l y , f r i e n d s , neighbours and v o l u n t e e r s , and dominates the n o n - i n s t i t u t i o n a l support of dependent i n d i v i d u a l s - aged, p h y s i c a l l y or m e n t a l l y d i s a b l e d i n d i v i d u a l s and c h i l d r e n — as w e l l as the spontaneous or community support f o r bereaved i n d i v i d u a l s . The l i t e r a t u r e f r e q u e n t l y mentions t h a t response t o l i f e s t r e s s e s i s l e s s c r i t i c a l f o r those who have good s o c i a l supports (Parkes, 1972; Rando, 1984; M i t c h e l l , 1986). Vachon has found t h a t "the b e s t form of i n t e r v e n t i o n w i t h the bereaved i s t h a t s u p p l i e d by f a m i l y and f r i e n d s who w i l l l e t them t a l k about the deceased" (Vachon, 1982, p.73). These i n f o r m a l networks of k i t h and k i n are supplemented by a number of o t h e r h e l p e r s — those c o n s i d e r e d " n a t u r a l h e l p e r s " and " s e l f - h e l p " groups. N a t u r a l h e l p e r s can be those found a l o n g everyday pathways — neighbours, the beauty p a r l o u r , b a r s . However, l a y r e l a t i o n s h i p s can a l s o be s u p p o r t i v e i n harmful ways by encouraging harmful 43 p r o c e s s e s . Kurtz and Powell (1987) suggest t h a t "these n a t u r a l networks may enable the d e v i a n t t o become more i n v o l v e d i n the problem ( p r o t e c t him from consequences), s t i g m a t i z e him f o r having the problem, or p r o v i d e f a u l t y guidance" (p.71). S e l f - h e l p groups — b r i d g i n g i n f o r m a l and formal  networks. S e l f - h e l p bereavement groups are g e n e r a l l y i n c l u d e d under i n f o r m a l support networks but have e v o l v e d w i t h v a r y i n g degrees of f o r m a l i t y . Pancoast e t a l . (1983) d e f i n e two models of s e l f - h e l p , both which encompass the support needs of bereaved i n d i v i d u a l s : " a c l i n i c a l model of s e l f h e l p i s a means of i n d i v i d u a l s and s m a l l groups d e a l i n g w i t h t h e i r own problems, s t r u g g l i n g t o s u r v i v e . ... a s t r u c t u r a l model p r e s e n t s s e l f - h e l p as a n a t u r a l and h e a l t h y way f o r communities t o o r g a n i z e themselves... a g a i n s t l o s s of c o n t r o l and s e l f - a w a r e n e s s " (p.12). That s e l f - h e l p i s l i n k e d with i n f o r m a l support networks i s open t o d i s c u s s i o n . However, Pancoast et a l . suggest t h a t i t i s through the l o c a l s o c i a l networks, the webs of f r i e n d s and f a m i l y , t h a t s e l f - h e l p groups emerge, and t h a t e f f e c t i v e i n t e r v e n t i o n s take advantage of these e x i s t i n g networks. S o c i e t a l and demographic changes i n t e n s i f y the l a c k of i n f o r m a l support networks — thus f o r g i n g the need f o r l i n k a g e w i t h s e l f - h e l p support groups. Demographic changes i n d i c a t e s m a l l e r and more d i s p e r s e d f a m i l i e s thus l a c k of f a m i l i a l support networks. Increas e d m o b i l i t y w i t h i n s o c i e t y r e s u l t s i n l a c k of s o c i a l support networks; Movement toward d e a t h - i n - h o s p i t a l versus d e a t h - i n -home /community i n c r e a s e s the i n v i s i b i l i t y of death, hence i n v i s i b i l i t y of the bereaved, which i n t u r n exacerbates d i s c o m f o r t w i t h death and o t h e r s ' p a i n ; I n c r e a s e d s o c i a l i s o l a t i o n i s a r e s u l t of decreased s o c i a l support. S e l f - h e l p bereavement groups are o r g a n i z e d around bereavement i s s u e s , and can be g e n e r a l i n approach or s p e c i f i c t o s e x / a g e / l i f e c y c l e f a c t o r s . There may be l i t t l e or no involvement by p r o f e s s i o n a l s , and emphasis i s on h e l p i n g one another through an environment t h a t " c r e a t e s community, enhances p e r s o n a l l o c u s of c o n t r o l , and 45 emphasizes i n t e r a c t i o n and growth" — a l l conducive t o s h a r i n g and h e a l i n g (Klass and Shinners, 1982, p.38). G e n e r a l l y t h i s i n f o r m a l c a r e g i v i n g r e s u l t s from people who have e x p e r i e n c e d t h e i r own l o s s e s i n the p a s t , and are a c t i v e l y m o t i v a t e d t o r e c i p r o c a t e a s s i s t a n c e they p r e v i o u s l y r e c e i v e d from o t h e r s . Hoehne (1986) i n d i c a t e s t h a t s o c i a l support groups comprise 39.8% of the s e l f - h e l p o r g a n i z a t i o n s i n Canada i n 1986, w i t h groups f o r widow/ers a c c o u n t i n g f o r 6% of t h i s number. These groups enhance the i n f o r m a l networks of i n d i v i d u a l s but are not the o n l y source of support. Churches, s e n i o r s groups, and v o l u n t a r y agencies a l s o f i l l t h i s gap. D i f f i c u l t i e s occur, however, i n the v o l u n t a r y aspect of s e l f - h e l p as l e a d e r s h i p waxes and wanes over time w i t h i n d i v i d u a l s moving i n and out of the groups, or groups becoming maladaptive as i n d i v i d u a l s get " s t u c k " and becoming t e r r i t o r i a l . Without a p r o f e s s i o n a l component, c o n t i n u i t y of support can be l a c k i n g , i n d i v i d u a l s r e q u i r i n g g r e a t e r a s s i s t a n c e may not be r e f e r r e d or f i n d t h e i r needs not b e i n g met, and p a t h o l o g i c a l g r i e v i n g can develop. Another concern with s e l f - h e l p i s the p e r s o n a l e f f o r t 46 i n v o l v e d i n c o n n e c t i n g w i t h a support group at a time when f o c u s s i n g energy beyond s u r v i v a l can be insurmountable. S e l f - h e l p i s a l s o not a panacea — i t i s not f o r everyone and i n some cases, as a l l u d e d t o above, can produce i a t r o g e n i c e f f e c t s . F i s h e r et a l . ( c i t e d i n G o t t l i e b , 1988) suggest t h a t i n d i v i d u a l s w i l l cope on t h e i r own: "to the extent t h a t they do not p e r c e i v e a p a r t i c u l a r c o n d i t i o n as p r o b l e m a t i c ; or t o the extent t h a t they b e l i e v e the b e n e f i t s o f seeking or a c c e p t i n g a s s i s t a n c e are outweighed by the c o s t s " (p.269) . T h i s puts the onus upon an g r i e v i n g i n d i v i d u a l t o seek a s s i s t a n c e at a time when s e l f esteem may be lowest and v u l n e r a b i l i t y h i g h e s t . P s y c h o l o g i c a l and s o c i a l c o s t s r e s u l t i f t h e r e i s a stigma a t t a c h e d t o b e i n g p e r c e i v e d as weak and unable t o cope wi t h the s t r e s s e s of bereavement, or i f the v a l u e s o f the person's r e f e r e n c e group do not s u b s c r i b e t o ^ o u t s i d e r s ' h e l p . Under these circumstances an i n d i v i d u a l w i l l not access needed support. Formal Support Networks The formal support s e c t o r i s made up of both n o n p r o f i t o r g a n i z a t i o n s — v o l u n t a r y 47 o r g a n i z a t i o n s , c h a r i t i e s and h o s p i t a l s — and the p r i v a t e -f o r - p r o f i t i n d u s t r i e s , as w e l l as d i r e c t government programmes. T h i s l a t t e r support i s g e n e r a l l y seen as a va s t a r r a y o f s o c i a l programmes and b e n e f i t s a v a i l a b l e t o members of a s o c i e t y and would encompass s u r v i v o r s ' b e n e f i t s and pe n s i o n s . Some f a l l w i t h i n the realm o f p r o v i n c i a l j u r i s d i c t i o n and are a v a i l a b l e through the M i n i s t r y o f S o c i a l S e r v i c e s and Housing, under which GAIN f o r S e n i o r s i s a d m i n i s t e r e d ; and the M i n i s t r y of Health, r e s p o n s i b l e f o r Se n i o r s and Community H e a l t h i s s u e s . U n f o r t u n a t e l y government p o l i c i e s , or l a c k t h e r e o f , do not encourage the development of c r e a t i v e bereavement support networks through s c h o o l s , community agencies and neighbourhood houses. While b a s i c b e n e f i t s come t o be accepted as e n t i t l e m e n t , the r e s i d u a l n ature and poor q u a l i t y of many s e r v i c e s f u n c t i o n t o c r e a t e a v o i d i n t o which s e l f - h e l p becomes a re m e d i a l compensator (Pancoast et a l . 1983). S u b s t i t u t e support systems H i s t o r i c a l l y , s o c i a l workers were g i v e n the r e s p o n s i b i l i t y t o develop e x p e r t i s e i n implementing s t r a t e g i e s f o r f i n d i n g and s u s t a i n i n g adequate, l i f e - g i v i n g , s u b s t i t u t e placements or a c t i v i t i e s 48 t h a t w i l l support i n d i v i d u a l s i n the community. These have been seen i n the development of f o s t e r care, a d u l t day c e n t r e s , and v o l u n t e e r networks. However, v e r y l i t t l e i s a v a i l a b l e o u t s i d e h o s p i c e / p a l l i a t i v e programming t o complement or enhance the g r i e f r e c o v e r y p r o c e s s . Even p a l l i a t i v e programs are r e c e i v i n g l i m i t e d f u n d i n g which r e s u l t s i n l e s s i n t e r v e n t i o n with bereaved i n d i v i d u a l s , a p a r t i c u l a r l y dangerous s i t u a t i o n f o r those at r i s k . Temporary support systems The h o s p i t a l or hos p i c e bereavement programmes t h a t e x i s t t e n d t o o f f e r support only t o i n d i v i d u a l s who are f a m i l y members i n v o l v e d i n t h e i r s p e c i f i c programming. These supports te n d t o be temporary. G e n e r a l l y t h i s support i s o f f e r e d i n f o u r t o e i g h t biweekly meetings a f t e r which i n d i v i d u a l s may be very much on t h e i r own. Only one program, the bereavement program of L i o n s Gate H o s p i t a l , o f f e r s an on-going, unbounded program t o which any bereaved i n d i v i d u a l i s welcome. There are pros and cons t o both approaches which w i l l be d i s c u s s e d f u r t h e r i n Chapter 6. 49 Summary This chapter has presented information that delineates r i s k factors and t h e o r e t i c a l framing of the bereavement process. Rationale for bereavement intervention was presented, as well as a summary of informal and formal support systems, with discussion of se l f - h e l p a c t i v i t i e s which "represent a continuum of arrangements for engaging i n mutual a i d " (Pancoast et a l . p.19, 1983). 50 CHAPTER 3 QUANTITATIVE ANALYSIS AND FINDINGS T h i s c h a p t e r p r o v i d e s a d e s c r i p t i o n o f the q u a n t i t a t i v e methodology f o l l o w e d i n t h i s study. The q u a n t i t a t i v e a n a l y s i s was undertaken i n an attempt t o r e p l i c a t e a study by Cameron and B r i n g s (1980)/Cameron and Parkes (1983), t o t e s t t he e f f i c a c y o f bereavement i n t e r v e n t i o n , and was c a r r i e d out a c c o r d i n g t o the Cameron and B r i n g s , (1980)/Cameron and Parkes (1983) p r o t o c o l s . The f i n d i n g s of the a n a l y s i s are a l s o p r e s e n t e d . R a t i o n a l e f o r the Q u a n t i t a t i v e A n a l y s i s There i s a de a r t h of i n f o r m a t i o n p e r t a i n i n g t o the assessment o f bereavement i n t e r v e n t i o n i n p a l l i a t i v e c a r e programming. E x i s t i n g r e s e a r c h has compared groups having p a l l i a t i v e c a r e e x p e r i e n c e and bereavement f o l l o w - u p w i t h groups who have n e i t h e r i n t e r v e n t i o n (Cameron and B r i n g s , 1980; Cameron and Parkes, 1983). The c u r r e n t study compares two groups o f i n d i v i d u a l s , both having p a l l i a t i v e c a r e e x p e r i e n c e , but only one group having bereavement 51 i n t e r v e n t i o n as w e l l . Osterweiss (1988) suggests t h a t " a s s e s s i n g the e f f e c t s and e f f e c t i v e n e s s of h o s p i c e bereavement components i s c o m p l i c a t e d by the f a c t t h a t bereavement support permeates a l l of h o s p i c e " (p.79). The p e r c e i v e d gap i n the l i t e r a t u r e and a s t r o n g i n d i c a t i o n o f need f o r v e r i f i a b l e ( i e . r e p l i c a b l e ) s t u d i e s w i t h which t o s u b s t a n t i a t e knowledge p r o v i d e d the impetus f o r r e p l i c a t i n g the Cameron study. A complementary r e p l i c a t i o n of a study c a r r i e d out by Cameron and B r i n g s at the Royal V i c t o r i a H o s p i t a l i n Montreal, p u b l i s h e d i n 1980, and r e p u b l i s h e d under Cameron and Parkes i n 1983, i s p r e s e n t e d i n t h i s c h a p t e r . "The aim of the study was t o e v a l u a t e the e f f e c t o f bereavement f o l l o w - u p p r o v i d e d by the P a l l i a t i v e Care U n i t (PCU) upon the s u r v i v i n g r e l a t i v e s o f p a t i e n t s who had d i e d thereby comparing them with a matched group of r e l a t i v e s o f p a t i e n t s who had d i e d i n o t h e r wards of the same h o s p i t a l " (Cameron and Parkes, 1983, pp.73). The purpose of the q u a n t i t a t i v e a n a l y s i s i n the c u r r e n t study i s t o a s c e r t a i n whether bereavement outcome d i f f e r s between those i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n and 52 those without bereavement i n t e r v e n t i o n . While a l l of the s u b j e c t s have P a l l i a t i v e Care Programme involvement, o n l y some choose t o p a r t i c i p a t e i n bereavement f o l l o w - u p . As p a r t o f the P a l l i a t i v e Programme under i n v e s t i g a t i o n , a l l programme f a m i l i e s are p e r s o n a l l y i n v i t e d and encouraged t o access bereavement f o l l o w - u p support. Roy and Sumpter (1983) have determined t h a t o n l y 25% respond — a s t a t i s t i c borne out by the annual response r a t e o f the study P a l l i a t i v e Programme. Questions have been r a i s e d about the e f f i c a c y of p r o v i d i n g such programming, wi t h the s u g g e s t i o n t h a t a p a l l i a t i v e programme i t s e l f may p r o v i d e s u f f i c i e n t a n t i c i p a t o r y bereavement and support thus a m e l i o r a t i n g the g r i e v i n g p r o c e s s . Methodology The o r i g i n a l study by Cameron and B r i n g s was c a r r i e d out twelve months and two weeks a f t e r the p a t i e n t ' s death. The t i m i n g was chosen so t h a t i t would be a f t e r the a n n i v e r s a r y date of the f a m i l y member's death and thus attempt t o a v o i d i n f l u e n c e of " a n n i v e r s a r y d e p r e s s i o n " , yet memories of the i l l n e s s and a c t i v i t i e s of e a r l y bereavement 53 would s t i l l be c l e a r . There were s i x t y - e i g h t (68) r e l a t i v e s c o n t a c t e d , of which f i f t y - n i n e (59) agreed t o be i n t e r v i e w e d . The q u e s t i o n n a i r e s were a d m i n i s t e r e d over the telephone and the r e s u l t s were examined t o p r o v i d e two matched groups of twenty (20) each, f o r f u r t h e r a n a l y s i s . To q u a n t i t a t i v e l y assess the e f f e c t o f bereavement group i n t e r v e n t i o n i n the c u r r e n t study, two groups of s u b j e c t s w i t h P a l l i a t i v e Care e x p e r i e n c e were i d e n t i f i e d — those w i t h the bereavement group p a r t i c i p a t i o n , and those without. To accommodate the a n a l y s i s , the base p r o t o c o l s developed by Cameron and B r i n g s — procedures, q u e s t i o n n a i r e , g r i e f and adjustment i n v e n t o r i e s — were i n c o r p o r a t e d i n t o a m o d i f i e d complementary r e p l i c a t i o n . Both p o p u l a t i o n s i n the study had the P a l l i a t i v e Care Programme support p r i o r t o the death of the f a m i l y member. In the Cameron de s i g n o n l y one group had the P a l l i a t i v e Care Programme and bereavement f o l l o w - u p experience, and the other had n e i t h e r . Sample S e l e c t i o n A d e s i r e d sample s i z e was f i f t e e n (15) f o r each group. The t o t a l number of the Bereavement Group p a r t i c i p a n t s was sampled as t h e r e were o n l y t e n (10) i n d i v i d u a l s i n t h i s group. The response r a t e was 80% w i t h 54 eight (8) out of ten (10) responses. The sample of those without bereavement intervention (a population of 34) was selected through disproportionate s t r a t i f i e d random sampling based upon the age and sex s t r a t i f i c a t i o n of the group with bereavement intervention, to f a c i l i t a t e a matching between the two samples (Appendix I ) . This method of sampling increases "precision i n estimating population value and improves adequacy of the size of each sample s t r a t a for the analysis" (Eckhardt and Ermann, 1977, p.193). From the derived sample of f i f t e e n (15) i n d i v i d u a l s , there was seven (7) responses for a 47% response rate. This portion of the study was not without complications — many of which are r e f l e c t e d i n a current evolution of s t r u c t u r a l change and commitment to P a l l i a t i v e Care within the study h o s p i t a l . At the outset, the r e p l i c a t i o n of the Cameron study included a t h i r d population — one with neither the P a l l i a t i v e Care nor bereavement support experience. A lack of i n d i v i d u a l s i n t h i s population was found and appears to be a r e f l e c t i o n of the changes which have occurred within the h o s p i t a l . Since the 55 i n c e p t i o n of i t s p a l l i a t i v e c a r e program t e n years ago, e s s e n t i a l l y a l l p h y s i c i a n s r e f e r t e r m i n a l l y i l l i n d i v i d u a l s and t h e i r f a m i l i e s t o the programme. The r e s u l t was a l i m i t e d population/sample of t e n (10) f a m i l y members, s i x of whom were a d u l t c h i l d r e n , not spouses. The response r a t e from t h i s p o p u l a t i o n p r e c l u d e d the use of a sample from t h i s group. Only two responses — both spouses — were r e c e i v e d , and another spouse's l e t t e r was r e t u r n e d w i t h no forw a r d i n g address. Of the two responses, one spouse r e f e r r e d h i m s e l f immediately f o r bereavement c o u n s e l l i n g and was t h e r e f o r e not p a r t o f the study. The oth e r spouse had e x t e n s i v e knowledge o f p a l l i a t i v e c are, but h i s wife had adamantly r e f u s e d t o p a r t i c i p a t e i n the programme or t o accept any o u t s i d e h e l p i n the home. Without t h i s p o p u l a t i o n the focus of the q u a n t i t a t i v e a n a l y s i s changed t o the one pr e s e n t e d i n t h i s Chapter. Thus the f i n a l study sample was f i f t e e n i n d i v i d u a l s of whom twelve c o u l d be p a i r e d f o r the q u a n t i t a t i v e a n a l y s i s . The p a i r i n g was based upon the c r i t e r i a e s t a b l i s h e d by the Cameron and B r i n g s study — age, sex and r e l a t i o n s h i p t o the deceased. Data d e r i v e d from a l l f i f t e e n s u b j e c t s were 56 i n c o r p o r a t e d i n t o the q u a l i t a t i v e a n a l y s i s (Chapter 4 ) . Data C o l l e c t i o n Procedures A l l s u b j e c t s were i n v o l v e d with the P a l l i a t i v e Care Programme at a t e r t i a r y care h o s p i t a l i n B r i t i s h Columbia. The samples f o r each group were d e r i v e d from the P a l l i a t i v e Care Programme l i s t s . The study covered a time p e r i o d o f t h r e e months. A l l i n d i v i d u a l s were c o n t a c t e d t h i r t e e n months post-bereavement. An i n t r o d u c t o r y l e t t e r from the P a l l i a t i v e Programme S o c i a l Worker accompanied the r e s e a r c h e r ' s request f o r the s u b j e c t s ' p a r t i c i p a t i o n i n the study. Upon r e c e i p t of the r e t u r n e d consent form, a telephone c a l l was p l a c e d t o make an appointment f o r a telephone i n t e r v i e w . The telephone i n t e r v i e w g e n e r a l l y took from 45 t o 60 minutes. The i n t e r v i e w s were conducted i n a c o n v e r s a t i o n a l s t y l e u s i n g the Cameron and B r i n g s Q u e s t i o n n a i r e which was u t i l i z e d as an i n t e r v i e w guide (Appendix I I ) . T h i s a l l o w e d f o r e l i c i t i n g b a s i c i n f o r m a t i o n from a l l respondents, but a l s o p e r m i t t e d p r o b i n g and e x p l o r i n g i n f o r m a t i o n t h a t i l l u m i n a t e d the s u b j e c t matter (Patton, 1989). Open-ended 57 q u e s t i o n s were added t o encourage f u r t h e r c l a r i f i c a t i o n of c e r t a i n areas not covered i n the o r i g i n a l document ( i e . c r e m a t i o n ) . The g e n e r a l i s s u e s addressed i n the i n t e r v i e w were: 1. Bereaved I n d i v i d u a l — age, sex, r e l a t i o n s h i p t o the deceased, q u a l i t y of t h a t r e l a t i o n s h i p , time of i l l n e s s / p r e p a r a t i o n f o r the death. 2. Family R e l a t i o n s h i p s — number of c h i l d r e n , r e l a t i o n s h i p changes, changes i n l i v i n g arrangements. 3. S o c i a l Support — n e i g h b o u r s / f r i e n d s , a c t i v i t i e s and hobbies, s o c i a l c l u b s / g r o u p s . 4. F i n a n c i a l Concerns — impact of the l o s s on employment, pension income, housing change, new employment, e s t a t e / w i l l . 5. P e r s o n a l H e a l t h Issues — p r i o r / p o s t bereavement h i s t o r y , use of t r a n q u i l l i z e r s , a l c o h o l , tobacco. 6. / A n t i c i p a t o r y Bereavement — the P a l l i a t i v e Care Experience, time f o r p r e p a r a t i o n f o r the death. 7. R e l i g i o n , R i t u a l , Bereavement A n n i v e r s a r y — r e l i g i o s i t y , f uneral/memorial s e r v i c e , b u r i a l / c r e m a t i o n , v i s i t s t o grave/other l o c a t i o n . 58 The Cameron and Brings Questionnaire A l l study subjects p a r t i c i p a t e d i n a telephone interview which incorporated a modified Cameron and Brings Questionnaire (Appendix I I ) . Changes were made to the Questionnaire when i t was found that the i t contained assumptions and biases that required rewording to preclude imposing symptoms onto the respondents. For example under "Health Since Bereavement", a question asked the respondent i f , "compared to the time immediately a f t e r the death, do you f e e l ... 'more depressed less depressed about the same '". Exception was taken to the term "depressed" by the second respondent. This term was changed to "sad or depressed" thus allowing the respondents to choose the best f i t for t h e i r experience, where upon ten chose "sad", and four r e p l i e d "depressed". While "sad" i s also naming the f e e l i n g , i t i s the f e e l i n g l a b e l suggested by the respondent 59 and i s a known bereavement r e a c t i o n (Worden, 1982). I t i s a l s o l e s s v a l u e laden than "depressed", which had very s p e c i f i c c o n n o t a t i o n f o r the respondents. Those who r e p l i e d "depressed" used both terms i n d i f f e r e n t c o n t e x t s which i n d i c a t e s d i s c r i m i n a t i o n of meaning. To account f o r changes i n f u n e r a l and b u r i a l p r a c t i c e , the s e c t i o n on "Cemetery" r e q u i r e d a d d i t i o n a l p r o b i n g t h a t would e l i c i t r i t u a l behaviour o t h e r than " v i s i t i n g the grave". Here a q u e s t i o n was added a s k i n g i f t h e r e was "a s p e c i a l p l a c e t h a t reminds you of (your f a m i l y member) t h a t you v i s i t ? " . The responses were a p p r o p r i a t e f o r the number of i n d i v i d u a l s whose f a m i l y member was cremated (70% of the sample), and f o r some, gi v e n the degree of g r i e f r e s o l u t i o n , q u i t e c r e a t i v e . Respondent: "I can always go and stand i n my c l o s e t . . . ( l a u g h t e r ) . . . you see, I d i d n ' t know what t o do with him f o r the l o n g e s t time, so I kept him i n my c l o s e t ! " Respondent: "The Parks Board wouldn't a l l o w me t o 60 i n t e r the ashes at the t e n n i s c o u r t s i n S t a n l e y Park, but I cheated and took a p i n c h [of ashes] over, and now I can go and watch a good game of t e n n i s w i t h him!" Respondent: "My f r o n t room i s f u l l of p l a n t s g i v e n t o me when my husband was dying. Now they are blooming and doing w o n d e r f u l l y . T h i s , i n a way, keeps him a l i v e f o r me. Being i n t h a t room makes me f e e l c l o s e t o him." The T h e r a p e u t i c I n t e r v i e w C o n s i d e r a t i o n was a l s o g i v e n t o the dynamics of the i n t e r v i e w , as i t has been e s t a b l i s h e d t h a t the i n t e r v i e w i t s e l f e f f e c t s responses. While the t h e r a p e u t i c i n t e r v i e w i s g e n e r a l l y d e f i n e d i n the c l i n i c a l sense, h a v i n g some i d e n t i f i a b l e outcome, the i n f o r m a t i o n i n t e r v i e w can a l s o be i n t e r p r e t e d i n t h i s v e i n . B a s i c t o g r i e f r e s o l u t i o n i s de v e l o p i n g an unde r s t a n d i n g o f the death event i t s e l f . The bereaved i n d i v i d u a l g e n e r a l l y accomplishes t h i s through numerous r e i t e r a t i o n s o f the death event, the i l l n e s s t r a j e c t o r y and other pertinent experiences i n which the event i s framed. Thus, "during the course of an interview, information-seeking questions and therapeutic consequences often coexist" (Fuchs Ebaugh, 1988, p.213). Two respondents were very s p e c i f i c about the interview process — one emphatically s t a t i n g "I have to do t h i s " , and the other sharing that "This form of interview [telephone] has been most h e l p f u l as I am very shy and would never have been able to share t h i s information i n a group or face-to-face s e t t i n g " (Respondent). Both i n d i v i d u a l s had never f u l l y t o l d t h e i r s t o r i e s ; the former f e l t ^driven' to do so. When dealing with p o t e n t i a l l y s t r e s s f u l areas of inves t i g a t i o n , the investigator must be se n s i t i v e to the respondent's need for information and con t r o l . This may e n t a i l " e x p l i c i t negotiation of [the] research r e l a t i o n s h i p " (Sutton and Schurman, 1988, p.345). Respondents to the current study were generally open i n expressing t h e i r g r i e v i n g experiences. Many commented that the opportunity to share t h e i r story had been therapeutic. However, p r i o r 62 t o i n t e r v i e w commencement, i t had been c l e a r l y e s t a b l i s h e d t h a t they c o u l d withdraw from the study at any time or c o u l d r e f u s e t o answer any of the q u e s t i o n s . The purpose of the study was c l e a r l y e x p l a i n e d , and any f u r t h e r q u e s t i o n s were answered openly by the r e s e a r c h e r . T h i s , i n e f f e c t , e s t a b l i s h e d not o n l y a t r u s t between the i n t e r v i e w p a r t i c i p a n t s , but a l s o a s h i f t o f c o n t r o l t o the respondent, a l l o w i n g t h e i r f u l l d i r e c t i o n w i t h i n the parameters of the i n t e r v i e w . The primary concern was the respondent's i n t e r p r e t a t i o n o f the death and g r i e v i n g events and i s s u e s , not the i n v e s t i g a t o r ' s . T h i s had r e s u l t e d as mentioned above, w i t h the Q u e s t i o n n a i r e b e i n g "opened up", and the respondents encouraged t o respond i n t h e i r own words and t o share t h e i r s t o r i e s w i t h a minimum of imposed s t r u c t u r e . While the q u e s t i o n n a i r e was used as a guide t o f a c i l i t a t e c o v e r i n g a range of g r i e v i n g experience, the i n d i v i d u a l " s t o r y " was f o s t e r e d through empowerment. Q u a n t i t a t i v e Data A n a l y s i s Cameron and B r i n g s G r i e f and Adjustment  I n v e n t o r i e s Each s u b j e c t p a r t i c i p a t e d i n a telephone i n t e r v i e w and the r e s u l t s were a s s e s s e d u s i n g two i n v e n t o r i e s developed by Cameron and B r i n g s , 1980 (Appendix I I I ) . A v a l u e of *one' was a s s i g n e d each time a c l a s s i f i e d i tem o c c u r r e d i n the s u b j e c t ' s p r o f i l e . The c l a s s i f i e d items corresponded t o symptoms o f g r i e f which i n c l u d e : somatic d i s t r e s s , p r e o c c u p a t i o n w i t h the image o f the deceased, g u i l t , h o s t i l e r e a c t i o n s , i m p a i r e d judgement, and appearance of t r a i t s of the deceased (Lindemann, 1944; Vachon, 1982). These val u e s were added up and r e s u l t e d i n two s c o r e s f o r each respondent — a G r i e f Score and an Adjustment Score. The G r i e f Score r e f l e c t e d the presence of g r i e f symptoms, some d e s c r i b e d as ^maladaptive', w h i l e the Adjustment Scores r e f l e c t e d the absence of the g r i e f symptoms. In t e r v i e w Coding; When coding the respondent's r e p l i e s , a v a l u e of one was a s s i g n e d each time a c l a s s i f i e d i tem o c c u r r e d i n the s u b j e c t ' s p r o f i l e . These items were c o n t a i n e d i n two coding frames — the Cameron-Brings A n n i v e r s a r y G r i e f Inventory and Adjustment Inventory (Appendix I I I ) — and p r e s e n t e d d i f f i c u l t i e s o f confounding v a r i a b l e s , c u l t u r a l b i a s , and hyperbole. F o r example: " U n d e s i r a b l e weight change s t i l l p e r s i s t s " and "Has not rec o v e r e d l o s t a p p e t i t e " can each be broken down t o t h r e e confounding v a r i a b l e s : " U n d e s i r a b l e / weight change / s t i l l p e r s i s t s " "Has not/ rec o v e r e d / l o s t a p p e t i t e " Words l i k e "haunted" and " i n t o l e r a b l e " t o g e t h e r i n a sentence not onl y exaggerates the v a r i a b l e "memory of the death" but a l s o has s e r i o u s c u l t u r a l c o n n o t a t i o n s f o r i n d i v i d u a l s w i t h p r e s c r i b e d r e l i g i o u s r i t u a l on the a n n i v e r s a r y of the death. M o d i f i c a t i o n s made t o the coding frame allowed f o r c o n s i s t e n c y i n s c o r i n g . T h i s p e r m i t t e d q u a n t i f i a b i l i t y and r e p l i c a t i o n o f the s t a t i s t i c a l a n a l y s es used i n the Cameron and Parkes study. A f i n a l concern r e l a t e d t o the codi n g frames was the u n d e r l y i n g premise of p e r s o n a l r e s p o n s i b i l i t y f o r g r i e v i n g r e s o l u t i o n and outcome. While the q u e s t i o n n a i r e e l i c i t e d i n f o r m a t i o n r e l a t i n g t o s o c i a l and f a m i l y supports, f i n a n c i a l and l i v i n g arrangements, t h i s i n f o r m a t i o n was not u t i l i z e d i n the i n v e n t o r i e s , and the i n d i v i d u a l , by i n f e r e n c e , was "blamed" f o r s o c i a l i s o l a t i o n , not engaging i n new a c t i v i t i e s or r e l a t i o n s h i p s ( f r i e n d s h i p s ) . These f a c t o r s can be h i g h l y dependent upon age, sex, and a c c e s s i b i l i t y — both f i n a n c i a l and p h y s i c a l — as w e l l as support network s t r e n g t h s . Both the i n t e r v i e w s and the co d i n g were c a r r i e d out by the i n v e s t i g a t o r thus imposing c o n s i s t e n c y i n t o the approach and a n a l y s e s . The Wilcoxon Matched-Pairs Signed-Ranked T e s t F o l l o w i n g the Cameron and B r i n g s (1980)/ Cameron and Parkes (1983) a n a l y s i s p r o t o c o l , the Wilcoxon Matched-Pairs Signed-Ranked Te s t was a d m i n i s t e r e d . The assumptions i n h e r e n t i n u s i n g t h i s t e s t were: 1. t h a t the samples were from the same p o p u l a t i o n and were t h e r e f o r e r e l a t e d — a l l the s u b j e c t s were matched on r e l e v a n t v a r i a b l e s — age, sex and r e l a t i o n s h i p t o the deceased — thereby a c h i e v i n g c o n t r o l through matching; 2. a group which had undergone a treatment was b e i n g compared t o one which had not — those w i t h bereavement i n t e r v e n t i o n were compared t o those without; 3. the sc o r e s of the two groups may or may not be 66 d i s t r i b u t e d n ormally i n the p o p u l a t i o n from which the sample was drawn, t h e r e f o r e a d i s t r i b u t i o n f r e e t e s t was d e s i r e d ; and, 4. the l e v e l of measurement i s o r d i n a l ( S i e g e l , 1956). In terms of the Wilcoxon Test, the n u l l h y p o t h e s i s would f i n d no d i f f e r e n c e i n g r i e f outcome between the two groups, thus the G r i e f and Adjustment Scores of the groups w i l l d i f f e r o n l y by chance. With the a l t e r n a t e h y p o t h e s i s , the sum of the p o s i t i v e ranks would s i g n i f i c a n t l y d i f f e r from the sum of the n e g a t i v e ranks f o r each s c o r i n g . F i s h e r ' s Exact Test The F i s h e r ' s Exact Test i s c a r r i e d out when c r o s s - t a b u l a t i n g s m a l l samples and r e p l a c e s the X 2 t e s t a d m i n i s t e r e d i n the o r i g i n a l s t u d i e s (which had a l a r g e r sample s i z e ) . I t i s a p r o b a b i l i t y t e s t which ana l y z e s d i s c r e t e data, and i s h e l p f u l i n a s c e r t a i n i n g whether independent v a r i a b l e s f a l l i n t o one of two mutually e x c l u s i v e c l a s s e s . D e s c r i p t i o n of Method of Q u a n t i t a t i v e A n a l y s i s The respondents -- e i g h t from the "bereavement" group, 67 and seven from the "non-bereavement" group — were matched i n t o s i x (6) p a i r s . F o l l o w i n g the o r i g i n a l p r o t o c o l , the p a i r s were matched f o r age, sex, and r e l a t i o n s h i p t o the deceased. The p a i r s were comprised of two daughters, f o u r widowers and s i x widows, ra n g i n g i n age from t w e n t y - e i g h t to s e v e n t y - n i n e . G r i e f and Adjustment Scores were d e r i v e d from the Cameron I n v e n t o r i e s . C r o s s - t a b u l a t i o n s were c a r r i e d out t o a s c e r t a i n v a r i a b l e r e l a t i o n s h i p s t h a t may have c o n t r i b u t e d t o the G r i e f and Adjustment Scores. The Scores were compared u s i n g the Wilcoxon Matched-Pairs Signed-Ranks Te s t which i n d i c a t e s both d i r e c t i o n and magnitude of d i f f e r e n c e s . F i n d i n g s of the Q u a n t i t a t i v e A n a l y s i s The complementary r e p l i c a t i o n of the Cameron-Brings study was c a r r i e d out with mixed r e s u l t s . As p r e v i o u s l y mentioned, the samples were matched a c c o r d i n g t o the c r i t e r i a e s t a b l i s h e d by Cameron and B r i n g s — age, sex and r e l a t i o n s h i p t o the deceased. These were c h a r a c t e r i s t i c s t h a t were a v a i l a b l e t o the i n v e s t i g a t o r p r i o r t o t h e i n t e r v i e w s and a n a l y s i s and were implemented i n the sampling 68 of the group without bereavement i n t e r v e n t i o n . A d i f f i c u l t y arose however when i t was found t h a t the two samples were i n f a c t not comparable. T h i s was found when the F i s h e r ' s Exact Test was c a r r i e d out and i t became apparent t h a t t h e r e was a d i f f e r e n c e i n the amount of time f o r p r e p a r a t i o n f o r the death which i n f l u e n c e d the d e c i s i o n t o p a r t i c i p a t e i n the bereavement i n t e r v e n t i o n . C r o s s - t a b u l a t i o n s A l l of the study respondents had been p a r t i c i p a n t s i n a P a l l i a t i v e Programme. C r o s s -t a b u l a t i o n s were c a r r i e d out t o see what v a r i a b l e r e l a t i o n s h i p s may have c o n t r i b u t e d t o the d i f f e r e n c e s observed i n the G r i e f and Adjustment Scores. I t was thought t h a t poor h e a l t h , r e l i g i o u s b e l i e f and p r a c t i c e , and s o c i a l support may have c o n t r i b u t e d i n some way t o p a r t i c i p a t i o n i n the bereavement support group. Almost the t o t a l p o p u l a t i o n i n d i c a t e d some h e a l t h - r e l a t e d g r i e v i n g d i f f i c u l t i e s and o n l y 30% i n d i c a t e d t h a t the h e a l t h i s s u e was r e s o l v e d . However a c r o s s - t a b u l a t i o n of h e a l t h and bereavement group p a r t i c i p a t i o n showed no s i g n i f i c a n t r e l a t i o n s h i p between these v a r i a b l e s . As w e l l , r e l i g i o u s p r a c t i c e d i d not d i f f e r e n t i a t e between those responding t o the bereavement 69 support and those who d i d n ' t . Age and sex were e q u a l l y n o n p r e d i c t i v e . Those with p e r c e i v e d low s o c i a l support were d i v i d e d e q u a l l y between the two groups. C r o s s - t a b u l a t i o n s were run on the v a r i a b l e s o f "prep" — months i l l b e f o r e death, and "BG" — bereavement group, with some s t a r t l i n g r e s u l t s . I t was s p e c u l a t e d t h a t some of those who p a r t i c i p a t e d i n the bereavement group may have had l i t t l e time t o prepare f o r the death o f t h e i r f a m i l y member. F i s h e r ' s Exact Test Table 3 shows the c r o s s -t a b u l a t i o n of ^bereavement group p a r t i c i p a t i o n ' w i t h ^time f o r p r e p a r a t i o n ' and the F i s h e r ' s Exact Test r e s u l t s . The conting e n c y t a b l e shows t h a t t h e r e i s a d i v i s i o n between those who p a r t i c i p a t e d i n the bereavement group and those who d i d not. A d i r e c t r e l a t i o n s h i p was found between the time i n d i v i d u a l s had t o prepare f o r the death and p a r t i c i p a t i o n i n the bereavement group. Those who had nine (9) or l e s s months t o prepare f o r the death were ALL i n the bereavement group. One i n d i v i d u a l had e l e v e n (11) months t o prepare but a l s o had no f a m i l i a l or s o c i a l network support and was a male over seventy years of age. The range of p r e p a r a t i o n 70 time f o r the Bereavement I n t e r v e n t i o n group was 3 - 1 1 months; while the range f o r the others was 11 - 72 months. Table 3 C r o s s - t a b u l a t i o n o f P r e p a r a t i o n Time and Bereavement Group P a r t i c i p a t i o n . Bereavement Group P a r t i c i p a t i o n Yes No Row T o t a l P r e p a r a t i o n Time (< 10 months) (> 10 months) Column T o t a l S t a t i s t i c F i s h e r ' s Exact Test S t a t i s t i c Lambda Symmetric 0.83333 5 100. 0 83.3 41.7 1 16.7 16.7 16.7 6 58 . 3 One T a i l 0.00408 With Prep Dependent 0.83333 6 83.3 100.0 41. 6 6 41. 6 Two T a i l 0.00466 5 41.7 7 58.3 12 100.0 With B.G. Dependent 0.83333 Both the o n e - t a i l and t w o - t a i l p r o b a b i l i t i e s were l e s s than p = .005, thus i n d i c a t i n g s i g n i f i c a n t r e s u l t s i n 7 1 these comparisons. The Lambda s t a t i s t i c i n d i c a t e d t h a t t h e r e i s an 83% r e d u c t i o n o f e r r o r when u s i n g xtime f o r p r e p a r a t i o n ' t o p r e d i c t ^bereavement group p a r t i c i p a t i o n ' and v i c e v e r s a and i s thus deemed symmetrical. From the s e data two o b s e r v a t i o n s can be made: 1. f a m i l y members who have l i t t l e time f o r p r e p a r a t i o n f o r the death appear t o p e r c e i v e a need f o r bereavement fo l l o w - u p ; and, 2. a c a r e f u l assessment i s r e q u i r e d of those w i t h l o n g e r p r e p a r a t i o n p e r i o d s — e s p e c i a l l y i f combined w i t h low s o c i a l support. G r e a t e r e f f o r t s h o u l d be made t o i n v o l v e them i n some form of bereavement f o l l o w - u p as some may r e q u i r e a d d i t i o n a l support (given the G r i e f and Adjustment Scores f o r the group without bereavement i n t e r v e n t i o n ) . The f i n d i n g c o n c e r n i n g the time f o r p r e p a r a t i o n b e n e f i t s from c l a r i f i c a t i o n . A l l the deceased d i e d o f cancer. Cancer i s a g e n e r i c term f o r a group of d i s e a s e s t h a t g e n e r a l l y have a d i s c o n t i n u o u s d i s e a s e t r a j e c t o r y over time. In the l i t e r a t u r e i t i s termed " e p i s o d i c " and r e l a t e s t o the c h a r a c t e r i s t i c s of a l t e r n a t i n g s t a b l e p e r i o d s of v a r y i n g l e n g t h -- normally r e f e r r e d t o as " r e m i s s i o n " — f o l l o w e d by e x a c e r b a t i o n (Rolland, 1989) . T h i s e f f e c t s f a m i l y system a d a p t a t i o n t o d i s e a s e i n many ways, p r i m a r i l y i n the manner i n which r o l e r e a l l o c a t i o n and c r i s i s response are i n c o r p o r a t e d i n t o f a m i l y f u n c t i o n i n g . Given a l o n g e r d i s e a s e t r a j e c t o r y , an a n t i c i p a t o r y bereavement pr o c e s s may be supported through the p a l l i a t i v e program. A l s o , the i n t e g r a t i o n o f time with p e r s o n a l i n t e r p r e t a t i o n and meaning of the death event may a l l o w f o r g r e a t e r r e s o l u t i o n of some of the g r i e v i n g i s s u e s . I t has been suggested t h a t the time f o r p r e p a r a t i o n s u b s t a n t i a l l y impacts f a m i l y f u n c t i o n i n g and a d a p t a t i o n -- s h o r t e r p e r i o d o f p r e p a r a t i o n time r e s u l t s i n g r e a t e r d i s i n t e g r a t i o n and r i s k (Adams and Lindemann, 1974; R o l l a n d , 1989). As i s observed i n t h i s study, the bereavement group i s e n t i r e l y composed of i n d i v i d u a l s who had c o m p a r a t i v e l y l i t t l e time t o prepare f o r the death of t h e i r f a m i l y member. Wilcoxon Matched-Pairs Signed-Ranks Test The Wilcoxon Test was c a r r i e d out and the r e s u l t s i l l u s t r a t e d 73 the d i f f i c u l t y of s m a l l sample s i z e compounded by l a c k of c o m p a r a b i l i t y of the two samples due t o the v a r i a b l e of ^time f o r p r e p a r a t i o n ' . While t h e r e was a v a r i a t i o n i n the G r i e f and Adjustment Scores between the samples, the d i f f e r e n c e s were not s i g n i f i c a n t and c o u l d not l e a d t o any c o n c l u s i o n s about the e f f i c a c y of bereavement i n t e r v e n t i o n . The s t a t i s t i c a l a n a l y s e s of the G r i e f and Adjustment Scores have been i n c l u d e d f o r i n f o r m a t i o n . Table 4: D i f f e r e n c e s i n G r i e f Scores between those With and Without Bereavement I n t e r v e n t i o n u s i n g the Wilcoxon Matched-Pairs Signed-Ranks T e s t . P a i r Without With d Sign Wilcoxon Rank with l e s s # I n t e r v e n t i o n D i r e c t i o n Rank frequent s i g n 1 6 2 - 4 2.5 2 14 9 - 5 3 3 5 11 + 4 + 2.5 2.5 4 0 7 + 7 + 4 4 5 20 5 -15 5 6 4 2 - 2 1 T = 6.5 G r i e f Scores: The l e a s t d e s i r a b l e score f o r the G r i e f Inventory i s 33, w i t h the most d e s i r a b l e i s 0. The range of s c o r e s a c h i e v e d f o r both samples was 20 t o 0. There 74 i s no i n f o r m a t i o n about 'expected range' i n the o r i g i n a l s t u d i e s (Cameron and B r i n g s , 1980/Cameron and Parkes, 1983) and the Scores l i s t e d i n Table 4 can o n l y i n d i c a t e i f one group has done/not done as w e l l as the o t h e r , thus are r e l a t i v e and not d e f i n i t i v e . Table 5: Computer A n a l y s i s of G r i e f Scores u s i n g the Wilcoxon Matched-Pairs Signed-Ranks T e s t . mean rank cases 3.00 4 - ranks (with < without) 4.50 2 + ranks (with > without) 0 t i e s 6 t o t a l z = -.3145 2 - t a i l e d p = .7532 "Without I n t e r v e n t i o n " G r i e f Scores The range of s c o r e s f o r those without bereavement fol l o w - u p was 20 t o 0, w i t h the mean e q u a l l i n g 8.167, and the median b e i n g 5. Both the maximal and minimal a t t a i n a b l e s c o r e s were r e p r e s e n t e d i n t h i s sample i n d i c a t i n g a wide range i n g r i e f r e s o l u t i o n d u r i n g the t h i r t e e n month p e r i o d — some doing v e r y w e l l , o t h e r s doing r e l a t i v e l y p o o r l y . Two i n d i v i d u a l s were each found t o have a 'maladaptive' g r i e f s c o r e (See Appendix I I I ) . 75 "With I n t e r v e n t i o n " G r i e f Scores The range of sc o r e s f o r those with bereavement f o l l o w - u p was 11 t o 01. The mean was 5.75, the median was 6 i n d i c a t i n g f a i r l y even g r i e f r e s o l u t i o n . Adjustment Scores The most d e s i r a b l e Adjustment Score i s 14, the l e a s t d e s i r a b l e b e i n g 0. THe range of sc o r e s f o r both samples was 01 t o 14. Table 6: D i f f e r e n c e s i n Adjustment Scores between those With and Without Bereavement I n t e r v e n t i o n u s i n g the Wilcoxon Matched-Pairs Signed-Ranks T e s t . P a i r Without With d Sign Wilcoxon Rank wi t h l e s s # I n t e r v e n t i o n D i r e c t i o n Rank fre q u e n t s i g n 1 10 12 + 2 + 1 2 5 12 + 7 + 3 3 6 9 + 3 + 2 4 14 5 - 9 - 4.5 4.5 5 1 10 + 9 + 4.5 6 14 12 - 2 2 2 T = 6.5 Table 7: Computer Analysis of Adjustment Scores using the Wilcoxon Matched-Pairs Signed-Ranks Test. mean rank 3.50 3.50 cases 2 - ranks ( with < without) 4 + ranks ( with > without) 0 t i e s 6 t o t a l z = -.7338 2- t a i l e d p = .4631 Without Intervention" Adjustment Scores The scores of t h i s group encompass the lowest and highest adjustment scores, with the range for the group without bereavement intervention being 01 - 14, the mean being 6 and the median being 5.5. As previously mentioned, two scores of 14 were found in the 'without intervention' group. These were also the individuals with the lowest Grief Scores for t h i s group thus bearing out assertions that bereavement follow-up i s not necessary for a l l bereaved i n d i v i d u a l s . These scores were achieved by in d i v i d u a l s who had cared extensively, over time, for t h e i r i l l family member at home, and one included a home death. There had been time to integrate i n t e r n a l r o l e reorganization as well as drawing upon the p a l l i a t i v e programme resources to f a c i l i t a t e t h i s p r o c e s s . The l e a s t d e s i r a b l e s c o r e s — even though a s c r i b e d t o i n d i v i d u a l s having " y e a r s " f o r a d a p t a t i o n — seem t o have r e s u l t e d from a the d i s e a s e t r a j e c t o r y of r e m i s s i o n / e x a c e r b a t i o n i n combination with c h r o n i c i t y . T h i s can r e s u l t i n c a r e g i v e r e x h a u s t i o n and/or i n co m p l i c a t e d g r i e v i n g due t o c a r e g i v e r d e p l e t i o n and f e e l i n g s o f apathy, h e l p l e s s n e s s and r e s i g n a t i o n t h a t develop as "defense mechanisms a g a i n s t overwhelming t h r e a t and l o s s " (Wasow and Coons, 1988, p.25; Rando, 1986, p. 6) . "With I n t e r v e n t i o n " Adjustment Scores The bereavement group range i s 05 - 13, wit h a mean of 10.5 and a median of 11.5. T h i s suggests t h a t the group with the bereavement f o l l o w - u p has a g r e a t e r o v e r a l l adjustment than those without the i n t e r v e n t i o n . I t can be observed however t h a t one i n d i v i d u a l i n t h i s group had what appears t o be a r e l a t i v e l y low score of 5. The s c o r i n g f o r t h i s i n d i v i d u a l p o i n t e d out a weakness i n the G r i e f and Adjustment I n v e n t o r i e s (Appendix I I I ) . There was l i t t l e d i f f e r e n c e between the G r i e f Score and 78 Adjustment Score f o r t h i s i n d i v i d u a l . However the coding c o u l d not d i s c r i m i n a t e how w e l l the i n d i v i d u a l was managing r e l a t i v e t o the e x p e r i e n c e of the l o s s — i n t h i s i n s t a n c e m u l t i p l e l o s s e s . C o m p a r a b i l i t y w i t h the Cameron-Brings /Cameron-Parkes  S t u d i e s Few of the c u r r e n t f i n d i n g s are c o n s i s t e n t w i t h those of the o r i g i n a l study p u b l i s h e d by Cameron and B r i n g s , 1980 and by Cameron and Parkes, 1983, i n which i n d i v i d u a l s h a v ing P a l l i a t i v e Care and Bereavement Support were compared with i n d i v i d u a l s h a v ing n e i t h e r s u p p o r t i v e i n t e r v e n t i o n . In the o r i g i n a l study, p a t i e n t s were not randomly a s s i g n e d t o the P a l l i a t i v e Programme and tended t o be younger i n d i v i d u a l s than those i n the g e n e r a l h o s p i t a l p o p u l a t i o n . The p a t i e n t s , hence the f a m i l i e s , i n the c u r r e n t study were r e p r e s e n t a t i v e of a l l ages as v i r t u a l l y a l l t e r m i n a l l y i l l i n d i v i d u a l s and t h e i r f a m i l i e s were r e f e r r e d t o the P a l l i a t i v e Program i n the study h o s p i t a l . Age c h a r a c t e r i s t i c s of the study p o p u l a t i o n r e f l e c t e d t h i s age range. The twelve matched study respondents were comprised of two daughters, f o u r widowers and s i x widows, and ranged i n age from twenty-e i g h t t o se v e n t y - n i n e . The number of years m a r r i e d ranged from 13 t o 53 with a mean of 36.6 years and a median of 37 y e a r s . Age S i m i l a r i t i e s between the s t u d i e s were noted w i t h those over 65 having g r e a t e r d i f f i c u l t i e s w i t h p e r s i s t e n t g r i e f — as i n d i c a t e d by the G r i e f and Adjustment S c o r e s . However, where Cameron and Parkes found h i g h use of s e d a t i v e s and p s y c h i a t r i c symptoms i n t h e i r p o p u l a t i o n over 65, the c u r r e n t study found only two i n d i v i d u a l s over 65 u s i n g s e d a t i v e s moderately and no one under 65. The c u r r e n t study samples were a l l non-smokers and o n l y one i n d i c a t e d h i g h e r a l c o h o l consumption than p r i o r t o the death. In f a c t , as an i n d i c a t i o n o f the times, e x e r c i s e was the Mrug of c h o i c e ' by h a l f o f the c u r r e n t study sample — f o r a l l ages. A d d i t i o n a l i n f o r m a t i o n found i n the c u r r e n t study was r e l a t e d t o d i f f i c u l t i e s encountered by s u r v i v i n g daughters i n t h e i r 20s -- these o b s e r v a t i o n s o f seven young women (daughters or s i b l i n g s ) were made by 80 respondents. They r e l a t e d observed d i f f i c u l t i e s t h a t i n c l u d e d : dropping out of u n i v e r s i t y , o c c u p a t i o n a l d i s r u p t i o n , b r e a k i n g up l o n g term r e l a t i o n s h i p s , moving home and i n one case, s e e k i n g the support o f a t h e r a p i s t . Manor concerns P a i n and s u f f e r i n g were major concerns w i t h the o r i g i n a l i n v e s t i g a t i o n . Only one mention was made of p a i n and s u f f e r i n g by the c u r r e n t study respondents which may w e l l be a d i r e c t r e s u l t o f improved pharmacopeia as w e l l as the maturation of p a l l i a t i v e c a r i n g . While Cameron and Parkes do mention t h a t " i t takes time t o break bad news and t o g i v e support t h a t i s necessary i f i t i s t o be d i g e s t e d and t o g i v e r i s e t o a p p r o p r i a t e 'worry work'", d e l i n e a t i o n of 'time' was i n "days" r a t h e r than months and was r e l a t e d t o "warning of death" r a t h e r than "time f o r p r e p a r a t i o n f o r the death" (Cameron and Parkes, p.77). T h i s again i s a r e f l e c t i o n of program m a t u r a t i o n as i n d i v i d u a l s c u r r e n t l y e n t e r the program when the d e c i s i o n i s made t o end a c t i v e , c u r a t i v e p rocedures. The emphasis i s on q u a l i t y time, at home, with f a m i l i e s , thus "months" r a t h e r than "days" becomes the measurement. 81 Support Networks L o n e l i n e s s was r e f e r r e d t o by twen t y o f t h e PCU sample and t e n o f t h e c o n t r o l s i n t h e o r i g i n a l s t u d y . I n t h e c u r r e n t s t u d y , t h e c o n c e p t o f ^a l o n e n e s s ' as w e l l as l o n e l i n e s s was c i t e d many t i m e s ( t w e l v e out o f f i f t e e n ) and was r e l a t e d t o b e i n g " u n c o u p l e d " o r " s i n g l e d " . I n f a c t , t h e o r i g i n a l s t u d y n o t e d 1) p a i n and 2) l o n e l i n e s s as t h e " h a r d e s t t h i n g s " whereas t h e c u r r e n t group i n d i c a t e d 1) t h e l o s s , 2) t h e f u n e r a l / b u r i a l p r o c e d u r e s and 3) l o n e l i n e s s as t h e " h a r d e s t t h i n g s " . Other F i n d i n g s The s i z e o f f a m i l i e s , t h e i r a c c e s s i b i l i t y , and r e l i g i o u s a f f i l i a t i o n a r e a l s o i n d i c a t o r s o f s u p p o r t networks n o t e d i n t h e c u r r e n t s t u d y . C h i l d r e n The number o f c h i l d r e n a v e r a g e d 1.75, w i t h 75% h a v i n g two c h i l d r e n . Of t h e t w e l v e r e s p o n d e n t s o n l y f o u r had c h i l d r e n a t home - two w i t h e i t h e r one and two c h i l d r e n under t h e age o f 12; a n o t h e r who had a twe n t y y e a r o l d d a u g h t e r move home; and a n o t h e r ' s f i f t y - y e a r o l d da u g h t e r had always l i v e d i n t h e home. 82 F a m i l y and s o c i a l support Family and s o c i a l support were judged average t o h i g h by 7 6% of the respondents — but those w i t h h i g h e s t G r i e f Scores and Lowest Adjustment Scores were a l s o among those with lowest s o c i a l and f a m i l y support. A l l the grown c h i l d r e n , except t h r e e , l i v e w i t h i n an hour d r i v e and c o n t a c t w i t h them i s h i g h . Only one respondent i n d i c a t e d t h a t h i s c h i l d r e n were out of p r o v i n c e — he a l s o had l i t t l e or no s o c i a l s u pport. Finances Only one spouse and one daughter noted t h a t f i n a n c e s were more d i f f i c u l t now than b e f o r e the death of the f a m i l y member — the w i f e had a 40% drop i n pension income and moved to a cheaper apartment; the daughter a l s o moved t o cheaper accommodation. A l l the other respondents owned t h e i r own homes and o n l y one widow worked p a r t - t i m e because "she enjoyed i t and had always done some work o u t s i d e the home". R e l i g i o s i t y The area of r e l i g i o s i t y was most i n t e r e s t i n g w i t h 25% n o t i n g church attendance — o n l y two i n d i v i d u a l s i n d i c a t e d t h a t r e l i g i o n and the church community were i n t e g r a l t o t h e i r l i v e s . Over 70% of the 83 respondents had t h e i r f a m i l y member cremated, w h i l e 60% of these ( n e a r l y h a l f the t o t a l sample) d i d not have a f u n e r a l or memorial s e r v i c e . T h i s f i n d i n g r e l a t e s d i r e c t l y t o the d i f f i c u l t i e s s u r r o u nding f u n e r a l and b u r i a l procedures encountered i n t h i s study. Bereavement group p a r t i c i p a t i o n P a r t i c i p a t i o n i n the bereavement f o l l o w - u p group r e l a t e d d i r e c t l y t o the amount of time of p r e p a r a t i o n f o r the death as d i s c u s s e d above, and v a r i e d from two months t o c u r r e n t l y a c t i v e (a year a f t e r commencement), wit h an even s p l i t between the fo u r c o n t i n u i n g at l e a s t s p o r a d i c a l l y and the f o u r who p a r t i c i p a t e d f o r a sh o r t p e r i o d of time. Those who d i s c o n t i n u e d e a r l i e r f e l t t h a t t h e i r needs — p r i m a r i l y f o r i n f o r m a t i o n — had been met. Others i n d i c a t e d t h a t with time they 'outgrew' the need f o r the group focus on bereavement and needed t o look more at i s s u e s r e l a t e d t o 'being s i n g l e ' . Three of the f o u r who continued, noted t h a t they c o u l d not "have made i t " without the support o f the group and the s o c i a l worker. The young c h i l d r e n , noted above, were i n c l u d e d i n A r t Therapy s e s s i o n s f o r bereaved c h i l d r e n . 84 Summary A complementary r e p l i c a t i o n was attempted but s m a l l sample s i z e and l a c k of c o m p a r a b i l i t y between the two groups g r e a t l y l i m i t e d the power of the a n a l y s i s . I t was found t h a t the amount of time f o r p r e p a r a t i o n of the death of a f a m i l y member was a c r i t i c a l f a c t o r i n p a r t i c i p a t i n g i n the bereavement f o l l o w - u p . Age f a c t o r s were a l s o a concern i n the c u r r e n t study w i t h men over seventy years of age and young women i n t h e i r t w e n t i e s found t o be at g r e a t e s t r i s k . I t i s known t h a t g r i e f r e s o l u t i o n can be e f f e c t e d by a number of v a r i a b l e s which are r e l a t e d t o s o c i a l support networks, aspects of f a m i l y s t r u c t u r e , f l e x i b i l i t y and r e s o u r c e s , combined wi t h the d i s e a s e t r a j e c t o r y and i t s concomitant symptom c o n t r o l and h o s p i t a l or home-based ca r e . Many of these v a r i a b l e s r e l a t e s p e c i f i c a l l y t o p e r s o n a l support networks. The q u a n t i t a t i v e a n a l y s i s d i d not address these f a c t o r s , even though the Cameron and B r i n g s Q u e s t i o n n a i r e i n c l u d e d t h i s area of i n q u i r y . The f i n d i n g s o u t l i n e d above and those i n c l u d e d i n the c o m p a r a b i l i t y to the Cameron and B r i n g s (1980)/Cameron 85 and Parkes, 1983 s t u d i e s , i n d i c a t e these f a c t o r s are important t o bereavement r e s o l u t i o n . G r i e f and Adjustment Scores f o r two i n d i v i d u a l s i n d i c a t e t h a t bereavement i n t e r v e n t i o n i s not r e q u i r e d by everyone. Lack of c o m p a r a b i l i t y of the c u r r e n t study w i t h the o r i g i n a l Cameron s t u d i e s i s seen t o be a r e s u l t o f p a l l i a t i v e programme maturation, changes i n medi c a l r e c o g n i t i o n of need f o r p a l l i a t i v e care and p r o g r e s s i n p a i n management. 86 CHAPTER 4 QUALITATIVE ANALYSIS AND FINDINGS T h i s chapter o u t l i n e s the q u a l i t a t i v e methodology, a n a l y s i s and f i n d i n g s of the r e s e a r c h . A q u a l i t a t i v e , grounded th e o r y approach was used i n an attempt t o b u i l d s u b s t a n t i v e theory r e l a t i n g t o the e f f i c a c y of bereavement i n t e r v e n t i o n . T h i s i n v o l v e d a r r a n g i n g data d e r i v e d from the i n t e r v i e w s i n t o broad c a t e g o r i e s or themes. From these data, two core c a t e g o r i e s were modelled, t h e i r dimensions s u b s t r u c t e d and analyzed u t i l i z i n g Worden's Tasks of G r i e v i n g . Respondents' quotes were i n c l u d e d v e r b a t i m from the i n t e r v i e w s f o r i l l u s t r a t i v e purposes. E d i t e d quotes were used i n m a t r i c e s t o p r e s e n t c o n c i s e r e p r e s e n t a t i o n s of the responses. The i n f o r m a t i o n c o n t a i n e d i n t h i s chapter p e r t a i n s d i r e c t l y t o the respondents and t h e i r p e r s o n a l e x p e r i e n c i n g of the g r i e f p r o c e s s . R a t i o n a l e f o r the Q u a l i t a t i v e A n a l y s i s I t has been noted by Yalom and Vinogradov (1988) and Osterweiss (1988) t h a t t h e r e i s l i t t l e i n f o r m a t i o n a v a i l a b l e about the e f f i c a c y of bereavement i n t e r v e n t i o n . T h e r e f o r e , very l i t t l e can be gleaned from the l i t e r a t u r e which a p p l i e s t o the e f f i c a c y of bereavement support programmes — e s p e c i a l l y w i t h i n the parameters of p a l l i a t i v e c a r e programming. One study by Roy and Sumpter (1983) p r e s e n t e d an o u t l i n e of t h e i r p a l l i a t i v e care bereavement program but no comparisons were made between those who d i d or d i d not p a r t i c i p a t e i n the bereavement group. There was no i n d i c a t i o n o f why c e r t a i n i n d i v i d u a l s attended, why o t h e r s d i d n ' t , or whether t h e r e was a d i s c e r n a b l e d i f f e r e n c e i n t h e i r bereavement outcomes. Vachon (1988) o f f e r s an overview of c o u n s e l l i n g and psychotherapy i n p a l l i a t i v e / h o s p i c e c a r e i n which the f o l l o w i n g r e s u l t s are presented: F r y e r ( c i t e d i n Vachon, 1988) i n f e r s t h a t c o n t i n u i t y of care and s h a r i n g s u p p o r t i v e i n f o r m a t i o n about the deceased with f a m i l y members may be h e l p f u l i n the bereavement p r o c e s s . Vachon ( c i t e d i n Vachon, 1988) w r i t e s t h a t assessment of i n t e r v e n t i o n i n the p a l l i a t i v e program i s d i f f i c u l t because the program as a whole i s g e n e r a l l y e v a l u a t e d , not components of c a r e . Parkes ( c i t e d i n Vachon, 1988) found i t d i f f i c u l t t o separate p s y c h o s o c i a l bereavement care f o r s u r v i v o r s 88 from the e f f e c t s of symptom c o n t r o l , but suggested t h a t h o s p i c e i t s e l f tended t o a m e l i o r a t e s u r v i v o r a n x i e t y , de S t . Aubin and Lund ( c i t e d i n Vachon, 1988) found a h i g h number of p a l l i a t i v e program s u r v i v o r s a c c e s s e d a bereavement support group but attendance was s p o r a d i c , a v e r a g i n g 2.1 bereavement c o n t a c t s . None of these s t u d i e s advanced knowledge about bereavement outcome a s s o c i a t e d with the p a l l i a t i v e c a r e programming, and i n d i c a t e d a g e n e r a l l a c k of r e s e a r c h i n t h i s a r e a . I t was noted i n Chapter 2 t h a t bereavement i s an a l l encompassing pr o c e s s which i n c l u d e s p s y c h o l o g i c a l , p h y s i o l o g i c a l and s o c i o l o g i c a l dimensions. The b e g i n n i n g p o i n t f o r r e s e a r c h i s t o determine how i n d i v i d u a l s frame t h i s p r o c e s s . From t h i s p e r s o n a l framing, a grounded understanding may be e s t a b l i s h e d about what c o n s t i t u t e s the bereavement pr o c e s s and what s t r a t e g i e s f o r i n t e r v e n t i o n are needed and most a p p r o p r i a t e . As noted above, t h e r e i s no d i f f e r e n t i a t i o n between the e f f e c t of h o s p i c e i n t e r v e n t i o n and the e f f e c t of, and/or need f o r bereavement i n t e r v e n t i o n . As g r i e v i n g pervades a l l realms of p e r s o n a l f u n c t i o n i n g , the b e s t sources of i n f o r m a t i o n are bereaved i n d i v i d u a l s themselves. From t h i s i n f o r m a t i o n a r e s e a r c h e r can formulate hypotheses c o n c e r n i n g s e r v i c e o b j e c t i v e s and modes 89 of i n t e r v e n t i o n . A c o n c e p t u a l approach seeking t o e x p l o r e the f u l l range o f "thoughts, f e e l i n g s , e x periences and i n t u i t i o n s " i n an e x p e r i e n t i a l and d i a l e c t i c e x p l o r a t i o n w i t h s u b j e c t s would be h i g h l y s u i t e d t o e x p l i c a t i n g the v a r i o u s dimensions of g r i e f (Rowan i n M i t r o f f and Kilman, 1982, p. 84). T h i s approach would v a l i d a t e the respondents' e x p e r i e n c e s through an i n t e r v i e w p r o c e s s w i t h the r e s u l t a n t data b e i n g r i c h i n depth and d e t a i l . A q u a l i t a t i v e grounded t h e o r y approach lends i t s f l e x i b i l i t y and c r e a t i v i t y t o t h i s endeavour. Q u a l i t a t i v e A n a l y s i s Methodology As an adjunct t o the q u a n t i t a t i v e a n a l y s i s which i s one measurement i n time, the q u a l i t a t i v e approach sought to i n c o r p o r a t e a l l s u b j e c t s and responses t o the Cameron and B r i n g s Q u e s t i o n n a i r e , t o e v o l v e an a n a l y s i s t h a t would a s s i s t i n understanding bereavement r e s o l u t i o n as a p r o c e s s over time. Sample S e l e c t i o n The samples were d e r i v e d t o accommodate the q u a n t i t a t i v e a n a l y s i s of the data as d i s c u s s e d i n Chapter 3. Responses from a l l f i f t e e n s u b j e c t s are i n c l u d e d i n the q u a l i t a t i v e a n a l y s i s . To f a c i l i t a t e a grounded theory approach only, a l l s u b j e c t s 90 c o u l d have been sampled through p u r p o s i v e sampling f o r s p e c i f i c c h a r a c t e r i s t i c s — f o r example, males over seventy years of age, daughters i n t h e i r t w e n t i e s , i n d i v i d u a l s m a r r i e d a c e r t a i n number of years, s i n g l e p a r e n t s of both sexes w i t h dependent c h i l d r e n — depending upon the i n v e s t i g a t i o n ( i e . g r i e f r e s o l u t i o n of e l d e r l y males). T h i s form of sampling i s h i g h l y s u i t e d t o grounded t h e o r y as i t i s f l e x i b l e , maximizes p r o s p e c t s f o r u s e f u l comparison, and can be u t i l i z e d as data c o l l e c t i o n proceed and v a r i o u s i n d i c a t o r s become v i s i b l e . P a t t o n suggests t h a t " n a t u r a l i s t i c i n q u i r y becomes a mixed s t r a t e g y as the i n v e s t i g a t o r moves back and f o r t h between ... i n d u c t i v e , open-ended and phenomenological encounters w i t h r e s e a r c h s e t t i n g s t o more h y p o t h e t i c a l d e d u c t i v e attempts t o v e r i f y "hypotheses" or s o l i d i f y i d e a s " (Patton, 1989, p.110). T h i s i s congruent w i t h G l a s e r ' s t h e o r e t i c a l sampling from which e x t e n s i v e comparisons are made i n order t o e l i c i t codes, emergent p a t t e r n s and i n d i c a t o r s , and t o c l a r i f y the " t h e o r e t i c a l p o s s i b i l i t i e s and p r o b a b i l i t i e s " (Glaser, 1978, p.42). T h i s does not r e l y upon c o m p a r a b i l i t y of groups but r a t h e r upon v a r i a b l e s which are c o n s i d e r e d v a l u a b l e to each group. The sampling e v o l v e s w i t h on-going a n a l y s i s 91 s u g g e s t i n g the d i r e c t i o n f o r f u r t h e r i n q u i r y through which to s u b s t a n t i a t e an emerging theory ( I b i d ) . Data C o l l e c t i o n Procedures Data d e r i v e d from the i n t e r v i e w s were i n c o r p o r a t e d i n t o the q u a l i t a t i v e a n a l y s i s . As the i n t e r v i e w focus had been on p r o v i d i n g a t h e r a p e u t i c m i l i e u as w e l l as t h a t of i n f o r m a t i o n g a t h e r i n g , the responses were r i c h i n d i v e r s i t y and depth. Coding Paradigm Responses to the q u e s t i o n n a i r e were f i r s t a s s e s s e d by c o n s i d e r i n g the seven g e n e r a l areas covered by the i n q u i r y : c h a r a c t e r i s t i c s of the bereaved i n d i v i d u a l , f a m i l y r e l a t i o n s h i p s , s o c i a l support, f i n a n c i a l concerns, p e r s o n a l h e a l t h i s s u e s , a n t i c i p a t o r y bereavement, and r e l i g i o s i t y , r i t u a l and the bereavement a n n i v e r s a r y ; and broken down i n t o themes. The comments i n c l u d e d w i t h i n the themes were s p e c i f i c a l l y s c r u t i n i z e d f o r : c o n d i t i o n s t h a t may be i n p l a c e ("He d i e d because of the treatments", "His job k i l l e d him -- the s t r e s s caused him to become i l l " ) ; i n t e r a c t i o n s between or among a c t o r s ("I'm p l e a s e d t o see my daughter t u r n i n g the corner", "I f e e l I don't f i t anywhere", " I t h e l p e d me to f e e l I was needed"); 92 s t r a t e g i e s or t a c t i c s ("I p a r t i c i p a t e d i n the Bereavement Group", "I sought p e r s o n a l c o u n s e l l i n g " , "I saw a p s y c h i c " , "I meditate and use c r e a t i v e v i s u a l i z a t i o n " , "I keep i n f i g h t i n g t r i m " ) ; and, consequences ("It made me f e e l needed", " I t ' s h a r d l i v i n g a l o n e ) . These are a l l elements of the coding paradigm i n h e r e n t i n grounded t h e o r y c o d i n g and a n a l y s i s (Strauss, 1987) . " I t f u n c t i o n s as a reminder t o code data f o r r e l e v a n c e t o whatever phenomena are r e f e r e n c e d by a g i v e n c a t e g o r y " ( I b i d , p.25). I n c l u s i o n of the f o u r c r i t e r i a subsumed w i t h i n the c o d i n g paradigm assures the r e s e a r c h e r t h a t the c o d i n g i s v a l i d . While the focus at t h i s l e v e l of i n v e s t i g a t i o n i s the p e r s o n a l experience of the bereaved i n d i v i d u a l s , broader s o c i a l i s s u e s p e r t a i n i n g t o s e r v i c e s and support networks f o r these i n d i v i d u a l s are i n c o r p o r a t e d i n t o the a n a l y s e s of Chapters 5 and 6. The c o d i n g and theme ana l y s e s are p r e s e n t e d under Grounded Theory Approach below. Frame f o r Bereavement A n a l y s i s . The responses were then a b s t r a c t e d u t i l i z i n g a frame which c o n s i s t e d of the Four Tasks of G r i e v i n g as e l u c i d a t e d by Worden (1982) which i n c l u d e : a c c e p t i n g the l o s s , e x p e r i e n c i n g the p a i n of the l o s s , a d j u s t i n g t o l i v i n g w i t h the l o s s , and r e i n v e s t i n g energy i n new a c t i v i t i e s or r e l a t i o n s h i p s ; and are d i s c u s s e d i n g r e a t e r d e t a i l below. Each of the respondents' comments were c o n s i d e r e d i n d i c a t o r s of a l e v e l of g r i e f r e s o l u t i o n and were a s s i g n e d t o the a p p r o p r i a t e Worden Task. These Four Tasks a l s o meet the coding paradigm c r i t e r i a — i n v o l v i n g c o n d i t i o n s , i n t e r a c t i o n s among a c t o r s , s t r a t e g i e s and t a c t i c s , and consequences. The raw d a t a c o n t a i n e d i n the Worden a b s t r a c t i n g are t o be found i n Appendix V. "Time" and " c o g n i t i v e b i a s e s " are o t h e r elements t h a t are i m p l i c i t i n the p e r s o n a l e x p e r i e n c i n g of the g r i e f event and the subsequent bereavement p r o c e s s . These are subsumed w i t h i n the comments t h a t frame the event and the subsequent r e s o l u t i o n . Time as a Study Parameter: R e t r o s p e c t i v e A n a l y s e s The c u r r e n t study was undertaken t h i r t e e n months p o s t -bereavement and l a c k s a b a s e l i n e assessment of f a m i l y dynamics, p o s s i b l e r i s k f a c t o r s , and i n d i v i d u a l r e s o u r c e s and c o p i n g s t r a t e g i e s . I t has been suggested t h a t i n t e r v e n i n g f a c t o r s may d i s t o r t outcome an a l y s e s when cond u c t i n g r e t r o s p e c t i v e s t u d i e s . However, f o r the purpose of a q u a l i t a t i v e a n a l y s i s , these i n t e r v e n i n g f a c t o r s are merely added dimensions t o the a n a l y s i s and w i l l be r e f l e c t e d i n the language as w e l l as the r e s o l u t i o n 94 t r a j e c t o r y . F i g u r e 3: F a c t o r s I n t e r v e n i n g i n the R e p o r t i n g of Events. (Simmon i n Berg and Smith, 1988, p.291). o r i g i n a l d i s t o r t i o n s J i n t e r v e n i n g events { I i J i n t e r v i e w dynamics i • • * . ^ <; . event memory informant 2 i n t e r v i e w e r encoding c u r r e n t memories Simmon ( i n Berg and Smith, 1988) noted t h a t w i t h the passage of time, a warm r e l a t i o n s h i p tended t o "expand" i n meaning, whereas l e s s important r e l a t i o n s h i p s were s u b j e c t t o "shrinkage". Meaning i s r e f l e c t e d i n expressed emotions --t e a r s , l a u g h t e r , apathy — and i s dependent upon the i n t e r v e n i n g f a c t o r s . Encoded memories are i n f l u e n c e d by o r i g i n a l d i s t o r t i o n s of the death event — the image of the deceased, the extent of s u f f e r i n g , the l a s t words spoken, d e n i a l — as w e l l as the p r e c e d i n g i l l n e s s e x p e r i e n c e . The c u r r e n t memories are responses t o i n t e r v e n i n g events — the a c t u a l e xperiences of g r i e v i n g ( i e . l o n e l i n e s s , the ' f i r s t s ' , the extent of r o l e d i s r u p t i o n and f a m i l y 95 congruence). C u r r e n t memories may r e f l e c t s e l e c t i v e f o r g e t t i n g o r avoidance o f circumstances s u r r o u n d i n g the death and the ensuing bereavement process may be enhanced by the s t r a t e g i e s t h a t had been developed w i t h i n the r e l a t i o n s h i p t o cope wi t h the p r e c e d i n g d i s e a s e p r o c e s s and thus c u r r e n t bereavement a m e l i o r a t i o n . A l l are r e f l e c t i o n s of i n t e g r a t i n g and a s s i m i l a t i n g the i n t e r p r e t a t i o n of the event i n the i n d i v i d u a l s ' l i v e s . C o g n i t i v e B i a s e s Bowlby (1985) c a u t i o n s t h a t t h e r e are a l s o c o g n i t i v e b i a s e s t h a t w i l l a f f e c t response t o l o s s , hence w i l l c o l o u r the " s t o r y " of t h a t l o s s e x p e r i e n c e . These c o g n i t i v e b i a s e s i n c l u d e : "how the bereaved construes the p a r t p l a y e d i n the l o s s by the dead person h i m s e l f " (Bowlby, 1985, p.233) — was t h e r e some form o f 'blame' f o r the i n d i v i d u a l not see k i n g medical support e a r l y enough?; had the deceased t r i e d e v e r y t h i n g they c o u l d t o f i g h t the d i s e a s e ? — "We fought the good f i g h t " (Respondent). "how he c o n s t r u e s h i s own p a r t i n the l o s s , and the way the deceased might r e g a r d i t " ( B o w l b y , 1985, p.233) — was enough done, d i d I f a i l i n some way? -- "She kept a s k i n g me t o take her away from a l l t h i s , ...to a s a f e p l a c e somewhere" (Respondent). "what e x p e c t a t i o n s he has o f the way t h a t anyone who might p r o f f e r a s s i s t a n c e would t r e a t him" (Bowlby, 1985, p.233) — w i l l the i n d i v i d u a l f e e l p a t r o n i z e d or p i t i e d ? —"No one's g o i n g t o f e e l s o r r y f o r me; no one's going t o be ab l e t o say 'Poor o l d E.'" (Respondent) "how aware he i s of the c o n s t r u c t i o n s he puts on pas t events and of t h e i r p e r v a s i v e i n f l u e n c e on the e x p e c t a t i o n s he has i n the present"(Bowlby, 1985, p.233) -- "I had an extremely hard c h i l d h o o d and was never l o v e d b e f o r e I knew her, she has been my l i f e [...now she'd gone and I am again unloved and w i l l not be l o v e d again] (Respondent) "the extent t o which whatever c o n s t r u c t i o n s and ex p e c t a t i o n s he may have are open t o new i n f o r m a t i o n and so t o r e v i s i o n , or e l s e are c l o s e d " (Bowlby, 1985, p.233) — "I hadn't a n t i c i p a t e d the p l u s e s o f be i n g s i n g l e " ; "There has been n o t h i n g p o s i t i v e about t h i s p a s t year, i t ' s as hard now as i t was at the b e g i n n i n g [and I can't see i t g e t t i n g any b e t t e r ] " (Respondents). 97 However, i t has been noted by Sutton and Schurman ( i n Berg and Smith, 1988) t h a t r e t r o s p e c t i v e s t u d i e s are most a p p r o p r i a t e when d e a l i n g w i t h "hot" ( e m o t i o n a l l y laden) t o p i c s . T h i s i n v e s t i g a t o r agrees with the above authors, and submits t h a t i n t e r v i e w i n g bereaved i n d i v i d u a l s p r i o r t o the a n n i v e r s a r y date i n any other circumstance than an i n t e r v e n t i o n m i l i e u may be deemed u n e t h i c a l . While c o g n i t i v e b i a s e s may be r e l a t e d t o e i t h e r o r i g i n a l d i s t o r t i o n s or i n t e r v e n i n g events t h a t have e f f e c t e d the framing of the event, the most s a l i e n t f e a t u r e i s the respondent's i n t e r p r e t a t i o n of the e x p e r i e n c e . The respondent's i n t e r p r e t a t i o n i s h i s / h e r r e a l i t y from which meaning i s d e r i v e d , hence i s a v a l i d o b s e r v a t i o n . Grounded Theory Approach The data were an a l y z e d u t i l i z i n g the r e s e a r c h e r ' s knowledge base and g e n e r a l u n d e r s t a n d i n g of the v a r i a b l e s i n v o l v e d i n the g r i e v i n g p r o c e s s . T h i s a l l o w e d a s e n s i t i v i t y t o i n f o r m a t i o n as i t e v o l v e d from the data t h a t c o u l d be c o n c e p t u a l i z e d u t i l i z i n g the grounded th e o r y approach e l u c i d a t e d by G l a s e r and S t r a u s s (1967), G l a s e r (1978), Strauss (1987) and i l l u s t r a t e d by the t e c h n i q u e s of M i l e s and Huberman (1984). U n d e r l y i n g the r e l a t i o n s h i p 98 between data and t h e o r y i s "a s e t of e m p i r i c a l i n d i c a t o r s w i t h i n the data" which c o n c e p t u a l i z e s r e l a t i o n s h i p s between c a t e g o r i e s and t h e i r p r o p e r t i e s (Glaser, 1978, p.55). In t h i s way, the r i c h n e s s and d i v e r s i t y of the respondents' e x p e r i e n c e s and unique e x p r e s s i o n s of t h e i r mourning pro c e s s e s were c a p i t a l i z e d upon through an "emergent f i t between the data and a p r e - e x i s t e n t c a t e g o r y " as w e l l as an on-going process of " r e f i t t i n g " the c a t e g o r i e s t o the data as they emerged ( I b i d , p . 4 ) . T h i s p r o c e s s i n i t s e l f l e n t v i g o u r to the e x e r c i s e . /Analysis and o r g a n i z a t i o n o c c u r r e d through r i g o r o u s reworking of the data u s i n g g u i d e l i n e s s e t out by G l a s e r (1978) and S t r a u s s (1987) . Q u a l i t a t i v e a n a l y s i s t e c h n i q u e s as discussed, by M i l e s and Huberman (1984) were a l s o i n c o r p o r a t e d . Open coding was used t o i d e n t i f y t o p i c s , i s s u e s and emergent themes. The c o d i n g paradigm of c o n d i t i o n s , i n t e r a c t i o n s , s t r a t e g i e s and consequences were i n c o r p o r a t e d i n t o t h i s a n a l y s i s t o m a i n t a i n focus and to e v o lve themes ( d i s c u s s e d below). Respondents' comments were f i r s t scanned, then grouped and analyzed word by word and/or l i n e by l i n e t o e l i c i t commonalities or r e l a t i o n s h i p s between these themes t h a t may r e f l e c t a s p e c i f i c s u b j e c t or concept g r o u p i n g . By r e p e a t i n g t h i s p r o c e s s , t h r e e major c a t e g o r i e s were i d e n t i f i e d through c l u s t e r i n g of the emergent bereavement themes — p r o c e s s , p l a c e , person. (Gl a s e r , 1978; S t r a u s s , 1987) A x i a l c o d i n g i s a f u r t h e r a n a l y s i s of each major c a t e g o r y t o e l u c i d a t e i n h e r e n t dimensions and c h a r a c t e r i s t i c s ( d i s c u s s e d below). S u b c a t e g o r i e s were e v o l v e d and t e n t a t i v e r e l a t i o n s h i p s were h y p o t h e s i z e d by the r e s e a r c h e r . A x i a l codes r e l a t i n g t o the open codes of p r o c e s s , p l a c e and person i n c l u d e stage/phase, t r a n s i t i o n , r i t u a l , t r a d i t i o n , c u l t u r e , r o l e language and e x p e r i e n c e . A l l these open and r e l a t e d a x i a l codes e v o l v e d from the data and r e l a t e d i r e c t l y t o the i n d i v i d u a l bereavement experience, the s t r u c t u r e s w i t h i n which the i n d i v i d u a l s are g r i e v i n g , and were r e f l e c t e d both i n t h e i r responses t o the q u e s t i o n n a i r e and the s t r u c t u r a l parameters of the study i t s e l f . Together, w i t h the open codes, the a x i a l codes form the " c l u s t e r s of a n a l y s i s " t h a t are r e l a t e d t o the c o r e c a t e g o r i e s (Strauss, 1987, p.70). Core c a t e g o r i e s were the c e n t r a l themes i n c o r p o r a t i n g 100 the a n a l y t i c c l u s t e r s t h a t c o n c e p t u a l l y bound them t o g e t h e r . The two core c a t e g o r i e s "meaning" and "time" were found t o be h i g h l y i n t e g r a t i v e , and are i n t e g r a l t o d e v e l o p i n g t h e o r e t i c a l codes which " c o n c e p t u a l i z e how the s u b s t a n t i v e codes may r e l a t e d t o each o t h e r as hypotheses t o be i n t e g r a t e d i n t o t h e o r y " (Glaser, 1978, p.72) . "Meaning" i s i m p l i c i t i n the language, i n emotional e x p r e s s i o n (anger, f e a r , sadness, g u i l t ) , i n c u l t u r a l and t r a d i t i o n a l e x p r e s s i o n ( r i t u a l , f u n e r a l s , r o l e s ) , i n e x p e r i e n t i a l c o n n o t a t i o n (time, p o s i t i v e / n e g a t i v e , growth) as w e l l as i n d i c a t i v e of the process i t s e l f . "Time" has been found t o be a c r i t i c a l component of the g r i e v i n g p r o c e s s . I t has become almost a x i o m a t i c t h a t "time h e a l s " and was r e f l e c t e d i n the e x p e r i e n t i a l framing o f the past year by the respondents. Time i s a component p a r t of t h i s study having been a d m i n i s t e r e d t h i r t e e n months post-bereavement. Bereaved i n d i v i d u a l s are embedded w i t h i n s o c i a l s t r u c t u r e s t h a t are c o n s t a n t l y changing imposing d i f f e r e n t i a l s t r e s s e s . "Time" i s deeply i n t e r t w i n e d w i t h the e x p r e s s i o n s of meaning, yet i s i t s own e n t i t y w i t h i t s own dimensions. "Time" i s the second core c a t e g o r y . 101 Thus, how an i n d i v i d u a l p e r c e i v e s the meaning of the l o s s i s i n t e g r a l t o the t a s k r e s o l u t i o n s . How the i n d i v i d u a l has i n t e r p r e t e d the meaning and dimension of time i s i n t e g r a l t o the s t r u c t u r i n g o f each i n d i v i d u a l ' s g r i e v i n g p r o c e s s . By c o n s i d e r i n g both c a t e g o r i e s t o g e t h e r , i t i s then p o s s i b l e t o f u r t h e r e x p l i c a t e outcome and the e f f i c a c y of bereavement i n t e r v e n t i o n . Memo w r i t i n g was used throughout the p r o c e s s as a separate a c t i v i t y which h e l p e d t o guide the e v o l u t i o n of the core c a t e g o r i e s . The 'memos' were w r i t t e n whenever 'something' o c c u r r e d t o the r e s e a r c h e r t h a t i n v o l v e d i n s i g h t s , q u e s t i o n s or hypotheses. I n t e g r a t i v e Diagrams and Charts were used t o c o n c e p t u a l i z e r e l a t i o n s h i p s / i n t e r r e l a t i o n s h i p s , t o model t h e o r e t i c a l codes and as a n a l y t i c a l t o o l s from which o b s e r v a t i o n s c o u l d be made. Report and T h e s i s W r i t i n g i s the l a s t stage o f the r e s e a r c h p r o c e s s . A summary of the f i n d i n g s i s pr e s e n t e d and i s i l l u s t r a t e d throughout w i t h a n e c d o t a l support from respondents' i n f o r m a t i o n . C o n c l u s i o n s i n the form of hypotheses and s u b s t a n t i v e t h e o r y p r o v i d e the b a s i s f o r a s c e r t a i n i n g the e f f i c a c y of bereavement i n t e r v e n t i o n , as w e l l as r e l a t i n g f ormal and i n f o r m a l support systems t o bereavement outcome. Themes F o l l o w i n g are examples of themes t h a t e v o l v e d from respondents' comments. G r i e f : G r i e f i s b e i n g c a s t out i n t o the middle of the ocean without a l i f e j a c k e t . G r i e f i s a deep abyss out of which you must c r a w l . F i n a l i t y : He's not coming back, t h i s i s the way t h i n g s have t o be. Things and p l a c e s get b u i l t i n t o your l i f e . There's no one t o share with, no companionship. D e n i a l : We d i d n ' t want t o know. She was very f r i g h t e n e d , would not t a l k about i t , d i d n ' t c o n s i d e r she would d i e u n t i l the l a s t week. We d i d n ' t t a l k about i t , and I s t i l l don't. I can't remember. He was a p o s i t i v e t h i n k e r , d e n i e d t h a t he would d i e . S o c i a l : Men seem t o f i n d someone e l s e very q u i c k l y . Men seem to need t o be taken care o f . D a t i n g i s r e h e a r s i n g f o r the time when I w i l l want to remarry. My f r i e n d s don't want t o hear the r e a l t h i n g s . We used to eat out a l o t — i t ' s hard t o do t h a t by myself. An acquaintance came up t o me and s a i d "Good t o 103 see you're g e t t i n g over i t " s i x weeks a f t e r the death. P h i l o s o p h y : He's not i n the grave, he's everywhere. There's more t o l i f e than worrying about d y i n g . He w i l l always be p a r t of my l i f e . The ocean i s a c o n n e c t i o n with l i f e r a t h e r than w i t h p l a c e . I t f r e e s you t o be anywhere. The ocean i s always t h e r e . I took time out f o r f o r t y days of mourning. I engage i n m e d i t a t i o n and c r e a t i v e v i s u a l i z a t i o n . Growth: I have more freedom now. There are some b e n e f i t s t o b e i n g alone. My son t r i e s t o boss me but I can handle i t . I've never gardened b e f o r e , now I l o v e i t . I have new f r i e n d s , my_ f r i e n d s , and I'm d o i n g t h i n g s I've never done b e f o r e . R i t u a l : We went bowling on the a n n i v e r s a r y . I t was g r e a t fun — w e ' l l do i t again every year. We eat d i n n e r t o g e t h e r every day. I t ' s important t o r e i n f o r c e t h a t time of coming t o g e t h e r . I'm c o m p i l i n g a book t h a t w i l l p r o v i d e the c h i l d r e n w i t h a sense of who t h a t person was. We've d e d i c a t e d a bench i n h i s memory. We p l a n t e d h i s f a v o u r i t e shrub on the a n n i v e r s a r y . We d i d n ' t have a f u n e r a l -- i t was nobody e l s e ' s damn b u s i n e s s . 104 Anger: She wasn't " r i g h t " f o r two years and when she f i n a l l y d i d see the doc t o r s i t was too l a t e . Why d i d she have t o d i e , she's the o n l y l o v e I've ever had i n my l i f e . I t ' s not f a i r . The d o c t o r was b r u t a l when he t o l d us — my husband f a i n t e d . I t was t e r r i b l e . We went a l l the way a c r o s s town and the h o s p i t a l t u r n e d us away and we had to go home. He p r o c r a s t i n a t e d and d i d n ' t see the d o c t o r u n t i l too l a t e . The themes were analyzed a c c o r d i n g t o the c o d i n g paradigm t o ensure t h a t they were c o n c e p t u a l l y complete. Examples are g i v e n below i n Table 8. 105 Table 8: Examples of Theme Assessment u t i l i z i n g the Coding Paradigm Components of C o n d i t i o n , I n t e r a c t i o n , S t r a t e g i e s and Consequences. THEME C o n d i t i o n I n t e r a c t i o n S t r a t e g i e s Consequences G r i e f no c o n t r o l - c a s t out alone -without sink/swim -ocean no guides -middle d e s p a i r -deep abyss s e l f - d r i v e n -you must s t a r t again -crawl out slow process -out o f whict F i n a l i t y i t s over he's gone -not coming back accept -have t o no c h o i c e - t h i s way h a b i t s memories - t h i n g s and p l a c e s i n c o r p o r a t e d l i t t l e change - b u i l t i n t o your l i f e R i t u a l r o u t i n e -every day f a m i l y - t o g e t h e r event -eat t r a d i t i o n - d i n n e r honouring - a n n i v e r s a r y t o g e t h e r -we t a n g i b l e - p l a n t e d memorial -shrub I t was found t h a t t h e r e were common r e l a t i o n s h i p s or concepts f o r some of the themes, thus r e s u l t i n g i n grouping, or c l u s t e r i n g them t o g e t h e r . g r i e f - f i n a l i t y - anger - d e n i a l (Process) r i t u a l - p h i l o s o p h y - t r a d i t i o n (Place) growth - p h i l o s o p h y - s o c i a l - r o l e (Person) 106 These c l u s t e r s were seen t o r e f l e c t v a r i o u s a s p e c t s of the g r i e v i n g p r o c e s s t h a t the i n d i v i d u a l i n c o r p o r a t e d i n t o r e s o l u t i o n and r e o r g a n i z a t i o n . These became the open codes of "Process, P l a c e , and Person". A x i a l c o d i n g around these open codes then took p l a c e i n c o r p o r a t i n g the themes, d e f i n i n g them s t r i n g e n t l y , and e v o l v i n g l i n k a g e s between them: Process When c o n s i d e r i n g "process", the frame o f " t r a n s i t i o n " encompasses the changes which may denote stages or phases of bereavement r e s o l u t i o n which occur over time. As i n Obershaw's system (See Chapter 2, F i g u r e s 1 and 2 ), t h i s p r o c e s s may be i d e n t i f i e d by c e r t a i n behaviours or r e a c t i o n s , i n d i c a t i n g r e i n t e g r a t i o n and/or r e o r g a n i z a t i o n . P l a c e " P l a c e " i n c o r p o r a t e s the r i c h d i v e r s i t y of r i t u a l , t r a d i t i o n and c u l t u r e which denote rootedness i n h i s t o r y . L i n k e d with " p r o c e s s " by r i t u a l , new t r a d i t i o n s are c r e a t e d t h a t are c o n s o l i d a t e d i n t o the f a m i l y c u l t u r e . Person As the "person" proceeds through the bereavement p r o c e s s , r o l e r e d e f i n i t i o n i s enhanced or l i m i t e d by e x p e r i e n c e of support and understanding, and i s expressed i n the language of 107 r e f o r m u l a t i o n which r e f l e c t s "the change from focus on l i m i t s and p r o b a b i l i t i e s t o p o t e n t i a l and the p o s s i b l e " (Schneider, 1984, p.225). F i g u r e 4 Dimensional A n a l y s i s of "Meaning" i n the Bereavement Process PROCESS stage/phase t r a n s i t i o n BEREAVEMENT I MEANING I METAPHOR I PLACE t r a d i t i o n (TIME) PERSON r o l e language r i t u a l c u l t u r e e x p e r i e n c e The suggested r e l a t i o n s h i p s i n F i g u r e 4 are not mutually e x c l u s i v e but attempt t o c o n c e p t u a l i z e the m u l t i p l e l a y e r s of o r g a n i z a t i o n t h a t an i n d i v i d u a l b r i n g s to an experi e n c e , and the manner i n which meaning i s expressed through metaphor. Process, p l a c e and person are the open codes through which meaning i s a s c r i b e d t o the p r o c e s s of bereavement. Metaphors best i l l u s t r a t e the c o n n o t a t i o n s i n h e r e n t i n each of these meaning 108 components. Worden's Four Tasks of G r i e v i n g I n c o r p o r a t e d i n t o the a n a l y s i s were the Tasks of G r i e v i n g as developed by W i l l i a m Worden (1982). These Tasks were u t i l i z e d as assessment t o o l s and were a p p l i e d t o dimensions of the core c a t e g o r i e s t o c o n c e p t u a l i z e bereavement outcome from which t o draw c e r t a i n c o n c l u s i o n s . W i l l i a m Worden o u t l i n e d a p r o c e s s of g r i e v i n g t h a t encompassed completion of c e r t a i n " t a s k s " , or a c t i o n s t h a t can be taken t o a m e l i o r a t e the g r i e f p r o c e s s . These t a s k s suggest a p e r c e p t i o n of c o n t r o l by the g r i e v i n g i n d i v i d u a l which can be seen as 'movement' through the p r o c e s s — the answer t o " w i l l i t ever end?" — as w e l l as t u r n i n g p o i n t s , or c r i t i c a l j u n c t u r e s . B r i e f l y the t a s k s a r e : Task I — To accept the r e a l i t y of the l o s s . Behaviours t h a t can circumvent a c c e p t i n g the l o s s i n c l u d e : d e n i a l of the l o s s through m i n i m i z i n g the meaning of the l o s s , s e l e c t i v e f o r g e t t i n g , or by denying the i r r e v e r s i b i l i t y of death or d i s t o r t i n g the l o s s through c o n t i n u i n g on as though the i n d i v i d u a l i s 109 a l i v e . Task II — To e x p e r i e n c e the p a i n of g r i e f . Working through the p a i n i s important or i t w i l l m a nifest i n some oth e r way — g e n e r a l l y through somatic i l l n e s s . U n f o r t u n a t e l y t h e r e i s a s o c i a l c o n s p i r a c y f o r i n d i v i d u a l s t o "get over i t " thus r e i n f o r c i n g s t o i c i s m . Negation of the p a i n r e s u l t s i n c u t t i n g o f f f e e l i n g s , a v o i d i n g p a i n f u l thoughts and i d e a l i z i n g the deceased. Task I I I — To a d j u s t t o the environment without the deceased. T h i s t a s k i s h i g h l y dependent upon the r e l a t i o n s h i p w i t h the deceased i n d i v i d u a l and the r o l e s a s c r i b e d t o t h a t i n d i v i d u a l . The work encompassed i n t h i s t a s k i s the c r i t i c a l j u n c t u r e f o r the g r i e v i n g i n d i v i d u a l . Withdrawing i n t o h e l p l e s s n e s s i s an example of not a d a p t i n g t o the l o s s . Task IV — To withdraw emotional energy from the deceased and t o r e i n v e s t i t i n another r e l a t i o n s h i p and/or a c t i v i t i e s . T h i s i s not t o be understood as f o r g e t t i n g or 110 d i s h o n o u r i n g the deceased i n some way, but i n d i c a t e s an outward o r i e n t a t i o n , l o o k i n g beyond 'what was' and 'what i s ' t o 'what c o u l d be'. Incompletion of t h i s task i s seen as h o l d i n g on t o the p a s t attachment. Summary of Methodology The data d e r i v e d from the f i f t e e n respondents was i n c o r p o r a t e d i n t o a r i g o r o u s p r o c e s s of coding, memoing, and r e c o d i n g . Core c a t e g o r i e s were ev o l v e d from the a x i a l and open c o d i n g . The data was then a n a l y z e d by a p p l y i n g Worden's Four Tasks of G r i e v i n g i n order t o assess g r i e f r e s o l u t i o n . Respondents' comments were r e l a t e d t o the t a s k d e f i n i t i o n s and i n d i c a t e d where i n d i v i d u a l s may have not addressed c e r t a i n i s s u e s , thus c r e a t i n g cause f o r concern about u n r e s o l v e d g r i e f . D i f f e r e n c e s were r e l a t e d t o bereavement f o l l o w - u p t o a s c e r t a i n e f f i c a c y of the i n t e r v e n t i o n . F i n d i n g s of the Q u a l i t a t i v e A n a l y s i s The r i c h n e s s and d i v e r s i t y of the respondents' experiences, t h e i r unique framing of the mourning p r o c e s s was c a p i t a l i z e d upon. I t became e v i d e n t t h a t t h e i r words I l l r e f l e c t e d both s u r f a c e e x p r e s s i o n of the bereavement p e r i o d and m u l t i p l e l a y e r s of meaning t h a t r e l a t e d t o the essence of the bereavement process — t o t h e i r i d e n t i t y , t o t h e i r sense of b e l o n g i n g , and t o t h e i r e x p r e s s i o n s of change and p o s s i b l e growth. These e x p r e s s i o n s i n t u r n r e l a t e d t o a deeper e x p l i c a t i o n of needs t h a t were a s s o c i a t e d w i t h broader concepts of "pathology p r e v e n t i o n versus the enhancement of w e l l - b e i n g , and an i n d i v i d u a l focus versus a s o c i a l environmental f o c u s " (Zautra and Sandler, 1983, p.36). T h i s s e c t i o n w i l l be p r i m a r i l y devoted t o c l a r i f y i n g the p e r s o n a l c o n n o t a t i o n s of meaning as they are e v a l u a t e d u t i l i z i n g Worden's framework as d i s c u s s e d above. The broader c o n c e p t u a l i m p l i c a t i o n s w i l l be e x p l o r e d e x t e n s i v e l y i n the next chapter. For the g r i e v i n g i n d i v i d u a l the r e l a t i o n s h i p o f time and meaning are t r a n s l a t e d i n t o metaphors which connote process, p l a c e and person as w e l l as p s y c h o l o g i c a l and s o c i o l o g i c a l s t r u c t u r e s with which the bereaved must contend. Metaphor as an E x p r e s s i o n of Meaning When framing a new experience, meaning i s l o s t when 112 termed as something o l d or f a m i l i a r . To enable understanding, analogy may well supercede precise statements. This analogous expression i s termed "metaphor" and incorporates i n t e r a c t i o n which has implications for selecting, emphasizing and organizing r e l a t i o n s h i p s . The i n t e r a c t i o n of metaphors can be understood i n a systemic delineation of meta-messages: each message having both primary and secondary in t e r p r e t a t i o n s . The primary message i s the observable language description, while the secondary message i s r e f l e c t i v e of the referent condition, empirical and l i n g u i s t i c ideas, and associated ideas. Weyant (1979) considers metaphors as bridges between cognition and perception having both i n t e r n a l and external referents and i n t e r s u b j e c t i v i t y (Hanen, Osier and Weyant, 1979). While the concept of 'time' cannot be separated from metaphor, 'meaning' and 'metaphor' are of primary concern i n t h i s part of the discussion with the 'time' dimension to be addressed below. Relationship of Metaphor to Worden's Tasks Metaphors of Process Process metaphors are highly 113 emotive and i l l u s t r a t e the t r a n s i t i o n from despair to resolution. These are found throughout the l i t e r a t u r e and i n the self-expressions of the study respondents. An o v e r a l l t r a n s i t i o n metaphor would be " I t [grief] i s a mental wound, which heals slowly and leaves scars" (Marris, p.27). Examples of early g r i e f metaphors connote external control, ostracism and d i s i n t e g r a t i o n : "I t f e e l s l i k e I have been cast into the middle of the ocean without a l i f e jacket" (Respondent); " I t i s a deep abyss out of which you must crawl" (Respondent); "I move through l i f e as i f I am a robot, programmed by some one or some thing" (Vachon, 1982, p.77); "A door slammed i n your face and a sound of b o l t i n g and double b o l t i n g on the i nside" (Lewis, 1961, p.9). Metaphors of l a t e r , or mid, t r a n s i t i o n show tentative resolution: "Things seem to be going f a i r l y well - but I'm waiting f o r the other shoe to drop" (Respondent). Next, the aspect of "time" i s used metaphorically as a turning point, as an awareness (cognition) of duration and moving on. "I used to smell the clothes. Then I found i n December the scent was gone — i t was time to l e t go" (Respondent). S t i l l l a t e r , a future ori e n t a t i o n i s noted: "The ashes were scattered i n the ocean. This gives the children a 114 c o n n e c t i o n w i t h l i f e r a t h e r t h a n p l a c e — f r e e i n g them t o move on i n t h e i r l i v e s — t h e ocean i s always t h e r e " (Respondent). A s i m p l e d e l i n e a t i o n o f P r o c e s s Metaphors w i t h Worden's f o u r t a s k s o f g r i e v i n g , r e l a t e d t o bereavement group p a r t i c i p a t i o n , f o l l o w s . Tasks I I I and IV have been combined as Task I I I i s seen by Worden as t h e c r i t i c a l j u n c t u r e i n t h e g r i e v i n g p r o c e s s . Task IV i s t h e h a r d e s t t a s k t o c o m p l e t e , and t h e r e s p o n d e n t s ' comments i n d i c a t e d t h a t some were v e n t u r i n g i n t o r e c o n c i l i n g t h i s t a s k , w h i l e many were s t i l l w o r k i n g t h r o u g h Task I I I . I t s h o u l d be remembered t h a t t h e t a s k s a r e not n e c e s s a r i l y s t e p - w i s e and i n many i n s t a n c e s o v e r l a p each o t h e r . T h e r e f o r e , i t i s p o s s i b l e t o i n c o r p o r a t e some o f Tasks I I I and IV w h i l e s t i l l w o r k i n g on i s s u e s r e l a t e d t o Task I I . However when a v o i d a n c e i s i n v o l v e d i n Task I I , i t i s not n e c e s s a r i l y h e a l t h y t o engage i n r e m a r r i a g e , s e l l i n g - o u t , t r a v e l l i n g e x t e n s i v e l y u n t i l t h e p a i n o f t h e l o s s has been a d d r e s s e d . 115 Table 9: Matrix of Process Metaphors with Worden's Four Tasks of Grieving r e l a t e d to Bereavement Group P a r t i c i p a t i o n . Group Task I Task II Task III/IV Accepting the Experiencing the Adjusting to loss Loss Pain Investing energy outward Gut wrenching Things don't b u i l d Time to l e t go Incredible pain b u i l d up "Uncoupled" T e r r i b l e numbness Scent gone Free to move on Ambushed Always there Memory hard Connection with YES "Security sweater" l i f e Alone and scared It's easier now Seven cracked teeth I have more freedom Stress overload I've made i t Rehearsing Bea u t i f u l world Cast-out Waiting L i f e goes on No l i f e jacket Good days/bad days Pa i n f u l at f i r s t Deep abyss No s e l f - p i t y Nothing p o s i t i v e NO Crawl out Harder now Unfinished business Door slammed I miss the c a l l s No longer a couple Can't remember It i s n ' t time yet Turned corner Played the game I t ' l l be another Po s i t i v e s to being He i s n ' t dead year single Abandoned Analysis of Table 9 "Yes Group" - Task I — tend to be physical referents - Task II -- shows engagement i n the process of experiencing the pain - Task III/IV — p o s i t i v e forward focus noted. 116 As t h e r e are few p s y c h o l o g i c a l l y p a i n f u l r e f e r e n t s noted i n t h i s groups' comments, i t suggests t h a t the bereavement i n t e r v e n t i o n promoted s e l f - e x p r e s s i o n of the p a i n f u l e x p e r i e n c e and e f f o r t s toward r e s o l u t i o n . "No Group" - Task I — h i g h l y emotive, p s y c h o l o g i c a l l y o r i e n t e d statements w i t h m u l t i p l e l a y e r s of meaning observed. - Task II — l i t t l e p r o c e s s engagement i n d i c a t e d ; t h e r e seems t o be an avoidance of the p a i n so w e l l e l u c i d a t e d i n Task I. - Task I I I / I V — The p o s i t i v e engagement noted a p p l i e s t o two i n d i v i d u a l s who had h i g h g r i e f r e s o l u t i o n s c o r e s i n the Cameron a n a l y s i s (Chapter 3, p.19). Others e i t h e r d i d not have remarks t h a t f e l l i n t o Task I I I c a t e g o r y or had n e g a t i v e c o n n o t a t i o n . The l a c k of engagement i n Task I I i s remarkable. T h i s i s i l l u s t r a t e d by one i n d i v i d u a l who had the h i g h e s t G r i e f Scores and lowest Adjustment Scores moving i n t o the t a s k s i n Task IV w hile s t i l l e x h i b i t i n g 117 profound g r i e f r e a c t i o n s and a v o i d i n g Task II engagement. There was ambivalence noted i n both groups w i t h r e g a r d t o b e i n g "uncoupled" w h i l e f i n d i n g b e n e f i t s t o b e i n g s i n g l e . T h i s i s a n a t u r a l occurrence as the i n d i v i d u a l s were not " s i n g l e d " by c h o i c e , but are f i n d i n g s t r e n g t h s and s e l f -e x p r e s s i o n t h a t are p o s i t i v e l y r e i n f o r c i n g . Metaphors of P l a c e Lack of f u n e r a l and b u r i a l r i t u a l were remarked upon i n both the P o p u l a t i o n C h a r a c t e r i s t i c s above and w i l l be expanded upon i n Chapter 5. These r i t u a l s are s i g n i f i c a n t r e i n f o r c e r s of s o c i a l l y a s c r i b e d v a l u e s and supports w i t h i n our s o c i e t y , as w e l l as w i t h i n some p e r s o n a l meaning s t r u c t u r e s . T h i s d i s c u s s i o n w i l l focus on a s p e c t s of our l i v e s t h a t may not be p e r c e i v e d as r i t u a l i s t i c but have e x t e n s i v e meaning t o us. R i t u a l i s a f e r t i l e domain of metaphor. I t i s u b i q u i t o u s i n our d a i l y l i v e s — where one s i t s at the t a b l e , who c a r v e s the turkey, the "Saturday" r o u t i n e — and lends i t s e l f t o drawing upon f a m i l y s t r e n g t h s and r e s o u r c e s t o f a c i l i t a t e g r i e v i n g , as w e l l as c r e a t i v e l y f o r m u l a t i n g new t r a d i t i o n s f o r the f a m i l y c o n f i g u r a t i o n . 118 R i t u a l s can be accessed f o r t h e r a p e u t i c i n t e r v e n t i o n as they n a t u r a l l y r e i n f o r c e membership, h e a l i n g , i d e n t i t y , b e l i e f e x p r e s s i o n , n e g o t i a t i o n and c e l e b r a t i o n w i t h i n a f a m i l y u n i t . " R i t u a l i s p r o b a b l y the most potent s o c i a l i z a t i o n mechanism a v a i l a b l e t o k i n and other groupings f o r p r e p a r i n g i n d i v i d u a l members t o understand the group's meanings, c a r r y on i t s t r a d i t i o n s and perform those s o c i a l r o l e s c o n s i d e r e d e s s e n t i a l t o i t s c o n t i n u a t i o n " (Imber-Black, Roberts and Whiting, 1988, p.333). By engaging i n r i t u a l s the f a m i l y can r e d e f i n e the frame f o r a p a r t i c u l a r event. For example, the a n n i v e r s a r y date of the death can be a very d i f f i c u l t time f o r the f a m i l y . One respondent spoke of how the s u g g e s t i o n of "bowling" from an e l e v e n year o l d grandson broke the sadness and t e n s i o n a s s o c i a t e d with a day of remembrance. I t was deemed so s u c c e s s f u l t h a t " w e ' l l do i t a g a i n each year — h i s g r a n d f a t h e r would have enjoyed knowing t h a t we're t o g e t h e r i n a happy s h a r i n g way r a t h e r than sad". T h i s i n t u r n makes p l a n n i n g the r i t u a l as important as the event i t s e l f . R i t u a l does not have t o be r e s e r v e d f o r d i f f i c u l t s p e c i a l o c c a s i o n s . The symbolism i n h e r e n t 119 i n r i t u a l a l s o has f u n c t i o n a l purpose i n d a i l y l i f e r o u t i n e s . As a p a r t of everyday f a m i l y l i f e , r i t u a l frames i n t e r a c t i o n a l h a b i t s , maintenance procedures and r o l e / i d e n t i t y d e f i n i t i o n — i t prepares us t o meet each day, makes l i f e more manageable, c o o r d i n a t e s s c h e d u l e s . "We make a p o i n t of having d i n n e r t o g e t h e r everyday — I do the c o o k i n g and we a l l t i d y up a f t e r — i t ' s important t o have the time t o g e t h e r " (Respondent). C r e a t i v e g r i e v i n g can i n c o r p o r a t e new r i t u a l s thus c r e a t i n g new t r a d i t i o n s — f o r example, what do you do w i t h the 'empty c h a i r ' ? "I bought a round t a b l e " ; "I sat i n the c h a i r " (Respondents). New r o l e s , i d e n t i t i e s and ways of e x p e r i e n c i n g the new f a m i l y c o n f i g u r a t i o n can a s s i s t w i t h r e i n t e g r a t i o n and r e c o n n e c t i o n of g r i e v i n g i n d i v i d u a l s i n the f a m i l y and i n the community. Decreased r e l i g i o s i t y -- not t o be confused w i t h s p i r i t u a l i t y — has l e d t o l o s s of a s s o c i a t i o n between r e l i g i o n and f a m i l y r i t e s and the u l t i m a t e l o s s of bonding between f a m i l y and r e l i g i o u s community/group. However r i t u a l e n t a i l s symbolism t h a t i s not o n l y r e l i g i o u s , i t i s "one of the most e f f i c i e n t ways f o r i d e n t i f i c a t i o n s t o be made. I wear c e r t a i n c l o t h i n g , I say an oath, I s i n g a song, I f a s t on a c e r t a i n day, I wear a 120 c e r t a i n headdress, I address people w i t h a c e r t a i n term, and by doing so I c o n s i d e r myself and am c o n s i d e r e d by others t o belong t o a c e r t a i n group" (Kertze r , 1989, p.24). Table 10 M a t r i x of P l a c e Metaphors w i t h Worden's Four Tasks of G r i e v i n g r e l a t e d t o Bereavement Group P a r t i c i p a t i o n . Group Task I Task I I Task I I I / I V A c c e p t i n g the E x p e r i e n c i n g the A d j u s t i n g t o Loss Loss P a i n I n v e s t i n g energy Outward Presence every- The group was a Things and p l a c e s where get b u i l t i n t o your s a f e refuge l i f e The s m e l l of A book of memories cologne/perfume Dinner t o g e t h e r each S a i l i n g day YES E a t i n g by s e l f Presence everywhere R i t u a l mourning De d i c a t e d a bench p e r i o d P l a n t e d f a v o u r i t e V i s i t i n g grave shrub R e v i s i t i n g Bowling on s p e c i a l p l a c e s a n n i v e r s a r y Cut a d r i f t V i s i t grave Presence every- Lon e l y where No d a i l y p h o n e c a l l NO P l a y e d the game Alone I have no p l a c e No one e l s e ' s b u s i n e s s A n a l y s i s of Table 10: "Yes Group" - Tasks I I , I I I / I V predominate t h i s group with a h i g h 121 p r o p e n s i t y f o r c r e a t i v e g r i e v i n g i n d i c a t e d . Many i n d i v i d u a l s demonstrated ne ways o f doing t h i n g s , i n c o r p o r a t i n g symbolic meaning i n c r e a t i n g new a c t i v i t i e s / r o l e s . "No Group" - Task I, II predominate which f o l l o w s d i r e c t l y from the f i n d i n g i n the Process Metaphor M a t r i x (Table 9). I t se t o d i f f i c u l t t o c r e a t e new r i t u a l / t r a d i t i o n or r o l e s when the death event and a s s o c i a t e d p a i n have not been r e c o n c i l e d . C r e a t i v i t y r e q u i r e s energy. Energy i n some members of t h i s group i s b e i n g consumed i n avoidance s t r a t e g i e s of Task II engagement. Metaphor of Person The g r e a t e s t c h a l l e n g e f a c i n g a bereaved i n d i v i d u a l i s t h a t o f r e d e f i n i t i o n . When a f a m i l y member d i e s , the whole f a m i l y c o n f i g u r a t i o n changes i n accordance with the r o l e the deceased had w i t h i n the f a m i l y , the r e l a t i o n s h i p t o t h a t i n d i v i d u a l and the val u e of t h a t r e l a t i o n s h i p . The death o f a f a t h e r may r e s u l t i n a son t a k i n g on the f a t h e r ' s p r e r o g a t i v e of ' a d v i s i n g ' the mother — "My son t r i e s t o boss me but I can handle i t " (Respondent) — or a daughter — "My daughter i s b o l d e r with me, t r i e s t o t e l l me what t o do, j u s t l i k e her mother" (Respondent). B l a c k would see t h i s as a m e t a p h o r i c a l 122 t r a n s f e r which s h i f t s meaning i n the f a m i l y system of the p r i n c i p l e metaphor of x r o l e ' (Hanen e t a l . 1979) . T h i s i s not r e f l e c t i v e of the primary message of " b o s s i n g " or " t e l l i n g me what t o do", but r a t h e r the secondary message of r o l e r e d e f i n i t i o n and i t s embeddedness w i t h i n f a m i l y systems. The meaning i s a l s o d e f i n e d through e x p e r i e n c e and r e f l e c t e d i n language. The experience of g r i e f i s a l l consuming, i t i s the l o s s o f i d e n t i t y and the l o s s o f a t t a c h m e n t / r e l a t e d n e s s . While d e v a s t a t i n g , i t can a l s o be a growth e x p e r i e n c e — many times r e f l e c t i v e of the q u a l i t y of the r e l a t i o n s h i p w i t h the deceased i n d i v i d u a l . "My husband was my c l o s e s t and b e s t f r i e n d . But a l l of our f r i e n d s were r e a l l y h i s f r i e n d s . Now I have my own f r i e n d s and I'm doing t h i n g s I never d i d b e f o r e " (Respondent). "I have more freedom now — t h e r e are some b e n e f i t s t o b e i n g alone t h a t I hadn't a n t i c i p a t e d " (Respondent). "Our o l d dog d i e d j u s t b e f o r e my husband d i e d . I have a new dog now. She's my. dog" (Respondent). Here the p r i n c i p l e / p r i m a r y meaning of death and b e i n g alone i s r e l a t e d t o the secondary meaning of s e l f - d e t e r m i n a t i o n / e x p r e s s i o n . Language a l s o expresses the q u a l i t y o f the e x p e r i e n c e and the r e f o r m u l a t e d meaning. Schneider (1984) sees t h i s as 123 the r e s u l t o f i n t e r n a l p r o c e s s i n g t h a t occurs w i t h e v o l v i n g r o l e r e d e f i n i t i o n and r e i n t e g r a t i o n . F o r example " p a i n " becomes "hu r t " , " a n x i e t y ( d i f f u s e d ) " become " s c a r e d ( f o c u s s e d ) " , "problems" become " c h a l l e n g e s " , "symptoms" become "reminders" and the "search f o r meaningful e x i s t e n c e " becomes "se a r c h f o r wholeness" (p.224). T h i s i s i l l u s t r a t e d by the d i f f e r e n c e i n h e r e n t i n the change of " c r y i n g " t o " t e a r i n e s s " which occurs d u r i n g t r a n s i t i o n i n g r i e v i n g . Table 11: M a t r i x of Person Metaphors w i t h Worden's Four Tasks of G r i e v i n g r e l a t e d t o Bereavement Group P a r t i c i p a t i o n . Group Task I A c c e p t i n g the Loss Task I I E x p e r i e n c i n g the P a i n Task I I I / I V A d j u s t i n g t o Loss I n v e s t i n g Energy Outward  YES no "poor me" get on with i t s c a r e d uncoupled l o n e l y p e r i o d i c sadness n o s t a l g i c I've made i t ! r e s i l i e n c e new r o l e s / d u t i e s r e h e a r s i n g c o n t r o l s e l f c o n f i d e n c e a n t i c i p a t i n g f u t u r e r e a c h i n g out s o f t e r - l e s s hardnosed independence p o s i t i v e a t t i t u d e too o l d abandoned NO d e s o l a t e don't need c r u t c h l o n e l y uncoupled r o l e l o s s d r i v e n ambiguous have done w e l l c h a l l e n g e independence p o s i t i v e a t t i t u d e adventurous no "poor me" A n a l y s i s of Table 11: The d i f f e r e n c e between the two groups i s found i n the s e l f -image r e l a t e d r e f e r e n t s , c o n t i n u i n g e x p r e s s i o n s of g r i e f , and a sense of r e d e f i n i t i o n . These are evidenced i n a g e n e r a l focus on the f u t u r e as i n d i c a t e d i n the Task I I I and IV engagement which are i n d i c a t i v e of a d j u s t i n g t o the environment without the deceased and i n v e s t i n g energy i n new 125 a c t i v i t i e s or r e l a t i o n s h i p s . Both groups are engaged t o some extent w i t h these Tasks. D i f f e r e n c e s appear between the groups p r i m a r i l y i n the Task I e x p r e s s i o n s of g r i e f which are s t i l l e v i d e n t i n the group without bereavement i n t e r v e n t i o n . T h i s group a l s o had the h i g h e s t g r i e f s c o r e s and lowest adjustment s c o r e s — which are again r e f l e c t e d i n the s e l f - i m a g e r e l a t e d t o the r e l a t i o n s h i p w i t h the deceased and engagement i n the e a r l i e r t a s k s . Engagement wi t h Task I I i s not unusual. When the l o s s i s i n t e r p r e t e d as l o s s of s e l f , d e v e l o p i n g new s e l f - i m a g e r e q u i r e s time. D i f f e r e n c e s are observed when the language/expressions are compared. Both groups aga i n noted the sense o f b e i n g incomplete, not b e i n g a couple (as i n Table 9 A n a l y s i s ) . However, the group w i t h bereavement i n t e r v e n t i o n i l l u s t r a t e s Schneider's (1984) i n t e r n a l p r o c e s s i n g and have i n c o r p o r a t e d many of the t r a n s i t i o n s i n h e r e n t i n r o l e r e d e f i n i t i o n and r e i n t e g r a t i o n . The group without bereavement i n t e r v e n t i o n s t i l l e vidence l a c k o f r e o r g a n i z a t i o n . Metaphor i s b a s i c t o our s t r u c t u r e of meaning — our connectedness, our bonds of attachment — where "a complexity of r e l a t i o n s h i p s and i n t e r r e l a t e d n e s s " s t r e t c h 126 l i k e webs and nets of t e n s i o n and movement i m p l y i n g "opposing c a p a c i t i e s f o r s n a r i n g or entrapment or r e s c u i n g and s a f e t y " (Belenky et a l , 1986, p.178). Conceptual framing of g r i e v i n g w i l l vary a c c o r d i n g l y . R e l a t i o n s h i p of Time t o Worden's Tasks As has been p r e v i o u s l y e s t a b l i s h e d , the g r i e v i n g p r o c e s s i s one t h a t occurs over time. In t h i s sense i t i s not time-bounded but r a t h e r r e l a t e d to the amount o f time i t takes t o complete the g r i e v i n g t a s k s . T h i s can take up t o f o u r y ears or more — and again, i s dependent upon the r e l a t i o n s h i p w i t h the deceased and r o l e r e d e f i n i t i o n . Not o n l y i s time p a r t of the process, p a r t of the study parameter, but i t i s a l s o a c o n s t r u c t used by a l l of the respondents t o r e f e r t o t h e i r g r i e v i n g p r o c e s s . I t was noted t h a t d i r e c t r e f e r e n c e t o time or time frames was f r e q u e n t l y made, as w e l l as comments t h a t i n c l u d e d time-d e l i n e a t e d concepts. I t was t h e r e f o r e important t o s u b s t r u c t the v a r i a b l e of time t o grasp i n h e r e n t dimensions of meaning and t o make o b s e r v a t i o n s . 127 Table 12: M a t r i x of P r e p a r a t i o n Time w i t h Bereavement Group P a r t i c i p a t i o n . Bereavement Group P a r t i c i p a t i o n Yes No P r e p a r a t i o n Time < 10 months 7 3 mos. 2 4 mos. 1 6 mos. 1 7 mos. 1 8 mos. 1 9 mos. 1 > 10 months 11 mos. 1 13 mos. 2 24 mos. 3 +72 mos. 1 I t was found t h a t time f o r p r e p a r a t i o n f o r the death of the f a m i l y member was an f a c t o r i n p a r t i c i p a t i n g i n the bereavement group. A l l p a r t i c i p a n t s i n the bereavement support group had e l e v e n or fewer months t o prepare, whereas those who d i d not chose t o p a r t i c i p a t e had e l e v e n t o over seventy-two months i n which t o prepare. Only one i n d i v i d u a l i n the bereavement i n t e r v e n t i o n group had a lo n g e r p e r i o d than t e n months, and t h i s 128 i n d i v i d u a l was a male over seventy with no f a m i l y or s o c i a l support networks. "I was t o t a l l y alone" (Respondent). I t i s i n t e r e s t i n g t h a t t h e r e was s e l f - p e r c e i v e d r i s k f o r t h i s group. A l l i n d i v i d u a l s were i n v i t e d t o p a r t i c i p a t e , and f o r the most p a r t , those w i t h more than ten months p r e p a r a t i o n time f e l t they d i d n ' t r e q u i r e a s s i s t a n c e at the time of i n v i t a t i o n . I t was found e a r l i e r t h a t the time f o r p r e p a r a t i o n f o r the death of the f a m i l y member d e l i n e a t e d one sample from the o t h e r . I t was a l s o i n t e r e s t i n g t o f i n d t h a t when the v a r i a b l e of "time" was s u b s t r u c t e d , t h e r e was s t i l l another d i v i s i o n between those h a v i n g the bereavement i n t e r v e n t i o n and those without. The respondents' r e f e r e n c e s t o time were l i s t e d f o r each group and were a n a l y z e d . From t h i s a n a l y s i s , f o u r dimensions of time were found: time l i n e , o c c a s i o n , c o n d i t i o n a l , and t u r n i n g p o i n t . (See Appendix VI) Before a n a l y z i n g t h e s e r e s u l t s , i t i s important t o be c l e a r on the d e f i n i t i o n s i n c o r p o r a t e d i n these terms. Both the Random House D i c t i o n a r y (1980) and the New Webster E n c y c l o p e d i c D i c t i o n a r y (1980) were u t i l i z e d i n the d e f i n i t i o n a l d e l i n e a t i o n . 129 Four Dimensions of Time Time L i n e Time l i n e i s the term a p p l i e d t o a concept used by the respondents t o denote or a l l u d e t o a time frame, a p e r i o d of time. Even w i t h i n t h i s dimension t h e r e were f o u r themes: 4 — no q u a l i t y time; no time t o d i s c u s s — r e g r e t s 3 — a r e l e a s e ; i t ' l l work out — time h e a l s 2 — p o s i t i v e ; a g i f t — q u a l i t y 3 — time t o prepare — r e c o n c i l i a t i o n Occasion T h i s dimension denotes the time of a c e r t a i n experience, occurrence or event and many times i n c l u d e s a s p e c i f i c r e f e r e n t . "The h a r d e s t time was my b i r t h d a y " ; "The i l l n e s s o f two years was the same as h i s r e t i r e m e n t of two y e a r s " ; We c o u l d go t o the h o s p i t a l any time"; "There was two years of s u f f e r i n g f o r us both"; "I looked a f t e r her f o r more than s i x years, now t h e r e ' s n o t h i n g " These two time dimensions o c c u r r e d f a i r l y e venly a c r o s s the two p o p u l a t i o n s as was observed i n Table 13 below. An expanded matrix, Table 14 below, i l l u s t r a t e s the d i f f e r e n c e s between the two sample groups and the remaining two time dimensions: c o n d i t i o n a l and t u r n i n g p o i n t . These are found t o r e l a t e d i r e c t l y t o t h r e e of Worden's Tasks. C o n d i t i o n a l C o n d i t i o n a l time denotes the c h o i c e or 130 p e r c e p t i o n of a proper moment i n the f u t u r e . T u r n i n g P o i n t T u r n i n g p o i n t i s seen t o be a r i g h t moment i n time or an aspect of t i m i n g t h a t o c c u r r e d i n the past and i s observed i n r e t r o s p e c t . Fuchs Ebaugh (1988) found t h a t t u r n i n g p o i n t s may be g r a d u a l or abrupt but ten d t o be s p e c i f i c events t h a t c r y s t a l l i z e r o l e ambivalence and are g e n e r a l l y reached a f t e r a g r a d u a l b u i l d - u p occurs which culminates i n a d e c i s i o n b e i n g made. The death event i t s e l f i s a major c h a l l e n g e t o an i n d i v i d u a l ' s l i f e g o a l s and r e o r g a n i z a t i o n e v o l v e s s l o w l y w i t h few or many t u r n i n g p o i n t s . There were f i f t e e n respondents n o t i n g time d i m e n s i o n a l i t y . A l l f i f t e e n r e f e r r e d t o a time l i n e , or time frame. E s s e n t i a l l y e q u a l numbers made r e f e r e n c e t o an o c c a s i o n — d u r a t i o n o f c e r t a i n e x p e r i e n c e s . Table 13: M a t r i x of Four Dimensions of Time with Bereavement Group P a r t i c i p a t i o n Time Dimension Bereavement Group P a r t i c i p a t i o n Yes No Time L i n e 8 7 Occasion 3 4 C o n d i t i o n a l 0 5 T u r n i n g P o i n t 5 1 131 The most p e r t i n e n t d e l i n e a t i o n occurs with the c o n d i t i o n a l and t u r n i n g p o i n t r e f e r e n t s — Table 14 below. Not only do these occurrences d i f f e r e n t i a t e between the two groups, but a l s o r e l a t e d i r e c t l y t o Worden's t a s k s and t o the Cameron G r i e f and Adjustment Scores i n Chapter 3. Table 14: M a t r i x of Two Dimensions of Time with Bereavement Group P a r t i c i p a t i o n r e l a t e d t o Worden's Tasks of G r i e f R e s o l u t i o n . Time Bereavement I n t e r v e n t i o n Worden's Task Dimension Yes No Reference C o n d i t i o n a l 0 5 I & II 4 Not time yet Avoidance of p a i n / i s s u e s He's not dead yet 1 Another year Turning P o i n t 5 1* I I I / I V 3 — t h e r e ' s a time 1 — i t was time l - - y e a r was over 1 — t u r n e d c o r n e r Moving forward, a d j u s t i n g t o l o s s * T h i s i n d i v i d u a l was one of two whose G r i e f and Adjustment Scores i n d i c a t e d h i g h g r i e f r e s o l u t i o n . I t can be observed i n t h i s m a t r i x t h a t the time dimensions are h i g h l y r e l a t e d t o the Process Metaphors. 132 I t was found i n the Process Metaphor A n a l y s i s , t h a t most of the "No I n t e r v e n t i o n Group" had not f u l l y r e s o l v e d i s s u e s p e r t a i n i n g t o Task I I — e x p e r i e n c i n g the p a i n of the l o s s . T h i s i s a g a i n seen i n t h i s m a t r i x — w i t h added o b s e r v a t i o n s . Those who have not addressed the p a i n a s s o c i a t e d w i t h death event w i l l not reach " t u r n i n g p o i n t s / c r i t i c a l j u n c t u r e s " . T h e i r framing w i l l encompass c o n d i t i o n a l time — " I t ' s not time y e t " . L i k e w i s e , those who have d e a l t with e x p e r i e n c i n g the p a i n have not avoided or put o f f a d d r e s s i n g these i s s u e s and can look back and p e r c e i v e t h a t "moment i n time" from which t h i n g s changed. 133 Table 5: Context M a t r i x of Temporal Dimensions i n the Bereavement Process MEANING BEREAVEMENT 1 METAPHOR I PERSON PLACE PROCESS TIME -time l i n e o c c a s i o n c o n d i t i o n a l •turning p o i n t F i g u r e 5 i s a c o n c e p t u a l i z a t i o n of the r e l a t i o n s h i p between time and meaning, i l l u s t r a t i n g the c o n n e c t i o n between the time dimensions and the process metaphors. Summary The core c a t e g o r i e s of "meaning" and "time" were both s u b s t r u c t e d and analyzed by a p p l y i n g Worden's Tasks of G r i e v i n g . I t was noted t h a t these c a t e g o r i e s are both i n t e r r e l a t e d and separate e n t i t i e s . They i n d i c a t e both an i n d i v i d u a l ' s meaning s t r u c t u r e of h i s / h e r g r i e v i n g e x p e r i e n c e as w e l l as p r o g r e s s i o n through the p r o c e s s . 134 I t can be observed t h a t bereavement r e s o l u t i o n i s p r o g r e s s i n g v e r y w e l l f o r those who have p a r t i c i p a t e d i n the bereavement i n t e r v e n t i o n . While t h e r e s t i l l may be some i s s u e s s u r r o u n d i n g Task II r e s o l u t i o n ( E x p e r i e n c i n g the Pain) when c o n s i d e r i n g Person Metaphors, t h i s group i s w e l l engaged wi t h Tasks I I I ( A d j u s t i n g t o the Loss) and IV ( I n v e s t i n g Energy Outward) when the o t h e r dimensions of meaning and metaphor are c o n s i d e r e d . Comparatively, the group without bereavement i n t e r v e n t i o n i s not doing as w e l l with many a v o i d i n g p a i n f u l i s s u e s a s s o c i a t e d w i t h g r i e f r e s o l u t i o n , thus becoming " s t u c k " at t h i s l e v e l (Task I I ) . I t s h o u l d not be f o r g o t t e n , however, t h a t two i n d i v i d u a l s i n t h i s group have shown e x c e l l e n t p r o g r e s s and are w e l l engaged i n Tasks I I I and IV i s s u e s . T h i s f i n d i n g s u b s t a n t i a t e s s p e c u l a t i o n s t h a t not a l l i n d i v i d u a l s r e q u i r e bereavement i n t e r v e n t i o n . I t was again observed t h a t time f o r p r e p a r a t i o n f o r the death of the f a m i l y member i s the major m o t i v a t o r f o r bereavement i n t e r v e n t i o n p a r t i c i p a t i o n . F i r s t d i s c u s s e d i n the Q u a n t i t a t i v e A n a l y s i s , i t was found t h a t the s i x i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n were seen t o have e l e v e n months or l e s s o f p r e p a r a t i o n . T h i s f i n d i n g holds when the t o t a l sample of e ight with bereavement in tervent ion i s considered. 136 CHAPTER 5 INTERPRETATION OF FINDINGS T h i s chapter w i l l c o n c e n t r a t e on the f i n d i n g s of the r e s e a r c h p r o j e c t as they r e l a t e t o the t h e s i s o b j e c t i v e s i t e r a t e d i n the I n t r o d u c t i o n . The primary o b j e c t i v e s were t o i d e n t i f y : the need f o r bereavement i n t e r v e n t i o n ; i m p l i c a t i o n s f o r p r a c t i c e which w i l l address f a m i l y r e s o u r c e e v a l u a t i o n through c o n t e x t u a l a n a l y s i s , and w i l l speak t o s o c i a l s t r u c t u r e s which impinge upon the g r i e v i n g p r o c e s s ; p o l i c y i m p l i c a t i o n s f o r p r o v i s i o n of bereavement i n t e r v e n t i o n programming. For the purposes of t h i s d i s c u s s i o n , the need f o r bereavement i n t e r v e n t i o n w i l l be addressed, with c o n s i d e r a t i o n of p r a c t i c e and p o l i c y i m p l i c a t i o n s t o be undertaken i n Chapter 6. The i n v e s t i g a t i o n was o r g a n i z e d around two methodologies — a q u a n t i t a t i v e r e p l i c a t i o n of a study based on symptomatology, and a q u a l i t a t i v e a n a l y s i s of meaning s t r u c t u r e s which frame the g r i e v i n g p r o c e s s — t o measure the e f f e c t of bereavement i n t e r v e n t i o n on g r i e f r e s o l u t i o n . 137 Two p o p u l a t i o n s were sampled — i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n , and those without. Both groups had p a r t i c i p a t e d i n a P a l l i a t i v e Care Programme. The s t r e n g t h o f the study i s t o be found i n the mixed s t r a t e g y of the i n v e s t i g a t i o n . The data i n Chapters 3 and 4 were addressed from the p e r s o n a l l e v e l of experience i n c o r p o r a t i n g a n e c d o t a l i n f o r m a t i o n and i n d i v i d u a l s c o r i n g on G r i e f and Adjustment i n d i c e s . T h i s chapter w i l l endeavour t o expand upon the p e r s o n a l i n f o r m a t i o n as w e l l as i n c o r p o r a t e a broader a n a l y s i s of the data i n order t o c l a r i f y the need f o r bereavement i n t e r v e n t i o n . An expanded a n a l y s i s takes the e x p l o r a t i o n beyond t h a t of i n d i v i d u a l experience, and i n c o r p o r a t e s consensual data of the aggregate — data t h a t has been d e r i v e d from m u l t i p l e s t u d i e s t o a s c e r t a i n symptomatology, as w e l l as s o c i a l t r e n d s which impinge upon i n d i v i d u a l g r i e v i n g p r o c e s s e s . T h i s e x p l o r a t i o n w i l l i l l u s t r a t e the meaning s t r u c t u r e s and t i m e / p r o c e s s parameters f o r g r i e v i n g i n d i v i d u a l s from a d i f f e r e n t p e r s p e c t i v e . I t extends the i d i o s y n c r a t i c data i n t o the realm of l a r g e r systemic i n t e r a c t i o n s as w e l l as a g e - r e l a t e d , g e n e r a t i o n a l , s o c i a l i z a t i o n d i f f e r e n c e s . In t h i s way, the p e r s o n - i n - t r a n s i t i o n i s a l s o c o n s i d e r e d from 138 the person-in-environment p e r s p e c t i v e which i n t e g r a t e s the p e r s o n a l w i t h the s o c i a l dimension. T h i s i s r e l a t e d t o the concept of B a s i c S o c i a l Process, d i s c u s s e d i n the I n t r o d u c t i o n , which c o n s i d e r s the m u l t i p l e l i n k a g e s between the i n d i v i d u a l and s o c i e t a l s t r u c t u r e s and the l e v e l s of enactment over time. I n t e r p r e t a t i o n of the Q u a n t i t a t i v e F i n d i n g s The q u a n t i t a t i v e a n a l y s i s i s a m o d i f i e d r e p l i c a t i o n of a study c a r r i e d out i n 1975-76 (Cameron and B r i n g s , 1980). P r o t o c o l s developed i n the o r i g i n a l study — q u e s t i o n n a i r e , g r i e f and bereavement cod i n g i n v e n t o r i e s , matching c r i t e r i a of age, sex and r e l a t i o n s h i p t o the deceased — are i n c o r p o r a t e d i n t o the c u r r e n t study d e s i g n . The Wilcoxon Matched-Pairs Signed-Ranks and the F i s h e r ' s Exact T e s t s are a l s o the s t a t i s t i c a l analyses i n c o r p o r a t e d i n t o both the o r i g i n a l and c u r r e n t s t u d i e s . However, the f i n d i n g s of the c u r r e n t study are i n c o n c l u s i v e f o r v a r i o u s reasons. At the s t r u c t u r a l l e v e l these i n c l u d e : s t r u c t u r a l changes i n the i n c o r p o r a t i o n and expansion of p a l l i a t i v e care i n t o the heathcare system, a t t i t u d i n a l changes toward care f o r the t e r m i n a l l y i l l and t h e i r f a m i l i e s , 139 m e d i c a l advances i n p a i n management, and p e r c e i v e d changes i n f a m i l y s i z e and support networks. These f a c t o r s , i n combination, r e s u l t e d i n an i n a b i l i t y t o a c q u i r e a sample from a l i m i t e d p o p u l a t i o n of i n d i v i d u a l s not having p a l l i a t i v e care experience nor bereavement i n t e r v e n t i o n e x p e r i e n c e at the study h o s p i t a l . The major s t r e s s o r s o f the bereavement experience are a l s o seen t o change over the y e a r s . The i n d i v i d u a l s i n the Cameron and Br i n g s (1980) study c i t e d p a i n and s u f f e r i n g o f the deceased as the hardest t h i n g t o bear, with 75% mentioning l o n e l i n e s s . The c u r r e n t study samples c i t e s f u n e r a l / b u r i a l e x p e r i e n c e s as the most d i f f i c u l t , with 80% n o t i n g l o n e l i n e s s — but i n most i n s t a n c e s as a product of s o c i a l o s t r a c i s m . S u f f e r i n g of the deceased f a m i l y member i s not an i s s u e . At the l e v e l of a n a l y s i s f a c t o r s a re: the l a c k o f s i g n i f i c a n t d i f f e r e n c e between the two samples' g r i e f and adjustment scores as i n d i c a t e d by the Wilcoxon T e s t s (Tables 4, 5, 6, and 7) the l a c k of c o m p a r a b i l i t y between the two samples due to the amount of p r e p a r a t i o n time f o r the death of the f a m i l y member i l l u s t r a t e d i n the F i s h e r ' s Exact Test (Table 3), and 140 the s i z e of the samples. F i n d i n g s a l s o i n d i c a t e t h a t bereavement i n t e r v e n t i o n i s not n ecessary f o r a l l i n d i v i d u a l s and t h a t support networks are i n t e g r a l t o bereavement r e s o l u t i o n . Two o b s e r v a t i o n s are drawn from the data a n a l y s i s : f a m i l y members who have l i t t l e time f o r p r e p a r a t i o n f o r the death appear t o s e l f p e r c e i v e the need f o r bereavement i n t e r v e n t i o n , and a c a r e f u l assessment i s r e q u i r e d of those w i t h l o n g e r p r e p a r a t i o n p e r i o d s — those over 24 months. I t can be seen, t h e r e f o r e , t h a t w hile the r e s u l t s may have been i n c o n c l u s i v e , t h e r e are f i n d i n g s of v a l u e i n the q u a n t i t a t i v e p o r t i o n of the a n a l y s i s . I t has been mentioned p r e v i o u s l y t h a t the i n t e r v i e w q u e s t i o n n a i r e i n c l u d e d q u e s t i o n s about f a m i l y and s o c i a l support f a c t o r s t h a t were not addressed i n the G r i e f and Bereavement I n v e n t o r i e s t h a t formed the b a s i s of the comparative a n a l y s i s . I n d i c a t i o n s from the study, and from the Cameron and Parkes (1983) d i s c u s s i o n , are t h a t these f a c t o r s are important i n bereavement r e s o l u t i o n . The G r i e f and Bereavement I n v e n t o r i e s are worth e x p l o r i n g f u r t h e r . Review of G r i e f and Adjustment Scores The G r i e f and Adjustment I n v e n t o r i e s d e r i v e d by Cameron and B r i n g s were e v o l v e d from consensual data i n the l i t e r a t u r e r e g a r d i n g bereavement r i s k . When the G r i e f and Adjustment Scores are r e l a t e d t o s o c i a l f a c t o r s , both t h e i r v a l u e and shortcomings as assessment t o o l s become apparent. The Scores are d i s c u s s e d e x t e n s i v e l y i n the Chapter 3. Of note i n t h i s d i s c u s s i o n are the s c o r e s of the o u t l i e r s — a l l o f whom appear i n the group without bereavement i n t e r v e n t i o n . Two i n d i v i d u a l s i n d i c a t e h i g h g r i e f r e s o l u t i o n , while two i n d i v i d u a l s have the p o o r e s t s c o r e s and thus i n d i c a t e some d i s t r e s s t h i r t e e n months p o s t -bereavement. I t i s a l s o observed t h a t one i n d i v i d u a l w i t h bereavement i n t e r v e n t i o n has r e l a t i v e l y poor s c o r e s which are s i m i l a r t o those observed i n the other group. T h i s appears t o i n d i c a t e t h a t the i n t e r v e n t i o n has not been of b e n e f i t t o t h i s person. U n f o r t u n a t e l y t h i s i s where an i n v e n t o r y of symptoms does not e x p l a i n o t h e r m i t i g a t i n g f a c t o r s . Thus while the G r i e f and Adjustment Scores are deemed i n d i c a t o r s of p o s s i b l e r i s k , they must be c o n s i d e r e d w i t h o t h e r i n t e r v e n i n g v a r i a b l e s . To show the d i f f e r e n c e s between these i n d i v i d u a l s , T a b l e 15 r e l a t e s the Scores and p e r c e i v e d r i s k t o r e l i g i o s i t y , f a m i l y support, s o c i a l support and h e a l t h . C l i e n t s #1 and #2 r e p r e s e n t the g r e a t e s t degree of 142 r e s o l u t i o n noted, c l i e n t s #3 and #4 the l e a s t , and are t h e r e f o r e o u t l i e r s — a l l found i n the group without bereavement i n t e r v e n t i o n . Scores of C l i e n t #5 (without i n t e r v e n t i o n ) and C l i e n t #6 (with i n t e r v e n t i o n ) i n d i c a t e p o s s i b l e bereavement d i f f i c u l t i e s . T a ble 15: R e l a t i o n s h i p of G r i e f and Adjustment Scores t o V a r i a b l e s of Health, Support Networks, and R e l i g i o u s B e l i e f / P r a c t i c e . C l i e n t G r i e f Adjustment S o c i a l Family R e l i g i o u s H e a l t h Scores Support B e l i e f S t atus Risk 1 20 1 N i l Some P e r s o n a l Good High 2 14 5 N i l N i l Unknown Poor High 3 0 14 Some High Church Good N i l 4 4 14 High Some P e r s o n a l Good N i l 5 5 6 Some N i l N i l Poor High 6 7 5 Some High Church V.Poor Mid When o b s e r v i n g Table 15, i t seems t h a t the Scores j u s t i f y the r i s k e v a l u a t i o n — except f o r c l i e n t s #5 and #6, where o t h e r v a r i a b l e s must be c o n s i d e r e d . The Scores f o r c l i e n t s #1 and #2 appear t o be i n agreement w i t h the r i s k assessment, as do those f o r C l i e n t s #3 and #4. C l i e n t #5, wh i l e not having an o v e r l y h i g h G r i e f Score ( u n d e s i r e d s c o r e ) , a l s o does not have a h i g h Adjustment Score ( d e s i r e d s c o r e ) , and i s deemed at h i g h r i s k because o f a combination 143 of t he low Adjustment Score with poor h e a l t h , low s o c i a l and f a m i l y support networks, and no r e l i g i o u s b e l i e f or p r a c t i c e . C l i e n t #6 i s not as s e s s e d as having a h i g h r i s k even though the G r i e f and Adjustment Scores do not appear t o be as good as those o f C l i e n t #5. The d i f f e r e n c e s may appear i n the h i g h f a m i l y support and church a c t i v i t y however, v e r y poor h e a l t h c o m p l i c a t e s the p i c t u r e . The h e a l t h o f t h i s c l i e n t , c oupled w i t h the death o f the f a m i l y member may have brought the f a m i l y c l o s e r t o g e t h e r but a l l are i n v o l v e d i n the g r i e v i n g p r o c e s s w h i l e concerned with the ve r y poor h e a l t h of the C l i e n t . Why then i s the r i s k assessment not g r e a t e r ? T h i s i s where the G r i e f and Adjustment Scores must be taken under advisement, and where other v a r i a b l e s r e q u i r e c o n s i d e r a t i o n . The major d i f f e r e n c e s between C l i e n t s #5 and #6 i s the p a r t i c i p a t i o n i n the bereavement i n t e r v e n t i o n by C l i e n t #6 and the degree of Task r e s o l u t i o n found when the Worden assessment was c a r r i e d out. C l i e n t #6, w h i l e s t i l l g r i e v i n g l o s s of f a m i l y member and poor p e r s o n a l h e a l t h i s moving w e l l i n t o Tasks I I I and IV i s s u e s and i s e x h i b i t i n g i n c r e a s e d s e l f - i m a g e and independence. C l i e n t #5 i s s t i l l d e a l i n g w i t h Task II i s s u e s and p r e s e n t s 144 low s e l f - i m a g e and l i t t l e d e s i r e or i n i t i a t i v e t o address Task I I I i s s u e s . I t i s known t h a t g r i e v i n g can take up t o f o u r years (or longer) and i s h i g h l y dependent upon the r e l a t i o n s h i p t o the deceased, the q u a l i t y of t h a t r e l a t i o n s h i p , and p e r s o n a l c o p i n g s t r a t e g i e s . One respondent noted t h a t i t would be "another year" b e f o r e g r i e v i n g i s s u e s c o u l d be addressed. T h i s i s the p e r s o n a l assessment f o r t h a t i n d i v i d u a l and w i l l i n most l i k e l i h o o d be a c c u r a t e . The Worden Task a n a l y s e s a s s i s t i n c l a r i f y i n g the i n h e r e n t r i s k assessments. I t i s important t h e r e f o r e t o i n c o r p o r a t e both assessment t o o l s when c o n s i d e r i n g need f o r i n t e r v e n t i o n . Thus the a n a l y s i s i s s trengthened through the mixed s t r a t e g y of both q u a n t i t a t i v e and q u a l i t a t i v e a n a l y s e s . I n t e r p r e t a t i o n of the Q u a l i t a t i v e A n a l y s i s F i n d i n g s A grounded t h e o r y approach i s used i n the q u a l i t a t i v e a n a l y s i s t o c o n c e p t u a l i z e the g r i e v i n g process e n u n c i a t e d by the study respondents. I n i t i a l l y , the comments underwent a r i g o r o u s p r o c e s s of theme d e l i n e a t i o n and c o d i n g i n o r d e r t o achieve an emergent f i t between the data and the concept of the bereavement p r o c e s s . The core c a t e g o r i e s were then a n a l y z e d by an a p p l i c a t i o n of Worden's Four Tasks of 145 G r i e v i n g (1982). The f i n d i n g s p r e s e n t e d i n Chapter 4 o u t l i n e v a r i o u s dimensions of the core c a t e g o r i e s of "meaning" and "time" ( F i g u r e s 4 and 5). "Meaning" was framed i n m e t a p h o r i c a l codes i n f e r r e d by the respondents' bereavement e x p e r i e n c e d e s c r i p t o r s , and "time" i s expressed both m e t a p h o r i c a l l y and d i m e n s i o n a l l y . From these analyses i t i s p o s s i b l e t o assess need f o r p r e v e n t i v e i n t e r v e n t i o n at c e r t a i n l e v e l s of t a s k engagement as w e l l as from the environmental and i n d i v i d u a l c o n t e x t s — which r e l a t e t o support systems and l i f e e x p e r i e n c e s as w e l l as i n d i v i d u a l c o p i n g s t y l e s . The data p r e s e n t e d i n Chapter 4 i s i d i o s y n c r a t i c i n nature, p e r t a i n i n g t o i n d i v i d u a l g r i e f t r a j e c t o r i e s and unique e x p r e s s i o n s of the p r o c e s s . To e x p l o r e t h e s e f i n d i n g s i n g r e a t e r depth, a recap of the Worden Task a n a l y s i s i s p r e s e n t e d . Review of the R e l a t i o n s h i p of Metaphor t o Worden's Tasks Process Metaphor (Chapter 4, Table 9) The a n a l y s i s found t h a t the group w i t h bereavement i n t e r v e n t i o n had few p s y c h o l o g i c a l l y p a i n f u l r e f e r e n t s and are w e l l 146 engaged i n Tasks I I I and IV ( a d j u s t i n g t o the environment without the deceased and i n v e s t i n g energy i n new a c t i v i t i e s and r e l a t i o n s h i p s ) . Some i n d i v i d u a l s without bereavement i n t e r v e n t i o n r e f e r r e d t o the death event i n e m o t i o n a l l y l a d e n terms and most of t h i s group avoided Task I I — engaging i n e x p e r i e n c i n g the p a i n of the l o s s . T h i s was thought t o be a remarkable occurrence and was f u r t h e r i l l u m i n a t e d when the dimensions o f time were s u b s t r u c t e d and i t was observed t h a t the m a j o r i t y of t h i s group had not reached a t u r n i n g p o i n t . They were, i n f a c t , p l a c i n g c o n d i t i o n s upon the g r i e v i n g p r o c e s s , r a t h e r than a d d r e s s i n g p a i n f u l i s s u e s — " i t ' s not time y e t " . P l a c e Metaphors (Chapter 4, Table 10) Again a d i f f e r e n c e i s observed between the two groups, w i t h those having bereavement i n t e r v e n t i o n b e i n g h i g h l y c r e a t i v e i n t h e i r g r i e v i n g p r o c e s s . R i t u a l and symbolic meaning are e xpressed by a number of t h i s group. T h i s i s a l s o t r u e f o r two i n d i v i d u a l s without bereavement i n t e r v e n t i o n , and i s i n d i c a t i v e of engagement wi t h Tasks I I I and IV i n d e f i n i n g new p o s s i b i l i t i e s w h i le engaging i n the t r a n s i t i o n out of o l d r e l a t i o n s h i p s and r o l e s (Imber-Black e t a l . 1988). Person Metaphors (Chapter 4, Table 11) These 147 e x p r e s s i o n s of s e l f - i m a g e and a sense of r e d e f i n i t i o n are the l e a s t d e f i n i t i v e of the metaphors i n d i s c r i m i n a t i n g between the two groups. Some i n d i v i d u a l s without bereavement i n t e r v e n t i o n expressed low s e l f - i m a g e r e f e r e n t s t h a t r e l a t e d t o Task I and the r e a l i t y of the l o s s . An i n t e r e s t i n g f i n d i n g i s the l a c k of person metaphors f o r t h i s group. Even those w i t h h i g h r e s o l u t i o n do not a l l u d e t o s e l f - i d e n t i t y i s s u e s — perhaps because these are n o n - i s s u e s f o r the two i n d i v i d u a l s , i n the sense t h a t they are r e s o l v e d and e n e r g i e s are b e i n g put i n t o other p e r s o n a l and f a m i l y needs. By and l a r g e , those w i t h bereavement i n t e r v e n t i o n are more e x p r e s s i v e and a b l e t o r e l a t e t h e i r e x p e r i e n c e s without c o n s t r a i n t . T h i s r e f l e c t s a more p o s i t i v e s e l f - i m a g e and a g r e a t e r sense of c o n t r o l and outward f o c u s . D i s c u s s i o n The Process Metaphors and Turning P o i n t s are the most dramatic i n d i c a t o r s of need f o r i n t e r v e n t i o n at e a r l y stages of bereavement. A l l those p a r t i c i p a t i n g i n the bereavement i n t e r v e n t i o n were i n v o l v e d i n the group w i t h i n t h r e e months post-bereavement. Through t h i s involvement they had acknowledged the r e a l i t y of the l o s s , had engaged i n 148 e x p e r i e n c i n g the p a i n of the l o s s and are moving w e l l i n t o Tasks I I I and IV of the p r o c e s s — Task I I I b e i n g c o n s i d e r e d a c r i t i c a l j u n c t u r e by Worden hence a t u r n i n g p o i n t (Worden, 1982) . I t c o u l d be suggested t h a t the Bereavement I n t e r v e n t i o n w i t h i t s emphasis on encouraging i n d i v i d u a l s h a r i n g of h i s / h e r s t o r y — a c t u a l i z i n g the l o s s ; a s s i s t i n g w i t h i d e n t i f y i n g and e x p r e s s i n g f e e l i n g s t h a t may be deemed s o c i a l l y unacceptable ( f o r example, anger at the deceased or r e l i e f t h a t the person has d i e d ) ; as w e l l as i n t e r p r e t i n g and acknowledging "normative" behaviours and i n d i v i d u a l g r i e v i n g s t y l e s — p a r t i c u l a r l y f a c i l i t a t e s engagement w i t h Tasks I and I I . During the i n t e r v i e w s i t became apparent t h a t few of those without bereavement i n t e r v e n t i o n had had the o p p o r t u n i t y t o express themselves — t o t e l l t h e i r s t o r i e s , t o v o i c e t h e i r anger and d e s p a i r — and t o be a f f i r m e d through t h i s e x p r e s s i o n . When one i n t e r v i e w became n o t i c e a b l y p a i n f u l f o r the respondent, the i n v e s t i g a t o r r e i t e r a t e d p e r m i s s i o n t o withdraw at any time, whereupon the response was "No, I have t o do t h i s , I have t o get i t out". Another respondent d i d withdraw s t a t i n g "I can't t a l k about i t yet ... t o me he's not dead y e t " . 149 Worden (1982) d e s c r i b e s p r i n c i p l e s o f g r i e f c o u n s e l l i n g t h a t i n c l u d e : a c t u a l i z i n g the l o s s , i d e n t i f y i n g and e x p r e s s i n g f e e l i n g s , l i v i n g without the deceased, f a c i l i t a t i n g r e i n v e s t i n g energy i n a c t i v i t i e s and o t h e r r e l a t i o n s h i p s , p r o v i d i n g time t o g r i e v e , i n t e r p r e t i n g "normal" g r i e v i n g behaviour, a l l o w i n g f o r i n d i v i d u a l d i f f e r e n c e s , p r o v i d i n g c o n t i n u i n g support, and examining defenses and coping s t y l e s . Through these procedures, g r i e v i n g i n d i v i d u a l s ' e x p e r i e n c e s are a f f i r m e d and engagement i n the t a s k r e s o l u t i o n i s enhanced. The r e s u l t s of the metaphor and time dimensions a n a l y s e s i n d i c a t e t h a t these a c t i v i t i e s were b e n e f i c i a l t o those who p a r t i c i p a t e d i n the bereavement i n t e r v e n t i o n . Bereavement I n t e r v e n t i o n — C o n c e p t u a l i z i n g the Need The r e s u l t s of the f i n d i n g s reviewed above i n d i c a t e t h a t w h i l e the time f o r p r e p a r a t i o n f o r the death of a f a m i l y member may be the prime m o t i v a t o r f o r p a r t i c i p a t i o n i n bereavement i n t e r v e n t i o n , the p a r t i c i p a n t s have b e t t e r bereavement r e s o l u t i o n than do the m a j o r i t y of those without i n t e r v e n t i o n . Most of those without i n t e r v e n t i o n are s t i l l d e a l i n g w i t h (or avoiding) Task II i s s u e s which r e l a t e to e x p e r i e n c i n g the p a i n of the l o s s . 150 I t can a l s o be observed i n the f i n d i n g s t h a t the group wi t h i n t e r v e n t i o n are f o c u s s i n g on d i f f e r e n t i s s u e s than are many o f the oth e r group. The h u r d l e o f p a i n has been c r o s s e d and i s s u e s of r e d e f i n i t i o n and independence are more cogent. There are areas of concern t h a t a f f e c t both groups and t h a t are i m p l i c a t e d i n c o n c e p t u a l i z i n g need f o r i n t e r v e n t i o n . These are at both the i n d i v i d u a l and s o c i e t a l l e v e l s and i n c l u d e : s o c i a l support networks, r i t u a l and t r a d i t i o n , and the s o c i a l p s y c h o l o g i c a l p r o c e s s e s o f r o l e r e d e f i n i t i o n . I t has been found t h a t the s t r e s s response t o the death event i n c r e a s e s v u l n e r a b i l i t y t o d i s e a s e (Lindemann, 1944; Parkes, 1975; Zautra and Sandler, 1983; F r e d e r i c k and F r e d e r i c k , 1985) and has r e s u l t e d i n a broad spectrum of r i s k v a r i a b l e s as d i s c u s s e d p r e v i o u s l y . As w e l l , the s o c i a l environment i s known t o enhance or d e l i m i t bereavement outcome through a v a i l a b i l i t y of f a m i l y and/or s o c i a l support networks as w e l l as community r e s o u r c e s and p e r c e i v e d s o c i a l e x p e c t a t i o n s . S o c i a l Support Chapter 2 d i s c u s s e d the v a l u e o f s o c i a l support systems as p r o t e c t i v e mechanisms. The data supports t h i s assumption. Informal Support S o c i e t a l t r e n d s i n f a m i l y 151 c o n f i g u r a t i o n enhance or j e o p a r d i z e the change p r o c e s s — the s i z e , the m o b i l i t y , the resource r e p e r t o i r e of f a m i l i e s , the p r e v a l e n c e of s i n g l e parent f a m i l i e s — hence the a v a i l a b i l i t y of i n f o r m a l support networks. The d a t a i n Chapter 3, Other F i n d i n g s , i n d i c a t e t h a t the s i z e of the f a m i l i e s averages 1.78 c h i l d r e n , with two of the respondents having dependent c h i l d r e n at home. Table 16 o u t l i n e s comparative p e r s o n a l v a r i a b l e s of the two groups — those with i n t e r v e n t i o n and those without. 152 Table 16: P e r s o n a l V a r i a b l e Comparison between I n d i v i d u a l s With and Without Bereavement I n t e r v e n t i o n . V a r i a b l e With Without I n t e r v e n t i o n Number of C h i l d r e n : 0 1 1 1 2 2 2 3 4 3 2 0 Heal t h : N i l 3 3 Poor h e a l t h s i n c e bereavement, r e s o l v e d 3 2 Poor h e a l t h s i n c e bereavement, u n r e s o l v e d 1 0 Poor h e a l t h p r i o r t o bereavement, c o n t i n u i n g 0 1 Poor h e a l t h and other l o s s e s 1 1 R e l i g i o n : N i l 2 2 S p i r i t u a l b e l i e f 2 1 P e r s o n a l b e l i e f , no church 1 2 Church 3 2 (Church and b e l i e f i n t e g r a l t o s e l f ) (2) (0) Family Support : N i l 1 2 Some 1 4 High 6 1 S o c i a l Support N i l 3 2 Some 3 4 High 2 1 I t was noted e a r l i e r i n both the q u a n t i t a t i v e and q u a l i t a t i v e a n a l y s e s t h a t the time of p r e p a r a t i o n f o r the 153 death of the f a m i l y member was the d e f i n e r of p a r t i c i p a t i o n i n the bereavement group (Chapter 3, Table 3; Chapter 4, Table 12). T h i s f a c t o r brought about the l a c k of c o m p a r a b i l i t y of the samples. T h i s was not known at the time of sample s e l e c t i o n which was based upon Cameron and B r i n g s (1980) c r i t e r i a f o r matching d e s c r i b e d above (Chapter 3; Appendix I ) . I t i s of i n t e r e s t t o note i n Table 16 how w e l l matched the samples otherwise appear t o be. There i s d i f f e r e n c e observed i n the v a r i a b l e s of f a m i l y and s o c i a l support. S i x of the e i g h t i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n i n d i c a t e h i g h f a m i l y support, with one having none. Conversely, t h i s group notes very low s o c i a l support networks. The death event (and the p r e c e d i n g i l l n e s s ) appears to have drawn the f a m i l y c l o s e r t o g e t h e r , but t h i s does not c o n f e r an a b i l i t y t o o f f e r one another the emotional support r e q u i r e d d u r i n g the g r i e v i n g p r o c e s s . A l l of t h e s e e i g h t i n d i v i d u a l s p a r t i c i p a t e d i n the bereavement i n t e r v e n t i o n . A l l had l i t t l e time t o prepare f o r the death of the f a m i l y member and i t can be surmised t h a t they p e r c e i v e d a need f o r support f o r themselves — as w e l l as support i n meeting the needs of t h e i r f a m i l i e s . Most of the group without bereavement i n t e r v e n t i o n i n d i c a t e "some" to "no" f a m i l y or s o c i a l support — these 154 i n d i v i d u a l s were found t o be a v o i d i n g engagement wi t h Task II i s s u e s and t o have the most c r i t i c a l t o mediocre G r i e f and Adjustment Scores. Only two i n d i v i d u a l s have a h i g h combination o f f a m i l y and s o c i a l support — the two whose Scores i n d i c a t e h i g h g r i e f r e s o l u t i o n . I t i s n o t a b l e t h a t f i v e i n d i v i d u a l s o f the f i f t e e n respondents i n d i c a t e d a " s p e c i a l f r i e n d who w i l l l i s t e n and l i s t e n and accept". A l l f i v e were observed t o be w e l l engaged i n Tasks I I I and IV, and had c o r r e s p o n d i n g low G r i e f and h i g h Adjustment Scores. T h i s tends t o f o l l o w Vachon's c o n t e n t i o n t h a t "the bes t form of i n t e r v e n t i o n ... i s s u p p l i e d by f a m i l y and f r i e n d s who w i l l l e t them t a l k about the deceased" (Vachon, 1982). "Semi-formal" Support F i v e i n d i v i d u a l s i n the bereavement i n t e r v e n t i o n group and one i n d i v i d u a l i n the group without bereavement i n t e r v e n t i o n u t i l i z e d v a r i o u s s t r a t e g i e s o f s e l f - h e l p , d u r i n g the i l l n e s s o f the deceased f a m i l y member and post-bereavement. F i v e respondents mentioned a p a r t i c u l a r book by name and author — 0. C a r l Simonton, Getting; Well Again — which a s s i s t e d them d u r i n g the i l l n e s s of the deceased f a m i l y member w i t h t h i n k i n g p o s i t i v e l y and l i v i n g f u l l y , one day at a time. Three of them had a l s o accessed s e l f - h e l p groups p r i o r t o t h e i r 155 bereavement — Bosom Buddies (mastectomy support group); HOPE ( c r e a t i v e l i v i n g w i t h c a n c e r ) ; Cansurmount (support f o r i n d i v i d u a l s w i t h cancer and t h e i r f a m i l i e s ) . While t h e s e groups may not have bereavement i n t e r v e n t i o n as a prime focus, they do o f f e r shared experience and s t r a t e g i e s f o r copi n g w i t h d i s e a s e and l o s s , and a c c e p t i n g environments. Formal Support E i g h t i n d i v i d u a l s a c c e s s e d the bereavement i n t e r v e n t i o n sponsored by the p a l l i a t i v e c a r e program of the study h o s p i t a l . The program i s not bounded by time and bereaved persons can come and go as they f e e l they r e q u i r e support and i n f o r m a t i o n . One person without bereavement i n t e r v e n t i o n sought p r i v a t e c o u n s e l l i n g . T h i s i n d i v i d u a l i n d i c a t e d t h a t i t was f o r a s h o r t p e r i o d of time and t h a t w hile t h e r e was an on-going need t o address some u n r e s o l v e d i s s u e s , " i t wasn't time y e t " . The bereavement group p a r t i c i p a n t s e x p r e s s e d needs b e i n g met t h a t i n c l u d e d : s o c i a l support, openness and acceptance, the normalcy o f the bereavement e x p r e s s i o n ( i e . not g o i n g crazy) , s h a r i n g and v a l i d a t i o n of e x p e r i e n c e , p e r c e p t i o n of growth i n ot h e r s and s e l f , p e r m i s s i o n t o t a l k about the death and about s e l f , a v a i l a b i l i t y of i n f o r m a t i o n from which t o d e f i n e own g u i d e l i n e s f o r g r i e v i n g , and the p r o v i s i o n o f a r e f u g e and support. These d i r e c t l y r e l a t e t o f i n d i n g s expressed by Zautra and Sandler (1983) which i n c l u d e " s i x types of s o c i a l support: c o g n i t i v e guidance, emotional support, p o s i t i v e feedback, s o c i a l p a r t i c i p a t i o n , t a s k a s s i s t a n c e , and a d v i c e and i n f o r m a t i o n " (p.42) and t o other r e s e a r c h f i n d i n g s noted i n Chapter 2. Upon a n a l y s i s , these i n d i v i d u a l s are a l s o found t o be t h o r o u g h l y engaged i n Worden's Tasks I I I and IV. R i t u a l and T r a d i t i o n As mentioned i n Chapters 1 and 4, a major concern f o r bereaved i n d i v i d u a l s i n our s o c i e t y i s the l o s s of r i t u a l s u r r o u nding death and bereavement. R i t u a l a c t s and behaviours c o n t a i n e d w i t h i n mourning customs of a s o c i e t y marks the t r a n s i t i o n "but a l s o makes a t r a n s i t i o n at the same time" (Imber-Black, 1988, p.14). While r i t u a l "marks" and "makes" the t r a n s i t i o n , c u l t u r a l meaning i s a l s o embedded w i t h i n the p r o c e s s and a s s i s t s p eople i n c o n s t r u c t i n g t h e i r maps of r e a l i t y . Yalom (1989) found t h a t " r i t u a l s of a f u n e r a l or s c h e d u l e d s e r v i c e s proved h e l p f u l by p r o v i d i n g s t r u c t u r e and i d e n t i f i a b l e norms of behaviour d u r i n g the f i r s t p a i n f u l weeks of bereavement" (p.440). However, the l a c k of f u n e r a l / b u r i a l r i t u a l s i s remarkable i n the c u r r e n t study. Loss of t r a d i t i o n a l f u n e r a l r i t u a l i s supported by the 157 number of cremations i n the study sample (70%), w i t h 60% of these having no m e m o r i a l / f u n e r a l s e r v i c e . Cremation can be e n t e r e d i n t o as a way t o escape the g r i e f p r o c e s s as r a p i d l y as p o s s i b l e and thus can have adverse e f f e c t s on the bereavement p r o c e s s . I t was found t h a t i n response t o "what was the h a r d e s t t h i n g t o bear t h i s year?", a l a r g e number of responses p e r t a i n e d t o f u n e r a l or b u r i a l procedures — many of these respondents had not p a r t i c i p a t e d i n a f u n e r a l or memorial s e r v i c e . Avoidance of r i t u a l i s s u b s t a n t i a t e d by Parkes (1972), Cassem (1976) and K e i t h (1981) as a r e f l e c t i o n of "'the [North] American way of not dying' [ i n which] mourners are d e p r i v e d of the s o c i a l context best s u i t e d f o r the i n t e g r a t i o n of l o s s " (Cassem, 1976, p.393). Roy and Sumpter (1983) note ambivalence about v i s i t i n g the grave and Rando (1984) a s s o c i a t e s the changes i n f u n e r a r y procedures w i t h the way i n which f a m i l i e s r e l a t e t o s o c i e t y w i t h fewer s o c i a l t i e s , i n c r e a s e d a l i e n a t i o n from each o t h e r and " n u c l e a r i z a t i o n " of the f a m i l y . "My w i f e d i d n ' t want a f u n e r a l , i t ' s no one e l s e ' s b u s i n e s s but ours" (Respondent), w e l l i l l u s t r a t e s t h i s c o n t e n t i o n . The p r o v i s i o n of s o c i a l s t r u c t u r e and support h e l p s t o frame the event and t o a l l o w e x p r e s s i o n of l o s s . T h i s l a c k 158 of s o c i a l s a n c t i o n i s e v i d e n t i n lack, of und e r s t a n d i n g of the g r i e v i n g p rocess t h a t pervades c u r r e n t s o c i e t y . The l o s s of s t r u c t u r e i s r e f l e c t e d i n o c c u p a t i o n a l "compassionate l e a v e " of t h r e e days; i n comments from an acquaintance s i x weeks post-bereavement "I'm g l a d t o see you're g e t t i n g over i t " ; and i n the g e n e r a l sense of ' f r i e n d s ' "not wanting t o hear about i t " . The need f o r v a l i d a t i o n , f o r open d i s c u s s i o n of the death and the process are important a s p e c t s of g r i e f r e s o l u t i o n t h a t were not b e i n g met o u t s i d e the bereavement group. The concept of 'aloneness' was c i t e d many times (twelve out of f i f t e e n ) and was r e l a t e d t o b e i n g "uncoupled" or " s i n g l e d " , a s e l f - d e f i n e d f e e l i n g of o s t r a c i s m from s o c i e t y . I t was expressed t h a t when t h e r e i s a death the focus i s on the dying person, but seldom on the " s e l f " — t h i s l o s s of focus r e s u l t s i n the l o s s of " s e l f i n a c t i o n — i n l i f e " . "People would c a l l and ask how he's g e t t i n g along, but never how are vou doing " (Respondent). People ( s o c i e t y ) do not want t o witness another's p a i n . I t i s e a s i e s t t o a v o i d or i m p e r s o n a l i z e the p r o c e s s , thus a l l o w i n g o b j e c t i f i c a t i o n — keeping " i t " at arms l e n g t h . "The group allowed me t o speak about t h i n g s t h a t my f r i e n d s d i d n ' t want t o hear — [they i n d i c a t e d t h a t ] I sh o u l d be 'past t h a t by 159 now'" (Respondent). As we t r y t o remove o u r s e l v e s from the p a i n and awareness of death, we become p e r s o n a l l y more v u l n e r a b l e to i t and l e s s s u p p o r t i v e of o t h e r s who are bereaved. Schneidman (1976) c r i t i q u e d c u r r e n t p e r s p e c t i v e s of death which t r e a t e d death as a s o c i a l d i s e a s e . He commented upon a stigma of death w i t h i t s r e s u l t a n t o u t c a s t s t a t u s f o r the s u r v i v o r s . "Being a widow i s l i k e having a c o n t a g i o u s d i s e a s e " (Silverman, 1986, p.16). A r i e s ( i n Schneidman, 1976) f u r t h e r developed t h i s theme by o b s e r v i n g t h a t "mourning i s no l o n g e r a necessary p e r i o d imposed by s o c i e t y ; i t has become a 'morbid s t a t e ' which must be t r e a t e d , shortened, erased by the "doctors of g r i e f " [ m o r t i c i a n s ] (p.80). With r e g a r d t o t r a d i t i o n a l wakes or community support f o r the bereaved, he s t a t e s t h a t "sadness and mourning have been banished from t h i s c alming r e u n i o n " (p.81), thus p e r p e t u a t i n g the o b j e c t i f i c a t i o n of the death event and m i n i m a l i z i n g i t s meaning f o r the bereaved f a m i l y members. To compensate f o r l a c k of community support, i n d i v i d u a l s are found to have c r e a t e d t h e i r own meaning f o r t h e i r e x p e r i e n c e . The " p l a c e metaphors" i n d i c a t e c r e a t i v e g r i e v i n g by i n d i v i d u a l s who are engaged i n Task I I I i s s u e s . 160 T h i s i n g e n u i t y encompasses c r e a t i v e v i s u a l i z a t i o n and m e d i t a t i o n t e c h n i q u e s , h o l i s t i c p h i l o s o p h i e s o f l i f e and p o s i t i v e t h i n k i n g , symbolic mourning p e r i o d s , and p r o j e c t s which r e f l e c t t he meaning and value of the deceased f a m i l y member t o f a m i l y and community. D i s c u s s i o n When the aggregate bereavement outcome i s reviewed, the group with bereavement i n t e r v e n t i o n shows evidence o f b e t t e r g r i e f r e s o l u t i o n t h i r t e e n months p o s t -bereavement than do those without bereavement i n t e r v e n t i o n . Tasks I and I I are w e l l r e s o l v e d f o r the former group. Many of the l a t t e r group are found t o be g r o p i n g w i t h these Tasks, and i t would seem, c o u l d b e n e f i t from i n t e r v e n t i o n at t h i s l e v e l . One of the r e s e a r c h q u e s t i o n s i s — "why do some i n d i v i d u a l s chose not to p a r t i c i p a t e ? " . When asked t h a t q u e s t i o n , the responses are t h a t they d i d n ' t f e e l they needed i t at the time of the i n v i t a t i o n . T h i s has i m p l i c a t i o n s f o r programme implementation. There are a l s o other i s s u e s . F i v e of the e i g h t i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n a c t i v e l y sought i n f o r m a t i o n and support p r i o r t o the death o f t h e i r f a m i l y member. Was t h i s i n d i c a t i v e of the sh o r t p e r i o d f o r p r e p a r a t i o n f o r the death or was i t due t o an i n f o r m a t i o n -161 seeking approach t o l i f e / p r o b l e m s which was i n c o r p o r a t e d i n t o t h e i r p e r s o n a l c o n t r o l and mastery i s s u e s ? There i s l i t t l e i n the l i t e r a t u r e i d e n t i f y i n g h e l p - s e e k i n g behaviour. F i s h e r et a l . ( i n G o t t l i e b , 1988) r e l a t e h e l p - s e e k i n g behaviour t o many dimensions o f s e l f - e s t e e m and s e l f -assessment. These encompass: the p e r c e p t i o n of the d i f f i c u l t y as p r o b l e m a t i c and the value s of the i n d i v i d u a l ' s r e f e r e n c e group, a sense o f v u l n e r a b i l i t y and c o n s i s t e n c y of the s e l f - w o r t h e v a l u a t i o n , the e g o - c e n t r a l i t y of the t a s k (importance t o s e l f - d e f i n i t i o n ) , embarrassment, whether the need t o seek h e l p i s due t o e x t e r n a l or i n t e r n a l causes, and the p e r c e i v e d o p p o r t u n i t y t o r e c i p r o c a t e . These v a r i a b l e s were not measured i n t h i s study but may be subsumed w i t h i n the r e a s o n i n g not t o p a r t i c i p a t e i n the bereavement i n t e r v e n t i o n . Role R e d e f i n i t i o n I t i s important t o address the i s s u e of r o l e s and r e d e f i n i t i o n as they are i n t e g r a l t o r e s t r u c t u r i n g one's l i f e post-bereavement. When a f a m i l y member d i e s , the m u l t i p l e and r e c i p r o c a l r o l e s which i n v o l v e d t h a t i n d i v i d u a l a l s o d i e . "I am no l o n g e r a wif e or l o v e r or bes t f r i e n d " , "I am no longer a daughter", "He was the w o r r i e r — I was the doer. Now I have no one t o worry about what I do", "He was my s e c u r i t y " , "She was my s o u l -162 mate" (Respondents). Wrapped up i n these r e l a t i o n s h i p s are a m u l t i t u d e of nuances t h a t do not become r e a l i t y u n t i l a f t e r the death event. These are r e f l e c t i v e of the l a y e r s of attachment and t r u s t developed i n c h i l d h o o d and extended i n t o the a d u l t r e l a t i o n s h i p over the y e a r s . M a r r i s (1986) expands upon Bowlby's t h e o r y of attachment — t h a t c h i l d h o o d bonds p r o v i d e the e x p e r i e n c e from which i n d i v i d u a l s w i l l approach a l l r e l a t i o n s h i p s i n which s e c u r i t y i s sought — a n d sees t h i s as the b a s i s f o r meaning s t r u c t u r e s encompassing "emotions and purpose" ( p . v i i i ) . T h i s "attachment becomes embedded i n p r i n c i p l e s which guide and i n t e r p r e t our l a t e r d i s c o v e r i e s of order and r e l e v a n c e , e f f e c t i v e n e s s and h e l p l e s s n e s s " ( I b i d ) . Bereavement d i s r u p t s t h i s attachment and the a b i l i t y t o o r g a n i z e our worlds. R e l a t i o n s h i p s p r o v i d e an i n t e g r a l source of v a l u e and reward, s e l f - e s t e e m or s e l f - w o r t h . With bereavement, t h i s r e s ource i s cut o f f , d i s r u p t i n g i n t e r a c t i o n p a t t e r n s , thus p r e s e n t i n g a need t o e s t a b l i s h new p a t t e r n s of attachment and meaning s t r u c t u r e s . T h i s e n t a i l s changing s e l f - c o n c e p t through a dual process of f o r f e i t i n g p r e v i o u s l y h e l d views about o n e s e l f as w e l l as i n t e g r a t i n g some of the pa s t i n t o the new. (Parkes, 1971; Thorn and Wright, 1979; Wynne, 1984; Silverman, 1986; Moos, 1986). 163 Worden's Tasks I and II are i n t e g r a l p r o c e s s e s i n d e v e l o p i n g schema f o r framing the new i d e n t i t y . Some r o l e s must be assumed f o r reasons of s u r v i v a l , however r e a l i g n i n g s e l f - i d e n t i t y / s e l f - w o r t h i s a d i f f i c u l t s h i f t , e s p e c i a l l y i f s o c i e t a l r o l e p r e s c r i p t i o n s are i l l - d e f i n e d . Silverman (1986) has found i n her work with widows t h a t the r o l e of widow i s s o c i a l l y m a r g i n a l i z e d when compared t o the h o n o u r a b l e / d e s i r a b l e r o l e of wife (p.15). Widows' comments about f e e l i n g " o u t c a s t " , about i n e q u i t i e s — "men are able t o f i n d someone e a s i e r than women", i n c r e a s e s i s o l a t i o n and the sense of r e j e c t i o n — "My f r i e n d s don't want t o hear about i t " , "They were h i s f r i e n d s , not mine", " I t ' s not the same, they are a l l couples and don't understand" (Respondents). Much of the s o c i a l framing of g r i e f and bereavement f o l l o w s from l a c k of r i t u a l and avoidance of p a i n i n our s o c i e t y , i s d i s c u s s e d above. However, the s o c i a l framing a l s o frames the i n d i v i d u a l ' s e x p e r i e n c e and the new meaning s t r u c t u r e s t h a t are developed. "I'm s u r p r i s e d at my r e s i l i e n c y " , "I'm much more independent", "I do t h i n g s my_ way now" (Respondents). 164 S o c i a l P s y c h o l o g i c a l Process I n d i v i d u a l s who are i n the process of r e f r a i n i n g t h e i r i d e n t i t i e s and i n t e g r a t i n g meaning with s e l f - i m a g e , are doing so w i t h i n a s o c i e t y which p l a c e s c e r t a i n e x p e c t a t i o n s upon them. T h i s b a s i c s o c i a l p rocess i s a l s o undergoing change and thus c l o u d s the c l a r i t y of s o c i a l e x p e c t a t i o n s and r o l e d e f i n i t i o n s which, i n t u r n , impinge upon the h e a l i n g , the r e d e f i n i n g , the m o d i f y i n g of frames t h a t the bereaved must address. I d i o s y n c r a t i c c o n s i d e r a t i o n s I n d i v i d u a l c o g n i t i v e s t y l e s , p a s t experiences which have l e d t o a s u c c e s s f u l i n t e g r a t i o n of p e r s o n a l b e l i e f about o n e s e l f , a f f e c t the worldview of the i n d i v i d u a l and whether or not an event i s p e r c e i v e d as a f a i l u r e or a c h a l l e n g e . P e r s o n a l a p p r a i s a l of the event's t h r e a t to s e l f i s the key t o whether an i n t e r v e n t i o n i s aimed at p r e v e n t i o n or growth enhancement. I t was noted i n the Worden a n a l y s i s of the P r o c ess and Person Metaphors t h a t those with lowest s e l f - i m a g e and the most e m o t i o n a l l y laden r e f e r e n t s were a v o i d i n g engagement with Task I I . These i n d i v i d u a l s would not b e n e f i t from a growth enhancement i n t e r v e n t i o n as t h e i r i n t e r a c t i o n w i t h t h e i r environment was not a p p r a i s e d as having a p o s i t i v e component. "Nothing was p o s i t i v e about t h i s y e a r " 165 (Respondent). P o s i t i v e a p p r a i s a l i n d i c a t e s h e a l i n g and suggests i n c r e a s e d competency which c o u l d be r e l a t e d t o the s u c c e s s f u l adjustment, through Task engagement, t o the l o s s of the f a m i l y member. " P o s i t i v e a f f e c t s a s s o c i a t e d w i t h ( s t r e s s f u l ) events are s i g n a l s t h a t events are o c c u r r i n g t h a t are congruent w i t h a person's i n t e r e s t s " (Zautra and Sandler, 1983, p.49). Aggregate c o n s i d e r a t i o n "The s t r u c t u r e and c l i m a t e of s o c i a l exchange can a l s o f a c i l i t a t e or a c t i v e l y i n t e r f e r e w ith i n t e g r a t i o n of mastery e x p e r i e n c e s " ( I b i d , p.48). The la c k of s o c i e t a l u nderstanding and support, and the l o s s of r i t u a l which b r i n g s community t o g e t h e r has been d i s c u s s e d above. Zautra and Sandler (1983) suggest t h a t "event-event c o r r e l a t i o n s would be u s e f u l t o gauge s p e c i f i c p e rson-environment responses" t o ex p e r i e n c e s , (p.49). The l i n k a g e s between the person and environment are a l s o r e f l e c t i v e of d i f f e r e n t s o c i a l i z a t i o n and t h e r e f o r e , e x p e c t a t i o n s i n h e r e n t i n s o c i a l p r o c e s s . These s o c i a l changes are r e f l e c t e d most e l o q u e n t l y i n s u b t l e shadings of meaning found i n responses t o the q u e s t i o n of "remarriage", which r e f l e c t changing s o c i a l norms and r o l e e x p e c t a t i o n s over time. Widows i n t h e i r 60s r e p r e s e n t a lo n g e r p e r i o d of marriage and a r o l e / i d e n t i t y s o c i a l i z a t i o n t h a t began p r i o r t o World War I I . T h i s age group spoke of m a i n t a i n i n g i d e n t i t y and ways of doing t h i n g s which r e f l e c t e d v a l u e s and h a b i t s d e r i v e d from t h e i r marriages and d i d not c o n s i d e r remarriage an o p t i o n . Mastery of t a s k s and i n c r e a s e d independence was a s s e s s e d through r e f e r e n c e t o the deceased husband — "My husband would be proud of me". The women i n t h e i r f i f t i e s express openness toward change and the p o s s i b i l i t y of remarriage "sometime" but q u a l i f y i t by s t a t i n g t h a t t h e r e are u n a n t i c i p a t e d advantages t o b e i n g alone, t o b e i n g able t o do whatever, whenever they wish. T h i s group was i n t h e i r t w e n t i e s d u r i n g the 1960s and seem to have a g r e a t e r outward focus and r e s i l i e n c y i n t h e i r approach t o bereavement and l i f e . A l l of them i n d i c a t e a c t i v e involvement with a s s i s t i n g daughters i n t h e i r t w enties through t h e i r bereavement. Younger respondents i n t h e i r f o r t i e s , are d i f f e r e n t s t i l l — i n c o r p o r a t i n g more of a h o l i s t i c approach, with death b e i n g viewed as p a r t of l i f e and e x p r e s s i n g hopes of making the g r i e f e x p e r i e n c e one of growth wi t h p o s i t i v e outcome. Remarriage i s not as important t o them at t h i s p o i n t as i s a s u c c e s s f u l , p o s i t i v e e x perience f o r both themselves and t h e i r c h i l d r e n . The most i n t e r e s t i n g aspect of the responses i s the g e n e r a t i o n a l change i n the p h i l o s o p h i c a l and p s y c h o l o g i c a l framing of 167 t h e i r bereavement e x p e r i e n c e s . A l l o f the above i n d i v i d u a l s are w e l l engaged i n Tasks I I I and IV wit h i n f e r r e d new r o l e d e f i n i t i o n and a c t i v i t i e s . Most have a c h i e v e d t h i s p o i n t by b e i n g i n v o l v e d i n the bereavement i n t e r v e n t i o n d u r i n g the e a r l y stages o f bereavement, when p r e v e n t i v e i n t e r v e n t i o n i s most i n d i c a t e d . Having had t h a t experience, these respondents now note a need t o "move on", t o address other i s s u e s — " i s s u e s r e l a t e d t o b e i n g s i n g l e " , t o f i n d other means of i n t e r a c t i o n and community. Models of Assessment f o r Bereavement I n t e r v e n t i o n I t i s important t o a s c e r t a i n those most at r i s k and to t a r g e t them f o r bereavement i n t e r v e n t i o n s t r a t e g i e s . I t i s noted i n the study t h a t e l d e r l y men and young women i n t h e i r t w e n t i e s seem t o be p a r t i c u l a r l y at r i s k . I t i s a l s o noted t h a t those w i t h l i t t l e time f o r p r e p a r a t i o n f o r the death of the f a m i l y member s e l f - p e r c e i v e d need f o r a s s i s t a n c e and chose t o p a r t i c i p a t e i n the bereavement i n t e r v e n t i o n . T h e i r p r o g r e s s w i t h t h e i r bereavement r e s o l u t i o n i n d i c a t e s t h a t the i n t e r v e n t i o n p r o v i d e d a s u p p o r t i v e m i l i e u w h i l e p r e v e n t i n g g r i e f r e l a t e d d i f f i c u l t i e s from a r i s i n g . As time went by, these i n d i v i d u a l s moved toward p e r s o n a l 168 r e d e f i n i t i o n r a t h e r than e x p e r i e n c i n g acute g r i e f i s s u e s . T h i s r e f l e c t s d i f f e r i n g needs t h a t are found i n two models of assessment f o r i n t e r v e n t i o n — p r e v e n t i o n and growth — developed by Zautra and Sandler (1983). They p o s i t two complementary models f o r " g u i d i n g needs assessment e f f o r t s f o r p r e v e n t i o n programs", one of which addresses p r e v e n t i o n of pathology, the other enhancement of p e r s o n a l development (p.35). While these models may appear t o have d i f f e r i n g focus, f o r the purposes of bereavement i n t e r v e n t i o n both are a p p l i c a b l e and adaptable. Both the dynamics of s o c i a l support networks and community r e s o u r c e s a v a i l a b i l i t y are important i n a s s e s s i n g the need f o r bereavement i n t e r v e n t i o n and t o mediate a p p r o p r i a t e l y f o r an i n d i v i d u a l and h i s / h e r f a m i l y . Through i n t e r p r e t i n g the f i n d i n g s p r e s e n t e d i n Chapter 4, i t i s observed t h a t s p e c i f i c t a s k r e s o l u t i o n , hence p r o g r e s s through the g r i e v i n g p r o c e s s , a s s i s t s i n d e l i n e a t i n g the i n t e r v e n t i o n needs and r e l e v a n t i n t e r v e n t i o n s t r a t e g y — t h a t of p r e v e n t i o n or p e r s o n a l growth enhancement. P s y c h o l o g i c a l D i s t r e s s Model T h i s model i s based upon the assessment of the impact of a s t r e s s f u l event upon an i n d i v i d u a l . I t i s a p r e v e n t i v e i n t e r v e n t i o n model which 169 f o c u sses needs assessment e f f o r t s on symptoms and ways i n which t o a l l e v i a t e t h e i r harmful e f f e c t s . C o l l e c t i v e l y a cross p o p u l a t i o n s — i t has been shown t h a t c e r t a i n r i s k f a c t o r s may p r e d i s p o s e i n d i v i d u a l s t o d i f f i c u l t g r i e v i n g t r a j e c t o r i e s . Thus c e r t a i n p o p u l a t i o n s are deemed "at r i s k " . An i d i o s y n c r a t i c i n t e r p r e t a t i o n o f d i s t r e s s would be the meaning a s c r i b e d t o the event by the i n d i v i d u a l — the i n d i v i d u a l ' s p e r s o n a l a p p r a i s a l . Even though the death event may have profound consequences f o r an i n d i v i d u a l , the p e r s o n a l a p p r a i s a l may not n e c e s s a r i l y be n e g a t i v e , or one of r e q u i r i n g a c t i v e i n t e r v e n t i o n . "Our time t o g e t h e r b e f o r e her death was h i g h l y p o s i t i v e and c l o s e ... we fought the good f i g h t " (Respondent). The G r i e f and Adjustment Scores are i n d i c a t o r s o f p o s s i b l e d i f f i c u l t i e s t h a t may r e q u i r e a p r e v e n t i v e i n t e r v e n t i o n . The d i f f i c u l t i e s are confirmed when the Worden Task analyses are undertaken — as w e l l as p i n p o i n t i n g the l e v e l of i n t e r v e n t i o n (Task I or I I ) . P s y c h o l o g i c a l Growth Model Zautra and Sandler (1983) i n d i c a t e t h a t "evidence of p e r s o n a l development begins with the assessment of events t h a t s i g n i f y e i t h e r s u c c e s s f u l t r a n s a c t i o n s with the environment or o p p o r t u n i t i e s f o r success" (p.45). In the bereavement p r o c e s s , t h i s model 170 r e l a t e s d i r e c t l y t o Task I I I engagement which Worden (1982) deems t o be the t u r n i n g p o i n t i n g r i e v i n g r e s o l u t i o n . The growth model a p p l i e s d i r e c t l y t o those i n d i v i d u a l s who have engaged s u c c e s s f u l l y i n Tasks I and I I and are seen t o be engaging i n a c t i v i t i e s / b e h a v i o u r s t h a t are s e l f - e n h a n c i n g . These are r e v e a l e d i n the P l a c e and Person Metaphors and r e l a t e t o s e l f - i m a g e , r o l e r e d e f i n i t i o n and a p o s i t i v e i n t e r a c t i o n with the environment (which may a l s o have undergone r e d e f i n i t i o n ) . Death of a l o v e d one i s a d e f i n i t i v e event. C e r t a i n c h a r a c t e r i s t i c s of p a l l i a t i v e care programming p r o v i d e u n d e r l y i n g support f o r g r i e f a m e l i o r a t i o n and the p o s s i b i l i t y of an e v e n t u a l p o s i t i v e a f f e c t a s s o c i a t e d with having e x p e r i e n c e d the l o s s . By i n c o r p o r a t i n g the f a m i l y as the u n i t of care and encouraging p e r s o n a l involvement i n d e c i s i o n s and c a r i n g , mastery and a sense of c o n t r o l , coping s t r a t e g i e s and p e r s o n a l e f f i c a c y , are enhanced. "I hadn't r e a l i z e d t h e r e were b e n e f i t s t o b e i n g s i n g l e " , "I f e e l much more s e l f - c o n f i d e n t and I'm d o i n g t h i n g s t h a t I've never done b e f o r e " (Respondents). These comments are i n d i c a t i v e of p o s i t i v e growth responses found w i t h i n bereavement r e s o l u t i o n . I t i s important t o note however t h a t the t r a n s f o r m a t i o n of the p a i n of g r i e f i n t o the energy r e q u i r e d 171 f o r c r e a t i v i t y and growth only seems p o s s i b l e a f t e r Tasks I and II have been experi e n c e d f u l l y . D i s c u s s i o n I n d i v i d u a l s who would b e n e f i t from the P s y c h o l o g i c a l Growth Model tend t o be those who approached l i f e problems with p o s i t i v e a t t i t u d e s and who were e i t h e r not deemed at r i s k or had s u c c e s s f u l l y engaged wi t h Tasks I and I I . Those who p a r t i c i p a t e d i n the i n t e r v e n t i o n have p r o g r e s s e d beyond a P s y c h o l o g i c a l D i s t r e s s Model of i n t e r v e n t i o n . T h i s i l l u s t r a t e s the success of the bereavement i n t e r v e n t i o n i n a m e l i o r a t i n g the bereavement p r o c e s s . While support may s t i l l be r e q u i r e d by some of t h i s group (those with the lower G r i e f and Adjustment s c o r e s ) , the i n t e r v e n t i o n i t s e l f may need reassessment and a change i n focus t o co n c e n t r a t e on growth i s s u e s . Assessment While assessment of need may address two models o f i n t e r v e n t i o n , the assessment f o r the a c t u a l bereavement i n t e r v e n t i o n r e q u i r e s two l e v e l s of a n a l y s i s — the community and the i n d i v i d u a l / f a m i l y . Community assessment A knowledge base of s e r v i c e s a v a i l a b l e i n the community, at both the formal and i n f o r m a l support l e v e l s i s necessary. There a l s o needs t o be an awareness of b a r r i e r s t o programming which may appear i n the g u i s e of p o l i c i e s or f u n d i n g parameters, and the 172 a v a i l a b i l i t y of t r a i n e d p e r s o n n e l . Target i n t e r c e p t s can be i d e n t i f i e d and may i n c l u d e : churches, neighbourhood houses, s e r v i c e c l u b s , community s e r v i c e s , w e l l n e s s groups, s c h o o l s and v a r i o u s agencies through which programming and/or other types o f supports may be made a v a i l a b l e . There may a l s o be need f o r p u b l i c e d u c a t i o n and thus an assessment of media a v a i l a b i l i t y , speakers, and the degree o f r e c e p t i v i t y which would u l t i m a t e l y d e f i n e content and t a r g e t p o p u l a t i o n s . With t h i s broad range of community based r e s o u r c e , a f u l l complement of both p r e v e n t i v e and growth o r i e n t e d i n t e r v e n t i o n s c o u l d be e v o l v e d i n a network of support s t r u c t u r e s . I n d i v i d u a l / f a m i l y assessment There are f o u r major r o u t e s through which an assessment of i n d i v i d u a l / f a m i l y needs can be made i n the p a l l i a t i v e programming p r i o r t o the death o f the f a m i l y member. P s y c h o - s o c i a l assessments o f the i n d i v i d u a l / f a m i l y c o p i n g r e p e r t o i r e s , support networks, h e a l t h f a c t o r s and o t h e r i n t e r v e n i n g v a r i a b l e s ( i e . f i n a n c i a l ) are common areas of assessment f o r s o c i a l workers i n h e a l t h c a r e s e t t i n g s . As w e l l , known bereavement r i s k f a c t o r s can be i d e n t i f i e d — c o n f l i c t e d r e l a t i o n s h i p w i t h the dy i n g i n d i v i d u a l , problem areas i n f a m i l y f u n c t i o n i n g , 173 men over age seventy, poor h e a l t h , no support networks, e t c . With t h i s i n f o r m a t i o n an assessment of a p p r o p r i a t e t a r g e t s f o r i n t e r v e n t i o n , and l e v e l s of i n t e r v e n t i o n (prevention/growth) can be assessed. For example, c h i l d r e n w i l l respond t o v a r i o u s s t r a t e g i e s - p l a y therapy, a r t / m u s i c therapy — g i v e n t h e i r l e v e l of development. A d o l e s c e n t s respond w e l l t o music/group t h e r a p i e s . The p e r s o n a l s t o r y of the i l l n e s s e x p e r i e n c e r e v e a l s c o p i n g mechanisms, areas o f s t r a i n e d r e s o u r c e s and concern, s t r e n g t h s and worldview/philosophy, as w e l l as the q u a l i t y of the r e l a t i o n s h i p between the p a t i e n t and the i n d i v i d u a l / f a m i l y . I t has been found through p e r s o n a l e x p e r i e n c e o f the i n v e s t i g a t o r t h a t newly admitted p a t i e n t s and/or t h e i r f a m i l y members a p p r e c i a t e the o p p o r t u n i t y t o t e l l t h e i r s t o r i e s and t o express t h e i r concerns — many of which focus on the we l f a r e of the f a m i l y post-bereavement. The advantage of a p a l l i a t i v e care programme i s the i n t e r d i s c i p l i n a r y n ature o f the care and the a b i l i t y of each team member t o share t h e i r concerns and o b s e r v a t i o n s about the w e l l - b e i n g of i n d i v i d u a l s and/or f a m i l y members. Dush (1988) outlines a health concern c h e c k l i s t that very simply e l i c i t s patients' concerns about t h e i r health status and "takes about f i v e minutes to complete. . . . I t appears that a c h e c k l i s t such as t h i s helps some patients to surface concerns that they would otherwise be reluctant to bring up -- such as 'sexual d i f f i c u l t i e s ' " (p.23). An adaptation of t h i s type of checklist may be of assistance i n assessing individual/family concerns and s u r v i v a l needs, and may be f i l l e d out r e t r o s p e c t i v e l y by the s o c i a l worker as a resource t o o l , or d i r e c t l y by the i n d i v i d u a l s concerned thus enhancing t h e i r control over information and interventive care. It i s important to remember that bereavement intervention i s not a treatment but the provision of professional intervention i n a caring and supportive environment, through which "the greatest g i f t we can o f f e r the bereaved i s to be with them" ( F i e f e l i n Moos, 1986, p.255) -- to t r u l y be with them i n whatever manner i s required. Planning Intervention It i s important therefore for bereavement programs to recognize the s o c i e t a l and 175 f a m i l y s t r u c t u r e s t h a t impinge upon an i n d i v i d u a l ' s bereavement e x p r e s s i o n . Myths of " f a m i l y " and " s o c i a l network support" must not i n t e r f e r e w i t h an assessment of a c t u a l need. When a f a m i l y member d i e s , the t o t a l f a m i l y system i s i n v o l v e d i n d i v i d u a l l y i n r e c o n c i l i n g t h a t l o s s . Thus i n t e r v e n t i o n r e q u i r e s f l e x i b i l i t y and i n g e n u i t y i n order t o meets the v a r i o u s needs of age groups and l i f e s t a g e s . While programmes f o r a d u l t s t e n d t o encompass a l l age groups, some i n d i v i d u a l s may r e l a t e b e t t e r t o sex and/or age d i f f e r e n t i a t i o n -- young s i n g l e d f a t h e r s , r a i s i n g c h i l d r e n and assuming c a r e g i v i n g and domestic r o l e s may have d i f f i c u l t i e s r e l a t i n g t o the needs of e l d e r l y men wit h grown f a m i l i e s and v i c e v e r s a . Teens and c h i l d r e n r e q u i r e t h e i r own co h o r t s t o enable freedom of e x p r e s s i o n . The types of programmes developed t h e r e f o r e depend a grea t d e a l upon the needs of the bereaved b e i n g met. Summary The s e a r c h f o r meaning i s seen as a key f a c t o r i n the g r i e f p r o c e s s . A d e s c r i p t i v e a n a l y s i s of f i n d i n g s from a bereavement i n t e r v e n t i o n study which i n c o r p o r a t e d two methodologies has been p r e s e n t e d t o p r o v i d e i n s i g h t i n t o the 176 structures of meaning which occur during the grieving process. Coding for a quantitative analysis of the data derived indices which provide measurement of the degree of bereavement resolution by the study respondents at one point i n time, t h i r t e e n months post-bereavement. Core categories were evolved and analyzed q u a l i t a t i v e l y to ascertain how i n d i v i d u a l s frame the grieving process over time and to what extent t h i s process has been ameliorated by bereavement intervention. The core categories are those of "time" and "meaning", unify the numerous themes presented i n the data and r e l a t e to the objectives of the study on both the personal and s o c i e t a l constructs under consideration. William Worden's Four Tasks of Grieving (1982) have been u t i l i z e d to assess the degree of bereavement resolution of the two groups, hence the need for intervention. Two models of intervention have been suggested — preventive and growth enhancing — at two l e v e l s of a p p l i c a t i o n — individual/informal and formal support networks. The roles of support networks, r i t u a l , role r e d e f i n i t i o n , and s o c i a l psychological processes have been discussed. The data indicates that i n d i v i d u a l s with the bereavement intervention have better g r i e f r e s o l u t i o n than 177 do the majority of i n d i v i d u a l s without the intervention. 178 CHAPTER 6 IMPLICATIONS FOR PRACTICE C h a p t e r 5 d e a l t w i t h t h e f i r s t o f t h e t h r e e p r i m a r y o b j e c t i v e s : t h e need f o r bereavement i n t e r v e n t i o n . Based upon d a t a d e r i v e d from t h e s t u d y , t h i s c h a p t e r w i l l a d d r e ss t h e r e m a i n i n g two o b j e c t i v e s o f t h e t h e s i s : i m p l i c a t i o n s f o r p r a c t i c e i n c o r p o r a t i n g f a m i l y r e s o u r c e e v a l u a t i o n t h r o u g h c o n t e x t u a l a n a l y s i s , and t h r o u g h i d e n t i f y i n g s o c i a l s t r u c t u r e s w h i c h impinge upon t h e g r i e v i n g p r o c e s s : p o l i c y i m p l i c a t i o n s f o r p r o v i s i o n o f bereavement i n t e r v e n t i o n programming and f o r t h e o v e r a l l w e l f a r e o f b e r e a v e d i n d i v i d u a l s . The d i s c u s s i o n w i l l be p r e s e n t e d i n two s e c t i o n s : SECTION I w i l l encompass a systems approach t o i n t e r v e n t i o n and w i l l be f o l l o w e d by i m p l i c a t i o n s f o r i n t e g r a t i v e p r a c t i c e . I n t e r v e n t i o n f o r a f a m i l y u n i t b e g i n s upon e n t r y i n t o t h e P a l l i a t i v e Care Programming w i t h a t h o r o u g h assessment of p a t i e n t / f a m i l y needs. 179 Social workers, as members of the P a l l i a t i v e M u l t i -D i s c i p l i n a r y Teams, with t h e i r knowledge of family systems and dynamics, are i n t r i n s i c elements i n the psycho-social dimensions of care for the family u n i t . They are also mediators for family/staff/support services i n t e r a c t i o n s . SECTION II w i l l cover p o l i c y and programming development. Subsumed within t h i s area of discussion are government p o l i c i e s and programmes which have consequences for bereaved i n d i v i d u a l s , government and hosp i t a l p o l i c i e s that define programming and funding parameters, and implications for programme development for both community and i n d i v i d u a l stakeholders. The role of the So c i a l Worker as p r a c t i t i o n e r and po l i c y i n i t i a t o r w i l l be discussed SECTION I To enable bereavement r i s k assessment and intervention i t i s incumbent upon "those caring for family members during bereavement to have basic understanding of human behaviour, family 180 dynamics, and the psychology of g r i e f and bereavement in order to i d e n t i f y needs" (Ajemian and Mount, 1980, p.426) . Family resources and transactional patterns — the creative capacity of the family system to promote coping and su r v i v a l , to e f f e c t healing, to generate new knowledge; and the family's capacity to in t e r a c t with the outside world i n a manner that i s conducive to enhancing and preserving family i n t e g r i t y — c r i t i c a l l y impact bereavement outcome (Karpel, 1986; Kirschner and Kirschner, 1986) . The challenge i s to ameliorate c r i s e s such that the continuity and consistency of the family's i n t e g r i t y are maintained. Every role, r e s p o n s i b i l i t y and function f u l f i l l e d by the dying member i s ... irreplaceably l o s t to the family system. Every member of the family i s being effected uniquely and d i f f e r e n t l y at many i n t e r a c t i n g l e v e l s (Brenner, 1985, p.15). Knowledge of family systems, of i n t e r r e l a t e d external and i n t e r n a l relationships and responses, and of family l i f e cycle dynamics, i s necessary to mediate the experience of g r i e f and bereavement — not only for the family but also for the s t a f f with whom the family i n t e r a c t s (Jenkins, 1989). 181 The l o s s of a f a m i l y member r e s u l t s i n a major d i s r u p t i o n i n f a m i l y c o n f i g u r a t i o n and r o l e d e l i n e a t i o n . From a systemic p e r s p e c t i v e , concerns are r e l a t e d t o i d e n t i f y i n g f a c i l i t a t i n g elements t h a t w i l l a m e l i o r a t e the t r a n s i t i o n and engender f e e l i n g s of s e c u r i t y and competence. T h i s l i f e stage i s brought about by the c r i t i c a l event of the death o f a s i g n i f i c a n t other, and r e s u l t s i n the l o s s of e s t a b l i s h e d pathways and f a m i l i a r i n t e r a c t i o n a l p a t t e r n s . Coping c a p a c i t i e s are s t r e t c h e d as the bereaved attempt t o i n c o r p o r a t e meaning and purpose i n t o t h i s new e x p e r i e n c e . The extent of the g r i e f r e a c t i o n i s e f f e c t e d by the i n t e r p r e t a t i o n of the i l l n e s s experience by the i n d i v i d u a l , and i s f u r t h e r i n f l u e n c e d by the r e l a t i o n s h i p t o the deceased, by the s t r e n g t h of t h a t r e l a t i o n s h i p and by the coping s t r a t e g i e s developed over the r e l a t i o n s h i p time span. (Raphael, 1982). I m p l i c a t i o n s f o r P r a c t i c e The systems approach of a n a l y s i s i s chosen as the means t o understand c o n t e x t of f a m i l y , s o c i a l support network, and community/societal network — t h e i r component p a r t s , s t r u c t u r e and dynamicism, and t o focus i n t e r v e n t i o n e f f o r t s . I t became apparent i n Chapter 5 t h a t i n d i v i d u a l s do not 182 g r i e v e i n i s o l a t i o n but are p a r t of l a r g e r systems which i n c l u d e both i n f o r m a l and formal support networks which are a l s o embedded w i t h i n s o c i e t a l v a l u e s and norms. I n t e r v e n t i o n S t r a t e g i e s The f a m i l y systems paradigm p r o v i d e s a framework f o r an a n a l y s i s of s u p p o r t i v e networks, a l l o w i n g i n t e g r a t i o n of v a r i o u s systemic designs w h i l e i n c o r p o r a t i n g a n a l y s i s of f a m i l y w i t h i n the l a r g e r network. This w i l l r e q u i r e a merging and c o n c e p t u a l i z i n g of these i s s u e s i n a manner conducive t o c l a r i f y i n g the p r o c e s s and dynamics of the f a m i l y i n p e r s o n a l and s o c i a l c o n t e x t s . "Family therapy [has] e v o l v e d out of a c o n t i n u i n g search f o r a u s e f u l paradigm t o understand human systems and t o work wit h human problems" (Anderson et a l , 1986, p.3). When c o n s i d e r i n g the death event from the systems p e r s p e c t i v e , i t i s important t o remember concepts t h a t would apply t o Family Systems and t o the g r i e v i n g p r o c e s s . These concepts i n c l u d e the c o n s i d e r a t i o n of the o v e r a l l i n t e r -r e l a t e d n e s s and i n t e r - d e p e n d e n c i e s of the component p a r t s , and the ways i n which they i n t e r a c t . The i n t e r a c t i o n s are p e r c e i v e d at d i f f e r e n t l e v e l s — e n v i r o n m e n t a l ( a b s t r a c t ) , f a m i l i a l subsystems (intermediate) and f a m i l y r e s o u r c e s 183 ( c o n c r e t e ) — a n d are bounded. These boundaries c o n f i n e the p a r t i c u l a r a c t o r s w i t h i n the system and may, or may not, be permeable or open t o movement i n / o u t ( Y e l a j a , 1985). Death of a f a m i l y member r e s u l t s i n a t r a n s f o r m a t i o n of the f a m i l y u n i t . I n i t i a l l y , t h e r e i s a l o s s o f f a m i l y homeostasis, a move away from s t a b i l i t y toward u n c e r t a i n t y (Goldsmith i n Walsh, 1982; I r v i n g and Benjamin i n Y e l a j a , 1985; K i r s c h n e r and K i r s c h n e r , 1986). V a r i o u s elements are i n v o l v e d i n t h i s change and i n c l u d e both i n d i v i d u a l and sy s t e m a t i c coping mechanisms which promote the s u r v i v a l of the f a m i l y u n i t . K a r p e l (1986) has found t h a t the response of these res o u r c e s t o a p e r c e i v e d h o s t i l e environment w i l l depend upon the magnitude of the t h r e a t , the extent of the copin g r e p e r t o i r e , and the a b i l i t y o f a f a m i l y member to assume a l e a d e r s h i p r o l e w h i l e m a i n t a i n i n g s e l f - i n t e g r i t y . F a mily c h a r a c t e r i s t i c s of p r o t e c t i o n , s e l f - r e s p e c t , hope, t o l e r a n c e , a f f e c t i o n and humour f u r t h e r enhance f a m i l y s u r v i v a l . In a d d i t i o n , f a m i l y a t t r i b u t e s o f : permanence, system l i n k a g e s , l e g a c i e s , e n t i t l e m e n t and t r u s t w o r t h i n e s s are p a r t of the resource r e p e r t o i r e a c c e s s e d f o r f a m i l y r e d e f i n i t i o n . V a r i o u s f a m i l y therapy designs can be u t i l i z e d i n p r a c t i c e , depending upon the network c h a r a c t e r i s t i c s t h a t 184 one wishes t o emphasize, and can be combined w i t h an approach encompassing f a m i l y r e s o u r c e s . The f o l l o w i n g t h e o r i e s are i n c l u d e d i n the study as they have s a l i e n t c h a r a c t e r i s t i c s which p e r t a i n t o the needs of bereaved i n d i v i d u a l s . I n t e g r a t i v e f a m i l y therapy p r o v i d e s the focus of context — the p a t t e r n e d behaviour responses and p r e c i p i t a t i n g events -- which r e i n f o r c e s communication p a t t e r n s and c l a r i f i e s the impact on the bereaved p e r s o n - i n -the-system encompassed w i t h i n network t r a n s a c t i o n s . I n t e r a c t i o n a l therapy i n c o r p o r a t e s the concept of r u l e s and i n t e g r i t y . Problem-determined system a n a l y s i s emphasizes the embeddedness of systems and the communication between and w i t h i n system l e v e l s which determine focus and f u n c t i o n i n g a t t r i b u t e s . The s o c i o c u l t u r a l approach embodies the n o t i o n of " c u l t u r e shock" and the consequences of d i s i n t e g r a t i o n and d i s r u p t i o n which may be a s s o c i a t e d w i t h the l o s s of a s i g n i f i c a n t o t h e r . I n t e g r a t i v e f a m i l y therapy. I n t e g r a t i v e f a m i l y therapy i s based upon v a l u e s of l i f e ' s sacredness, the r i g h t t o i n f o r m a t i o n and t o s e l f - d e t e r m i n a t i o n . R e a l i t y i s s t r u c t u r e d by the i n d i v i d u a l r e s u l t i n g i n p e r c e p t i o n - based v u l n e r a b i l i t i e s / d e f e n s e s , communication s t y l e s , c o g n i t i o n s and r e s p o n s i v e p a t t e r n s . "The assessment of the problem 185 depends on a s s e s s i n g the s t r e s s , the d i s c r e p a n c y between image and exp e r i e n c e , imaged s o l u t i o n and a c t u a l i t y , deviance and r e s o u r c e " (Duhl and Duhl, 1981, p.495). The meaning, or person s p e c i f i c p o i n t - o f - v i e w , the communication and t r a n s a c t i o n s among i n d i v i d u a l s , and the impact of the s o c i a l and/or f a m i l y system on the i n d i v i d u a l and v i c e v e r s a are n e c e s s a r y c o n s i d e r a t i o n s . Problem d e t e r m i n a t i o n i n c l u d e s a s s e s s i n g both s i t u a t i o n a l and e x p e r i e n t i a l components -- co p i n g s t y l e s , i n t e r n a l r e s o u r c e s , and the r e p e r t o i r e of automatic p a t t e r n e d behaviours — i n the context o f the be h a v i o u r s . P r e c i p i t a t i n g events and the degree of the d i s t r e s s response are r e l a t e d t o the f l e x i b i l i t y of the network/system. The context o f the death of a f a m i l y member encompasses i n t e r a c t i o n a l , complementary and independency p a t t e r n s e s t a b l i s h e d over the years o f the r e l a t i o n s h i p and an incongruence o f e s t a b l i s h e d f a m i l y r o l e s and h a b i t s w i t h the new s i t u a t i o n . In order t o p l a c e the l o s s o f the f a m i l y member i n p e r s p e c t i v e , i t i s necessary t o look at complementarity w i t h i n the f a m i l y u n i t , the sub-systems/boundaries and the t r a n s a c t i o n a l p a t t e r n s t h a t were e s t a b l i s h e d over the ye a r s . Who assumed the l e a d e r s h i p r o l e f o r the f a m i l y ; who s e t the parameters f o r the l o c a t i o n of 186 f u n c t i o n i n g ; who m aintained the f a m i l y e x e c u t i v e f u n c t i o n s ; who c a r r i e d the f a m i l y v i s i o n t h a t enabled f a m i l y c o n t i n u i t y ? I n t e r a c t i o n a l therapy. I n t e r a c t i o n a l therapy i s c l o s e l y a l i g n e d w i t h i n t e g r a t i v e t h e o r y and i s h e l p f u l i n d e l i n e a t i n g the development of f a m i l y dynamics and i n p e r c e i v i n g u n r e a l i s t i c e x p e c t a t i o n s which e f f e c t the s u r v i v o r ' s t r a n s i t i o n through the g r i e v i n g p r o c e s s . These i n c l u d e the n o t i o n s of " e x p e c t a b i l i t y " and p r e d i c t a b i l i t y ; the balance of separateness and t ogetherness — autonomy i n c o r p o r a t i n g m u t u a l i t y , r e c i p r o c i t y and connectedness; the r u l e s and meta-rules through which the f a m i l y a s s u r e d s t a b i l i t y and change (Bodin, 1981, p.276). The a b i l i t y t o adapt and t o cope w i t h the new f a m i l y c o n f i g u r a t i o n can i n i t i a l l y become overtaxed and the r e s i l i e n c y r e q u i r e d t o s u r v i v e i s s t r e s s e d . T h i s i n a b i l i t y t o f i l l the gaps l e f t by u n f u l f i l l e d e x p e c t a t i o n s and l o s s of v a l u e o r i e n t a t i o n r e s u l t s i n a l a c k of mastery of the environment, and an i n a b i l i t y t o i n c o r p o r a t e the new ' l i f e space'. The r e a l i z a t i o n i s p a i n f u l as i t i s p e r c e i v e d as a t h r e a t t o p e r s o n a l i d e n t i t y and i n t e g r i t y . T h i s a n a l y s i s a l s o a p p l i e s t o s o c i e t y ' s " e x p e c t a t i o n s " of newly bereaved i n d i v i d u a l s / f a m i l i e s ; the " r u l e s " of the 187 network and t h e i r impact on the bereaved. What does a "thre e day bereavement l e a v e " s i g n i f y ? Problem-determined system a n a l y s i s . In t h i s approach " h e l p i n g agents and c l i e n t s ... must be understood w i t h i n the e n t i r e context o f the l a r g e r system" (Levin, e t a l , 1986, p.66). The c o n t e x t u a l components are i n c l u s i v e of the v a l u e s and meaning systems o f the bereaved i n d i v i d u a l s and the s o c i a l s t r u c t u r e s with which they i n t e r a c t . The problem d e f i n i t i o n l i e s i n the shared communication of " a l l i n d i v i d u a l s a c t i v e l y i n v o l v e d i n communicative i n t e r a c t i o n ... [who] form the ecology o f id e a s t h a t d e f i n e the membership of the communicating system" (Anderson e t a l , 1986, p.8). The membership of t h i s network i s d e r i v e d from the observed communications between f a m i l y members, h e l p i n g agencies and f a m i l i e s , community and f a m i l i e s . T h i s i n c l u d e s the assessment f o r community i n t e r v e n t i o n o u t l i n e d i n Chapter 5. Evan Imber-Black (1986) suggests t h a t f a m i l y therapy sh o u l d be c o n s i d e r e d i n a much broader context than t h a t of the n u c l e a r c o n s t e l l a t i o n , n o t i n g t h a t "the f a m i l y i s embedded i n l a r g e r systems, which are, i n t u r n , embedded i n a wider s o c i a l and economic c o n t e x t " (p.30), and c a u t i o n s t h a t i n t e r v e n t i o n must be at the a p p r o p r i a t e l e v e l . 188 Communication p a t t e r n s must be r e l a t e d t o content i n order t o understand the r e a l i t i e s f a c i n g bereaved i n d i v i d u a l s / f a m i l i e s . Normal a n a l y s e s of r e c i p r o c i t y and c i r c u l a r i t y tend not t o c o n s i d e r i s s u e s of power. Lack of access t o r e s o u r c e s t h a t ensure s e l f - d e t e r m i n a t i o n (through l o s s or i n a b i l i t y t o access power) " r e p r e s e n t s a d i s t o r t i o n o f the systemic paradigm" and h i g h l i g h t s p o s s i b l e b e r e a v e d / s o c i a l communications as mentioned above. The concept o f t r i a d s a l s o takes on a new t w i s t when c o n s i d e r e d as i n t e r a c t i o n s between t h r e e systems — the i n d i v i d u a l / f a m i l y , the community support network, the p a l l i a t i v e program or h e a l t h c a r e system — and the p o s s i b l e impact on support g i v e n the d i f f e r i n g focus on needs. S o c i o c u l t u r a l approach Another way of a n a l y z i n g the formal support network i s a s o c i o c u l t u r a l approach which i s concerned with "the behaviour of i n d i v i d u a l s w i t h i n the impersonal i n s t i t u t i o n s of s o c i e t y " (De Hoyos e t a l , 1986, p.62). The authors combine i n t e g r a t i v e and i n t e r a c t i o n a l approaches with a t h i r d stage — s o c i o c u l t u r a l i n t e r v e n t i o n . While t h i s approach has been developed t o c o u n s e l e t h n i c m i n o r i t i e s , t h e r e i s d i r e c t a p p l i c a t i o n f o r bereaved i n d i v i d u a l s and access to formal support. The concept of d i s c r i m i n a t i o n c o u l d be understood i n the context of pension 189 a v a i l a b i l i t y and/or s u r v i v o r s ' b e n e f i t s , a c c e s s ( r e f e r r a l ) t o community s u p p o r t networks t h r o u g h m e d i c a l g a t e k e e p e r s , and p o l i c i e s / f u n d i n g t h a t s t r u c t u r e program a v a i l a b i l i t y . C u l t u r a l d i s s o n a n c e a p p l i e s t o t h e c o n t r a s t between s o c i a l r o l e s (and acceptance) b e f o r e and a f t e r t h e bereavement. Consequences t o t h o s e deemed a t r i s k i n t h i s a n a l y s i s a r e e x t e n s i v e and r e s u l t from t h e combined e f f e c t o f : s o c i a l d i s l o c a t i o n - d e n i a l o f " a c c e s s t o c o n d i t i o n a l l y r e w a r d i n g r o l e s " [ i e . no l o n g e r p a r e n t , spouse, c h i l d • • • ] ; c u l t u r a l d i s l o c a t i o n - from l o s s o f a s c r i b e d meaning o f mourning t r a d i t i o n s and community s u p p o r t ; s o c i o c u l t u r a l d i s l o c a t i o n - " v a l u e s and s o c i a l s t r u c t u r e s a r e f a r removed from and a t v a r i a n c e w i t h t h e . . . [ n e t w o r k ] . . . v a l u e s and s o c i a l s t r u c t u r e " [ i e . no l o n g e r a c o u p l e ; 'abandoned' a f t e r d e a t h o f o n l y p a r e n t ; ' c a s t - o u t ' . ] ( I b i d , p.64) D i s c u s s i o n The f o r e g o i n g d i s c u s s i o n has o u t l i n e d f o u r f a m i l y systems t h e r a p y approaches f o r a s s i s t i n g t h e p e r s o n -i n - t r a n s i t i o n - i n - e n v i r o n m e n t and a r e not m u t u a l l y e x c l u s i v e , as an a n a l y s i s can i n c o r p o r a t e many systems frameworks o f f a m i l y t h e r a p y i n m e d i a t i n g t h e g r i e v i n g p r o c e s s . A s p e c t s 1 9 0 of Salvador Minuchin's s t r u c t u r a l a n a l y s i s can be i n c o r p o r a t e d i n t o a n a l y z i n g sub-system boundaries, the s h i f t s o f r e l a t i o n s h i p s and i n t e r a c t i o n s between and w i t h i n the sub-systems, and the r e s t r u c t u r i n g t h a t occurs w i t h the f a m i l y r e d e f i n i t i o n ( c i t e d i n K i r s c h n e r and K i r s c h n e r , 1986). Psycho-dynamic concepts o f J . R i c e and D. Ri c e (1986) i n c l u d e s the concepts f a m i l y l e g a c i e s and r o l e models. Through K i r s c h n e r and K i r s c h n e r (1986), an understanding of u n r e a l i s t i c e x p e c t a t i o n s and unmet needs a s s i s t s w i t h c l a r i f y i n g the r e l a t i o n s h i p and ne g a t i n g i d e a l i z i n g t e n d e n c i e s . The emphasis on f a m i l y r e s o u r c e s f u r t h e r expands the realm o f p s y c h o t h e r a p e u t i c i n t e r v e n t i o n t o i n c l u d e context, t r a n s i t i o n and pr o c e s s (Karpel, 1986). Paul and M i l l e r ( i n K a r p e l , 1986) c a u t i o n t h a t " i n t e l l e c t u a l knowledge w i t h e r s i n the f a c e of the c h a l l e n g e of u s i n g these n o t i o n s e x p e r i e n t i a l l y " (p.439). I m p l i c a t i o n s f o r I n t e g r a t e d P r a c t i c e The data show t h a t t h e r e are m u l t i f a r i o u s combinations and permutations of coping c a p a c i t i e s and s k i l l s , as w e l l as d i f f e r e n t i a l g r i e f r e s o l u t i o n among members of the two study groups. These are r e l a t e d t o support networks, r i t u a l , r o l e r e d e f i n i t i o n , and s o c i a l p s y c h o l o g i c a l p r o c e s s e s t h a t may 191 have p o s i t i v e or n e g a t i v e i n f l u e n c e upon i n d i v i d u a l g r i e v i n g and p r e s e n t the c h a l l e n g e f o r i n t e g r a t e d p r a c t i c e . " S o c i a l network i s viewed ... as a s h i f t i n g c o n f i g u r a t i o n of s t r u c t u r e s and p r o c e s s e s t a k i n g p l a c e w i t h i n c o n c e p t u a l l y bounded sets* of i n d i v i d u a l s " ( E r i c k s o n , 1984, p.187). R e f e r e n t i a l frameworks of bereaved i n d i v i d u a l s s h i f t i n s t r u c t u r e and p r o c e s s . The complex i n t e r a c t i o n a l p a t t e r n s t h a t s t r u c t u r e the i n d i v i d u a l ' s s o c i a l and p h y s i c a l environments undergo s u b t l e shadings of change from t h a t of d i s c r e t e f a m i l y u n i t with spouse/parent a l i v e t o f a m i l y without spouse/parent . The c o m p a t i b i l i t y of changed p r i o r f a m i l y ' r u l e systems' w i t h the new i d e n t i t y c o m p l i c a t e s t r a n s i t i o n . T h i s may be augmented by the degree of p e r s o n a l d i f f e r e n t i a t i o n or c o n s t r a i n e d by past r o l e a s c r i p t i o n or may be exacerbated by the degree of anomie from the v a l u e s of the s o c i a l network. With the focus of a n a l y s i s expanding t o the support network, the i n d i v i d u a l / f a m i l y system i s subsumed i n t o the l a r g e r environment and i n t o the m u l t i p l e l a y e r s of i n t e r a c t i o n s and feedback w i t h which the i n d i v i d u a l must contend. I t i s here t h a t network f u n c t i o n i n g i s deemed e i t h e r s u p p o r t i v e or i n h i b i t i v e i n i t s e f f e c t upon the 192 d i s c r e t e system and i n i t s a b i l i t y t o absorb the s y s t e m i c needs of the bereaved i n d i v i d u a l s . The i n d i v i d u a l ' s network, which may s t i l l i n c l u d e the f a m i l y , now s h r i n k s as f r i e n d s , r o l e s and e x p e c t a t i o n s change and/or d i s a p p e a r — and as decreased income/mobility i n f r i n g e upon a b i l i t y t o m a i n t a i n a c t i v i t i e s / c o n n e c t i o n s . T h i s i m p l i e s a system of response r e a c t i o n s / p a t t e r n s to environmental cues and r e a l i t i e s t h a t d e f i n e the context and s t r e n g t h / s u p p o r t of the environment. I t i s t h e r e f o r e , important t o a s c e r t a i n the v a r i o u s i n d i c a t o r s of p o s i t i v e support and e n a b l i n g mechanisms w i t h i n the s t r u c t u r e of the network system and t o i n d i c a t e ways i n which s o c i a l workers can mediate the process f o r the bereaved. Network i n t e r v e n t i o n c o n s i d e r s m i s s i n g s t r u c t u r e s of p a s t (and p o s s i b l e f u t u r e ) t r u n c a t e d s o c i a l systems and attempts t o i n c o r p o r a t e new s t r u c t u r e through p r o v i d i n g l i n k a g e s t o o p p o r t u n i t i e s f o r shared experience and i n f o r m a t i o n . The i n d i v i d u a l i s [re]connected w i t h a s o c i a l network which may i n c l u d e v o l u n t e e r support, bereavement group p a r t i c i p a t i o n , mutual a i d / s e l f h e l p o r g a n i z a t i o n s , p r o f e s s i o n a l c o u n s e l l i n g , telephone buddy systems, w e l l n e s s programs, art/ m u s i c therapy f o r c h i l d r e n / t e e n s . C o n f l i c t and disharmony i s g e n e r a l l y the s i g n a l e r of a 193 broader base of problems w i t h i n the f a m i l y systems i t s e l f , as w e l l as r e f l e c t i v e of d i f f i c u l t i e s with network t r a n s a c t i o n s . Bowen (Kerr, 1982) suggests t h a t : "In t h i s sense, symptoms r e f l e c t a f a i l u r e of a d a p t a t i o n by the system and are exaggerations of normal p r o c e s s e s . T h i n k i n g of symptoms as p a t h o l o g i c a l can obscure t h i s view of the u n d e r l y i n g system f o r c e s " (p.235). I n t e r v e n t i o n i n the f a m i l y and family/network t r a n s a c t i o n s , w i t h a focus on the changing p a t t e r n s and forms of both system l e v e l s may be i n d i c a t e d . S o c i a l networks f u n c t i o n as powerful determinants of a person's access to i n f o r m a t i o n , a s s i s t a n c e , s o c i a l support, o p p o r t u n i t i e s t o g a i n competence and t o i n f l u e n c e d e c i s i o n s a f f e c t i n g w e l l - b e i n g . Network processes a l s o f u n c t i o n "to r e i n f o r c e norms and v a l u e s r e g u l a t i n g behaviour" (Mclntyre, 1986, p.422). F o l l o w i n g i s an e x p l o r a t i o n of some network components where change s t r a t e g i e s may be t a r g e t e d . Each grouping of components i s not meant t o be mutually e x c l u s i v e . In f a c t , a l l are h i g h l y i n t e r r e l a t e d . The groupings are simply ways of d e l i n e a t i n g areas or concepts f o r e a s i e r e l u c i d a t i o n . I t i s a l s o h e l p f u l i n a s c e r t a i n i n g where the access t o i n f o r m a t i o n may l i e , how o p p o r t u n i t i e s f o r competency and w e l l - b e i n g are encouraged — or not, as the case may be. P rocesses t h a t r e i n f o r c e p a t t e r n s of behaviour responses are noted and r e f l e c t the c u l t u r e of the network. Co n t e x t u a l R e a l i t i e s and R e l a t i o n a l Processes The response of i n d i v i d u a l s t o p r e s s u r e s p l a c e d upon t h e i r i n t e g r i t y w i l l depend a g r e a t d e a l upon the meaning of the death event t o the i n d i v i d u a l . Parkes (1971) r e l a t e s l i f e t r a n s i t i o n competency t o the number of other change events t h a t have o c c u r r e d i n the i n d i v i d u a l ' s l i f e . T h i s i s brought t o bear on the i n d i v i d u a l g r i e f e x p e r i e n c e and may n e c e s s i t a t e a t o t a l r e s t r u c t u r i n g of the i n d i v i d u a l ' s assumptive world. A s c e r t a i n i n g the bereaved i n d i v i d u a l ' s c o n s t r u c t i o n of r e a l i t y — the meaning of l o s s and the i m p l i c a t i o n s on a d a p t a b i l i t y and adjustment t o the system c o n f i g u r a t i o n — i s one way the s o c i a l worker can enable r e d e f i n i t i o n . T h i s meaning a l s o r e q u i r e s d e l i n e a t i o n i n terms of secondary gains which w i l l impede g r i e f r e s o l u t i o n . For example, a r o l e of d i s a b i l i t y and i l l n e s s may i n t e n s i f y f a m i l y a t t e n t i o n and r e i n f o r c e h e l p l e s s n e s s / h o p e l e s s n e s s r a t h e r than d e v e l o p i n g compensatory a d a p t a t i o n a b i l i t i e s . Duhl and Duhl (1981) i n c o r p o r a t e the concept of " v u l n e r a b i l i t i e s " or "defenses" as ways i n which f a m i l y 195 p a t t e r n s are "played" i n "the quasi- s i m u l t a n e o u s , the r i c o c h e t - l i k e r e l e a s e of automatic b e h a v i o u r s ... as one person's defense t r i g g e r s another's v u l n e r a b i l i t y " (p.502). E n a b l i n g r e d e f i n i t i o n draws upon the need f o r empathic v a l i d a t i o n . Encouraging the t e l l i n g of the s t o r y , s h a r i n g the " i n s " and "outs" of the experi e n c e i s c r i t i c a l . Extreme p a t i e n c e and empathic understanding are bonuses i n t h i s p r o c e s s . I n i t i a l l y , the most one may expect i s d e v e l o p i n g a sense of s a f e t y and t r u s t . " S a f e t y i s the f e e l i n g e x p e r i e n c e d when you know t h a t one's boundaries w i l l be res p e c t e d , t h a t you are regarded by ot h e r s w i t h c a r i n g " ( I b i d , p.506). As a l l u d e d t o above, i t i s a l s o necessary t o a s c e r t a i n ways i n which the network c o l l u d e s t o m a i n t a i n avoidance behaviours r a t h e r than i n t e r v e n i n g t o f a c i l i t a t e the p s y c h o - s o c i a l t r a n s i t i o n . The concept o f m u l t i p l e r e a l i t i e s o f problem d e f i n i t i o n and problem s o l u t i o n — where e v e r y t h i n g i s connected t o e v e r y t h i n g e l s e — lends i t s e l f t o m a i n t a i n i n g a s t a t u s quo u n l e s s t h e r e are ways t o work through what may be a t h e r a p e u t i c impasse. When an i n d i v i d u a l i s i n v o l v e d i n the emotional t r a n s i t i o n of a d j u s t i n g t o a new s i t u a t i o n , the a b i l i t y t o ma i n t a i n separate emotional and i n t e l l e c t u a l system f u n c t i o n i n g i s impaired. "When these two systems are not 196 f u n c t i o n a l l y separate, man l o s e s t h a t c h o i c e and behaviour and t h i n k i n g are more e m o t i o n a l l y determined" (Kerr, 1981, p.237). The emotional o v e r l o a d e x p e r i e n c e d by most newly bereaved i n d i v i d u a l s r e s u l t s i n withdrawal from the v e r y t h i n g t h a t i s needed most - the i n t e r a c t i o n and support of o t h e r s . When the system i s non-responsive, or i s 'stuck' i n i t s approach, i t overlooks the f a c t t h a t withdrawal i s as much an i n d i c a t i o n of need f o r others as i s o v e r t emotional dependence. The demands or e x i g e n c i e s of the s p e c i f i c g r i e f c ontext are n e c e s s a r i l y d e f i n e d by the i n d i v i d u a l ' s and/or f a m i l y ' s c o p i n g r e p e r t o i r e . The e f f e c t i v e n e s s of t h i s c o p i n g must be c o n c e p t u a l i z e d when a n a l y z i n g p a r t i c u l a r i n t e r v e n t i o n s . The r e l a t i o n s h i p between the s u p p o r t i v e environment and the bereaved r e q u i r e s c a r e f u l c o n s i d e r a t i o n i n o r d e r t o f u l l y understand the m u l t i p l e r e a l i t i e s t h a t e x i s t and the ways i n which the 'message' i s imparted (see metacommunications, below). To t h i s end, Gunderson (1985) suggests f i v e h i e r a r c h i c a l t h e r a p e u t i c f u n c t i o n s t h a t meet v a r i o u s needs. The f i r s t , found i n e a r l y g r i e f , i s "containment", and r e l a t e s d i r e c t l y t o Maslow's f i r s t h i e r a r c h i c a l need — t h a t of s e c u r i t y . T h i s i s the assurance of p h y s i c a l w e l l - b e i n g and s a f e t y f o r the bereaved and may be as simple as who w i l l 197 be i n the house, who w i l l prepare the meals, or as c o m p l i c a t e d as who w i l l pay the b i l l s . Secondly i s "support" — which c o n s i s t s of d e l i b e r a t e attempts t o decrease a n x i e t y and d i s t r e s s . " S t r u c t u r e " r e s u l t s a f t e r the f i r s t month and i n c l u d e s the o r g a n i z a t i o n of the support environment such t h a t the i n t e g r i t y i s p r e s e r v e d through meeting b a s i c needs. Over time two f u r t h e r components would be "involvement" — the g r a d u a l enhancement of ego f u n c t i o n i n g through support a c t i v i t i e s designed t o r e i n f o r c e competence — and, " v a l i d a t i o n " -- enhancing the uniqueness and p e r s o n a l v a l u e of the i n d i v i d u a l . Boundaries, System F l e x i b i l i t y and Morphostasis Family and support network c h a r a c t e r i s t i c s can e i t h e r f a c i l i t a t e or h i n d e r the t r a n s i t i o n i n t o the new c o n f i g u r a t i o n . The a c t u a l boundaries of the system — the degree of exchange w i t h i n and permeation from without t h a t has been t o l e r a t e d — and the conceptual boundaries — the assumptive world meaning a s c r i b e d t o the death event and the r e l a t e d s t r e s s e s — are a t t r i b u t e s t o be c o n s i d e r e d . The openness of the f a m i l y system, i t s c r e a t i v e response and growth enhancement a b i l i t y , the m u l t i p l i c i t y of emotional needs and concerns, and i t s c a p a c i t y f o r a d a p t a t i o n , are other p r o p e r t i e s i n h e r e n t i n e a s i n g the t r a n s i t i o n . 1 9 8 An awareness of c l i e n t / f a m i l y systems i n need of h e l p and support, and r e o r g a n i z a t i o n o f the f a m i l y r o l e s , i s necessary. The p a r t i c u l a r i n t e r r e l a t i o n a l and t r a n s a c t i o n a l p a t t e r n s w i t h i n the f a m i l y system d e f i n e t h a t system. R i g i d i t y of f u n c t i o n , double b i n d s , n e gations are i n d i c a t i v e of r e l a t i o n s h i p r o l e s i n a c l o s e d system. A f a m i l y system i n c o r p o r a t i n g these q u a l i t i e s would suggest h i e r a r c h i c a l power bases or complementarity. P r e f e r e n c e f o r m a i n t a i n i n g s t a t u s quo system f u n c t i o n i n g , r a t h e r than changing pseudo-m u t u a l i t y , r e i n f o r c e s o l d r o l e s and e x p e c t a t i o n s which may not be conducive t o g r i e f r e s o l u t i o n . P a t t e r n s of i n t e r a c t i o n t h a t have become r o u t i n i z e d and impersonal are i n d i c a t i v e of a c l o s e d system w i t h i n f l e x i b l e r e l a t i o n s h i p r u l e s . A happy medium would embody the a b i l i t y of a system t o mai n t a i n an e q u i l i b r i u m and s t a b i l i t y w i t h i n a framework of growth and i n t e g r a t i o n . T h i s would be i n d i c a t i v e of having achieved a balance between morphogenesis and morphostasis — the c o n s o l i d a t i o n of i n n o v a t i o n and change w i t h s t a b i l i t y — thus p r o v i d i n g an even r e f e r e n t i a l p o i n t f o r the bereaved having p r e d i c t a b l e s t r u c t u r e w h i l e a l l o w i n g f o r c r e a t i v e response t o t h e i r m u l t i f a c e t e d needs. R i t u a l s , symbolism and c r e a t i v e g r i e v i n g s t r a t e g i e s i l l u s t r a t e t h i s b a l a n c e . A 199 c r e a t i v e response can a l s o be a product of mutual e x p l o r a t i o n by the i n d i v i d u a l / f a m i l y and s o c i a l worker — an i n t e r p r e t a t i o n of environmental s t r e s s and/or i n d i v i d u a l v a l i d a t i o n needs .. "I have my own f r i e n d s now". From the s o c i o c u l t u r a l p e r s p e c t i v e , the s o c i a l worker can work acr o s s the " c u l t u r e s " of the support network and the f a m i l y environment t o d e a l " s i m u l t a n e o u s l y w i t h the c l i e n t s ' emotional adjustment, i n t e r p e r s o n a l r e l a t i o n s w i t h support systems [formal and i n f o r m a l ] , and adjustment t o s o c i e t a l s t r u c t u r e s " (De Hoyos et a l , 1986, p. 66). "My f r i e n d s don't want t o hear these t h i n g s " ; " I t doesn't seem t o take men l o n g t o f i n d someone e l s e " (Respondents). Communication As d i s c u s s e d p r e v i o u s l y i n Chapter 4, communication i s never s t r a i g h t f o r w a r d , b e i n g comprised of the t r a n s a c t i o n s and l i n k a g e s w i t h i n the f a m i l y / s o c i a l system — and g e n e r a l l y c o n t a i n s messages w i t h i n messages (metaphorical l e v e l s of meaning) (Hanen et a l . 1979). T h i s i s f u r t h e r d e f i n e d by the context i n which the message occurs — the time, p l a c e , with whom. How the bereaved p e r c e i v e s the support network/family c o n f i g u r a t i o n i s very much a product of p e r c e p t i o n of "analogs" or r u l e s which d e f i n e the r e l a t i o n s h i p of f a m i l y members t o each other and t o support system. In systems theory, communication i s 200 d e f i n e d i n i n f o r m a t i o n - p r o c e s s i n g terms which i n c o r p o r a t e a l l t he above dynamics and r e l a t e i t s flow — d i r e c t i o n a l i t y , energy and content c h a r a c t e r i s t i c s — t o the boundary p e r m e a b i l i t y and the openness of the system. Communication assumes many purposes. Boundaries between f a m i l y and network or between f a m i l y members may be s u s t a i n e d f o r reasons of separateness. I t may a l s o be an e x p r e s s i o n o f a need f o r c o n t i n u a t i o n of a l i f e - l o n g c o n t r o l of r o l e s and r e l a t i o n s h i p s . I t may be expressed as a c t i v e withdrawal. D i f f e r e n t f a m i l y members may be p e r c e i v e d as p a r t of the power system. Lack of r e s p o n s e / p a r t i c i p a t i o n may not merely be the e x e r c i s i n g of an i n d i v i d u a l ' s p r e r o g a t i v e of c h o i c e , but may be a s t r o n g d i s a p p r o v a l of the i m p o s i t i o n o f i r r e l e v a n t e x p e c t a t i o n s . I t i s worth a s s e s s i n g who i s i n v o l v e d and who i s u n i n v o l v e d when e v a l u a t i n g the e f f i c a c y of coping s t r a t e g i e s . A major concern i n f a m i l y therapy i s the metacommunication c o n t a i n e d at the s u b l i m i n a l l e v e l t h a t s t r u c t u r e s the r e l a t i o n s h i p s , r u l e s , r e c i p r o c i t y , and complementarity found w i t h i n the system. T h i s communication i s the meaning behind messages l i k e " We d i d n ' t have a f u n e r a l . I t was nobody's b u s i n e s s but our own." and i s more than boundary r i g i d i t y . I t i s r e f l e c t i v e of "the nature of 201 interdependence between p a r t s ; and ... the degree t o which u n c e r t a i n t i e s a f f e c t the behaviour of the system" as w e l l as the complexity of the i n t e r a c t i o n s ( R i c c i and S e l v i n i -P a l a z z o l i , 1984, p.169). The complexity i s heightened by the number o f p l a y e r s , the r e l a t i o n s h i p s o f r e l a t i o n s h i p s and the l i n k a g e s between these r e l a t i o n s h i p t e r r i t o r i e s . "I'm c l o s e r t o the in-laws, my f a m i l y always t r y t o t e l l me what t o do". To i l l u s t r a t e the nature of complexity, R i c c i and S e l v i n i - P a l a z z o l i (1984) move beyond dyadic communication t o a h i g h e r l e v e l t h a t i n c o r p o r a t e s the metacommunication meaning: "the game i t s e l f , and not the v a r i o u s p l a y e r s , s h o u l d be c o n s i d e r e d the " r e a l " r e c e i v e r of the sender's communication" (p.171). They p r e s e n t a g r a p h i c i l l u s t r a t i o n of t h i s schema which i s e v i d e n t at a l l l e v e l s of communication — p e r s o n a l , i n t e r p e r s o n a l , and s o c i e t a l : 1. I (sender) 2. am s a y i n g something (message) 3. t o you (apparent r e c e i v e r ) i n e v i t a b l y and co n c o m i t a n t l y 4. t o him/them 5. i n t h i s s i t u a t i o n (context) " ( I b i d ) . Stanton (1984) r e l a t e s communication t o : s p a t i a l "maintenance of s e l f - o t h e r c l a r i t y " (personal 202 space) — "My son t r i e s t o t e l l me what t o do, but I can handle i t " (Respondent); g r a d a t i o n s t h a t are i n c o r p o r a t e d i n " c l o s e n e s s - i n t i m a c y or d i s t a n c e - s t r a n g e n e s s " — " [with new f r i e n d s . . . ] my son has the k i l l e r i n s t i n c t , he always goes f o r the j u g u l a r " (Respondent). These dynamics must be c o n s i d e r e d i n l i g h t of the impact on the bereaved — c o n s i d e r e d i n l i g h t of the ambience of the f a m i l y system — and the " c u l t u r e " of the s u p p o r t i v e environment. D i s c u s s i o n The f a m i l y systems t h e r a p i e s and i m p l i c a t i o n s f o r i n t e g r a t i v e p r a c t i c e d i s c u s s e d above s e n s i t i z e the t h e r a p i s t / s o c i a l worker t o the many l e v e l s of i n t e r v e n t i o n t h a t maybe r e q u i r e d t o mediate the g r i e v i n g p r o c e s s f o r an i n d i v i d u a l / f a m i l y . I t i s a l s o p o s s i b l e t o d e l i n e a t e g e n e r a l t h e r a p e u t i c s t r a t e g i e s which w i l l a m e l i o r a t e the g r i e v i n g e x p e r i e n c e : s u p p o r t i n g and a l l o w i n g the g r i e f process, and a c c e p t i n g the permanence of the change; a s s i s t a n c e by the t h e r a p i s t with p r a c t i c a l and immediate consequences of the m u l t i p l e l o s s e s i n h e r e n t i n the death of the f a m i l y member; a c h i e v i n g a deeper u n d e r s t a n d i n g of t r a n s a c t i o n a l 203 p a t t e r n s t h a t l i m i t / a s s i s t the t r a n s i t i o n ; l e t t i n g g o — b o t h s y m b o l i c a l l y and a c t u a l l y — t h e f a n t a s i e s of the l o s t r e l a t i o n s h i p . In t h i s way the stage i s s e t f o r r e b u i l d i n g s e l f - e s t e e m , f o r a renewed b e l i e f i n the f u t u r e and i n a p e r s o n a l a b i l i t y t o form i t . As Judy Tatlebaum (1980) so a p t l y w r i t e s i n the c l o s e of her book The Courage t o G r i e v e , "As we journey through these p a i n f u l e x p e r i e n c e s of l i v i n g , we must never f o r g e t t h a t we have an amazing r e s i l i e n c e and c a p a c i t y t o s u r v i v e . ... j u s t as s p r i n g f o l l o w s winter, so i t ' s nature's way, t h a t through i t a l l , whatever we s u f f e r , we can keep growing. I t takes courage t o b e l i e v e we can s u r v i v e , t h a t we w i l l grow. I t takes courage, too, t o l i v e now and not postpone l i v i n g u n t i l some vague tomorrow" (p.160). SECTION II C h a r a c t e r i s t i c s of the Sampled Bereavement Programme C u r r e n t l y two hundred p a t i e n t s / f a m i l i e s per year are c a r e d f o r through the P a l l i a t i v e Care Programme at study h o s p i t a l . The program i s d e d i c a t e d t o p r o v i d i n g comfort and emotional support f o r the p a t i e n t and f a m i l y members, both 204 i n the h o s p i t a l and at home. E x t e n s i v e i n t e r v e n t i o n and a m e l i o r a t i o n are c a r r i e d out p r i o r t o the death of the f a m i l y member by the P a l l i a t i v e Care Team, through c o o r d i n a t i o n by the S o c i a l Worker, Head Nurse and M e d i c a l D i r e c t o r . V o l u n t e e r support i s p r o v i d e d by t r a i n e d v o l u n t e e r s , both on the P a l l i a t i v e Care U n i t and i n the community under the d i r e c t i o n of a V o l u n t e e r C o o r d i n a t o r (B.S.W.) and the program S o c i a l Worker. Bereavement c o u n s e l l i n g i s p r o v i d e d b e f o r e , d u r i n g and a f t e r death. The S o c i a l Worker p r o v i d e s 1:1 bereavement c o u n s e l l i n g and d i r e c t s on-going, bi-weekly bereavement groups of up t o t w e n t y - f i v e (25) persons. The f i r s t meeting of each month i s d e d i c a t e d t o i n f o r m a t i o n about g r i e f and bereavement and t o r e s o l v i n g p a r t i c i p a n t i s s u e s . The second meeting i s p r i m a r i l y concerned with b u i l d i n g s o c i a l support amongst the p a r t i c i p a n t s . New p a r t i c i p a n t s are asked t o s t a r t w i t h the f i r s t monthly meeting which i s s t r u c t u r e d , r a t h e r than the second which i s more i n f o r m a l . V o l u n t e e r s are i n t e g r a l components of these s e s s i o n s and a l s o c a r r y out 1:1 support under the d i r e c t i o n of the S o c i a l Worker. I n d i v i d u a l s are f r e e to p a r t i c i p a t e f o r any l e n g t h of time -- g i v e n t h e i r p e r s o n a l needs, and can a l s o drop-out and r e t u r n at any time should they so wish. 205 A l l f a m i l i e s i n the P a l l i a t i v e Programme r e c e i v e an i n v i t a t i o n t o p a r t i c i p a t e i n Bereavement Follow-up through a l e t t e r and a telephone c a l l one month post bereavement — from the S o c i a l Worker wi t h v o l u n t e e r a s s i s t a n c e . Family members are encouraged t o a t t e n d i n d i v i d u a l l y , w i t h o t h e r f a m i l y members, or with a c l o s e f r i e n d . Of the f a m i l y members p a r t i c i p a t i n g i n the P a l l i a t i v e Programme, onl y t w e n t y - f i v e per cent (25%) f e e l they need f u r t h e r support and choose t o p a r t i c i p a t e i n Bereavement Follow-up. (This i s c o n s i s t e n t with h o s p i c e study f i n d i n g s i n the U n i t e d S t a t e s (Roy and Sumpter, 1983; 0'Toole, 1987)). E i g h t y f i v e per cent (85%) of the Bereavement Group p a r t i c i p a n t s are s e l f - r e f e r r e d from the community at l a r g e and r e p r e s e n t s i n d i v i d u a l s whose f a m i l y member d i e d at a d i f f e r e n t h o s p i t a l . T h i s t r a n s l a t e s t o approximately f i f t y (50) s u r v i v o r s e n r o l l e d from the P a l l i a t i v e S e r v i c e s , and one hundred-seventy f i v e (175) s e l f - r e f e r r e d i n d i v i d u a l s p a r t i c i p a t i n g per year. I m p l i c a t i o n s Concerning Bereavement I n t e r v e n t i o n from the  F i n d i n g s The study bereavement group i s an open-ended, on-going group and i s t h e r e f o r e not time-bounded as are most 206 programmes o u t l i n e d i n the l i t e r a t u r e (Yalom, 1989; Silverman, 1986; Osterweiss et a l . 1984). There are advantages t o both approaches which accounts f o r i n c l u s i o n of both types i n Program Components (below). Respondents t o the study noted the b e n e f i c i a l e f f e c t s of group, v o l u n t e e r and s o c i a l worker support and i n f o r m a t i o n . Some i n d i c a t e d t h a t they found i t d i f f i c u l t t o connect w i t h people c o n s i s t e n t l y — because of the f l e x i b l e in-and-out nature of the programme — thus missed d e v e l o p i n g a support network/group w i t h whom they c o u l d i n t e r a c t o u t s i d e the group environment. Even though some p a r t i c i p a n t s were a b l e t o do t h i s , t h e r e was concern v o i c e d about the d i f f e r e n t l e v e l s of g r i e v i n g w i t h i n the bereavement group and t h e r e f o r e d i f f e r i n g needs. P a r t i c i p a n t s a l s o mentioned t h a t they wished f o r i s s u e s t o change as they changed and t o address aspects of b e i n g s i n g l e and the s o c i a l c o n s t r a i n t s they f e l t o l d f r i e n d s , b u s i n e s s a s s o c i a t e s and the community i n g e n e r a l p l a c e d on them. Most f e l t t h a t t h e i r g r i e v i n g needs had been met but t h a t t h e i r s o c i a l needs had not been. Most of those who d i d not p a r t i c i p a t e i n the group i n d i c a t e d t h a t they d i d not f e e l they r e q u i r e d a s s i s t a n c e when f i r s t c o n t a c t e d . T h i s i s v a l i d as not a l l i n d i v i d u a l s 207 r e q u i r e bereavement i n t e r v e n t i o n . Outcome a n a l y s i s however, found t h a t f i v e of the seven i n d i v i d u a l s without bereavement i n t e r v e n t i o n would have b e n e f i t t e d from a s s i s t a n c e — and t h a t one had sought p r i v a t e c o u n s e l l i n g s i x months p o s t -bereavement. The i m p l i c a t i o n from t h i s group and from the l i t e r a t u r e (Silverman, 1986, Vachon, 1988) i s t h a t a one-month post-bereavement fol l o w - u p may be too soon as the support network may s t i l l be engaged at t h a t time. Disengagement of f r i e n d s and d i s t a n t f a m i l y members may not occur u n t i l a f t e r the one month p e r i o d , thus g i v i n g the bereaved i n d i v i d u a l f a l s e sense of w e l l - b e i n g . The i m p l i c a t i o n i s t h a t a one-month c o n t a c t i s i n d i c a t e d t o "touch base" and a three-month c o n t a c t r e g a r d i n g bereavement group p a r t i c i p a t i o n may be more r e a l i s t i c . For those who r e f u s e p a r t i c i p a t i o n , a r e g u l a r three-month c o n t a c t i s suggested f o r the f i r s t year. While the i n d i v i d u a l who withdrew from the study s t a t e d t h a t another year was needed, an on-going c o n t a c t would make i t e a s i e r f o r t h i s i n d i v i d u a l t o r e a c h out f o r h e l p or f o r group i n t e r v e n t i o n when the time i s r i g h t . The p a l l i a t i v e care programme i t s e l f was s u f f i c i e n t support f o r two people i n the study. Programme support f o r the p a t i e n t / f a m i l y and f o r a n t i c i p a t o r y bereavement i s s u e s , 208 l i f e - l o n g h a b i t s of meeting a d v e r s i t y as c h a l l e n g e s , the q u a l i t y o f the r e l a t i o n s h i p with the deceased, and p e r s o n a l h e a l t h , s t r e n g t h s , sex and age combined t o a s s i s t these i n d i v i d u a l s through t h e i r g r i e v i n g p r o c e s s . Time-bounded programmes tend t o run f o r e i g h t s e s s i o n s — e i t h e r one per week f o r two months, or biweekly f o r f o u r months — d u r i n g which time a n a t u r a l p r o g r e s s i o n from engaging i n the r e a l i t y of the l o s s and e x p e r i e n c i n g the p a i n through t o disengagement from the group and an outward focus on meeting needs from community and i n f o r m a l support networks i s encouraged. "Homework" and/or g r i e v i n g e x e r c i s e s may be undertaken d u r i n g these s e s s i o n s but Yalom and Vinogradov (1988) c a u t i o n t h a t the use of t e c h n i q u e s and formulae are not always a p p r o p r i a t e f o r the i n d i v i d u a l s i n the group or f o r group dynamics t h a t may develop d u r i n g a s p e c i f i c s e s s i o n . Thus i f t h i s approach i s t o be u t i l i z e d , group f a c i l i t a t o r s must be j u d i c i o u s and f l e x i b l e i n t h e i r use. The advantage of these groups i s the a b i l i t y t o focus on s p e c i f i c i s s u e s which encourages preparedness by p a r t i c i p a n t s , and enhancement of group c o h e s i o n and the i n f o r m a l support t h a t r a p i d l y develops d u r i n g the programme which has a tendency t o s p i n o f f i n t o o u t s i d e a c t i v i t i e s . 209 The disadvantages are found i n the time- boundedness — i n the l a c k of o p p o r t u n i t y t o opt back i n t o the bereavement i n t e r v e n t i o n s h o u l d d i f f i c u l t i e s need a d d r e s s i n g , and i n the maximum four-month p e r i o d i n h e r e n t i n the programme d e s i g n s . Some programmes have i n c o r p o r a t e d f l e x i b i l i t y i n a l l o w i n g an i n d i v i d u a l t o a t t e n d two c o n s e c u t i v e bereavement i n t e r v e n t i o n s i f necessary, as w e l l as d e v e l o p i n g a p r o f e s s i o n a l l y s u p e r v i s e d , v o l u n t e e r run s o c i a l support group f o r those who have completed the i n i t i a l e i g h t s e s s i o n s . Another advantage l i e s i n a concern f o r l i m i t e d r e s o u r c e s and t r a i n e d p e r s o n n e l . Lack of both d e l i m i t the a v a i l a b i l i t y of on-going programming, thus p r o v i d i n g an i n c e n t i v e f o r time-bounded programmes. Bereavement I n t e r v e n t i o n Programme Development Programme development i s r e l a t e d t o meeting the c h a l l e n g e of " p r o v i d i n g the most a p p r o p r i a t e care, i n the most a p p r o p r i a t e p l a c e , at the most a p p r o p r i a t e time" (Fyke, P a l l a n and J u z w i s h i n , 1988) . In d e l i n e a t i n g standards f o r p a l l i a t i v e / h o s p i c e care, the I n t e r n a t i o n a l Work Group i n Death, Dying and Bereavement (1978) e l u c i d a t e d assumptions, p r i n c i p l e s and standards which r e l a t e t o bereavement care and are o u t l i n e d i n Table 210 17 below. Many standards which p e r t a i n t o h o s p i c e / p a l l i a t i v e care p h i l o s o p h y , team, l i n k s t o the community, and p s y c h o s o c i a l needs of p a t i e n t s and f a m i l i e s are a p p l i c a b l e t o t h i s d i s c u s s i o n but are not i n c l u d e d as space would not permit. These assumptions and p r i n c i p l e s p r e s e n t e s s e n t i a l u n d e r l y i n g standards f o r p a l l i a t i v e s e r v i c e s e s t a b l i s h i n g bereavement i n t e r v e n t i o n programmes. They do not address content nor t a r g e t p o p u l a t i o n s of programming but may a c t as g u i d e l i n e s from which t o address bereavement needs of s u r v i v o r s . 211 Table 17: Assumptions p e r t a i n i n g , Standards and P r i n c i p l e s t o Bereavement I n t e r v e n t i o n "Assumptions P r i n c i p l e s S u r v i v o r s are at r i s k e m o t i o n a l l y and p h y s i c a l l y d u r i n g bereavement The p r o v i s i o n of a p p r o p r i a t e care f o r s u r v i v o r s i s the r e s p o n s i b i l i t y o f the team who gave care and support t o the deceased. Standards P r i n c i p l e s Hospice care p r o v i d e s c o n t i n u i t y of c a r e . C o n t i n u i t y of care ( s e r v i c e s and personnel) reduces the p a t i e n t ' s and the f a m i l y ' s sense of a l i e n a t i o n and fragmentation. Hospice care f o r the f a m i l y extends i n t o the bereavement p e r i o d . Family needs co n t i n u e a f t e r the death of one of t h e i r members. Hospice care i s p r o v i d e d by an i n t e r d i s c i p l i n a r y team. No one i n d i v i d u a l or p r o f e s s i o n can meet a l l the needs of t e r m i n a l l y i l l p a t i e n t s and f a m i l i e s a l l the time." (Rando, 1984, pp.293-300) Ajemian and Mount (1980) supplemented these e f f o r t s by o u t l i n i n g f o r t y - o n e assumptions and p r i n c i p l e s s p e c i f i c a l l y designed t o " a s s i s t i n "the development of care programs t o a s s i s t the g r i e v i n g and bereaved" (Ajemian and Mount, 1980, pp. 422-428). These g e n e r a l assumptions and p r i n c i p l e s are o r g a n i z e d i n t o f o u r major areas of concern: f a m i l y , c a r e g i v e r s , bereavement programmes and community, and r e s e a r c h i n bereavement. Many of these are i m p l i c i t i n the f o l l o w i n g programme d e l i n e a t i o n . 212 P h i l o s o p h y Encompassed w i t h i n the P a l l i a t i v e Care p h i l o s o p h y , bereavement i n t e r v e n t i o n i s subsumed w i t h i n c o n t i n u i t y of care and enables s u r v i v o r s t o f i n d q u a l i t y and meaning from l i f e and death e x p e r i e n c e s . I t i s p r o v i d e d t o a s s i s t i n d i v i d u a l s with a d j u s t i n g t o the l o s s o f a l o v e d one. G r i e f i s c o n s i d e r e d a n a t u r a l , h i g h l y p e r s o n a l response t o t h i s l o s s which i s m a n i f e s t e d i n a v a r i e t y o f p h y s i c a l and emotional d i s t r e s s e s and i s a l i f e t r a n s i t i o n through which some i n d i v i d u a l s r e q u i r e compassionate support. Bereavement care p r o v i d e s a n u r t u r i n g environment which f a c i l i t a t e s s a f e passage f o r the p e r s o n - i n - t r a n s i t i o n . Goals The goals of bereavement i n t e r v e n t i o n are t o f a c i l i t a t e the g r i e v i n g p r o c e s s through the p r e v e n t i o n or a l l e v i a t i o n of d e t r i m e n t a l consequences of g r i e v i n g , and t o enhance the i n t e g r i t y of the person and the f a m i l y u n i t . O b j e c t i v e s The o b j e c t i v e s of bereavement i n t e r v e n t i o n are : t o p r o v i d e f a m i l y members wit h i n f o r m a t i o n about the normal g r i e f p r o c e s s ; t o p r o v i d e o p p o r t u n i t i e s t o review and r e f l e c t upon the l o s s e xperience; t o assess and monitor i n d i v i d u a l c o p i n g a b i l i t i e s , s t r e s s l e v e l s and a v a i l a b l e support; 213 t o encourage f a m i l i e s t o u t i l i z e e x i s t i n g support systems or t o seek and c r e a t e a d d i t i o n a l sources of support. Programme Components Not everyone r e q u i r e s e x t e n s i v e i n t e r v e n t i o n and support d u r i n g the bereavement p r o c e s s , but most a p p r e c i a t e i n f o r m a t i o n and v a l i d a t i o n of t h e i r p a i n and sorrow. C e r t a i n p o p u l a t i o n s are at g r e a t e r r i s k f o r prolonged, and p o s s i b l y p a t h o l o g i c a l , g r i e f r e a c t i o n s . In order t o respond t o the broad range of need, programme components need t o be f l e x i b l e i n terms of content, time of day, and age/time of l i f e s p e c i f i c i t y . A broad range of programmes — a l l encompassing p r o f e s s i o n a l s u p e r v i s i o n and v o l u n t e e r involvement — are t h e r e f o r e suggested: I n - h o s p i t a l monthly memorial s e r v i c e t o which f r i e n d s and f a m i l i e s bereaved i n the p r i o r month are i n v i t e d ; s t a f f are a l s o encouraged t o a t t e n d . Four week fo l l o w - u p group — 1 meeting per week — o f f e r e d t o a l l who a t t e n d the memorial s e r v i c e , d u r i n g which p r a c t i c a l i s s u e s r e g a r d i n g f i n a n c e s , income tax, p e n s i o ns, g r i e f p r o c e s s w i l l be d i s c u s s e d . Attendees r e q u e s t i n g f u r t h e r a s s i s t a n c e or i n d i c a t i n g g r e a t e r need w i l l be r e f e r r e d t o an a p p r o p r i a t e i n t e r v e n t i o n group or t o 1:1 c o u n s e l l i n g . 214 Bi-weekly evening group — 2 per month — on-going d r o p - i n f o r mutual support and f o r i n f o r m a t i o n / i s s u e r e s o l u t i o n . Widow-to-widow — can be c a r r i e d out i n c o n j u n c t i o n w i t h a church or a community resource, under p r o f e s s i o n a l s u p e r v i s i o n . Men's Group - may be a g e - s p e c i f i c g i v e n p o p u l a t i o n needs and may cover i s s u e s of s i n g l e p a r e n t i n g , c h i l d -care as w e l l as g r i e f - s p e c i f i c needs and o t h e r l i f e s k i l l s ; may a l s o be c a r r i e d out i n c o n j u n c t i o n w i t h a community group or agency, again, under p r o f e s s i o n a l s u p e r v i s i o n . S p e c i a l groups and 1:1 f o r ad o l e s c e n t s - c o n t r a c t e d out t o a s p e c i a l i s t working with teens. A r t Therapy/Music Therapy and groups f o r c h i l d r e n t o age 12 and f a m i l i e s , both s e p a r a t e l y and i n combination. P o r t i o n s c o n t r a c t e d out. A d u l t f a m i l y groups - r e c o g n i z i n g the i n d i v i d u a l response t o death and g a i n i n g some unde r s t a n d i n g o f how each f a m i l y member i s working through s p e c i f i c g r i e f i s s u e s . 1:1 c o u n s e l l i n g f o r h i g h r i s k i n d i v i d u a l s . On-going c o n t a c t w i t h bereaved i n d i v i d u a l s who do not 215 p a r t i c i p a t e i n Bereavement I n t e r v e n t i o n , at t h r e e month i n t e r v a l s (or more f r e q u e n t l y as i n d i c a t e d ) , by telephone. A Bereavement A n n i v e r s a r y Card sent from the P a l l i a t i v e Care S t a f f and V o l u n t e e r s on the a n n i v e r s a r y of the death of the f a m i l y member. Economic C o n s i d e r a t i o n s C u r r e n t l y the government i s i n v e s t i n g monies i n expensive h e a l t h care f a c i l i t i e s and d o c t o r s f e e s i n order t o p r o v i d e e x c e l l e n t medical care f o r i t s c i t i z e n s . I t i s important t o c o n s i d e r how the money i s spent and what b e n e f i t s accrue. As monies are b e i n g expended, maximum b e n e f i t s h o u l d be a t t a i n e d f o r minimum investment. The s o c i a l c o s t s i n h e r e n t i n u n r e s o l v e d bereavement need to be addressed as these c o s t s r e f l e c t o p p o r t u n i t i e s foregone. In a market economy, people are f r e e t o choose o p t i o n s t h a t b r i n g them the h i g h e s t p e r s o n a l g a i n . When markets f a i l , r e s t r i c t i o n s are p l a c e d on the a b i l i t y t o choose. Bereavement support i s o n l y a v a i l a b l e t o a l i m i t e d number of i n d i v i d u a l s i n v o l v e d w i t h p a l l i a t i v e programmes and seldom are s e r v i c e s a v a i l a b l e f o r c h i l d r e n or a d o l e s c e n t s i n the community ot h e r than on an ad hoc b a s i s . The i n c e p t i o n of broad based bereavement i n t e r v e n t i o n 216 comprised of both h o s p i t a l and community a g e n c y / s e r v i c e c l u b / s c h o o l c o o p e r a t i o n ( c o o r d i n a t e d by the P a l l i a t i v e Programme S o c i a l Worker) would amount t o a per c a p i t a c o s t of l e s s than one d o l l a r ($1.00) per person i n the study catchment area. As everyone w i l l e x p e r i e n c e g r i e f and bereavement, t h i s i s a u t i l i t y c o s t t h a t i s redeemable merely through p r o v i d i n g l e s s - c o s t o p t i o n s f o r the p o p u l a t i o n . In e f f e c t , t h i s i n t e r v e n t i o n would r e p r e s e n t an a b s o l u t e advantage over medical i n t e r v e n t i o n when c o n s i d e r i n g l i m i t e d r e source a l l o c a t i o n . Bereavement i n t e r v e n t i o n a l s o embodies government p h i l o s o p h y i n h e r e n t i n g u i d i n g p r i n c i p l e s e s t a b l i s h e d f o r c o o p e r a t i v e health/community v e n t u r e s . I t i n c o r p o r a t e s r e s p o n s i v e programming, wi t h community-based i n t e g r a t i o n of s e r v i c e s through c e n t r a l l y c o o r d i n a t e d program p l a n n i n g t h a t are a p p r o p r i a t e and c o s t - e f f e c t i v e ; and sponsors outreach and community agency/school involvement i n meeting the broad range of needs of bereaved of a l l ages. T h i s enables necessary r e f e r r a l and the f l e x i b i l i t y t o t a i l o r programmes t o changing p o p u l a t i o n c h a r a c t e r i s t i c s . Other i m p l i c a t i o n s are r e l a t e d t o b e n e f i t s a ccrued by the i n d i v i d u a l through awareness and a c c e s s i b i l i t y o f s u p p o r t i v e , s o c i a l r e s o u r c e s ; through changes i n worldview 217 and s e l f - v i e w which evolve from understanding and a c c e p t i n g environment; and the r e d e f i n i t i o n of bereavement as a l i f e t r a n s i t i o n r a t h e r than an i l l n e s s . The end r e s u l t s are l e s s t r a u m a t i c r e s o l u t i o n s and growth i n p e r s o n a l competency through a c q u i r i n g new s t r a t e g i e s and r o l e r e d e f i n i t i o n . P o l i c y I m p l i c a t i o n s P a l l i a t i v e Care/Hospice Care P o l i c y Bereavement Care i s encompassed w i t h i n g u i d e l i n e s f o r Hospice Care programming which were f o r m a l i z e d i n the U n i t e d S t a t e s w i t h i n Medicare Reimbursements i n the Tax E q u i t y and F i s c a l R e s p o n s i b i l i t y Act, 1982, f o l l o w i n g years of development and d i s c u s s i o n : i n the U n i t e d S t a t e s Congress, House of R e p r e s e n t a t i v e s , 197 6; from Hospice Standards developed by the N a t i o n a l Hospice A s s o c i a t i o n , 1978; from v a r i o u s N a t i o n a l Hospice Symposia; and, through S t a t e e f f o r t s t o s t a n d a r d i z e care f o r t e r m i n a l l y i l l i n d i v i d u a l s and bereaved f a m i l i e s (Hudson, 1988; 0'Toole, 1987; Hospice Development and T e c h n i c a l A s s i s t a n c e Group, 1978). "Hospices are mandated by f e d e r a l and s t a t e r e g u l a t i o n s and 218 by a c c r e d i t a t i o n agencies t o p r o v i d e bereavement care t o f a m i l y members" (O'Toole, 1987, p.185). Canadian g u i d e l i n e s were f i r s t e s t a b l i s h e d i n 1981/82 but are not l e g i s l a t e d (Government of Canada, N a t i o n a l H e a l t h and Welfare, 1981, 1982) . A l l o f these s t a n d a r d s / g u i d e l i n e s o u t l i n e comprehensive bereavement support s e r v i c e s f o r the f a m i l i e s as p a r t o f the h o s p i c e / p a l l i a t i v e care mandate. The o u t l i n e d purposes of the bereavement care are t o : "maintain c o n t i n u i t y of care of the f a m i l y from h o s p i c e admission t o r e s o l u t i o n of g r i e f ; decrease bereavement-related i l l n e s s and death among those a f f e c t e d , w i t h a r e s u l t i n g r e d u c t i o n i n h e a l t h care c o s t s " (Hospice Development and T e c h n i c a l A s s i s t a n c e Group, 1978, p.59). T h i s i n c l u d e s pre-death care and assessment, with a c t i v e bereavement f o l l o w - u p by the s o c i a l worker b e i n g deemed im p e r a t i v e f o r h i g h r i s k i n d i v i d u a l s ( I b i d ) . As a n e c e s s a r y component of P a l l i a t i v e Care S e r v i c e s , the Canadian G u i d e l i n e s i n c l u d e "the development, implementation and e v a l u a t i o n of e f f e c t i v e bereavement s e r v i c e s " (Government of Canada, N a t i o n a l H e a l t h and Welfare, 1981, p.8), with the d e l i v e r y of the p e r s o n a l 219 h e a l t h c a r e and we l f a r e s e r v i c e s b e i n g a p r o v i n c i a l r e s p o n s i b i l i t y . However, t h e r e i s no e x i s t i n g p o l i c y on P a l l i a t i v e Care/Hospice Care at e i t h e r the f e d e r a l or p r o v i n c i a l l e v e l s . P r a c t i c e i n B r i t i s h Columbia has e v o l v e d from the B r i t i s h Columbia H o s p i c e / P a l l i a t i v e Care A s s o c i a t i o n ' s adoption o f components f o r p a l l i a t i v e care from E n g l i s h and American s o u r c e s . I n c l u d e d w i t h i n these programmes i s the Bereavement Component: " Q u a l i f i e d bereavement c o u n s e l l o r s s u p e r v i s e v o l u n t e e r support t o f a m i l y and f r i e n d s a f t e r the death of a p a t i e n t . In a d d i t i o n , the c o u n s e l l o r s are abl e t o i d e n t i f y i n d i v i d u a l s at r i s k of p a t h o l o g i c a l g r i e v i n g " ( S t e e r i n g Committee, M i n i s t r y of Hea l t h , 1987, p.4). While no d e c i s i o n has been made wit h r e g a r d t o implementing p o l i c y — or r a t h e r a d e c i s i o n has been made t o not make one — l a t t e r l y funded programs (St. P a u l ' s H o s p i t a l , Vancouver and S t . Mary's H o s p i t a l , New Westminster) have i n c l u d e d t h i s program component. I n c o r p o r a t i o n o f bereavement i n t e r v e n t i o n can be impeded by l a c k of community reso u r c e s and networks through which bereaved i n d i v i d u a l s and t h e i r f a m i l i e s are a c t i v e l y supported. I n c l u s i o n of bereavement s e r v i c e s i n the h o s p i c e / p a l l i a t i v e programming r e s u l t e d from constant e f f o r t 2 2 0 on the p a r t of h e a l t h care p r o f e s s i o n a l s who emphasized the importance of t h i s component of c a r e . U n f o r t u n a t e l y , while t h i s c o n t i n u i t y o f care has been i n c l u d e d i n American s t a t u t e s , the f u n d i n g r e q u i r e d t o ensure bereavement programme d e l i v e r y and t r a i n i n g of s t a f f has not. 0'Toole (1987) i n d i c a t e s t h a t t h i s has r e s u l t e d i n " c o n f l i c t between mandate and h o s p i c e p h i l o s o p h y on the one hand and l a c k of funds and adequately t r a i n e d s t a f f on the o t h e r ... [thus] c r e a t i n g c o n f l i c t between r e s p o n s i b i l i t y and a b i l i t y " (p.185). Funding f o r programmes i n Canada has h i s t o r i c a l l y been " h o s p i t a l g l o b a l budgets and v o l u n t a r y d o n a t i o n s " (Hudson, 1988, p.40). T h i s has r e s u l t e d i n problems w i t h d e d i c a t i n g r e q u i r e d s t a f f i n g l e v e l s and p o s i t i o n s e x c l u s i v e l y t o the P a l l i a t i v e S e r v i c e s , e s p e c i a l l y at times of l i m i t e d government f u n d i n g and p r e s s u r e on h o s p i t a l bed u t i l i z a t i o n . While the impetus f o r p a l l i a t i v e care i n c l u d e s a c o s t -containment component — p a l l i a t i v e c a r e b e i n g deemed l e s s expensive than acute care i n t e r v e n t i o n — h o s p i t a l s w i l l s t a f f on p r o - r a t e d bases r a t h e r than f u l l y d e d i c a t e s t a f f . T h i s has a f f e c t e d n u r s i n g l e v e l s as w e l l as o t h e r s t a f f i n g -- s o c i a l work, r e h a b i l i t a t i o n s e r v i c e s . Because i t i s d i f f i c u l t t o assess e f f e c t i v e outcome, i t has not been 221 p o s s i b l e t o document and prove the need f o r e x t r a s t a f f i n g and s e r v i c e s (Lamers, 1988; Dush 1988). R e c e n t l y approved p a l l i a t i v e programmes have b e n e f i t t e d from a p r o v i n c i a l impetus toward community-based care which i n c r e a s e s home care w h i l e d e c r e a s i n g h o s p i t a l bed u t i l i z a t i o n . P a l l i a t i v e Care programmes emphasize symptom a l l e v i a t i o n , q u a l i t y of l i f e i s s u e s , and m a i n t a i n i n g t e r m i n a l l y i l l i n d i v i d u a l s i n the home with f u l l support f o r as l o n g as p o s s i b l e . T h i s support combines h o s p i t a l and community e f f o r t s and i n c l u d e s home care n u r s i n g , v o l u n t e e r s and s o c i a l work i n t e r v e n t i o n . Inherent w i t h i n the l a c k of p o l i c y and government p o s i t i o n are f u n d i n g d i f f i c u l t i e s which c o n t i n u e t o plague g l o b a l l y funded h o s p i t a l programmes due t o changing p r i o r i t i e s , l a c k of t r a i n i n g programmes and low l e v e l s of community-based support. Myths surround the concept of community-based care which delude p o l i c y - m a k e r s i n t o b e l i e v i n g t h a t i t w i l l p r o v i d e a magic wand of h e a l t h care cost-containment as w e l l as empower those r e q u i r i n g the system's support. I t i s assumed t h a t community-based care i s cheaper than l a r g e i n s t i t u t i o n a l s e t t i n g s and i n v o l v e s non-paid f a m i l y and v o l u n t a r y community support. I t i s a l s o seen as i n v o l v i n g 222 j o i n t f i n a n c i n g between government m i n i s t r i e s ( h e a l t h and s o c i a l s e r v i c e s ) , t h e r e f o r e c i r c u m v e n t i n g f u t u r e need t o commit r e s o u r c e s t o o t h e r s e r v i c e s . However, Shannon (1989) has noted t h a t w h i l e e s c a l a t i n g h e a l t h care c o s t s have encouraged the r e d u c t i o n of h o s p i t a l - b a s e d care, the p o p u l a r i t y of a c c e s s i b l e community/neighbourhood h e a l t h c e n t r e s has r e s u l t e d i n " r a d i c a l c o s t containment p o l i c i e s " f o r these c e n t r e s (p.34). T h i s i l l u s t r a t e s t h a t merely s h i f t i n g d o l l a r s w i l l not meet the needs of the populace. S o c i a l support systems and v o l u n t a r y e f f o r t s are a l s o m ythologized and not as r e a d i l y a v a i l a b l e as wished. Th e r e f o r e , s u c c e s s f u l community-based programming becomes co n t i n g e n t upon i n c r e a s i n g s t a f f i n g at the community l e v e l . The other problem i n h e r e n t i n funding c u t s i s t h a t the r i s k v a r i a b l e s o u t l i n e d i n Chapter 2 r e p r e s e n t a c t u a l h e a l t h c a r e o p p o r t u n i t y c o s t s r e s u l t i n g from l a c k of response t o the needs of bereaved i n d i v i d u a l s through the a p p r o p r i a t e l e v e l of i n t e r v e n t i o n . S u c c e s s f u l bereavement i n t e r v e n t i o n a l s o r e q u i r e s d e d i c a t e d f u n d i n g and s t a f f i n g t o ensure programme development and i n t e r v e n t i o n , and l i a i s o n with the community support network. P o l i c y d e d i c a t e d t o Bereavement I n t e r v e n t i o n as a component of P a l l i a t i v e Care S e r v i c e s c o u l d be addressed 223 through the f o l l o w i n g o p t i o n . The M i n i s t r y of H e a l t h through the Department of Community and Family H e a l t h c o u l d t o t a l l y fund and p r o v i d e Bereavement I n t e r v e n t i o n S e r v i c e s as a d i r e c t program a d d i t i o n t o P a l l i a t i v e Care S e r v i c e s . The programmes would be d e l i v e r e d and c o o r d i n a t e d through the P a l l i a t i v e Programme S o c i a l Worker i n c o n j u n c t i o n with community agencies and v o l u n t e e r s . Advantages Bereavement care would be f o r m a l l y r e c o g n i z e d as an i n t e g r a l component of p r e v e n t i v e h e a l t h programming i n the h e a l t h care system. D e d i c a t e d funding and a d m i n i s t r a t i o n of the Bereavement I n t e r v e n t i o n would take p l a c e w i t h i n e x i s t i n g s t r u c t u r e s . Funds now b e i n g used t o care f o r bereaved i n d i v i d u a l s i n acute and p s y c h i a t r i c care s e t t i n g s , and through the M i n i s t r y of S o c i a l S e r v i c e s and Housing, would be r e d i r e c t e d t o more a p p r o p r i a t e , economical bereavement support s e r v i c e s . Community energy and committment would be developed and maintained through v o l u n t e e r support component and through community r e s o u r c e s p a r t i c i p a t i o n . Disadvantages 224 A d d i t i o n a l funds would be r e q u i r e d t o meet the most b a s i c c r i t e r i a f o r comprehensive Bereavement I n t e r v e n t i o n . F i n a n c e s As w e l l as fund i n g and re s o u r c e a l l o c a t i o n i n h e r e n t i n programme p o l i c y , f i n a n c e s are a l s o a c r i t i c a l area of concern f o r bereaved i n d i v i d u a l s . Income a f f e c t s our t o t a l w e l l - b e i n g — our access t o food, c l o t h i n g , housing, t r a n s p o r t a t i o n and amenities o f l i f e . While o n l y t h r e e of the f i f t e e n respondents mentioned l o s s o f income, wi t h two n o t i n g d e t r i m e n t a l e f f e c t s , t h i s i s not the norm and i s r e f l e c t i v e o f the upper middle c l a s s catchment area o f the study h o s p i t a l . A l a r g e number of i n d i v i d u a l s i n Canada who l i v e i n pov e r t y are e l d e r l y women and female heads o f households w i t h dependent c h i l d r e n . F a c t o r s which c o n t r i b u t e t o o l d age p o v e r t y are edu c a t i o n and e t h n i c i t y , sex, and the l e n g t h of time i n the labour f o r c e . Hence "to be o l d and female i s the b e s t combination t o ensure b e i n g poor i n Canada" (Delude, 1978, p.38). L o u i s e Delude (1978) i n Women and  Aging adds " t h a t t o be o l d and a widow i s an even b e t t e r combination" and many are seen t o be " l i v i n g i n f i n a n c i a l c i r cumstances t h a t the word "poor" i s too weak t o d e s c r i b e " ( I b i d ) . The Hea l t h and Welfare Canada Monthly S t a t i s t i c s : 225 Income S e c u r i t y Programs, August, 1988, i n d i c a t e s : 1,352,395 p e n s i o n e r s r e c e i v e OAS/GIS and t h a t 47% of t h i s number are s i n g l e women. The N a t i o n a l C o u n c i l of Welfare (NCW), based on 1987 f i g u r e s , found t h a t the pov e r t y r a t e f o r unattached e l d e r l y females was 46.1 per cent (NCW, A p r i l 1988, p . 7 ) . The p l i g h t o f r e t i r e d , widowed women i s ex a c e r b a t e d by a h i s t o r y o f low employment p a r t i c i p a t i o n ( l e s s than 50% of employable women i n the 70s), only 25% covered by pensions which i n t u r n were l i m i t e d by low wages, p e r i o d i c work h i s t o r i e s and a l a r g e amount of p a r t - t i m e employment (Retirement without Tears: Senate Committee Report on Retirement, 1979). Poor s u r v i v o r ' s b e n e f i t s add t o the disadvantaged p o s i t i o n . Very few p r i v a t e pensions c a r r y over t o the widowed spouse. While some of these data may appear t o be dated, the s i t u a t i o n has changed very l i t t l e f o r today's bereaved e l d e r l y woman, many of whom have never worked — or f o r younger women who are f o r c e d t o work post-bereavement. I t s t i l l remains a f a c t t h a t women i n the workforce earn 64% of male e a r n i n g s f o r comparable employment and the a v a i l a b i l i t y of q u a l i t y daycare and a f t e r s c h o o l care i s a grave concern. Guest (1985) has found t h a t pension r i s k i s height e n e d by 226 " s e x i s t b i a s o f s o c i a l s e c u r i t y programmes [which] d i s c r i m i n a t e a g a i n s t women" (p. 173). T h i s i s f u r t h e r exacerbated by a f e d e r a l government p r o p o s a l t o c u r t a i l Canada A s s i s t a n c e P l a n payments t o wealthy p r o v i n c e s (which i n c l u d e s B r i t i s h Columbia) thus p l a c i n g pension supplements, h e a l t h c a r e and low c o s t housing programming i n jeopardy. Issues r a i s e d i n the House of Parli a m e n t i n 1975 with r e g a r d t o the Omnibus B i l l on the Status o f Women, B i l l C-16, are s t i l l p e r t i n e n t f i f t e e n years l a t e r and d i r e c t l y e f f e c t women of a l l ages. These i s s u e s i n c l u d e : the numbers of women co n c e n t r a t e d i n low paying, low s t a t u s jobs, p e r c e i v e d as a re s e r v e p o o l o f la b o u r , are t h e r e f o r e the l e a s t secure and most a f f e c t e d by l a y - o f f s ; l i p s e r v i c e t o e q u a l i t y i n the workforce m a i n t a i n i n g the " g h e t t o i z a t i o n " o f working women with equal pay laws l a c k enforcement and p e n a l t i e s ; the c o n t i n u i n g need f o r day care; pension p l a n s c o n t a i n i n g sex based d i f f e r e n t i a l payments and b e n e f i t s ; and, i n e q u i t i e s of s u r v i v o r s b e n e f i t s i n pen s i o n p l a n s . For the woman under age 65 and widow of a pen s i o n e r , t h e r e i s a s u r v i v o r ' s pension of 60 per cent of the deceased 227 spouse's pension (CPP) - which i s based upon the spouse's work h i s t o r y and income. The p i c t u r e w i t h O ld Age S e c u r i t y and Guaranteed Income Supplement i s no l e s s b l e a k - f o r both men and women. For a s i n g l e , e l d e r l y person, maximum pension b e n e f i t s from OAS($343)/GIS($407) amounted t o $750 per month i n June, 1990. GAIN f o r S e n i o r s , p r o v i d e s supplementary income t o i n d i v i d u a l s on OAS/GIS and a l s o p r o v i d e s income a s s i s t a n c e t o s e n i o r s aged 60 - 64. The program i s a d m i n i s t e r e d by the M i n i s t r y of S o c i a l S e r v i c e s and Housing i n B r i t i s h Columbia and i s p a r t of a f e d e r a l / p r o v i n c i a l c o s t s h a r i n g program under the Canada A s s i s t a n c e P l a n (Health and Welfare Canada, March 1987, p . l ) . The supplementary b e n e f i t s (GFSS) are u s u a l l y p a i d only t o persons i n r e c e i p t of the GIS and as of A p r i l 1, 1987 the GFSS was s e t at $49.30 f o r a s i n g l e person, whereas each of a couple r e c e i v e d $60.25. Again, while these f i g u r e s may seem dated, the f i n a n c i a l p o s i t i o n f o r bereaved i n d i v i d u a l s has not changed, and i n c r e a s i n g housing c o s t s c r e a t e s even g r e a t e r r i s k . The above d i s c u s s i o n does not i n c l u d e immigrant men and women. A new Canadian must l i v e here f o r t y years b e f o r e q u a l i f y i n g f o r f u l l OAS p e n s i o n . While the r a t i o n a l e b ehind extend i n g the q u a l i f i c a t i o n time was t o enable 228 " t o t a l i z a t i o n " o f pensions with r e c i p r o c a l agreement c o u n t r i e s , many of our new Canadians come from c o u n t r i e s t h a t don't have pension p l a n s or s o c i a l s e c u r i t y systems. T h i s p l a c e s an added burden on the bereaved — young and o l d — of these p o p u l a t i o n s - many of whom w i l l have lower ed u c a t i o n , a h i s t o r y o f low p a y i n g jobs, and E n g l i s h as a second language. Changes may occur over time with added p r e s s u r e from women's groups concerned wi t h pay e q u i t y and day care i s s u e s , and from s e n i o r s groups concerned wi t h q u a l i t y o f l i f e i s s u e s t h a t i n c l u d e p e n s i o n reform and i n c r e a s e d community support f o r t e r m i n a l l y i l l i n d i v i d u a l s . The r e c e n t l y p u b l i s h e d r e p o r t Toward a B e t t e r Age o u t l i n e s s e n i o r s ' involvement w i t h these i s s u e s (Province of B r i t i s h Columbia, 1990). Two new M i n i s t r y of H e a l t h programmes — the V i c t o r i a H e a l t h P r o j e c t and the Hospital/Community P a r t n e r s h i p Program — are seen by s e n i o r s t o be a s t a r t i n g p o i n t f o r c o o r d i n a t i n g s e r v i c e s ( I b i d ) . A b r i d g e w i l l be r e q u i r e d from t h i s type o f programming t o encompass a l l - a g e d bereaved and t h e i r r e s p e c t i v e needs. D i s c u s s i o n I t i s d i f f i c u l t t o a s c e r t a i n where f i s c a l p o l i c y i s s u e s leave o f f and h e a l t h p r e vention/promotion p o l i c y i s s u e s b e g i n . P o l i c y and programming t h a t i s of b e n e f i t t o bereaved i n d i v i d u a l s - whether d i r e c t p e r s o n a l i n t e r v e n t i o n or i n d i r e c t i n t e r v e n t i o n through p e n s i o n / s u r v i v o r ' s b e n e f i t s reform, pay e q u i t y i s s u e s , day care, low c o s t housing — are d i r e c t l y r e l a t e d t o a l l o c a t i o n of r e s o u r c e s . T h e r e f o r e , i t i s apparent t h a t m u l t i l e v e l i n t e r v e n t i o n i s necessary. S o c i a l workers are w e l l aware of the r e l a t i o n s h i p between u n r e s o l v e d g r i e f i s s u e s and the development o f i l l n e s s , d i s r u p t i o n of p e r s o n a l and f a m i l y e q u i l i b r i u m maladaptive c o p i n g s t r a t e g i e s , and death. Economic c o n s i d e r a t i o n s are paramount to the s u r v i v a l of bereaved i n d i v i d u a l s and t h e i r f a m i l i e s . S o c i a l w e l f a r e and h e a l t h w e l f a r e are i n d i v i s i b l e . P o l i c y needs t o address these i s s u e s through implementing comprehensive, p r e v e n t i v e programming, thus d e c r e a s i n g waste of s c a r c e h e a l t h c a r e r e s o u r c e s . "The spectrum of p u b l i c p o l i c y c r e a t e s , s u s t a i n s , a l t e r s or damages the s o c i a l , economic, p h y s i c a l , and n a t u r a l environments t h a t s u s t a i n or f a i l t o n u r t u r e p e o p l e ' s h e a l t h ( M i l i o , c i t e d i n Shannon, 1989, p.33). Role of the S o c i a l Worker i n Bereavement I n t e r v e n t i o n The r o l e of the s o c i a l worker i s a l l encompassing. I t 230 e n t a i l s both the "foregrounds and backgrounds of the c l i e n t " which i n c l u d e s the background of " s o c i a l , p s y c h o l o g i c a l , economic, c u l t u r a l and environmental f a c t o r s which c o n t r i b u t e t o the e t i o l o g y of d i s e a s e and the process of r e c o v e r y . ...[and the foreground of] the observable f e e l i n g s and needs which might be o v e r l o o k e d by those f o c u s i n g s o l e l y on the d i a g n o s i s and c u r i n g of d i s e a s e " (Ontario A s s o c i a t i o n of P r o f e s s i o n a l S o c i a l Workers, 1986, p 1) . S o c i a l Worker i n Family P r a c t i c e As mentioned i n S e c t i o n I, the s o c i a l worker must have a f i r m f o u n d a t i o n i n f a m i l y systems an a l y s e s — but a l s o must have an e c o l o g i c a l framing. T h i s encompasses understanding of network v a r i a b l e s t h a t e f f e c t bereavement outcome — s o c i e t a l e x p e c t a t i o n s , a v a i l a b i l i t y o f i n f o r m a l / f o r m a l s o c i a l supports, a v a i l a b i l i t y of programmes and p e r s o n n e l t o whom i n d i v i d u a l s may be r e f e r r e d . I t a l s o r e q u i r e s an a b i l i t y t o i n t e g r a t e these v a r i a b l e s . Coupled w i t h t h i s knowledge base must be an und e r s t a n d i n g of the bereavement process and how i t r e f l e c t s the m u l t i p l e dynamics of p e r s o n a l , f a m i l y and s o c i a l e x p e c t a t i o n s of outcome. Roles i n c l u d e assessment and i n t e r v e n t i o n , group and 231 i n d i v i d u a l c o u n s e l l i n g , r e f e r r a l and l i a i s i n g which a l l combine t o meet c r i t e r i a o f 1 ) i n t e r v e n t i o n , based upon 2) p s y c h o s o c i a l assessment, toward 3) c l a r i f i c a t i o n of problems and g o a l s , and 4) i d e n t i f i c a t i o n of a mutually a c c e p t a b l e p l a n o f a c t i o n , l e a d i n g t o 5) attainment of go a l s ( I b i d ) . S o c i a l Worker as P r o f e s s i o n a l On-going r e s e a r c h and q u a l i t y assurance are c r i t i c a l t o s o c i a l work p r a c t i c e , as i s c o n t i n u i n g e d u c a t i o n . Adherence t o Canadian A s s o c i a t i o n of S o c i a l Workers' p r o f e s s i o n a l e t h i c s i s i m p l i c i t i n a l l areas of p r a c t i c e . Teaching, d e v e l o p i n g assessment t o o l s and i n t e r v e n t i o n s t r a t e g i e s , t r a i n i n g and s u p e r v i s i o n of ot h e r p r o f e s s i o n a l s and v o l u n t e e r s , c o o r d i n a t i n g programmes and other a d m i n i s t r a t i v e r o l e s , may a l l be subsumed w i t h i n p r o f e s s i o n a l e x p e c t a t i o n s o f the s o c i a l worker. P o l i c y i n i t i a t i o n and a d v o c a t i n g on b e h a l f o f g r i e v i n g c o n s t i t u e n t s i s a c r i t i c a l dimension of p r o f e s s i o n a l involvement. A c t i v e p a r t i c i p a t i o n i n p r o f e s s i o n a l a s s o c i a t i o n s which address p o l i c y i s s u e s and "st r e n g t h e n the p r o f e s s i o n ' s r o l e and improves q u a l i t y of s e r v i c e " are important a s p e c t s of p r a c t i c e (Ontario A s s o c i a t i o n of P r o f e s s i o n a l S o c i a l Workers, 1986) . S o c i a l Worker as Team Member Re c o g n i z i n g t h a t 232 i n t e r d i s c i p l i n a r y teams can be cumbersome and t h a t n e g o t i a t i o n i s hard work, s o c i a l workers can be p a r t i c u l a r l y e f f e c t i v e i n the team s e t t i n g . Not o n l y do they i n t e r p r e t the p s y c h o s o c i a l needs and requirements f o r c e r t a i n s u p p o r t i v e a c t i v i t i e s , but they are f a c i l i t a t o r s of communication w i t h i n the team, h e l p i n g t o focus and i n t e g r a t e team e f f o r t s . P e r c e i v e d s o c i a l worker r o l e s on the team i n c l u d e : c l i e n t advocacy, c o o r d i n a t o r s of a c t i o n , n e g o t i a t o r s , c o n f l i c t d i f f u s e r s and group l e a d e r s . " S o c i a l work team members are more l i k e l y than o t h e r members t o take a c t i v e r o l e s i n h e l p i n g teams f u n c t i o n e f f e c t i v e l y " (Toseland, et a l , 1986, p.48). The g r e a t e s t p l u s the s o c i a l worker b r i n g s t o the team i s the e c o l o g i c a l approach which i n c o r p o r a t e s concern f o r the i n d i v i d u a l , the s i t u a t i o n and the h e l p i n g r e l a t i o n s h i p . T h i s can be u t i l i z e d f o r c l i e n t b e n e f i t or f o r team b e n e f i t . An a d d i t i o n a l r o l e i s t h a t of a d d r e s s i n g g r i e f i s s u e s of team members themselves which r e s u l t from p r o l o n g e d c a r i n g f o r dying i n d i v i d u a l s and t h e i r f a m i l i e s . S o c i a l Worker as an I n d i v i d u a l In o r d e r t o be an e f f e c t i v e p a l l i a t i v e care team member and g r i e f c o u n s e l l o r , i t i s important t h a t the s o c i a l worker r e s o l v e p e r s o n a l i s s u e s s u r r ounding death and d y i n g p r i o r t o involvement i n 2 3 3 t h i s area o f p r a c t i c e . While i t may not be necessary f o r the s o c i a l worker t o have p e r s o n a l l y e x p e r i e n c e d the death of a c l o s e f a m i l y member, other l i f e e x p e r i e n c e s w i l l p r o v i d e an e x p e r i e n t i a l base from which t o draw knowledge, u n d e r s t a n d i n g and compassion f o r g r i e v i n g i n d i v i d u a l s . I t i s t h i s r i c h n e s s of experience and compassion t h a t u n d e r l i e s the s o c i a l worker's e f f e c t i v e n e s s with the c l i e n t s . At the same time, i t i s important t o remember t h a t every l o s s experience i s d i f f e r e n t f o r every i n d i v i d u a l , and t h a t the expert i n a s p e c i f i c l o s s s i t u a t i o n i s the i n d i v i d u a l i n v o l v e d i n t h a t l o s s . Summary T h i s chapter addresses two t h e s i s o b j e c t i v e s . I m p l i c a t i o n s f o r p r a c t i c e , p r e s e n t e d i n S e c t i o n I, addresses i s s u e s r a i s e d by the data from a f a m i l y systems t h e o r y p e r s p e c t i v e . T h i s p e r s p e c t i v e p r o v i d e s the framework f o r assessment and i n t e r v e n t i o n , f o r u n d e r s t a n d i n g b o t h f a m i l y and s o c i a l t e n s i o n s which impinge upon the g r i e v i n g p r o c e s s of an i n d i v i d u a l , and f o r a m e l i o r a t i n g t h a t p r o c e s s . 234 S e c t i o n II addresses i s s u e s of bereavement i n t e r v e n t i o n programme development, p o l i c y i m p l i c a t i o n s which impinge upon t h i s development, and upon the g e n e r a l w e l f a r e of bereaved i n d i v i d u a l s . The m u l t i p l e r o l e s of the s o c i a l worker through which e f f e c t i v e p r a c t i c e i s developed and m a i n t a i n e d are d i s c u s s e d . 235 CHAPTER 7 SUMMARY AND CONCLUDING REMARKS Thi s chapter w i l l p r e s e n t a summary o f the study and c o n c l u s i o n s drawn from the f i n d i n g s . I m p l i c a t i o n s f o r f u r t h e r r e s e a r c h are a l s o addressed. Summary The purpose of the study was t o determine i f bereavement i n t e r v e n t i o n had an e f f e c t on the bereavement outcome of i n d i v i d u a l s who had p a r t i c i p a t e d i n a p a l l i a t i v e care programme. Bereavement i n t e r v e n t i o n i s subsumed w i t h i n p a l l i a t i v e programme p h i l o s o p h y which encompasses the f a m i l y as the u n i t of care and p r o v i d e s a continuum of care t h a t extends beyond the death of the f a m i l y member, through bereavement. There i s no a v a i l a b l e r e s e a r c h on the e f f e c t of post-bereavement i n t e r v e n t i o n w i t h i n p a l l i a t i v e programming, and very l i m i t e d r e s e a r c h e x i s t s which compares a p a l l i a t i v e p o p u l a t i o n w i t h a g e n e r a l p o p u l a t i o n of bereaved i n d i v i d u a l s . Cameron and B r i n g s (1980) s t u d i e d the e f f e c t of bereavement i n t e r v e n t i o n as a p r e v e n t i v e h e a l t h s t r a t e g y f o r bereaved i n d i v i d u a l s whose f a m i l y member d i e d at the same h o s p i t a l . One p o p u l a t i o n had p a r t i c i p a t e d i n 236 the p a l l i a t i v e care programming and bereavement follow-up, the other p o p u l a t i o n had n e i t h e r i n t e r v e n t i o n (Cameron and B r i n g s , 1980; Cameron and Parkes, 1983). The r e s u l t s i n d i c a t e d t h a t those w i t h the p a l l i a t i v e care and bereavement i n t e r v e n t i o n had b e t t e r g r i e f r e s o l u t i o n outcome than d i d those without i n t e r v e n t i o n . A m o d i f i e d r e p l i c a t i o n of the Cameron and B r i n g s (1980) study was c a r r i e d out t o a s c e r t a i n i f bereavement i n t e r v e n t i o n had an e f f e c t on the g r i e f r e s o l u t i o n of i n d i v i d u a l s a l l having the p a l l i a t i v e c a r e e x p e r i e n c e . Only one group had the bereavement i n t e r v e n t i o n w h ile the other group d i d not. An a d d i t i o n a l a n a l y s i s of outcome was a l s o i n c l u d e d which u t i l i z e d W i l l i a m Worden's (1982) Four Tasks of G r i e v i n g through which meaning s t r u c t u r e s and the bereavement p r o c e s s over time were c l a r i f i e d . The study encompassed the n o t i o n of s t r u c t u r a l change i n s o c i e t y and i n medical approaches t o c a r e f o r the t e r m i n a l l y i l l . T h i s l e d t o a broader a n a l y s i s of bereavement care a d d r e s s i n g s o c i o l o g i c a l dimensions which e f f e c t e d the g r i e v i n g p r o c e s s and i n c l u d e d i s s u e s of f u n e r a l and b u r i a l procedures, support networks, p o l i c i e s , and s o c i a l e x p e c t a t i o n s of g r i e v i n g i n d i v i d u a l s . Study Parameters The study d e s i g n i n c l u d e d a mixed 237 s t r a t e g y of methodology i n the e x p l o r a t i o n of t h i s q u e s t i o n and was an ex post f a c t o r e t r o s p e c t i v e study, t h i r t e e n months post-bereavement. A q u a n t i t a t i v e methodology was u t i l i z e d i n an attempt t o c a r r y out a m o d i f i e d r e p l i c a t i o n of the Cameron and B r i n g s (1980) study. A q u a l i t a t i v e , grounded t h e o r y approach was used t o e l u c i d a t e the meaning s t r u c t u r e s which frame the g r i e v i n g p r o c e s s , and t o p r o v i d e support f o r i t s u t i l i t y as a p r e v e n t i v e h e a l t h i n t e r v e n t i o n . Q u a n t i t a t i v e A n a l y s i s The q u a n t i t a t i v e a n a l y s i s f o l l o w e d p r o t o c o l s e s t a b l i s h e d i n the o r i g i n a l study — t i m i n g of the study, telephone i n t e r v i e w , q u e s t i o n n a i r e , c o d i n g i n v e n t o r i e s , matching of samples through c r i t e r i a of age, sex and r e l a t i o n s h i p t o the deceased, and s t a t i s t i c a l t e s t s . Data were c o l l e c t e d i n c o r p o r a t i n g the o r i g i n a l study q u e s t i o n n a i r e (see Appendix I I ) , m o d i f i e d through the a d d i t i o n of c l a r i f y i n g open-ended q u e s t i o n s , and used as a guide f o r an i n t e r v i e w which was framed as t h e r a p e u t i c not merely i n f o r m a t i o n - s e e k i n g . The samples c o n s i s t e d of e i g h t i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n and seven i n d i v i d u a l s without the i n t e r v e n t i o n . A l l had p a r t i c i p a t e d w i t h t h e i r deceased f a m i l y member i n the same p a l l i a t i v e c a r e programme. The i n i t i a l sampling had i n c o r p o r a t e d a random d i s p r o p o r t i o n a t e sampling technique based upon the 238 Cameron and B r i n g s (1980) c r i t e r i a o f age, sex and r e l a t i o n s h i p t o the deceased (Appendix I ) . T h i s was t o f a c i l i t a t e matching of the samples r e s u l t i n g i n s i x matched p a i r s . Data were coded u s i n g the Cameron and B r i n g s G r i e f and Adjustment I n v e n t o r i e s (Appendix I I I and IV), from which G r i e f and Adjustment scores were d e r i v e d . The s t a t i s t i c a l measures of the F i s h e r ' s Exact Test and the Wilcoxon Signed-Ranks Matched-Pairs Test were a p p l i e d t o the s c o r e s . Q u a l i t a t i v e A n a l y s i s A q u a l i t a t i v e grounded t h e o r y approach u t i l i z e d data from a l l f i f t e e n respondents. The data were a n a l y z e d u s i n g a method of s c a n n i n g f o r thematic v a r i a b l e s , c l u s t e r i n g the themes, s u b j e c t i n g the themes t o open and a x i a l coding, memo w r i t i n g , d e v e l o p i n g i n t e g r a t i v e m a t r i c e s and diagrams, and, through emergent f i t , e v o l v i n g core c a t e g o r i e s which c o n c e p t u a l l y bound the codes t o g e t h e r . Core c a t e g o r i e s of "meaning" and "time" were i d e n t i f i e d . "Meaning" was o p e r a t i o n a l i z e d as "metaphor" which r e f l e c t e d the e x p e r i e n t i a l framing of the respondents. "Time" was subsumed w i t h i n the m e t a p h o r i c a l framing, e x h i b i t e d i t s own d i m e n s i o n a l i t y , and was a l s o a study parameter. W i l l i a m s Worden's Four Tasks of G r i e v i n g (1982) were used as a frame t o d e l i n e a t e the bereavement p r o c e s s and g r i e f 239 resolution (Appendix V). Findings The o v e r a l l findings of the quantitative analysis were inconclusive as an intervening variable of "time for preparation for the death of the family member" was found to be the prime motivator for bereavement intervention p a r t i c i p a t i o n and rendered the two samples incomparable. S t a t i s t i c a l analysis of the Grief and Adjustment scores found differences between the two samples i n bereavement resolution but they were not s i g n i f i c a n t . The r e p l i c a t i o n was also unsuccessful due to small sample size, to maturation of p a l l i a t i v e care and to improved pharmacopeia since the o r i g i n a l study was c a r r i e d out i n 1975-7 6. Thus s t r u c t u r a l change and h i s t o r y impinged d i r e c t l y upon the r e p l i c a t i o n of the o r i g i n a l study. The Worden Task analyses of the core categories of "meaning" and "time" indicated that the group with bereavement intervention had better g r i e f resolution than did those without the intervention. Consolidating the Worden Tasks analyses with the scores derived from the Cameron and Brings Grief and Adjustment Inventories resulted i n a complementary assessment of g r i e f resolution and i n d i v i d u a l s at r i s k of bereavement d i f f i c u l t i e s . This further substantiated, and lent strength 240 t o , the Worden Task a n a l y s e s f i n d i n g s t h a t bereavement i n t e r v e n t i o n had a p o s i t i v e e f f e c t on the bereavement r e s o l u t i o n outcome. I n t e r p r e t a t i o n of the F i n d i n g s The data i n d i c a t e d t h a t i n d i v i d u a l s with bereavement i n t e r v e n t i o n had b e t t e r g r i e f r e s o l u t i o n than d i d the i n d i v i d u a l s without the i n t e r v e n t i o n . There were g e n e r a l f i n d i n g s t h a t apply t o both sample groups and t o both the i n d i v i d u a l / i n f o r m a l and community/formal c o n t e x t u a l l e v e l s . These i n c l u d e d l a c k of r i t u a l , l a c k of s o c i a l support networks, b a r r i e r s t o both i n f o r m a l and formal support, l a c k of s o c i a l r o l e s with r e g a r d t o r o l e r e d e f i n i t i o n , and l i m i t e d bereavement programme a v a i l a b i l i t y . The r e s e a r c h q u e s t i o n s posed i n Chapter 1, I n t r o d u c t i o n , p r o v i d e a framework f o r a s y n o p s i s of the study i n t e r p r e t a t i o n . 1) For whom i s bereavement care e f f e c t i v e ? I t was noted i n Chapter 2, T h e o r e t i c a l Framework, t h a t t h e r e were p a r t i c u l a r p o p u l a t i o n s at r i s k f o r p r o l o n g e d and/or d i f f i c u l t g r i e f r e s o l u t i o n . B r o a d l y d e f i n e d , the bereavement outcome was seen t o depend upon the r e l a t i o n s h i p t o deceased, the q u a l i t y of t h a t r e l a t i o n s h i p and the c o p i n g r e p e r t o i r e of the i n d i v i d u a l / f a m i l y — which i n c l u d e d the 241 s t r e n g t h o f s u p p o r t networks. I n d i v i d u a l s s p e c i f i c a l l y deemed a t r i s k were: c h i l d r e n , young m a r r i e d s and t h o s e w i t h dependent c h i l d r e n , men o v er s e v e n t y y e a r s o f age, and i n d i v i d u a l s w i t h poor p h y s i c a l o r m e n t a l h e a l t h and/or m u l t i p l e l o s s e s . The s t u d y samples were r e p r e s e n t a t i v e o f a l l t h e s e r i s k g r o u p s . A l l r e s p o n d e n t s e x c e p t two had l i m i t e d f a m i l y and s o c i a l s u p p o r t n e t w o r k s . The r i s k f a c t o r s o b s e r v e d i n t h e groups were: age and sex, c o n f l i c t e d r e l a t i o n s h i p s w i t h t h e d e ceased, poor h e a l t h , c h i l d r e n o f t h e d eceased, young widowed w i t h dependent c h i l d r e n , and i n d i v i d u a l s w i t h m u l t i p l e l o s s e s . The a t - r i s k i n d i v i d u a l s h a v i n g bereavement i n t e r v e n t i o n a c h i e v e d b e t t e r g r i e f r e s o l u t i o n t h a n a t - r i s k i n d i v i d u a l s w i t h o u t bereavement i n t e r v e n t i o n . The s t u d y a l s o c o r r o b o r a t e d o t h e r r e s e a r c h f i n d i n g s t h a t not a l l i n d i v i d u a l s r e q u i r e bereavement i n t e r v e n t i o n . Two i n d i v i d u a l s i n t h e group w i t h o u t i n t e r v e n t i o n had c o m b i n a t i o n s o f h i g h f a m i l y and s o c i a l s u p p o r t n e t w o r k s , d i d not have c o n f l i c t e d r e l a t i o n s h i p s w i t h t h e d e c e a s e d and had a c t i v e l y p a r t i c i p a t e d i n t h e c a r e o f t h e d e c e a s e d — w i t h home d e a t h b e i n g p o s s i b l e f o r one o f t h e d e c e a s e d . 2) What needs a r e met f o r t h o s e who p a r t i c i p a t e  i n bereavement i n t e r v e n t i o n ? The answer t o t h i s q u e s t i o n was e l o q u e n t l y addressed by the bereavement i n t e r v e n t i o n p a r t i c i p a n t s and r e f l e c t e d many of the t h e o r e t i c a l frameworks suggested i n Chapter 2. These responses i n c l u d e d : s h a r i n g and v a l i d a t i o n of the g r i e v i n g e x p e r i e n c e , openness and acceptance, p e r m i s s i o n t o t a l k about the death and one's s e l f , a v a i l a b i l i t y of i n f o r m a t i o n from which t o d e f i n e one's own g u i d e l i n e s f o r g r i e v i n g , p e r c e p t i o n of growth i n others and s e l f , p r o v i s i o n of a refuge, a f f i r m a t i o n of i d e n t i t y and a s s i s t a n c e w i t h r o l e r e d e f i n i t i o n , s o c i a l support and p r o f e s s i o n a l guidance. 3) Why do some i n d i v i d u a l s chose not t o p a r t i c i p a t e ? and, 4) what p e r s o n a l / s o c i a l b a r r i e r s e x i s t t o  p a r t i c i p a t i o n i n bereavement support a c t i v i t i e s ? These two q u e s t i o n s are i n t r i n s i c a l l y r e l a t e d and are t h e r e f o r e c o n s i d e r e d t o g e t h e r . There are t h r e e c o n t e x t u a l elements which frame the c h o i c e of p a r t i c i p a t i o n i n bereavement i n t e r v e n t i o n — i n d i v i d u a l / i n f o r m a l , community/formal, and i d e o l o g i c a l t h a t p r o v i d e p e r c e i v e d b a r r i e r s and i n f l u e n c e c h o i c e . 243 At the informal l e v e l there are various factors which impede p a r t i c i p a t i o n : personal values and reluctance to seek help or to appear weak, concern about loss of control, personal response to s o c i a l pressures — being strong, getting over i t quickly, being s t o i c , family c o n f l i c t , financial/access concerns (ie. no car, time of day), reluctance to admit l i m i t a t i o n s and emotional needs, support i s not required because of s u f f i c i e n t family and s o c i a l support networks and coping repertoires. The formal context of community resources and s o c i a l l y sanctioned behaviours can r e s t r i c t options through s t r u c t u r a l and s o c i a l conventions which r e s u l t i n : lack of information and knowledge about g r i e f and bereavement, lack of r i t u a l or s o c i a l framing of the death event, discomfort with and avoidance of other's pain, an expectation of early g r i e f resolution, l i m i t e d a v a i l a b i l i t y of programmes, li m i t e d access.to programmes either through r e s t r i c t i o n to s p e c i f i c groups or to time and distance parameters, 244 l a c k of t r a i n e d p e r s o n n e l , programmes u n s u i t e d t o s p e c i f i c needs, t i m i n g of the i n v i t a t i o n t o p a r t i c i p a t e . The i d e o l o g i c a l c o n t e x t u a l l e v e l encompasses p o l i c i e s and procedures, and f u n d i n g p r i o r i t i e s t h a t p r o v i d e b a r r i e r s t o programming and are d i s i n c e n t i v e s t o p a r t i c i p a t i o n . The p h i l o s o p h y of p a l l i a t i v e care i n c o r p o r a t e s the f a m i l y as the u n i t of care and p r o v i d e s f o r a continuum of care t h a t i n c l u d e s post-bereavement support. However, u n l e s s p a l l i a t i v e care programming i s s t a f f e d and funded a p p r o p r i a t e l y , bereavement i n t e r v e n t i o n cannot be i n i t i a t e d w i t h f a m i l i e s p r i o r t o the death of the f a m i l y member. Thus the p h i l o s o p h y becomes hollow and meaningless i n i t s o p e r a t i o n a l i z a t i o n and a t - r i s k f a m i l y members f e e l cut a d r i f t w i t h the i s o l a t i o n of bereavement r e i n f o r c e d . The t i m i n g of the r e f e r r a l of t e r m i n a l l y i l l p a t i e n t s t o the p a l l i a t i v e programme by p h y s i c i a n s may a l s o i n t e r f e r e with s t a f f a b i l i t y t o assess and support f a m i l i e s through t h e i r l o s s e s . Bereavement r e l a t e d d i f f i c u l t i e s may be e x h i b i t e d i n somatic d i s e a s e m a n i f e s t a t i o n . S o c i a l c o s t s and l o s t o p p o r t u n i t i e s i n h e r e n t i n c a r i n g f o r bereavement-245 r e l a t e d i l l n e s s can be a l l e v i a t e d by a p p r o p r i a t e , e a r l y i n t e r v e n t i o n w hich a l s o r e s u l t s i n l o w e r h e a l t h c a r e e x p e n d i t u r e s . Assessment Two models o f assessment — p r e v e n t i v e and g r o w t h e n h a n c i n g — a t two l e v e l s o f a p p l i c a t i o n — i n d i v i d u a l / i n f o r m a l and f o r m a l s u p p o r t n e t w o r k s were s u g g e s t e d t o e n a b l e i n t e r v e n t i o n as i n d i c a t e d by t h e r i s k f a c t o r s and p o p u l a t i o n needs. I m p l i c a t i o n s f o r P r a c t i c e F a m i l y systems t h e r a p i e s were s u g g e s t e d as i n t e r v e n t i v e s t r a t e g i e s f o r b o t h f a m i l y and s u p p o r t network systems. I n t h i s way, f a m i l y r e s o u r c e e v a l u a t i o n was a d d r e s s e d t h r o u g h c o n t e x t u a l a n a l y s e s and s o c i a l s t r u c t u r e s c o u l d be i d e n t i f i e d t h a t i m p i n g e d upon o r a m e l i o r a t e d t h e g r i e v i n g p r o c e s s . E n g a g i n g i n f a m i l y systems t h e r a p i e s and i n t e g r a t i v e p r a c t i c e s e n s i t i z e s t h e t h e r a p i s t / s o c i a l worker t o t h e many l e v e l s o f i n t e r v e n t i o n t h a t maybe r e q u i r e d t o mediate t h e g r i e v i n g p r o c e s s f o r an i n d i v i d u a l / f a m i l y . A d e f i n i t i v e e x p l o r a t i o n o f bereavement i n t e r v e n t i o n programme development was p r e s e n t e d as a means by wh i c h bereavement needs o f d i v e r s e p o p u l a t i o n s c o u l d be a d d r e s s e d . Bereavement programming was o u t l i n e d w i t h p o l i c y and f u n d i n g i m p l i c a t i o n s o f p a l l i a t i v e c a r e and bereavement i n t e r v e n t i o n 246 programming explored. F i n a l l y , discussion of the role of the s o c i a l worker i n stressed intervention at both c l i e n t and p o l i t i c a l l e v e l s with s e n s i t i v i t y to broader issues and advocacy on behalf of bereaved c l i e n t s emphasized. It i s necessary to remember that the development of protocol and programming occurs within s o c i a l parameters and constraints that evolve from changing values and p r i o r i t i e s . Therefore, inherent i n rest r u c t u r i n g family i d e n t i t y i s active p a r t i c i p a t i o n i n the evolution of programming development, and awareness of p o l i c y implications. Implication for Further Research The exploration of the e f f i c a c y of bereavement intervention examined the e f f e c t of the intervention on bereavement outcome. It has also noted lack of research, programme a v a i l a b i l i t y , community resources and p o l i c i e s that define funding and s t a f f i n g parameters. These present some of the possible areas of concern for further research. S p e c i f i c a l l y , some of these may be: Assessment of community resources and interested stakeholders through which to e s t a b l i s h a community-wide bereavement support network. 247 Developing e d u c a t i o n packages t o s e n s i t i z e community groups, i n t e r e s t e d c o n s t i t u e n t s , and s c h o o l s , about the bereavement process, and needs of bereaved i n d i v i d u a l s . Assess and develop bereavement i n t e r v e n t i o n programmes designed f o r meeting s p e c i f i c age, l i f e - s t a g e needs as w e l l as g e n e r a l a l l - a g e d programming. C a r r y out content analyses of v a r i o u s bereavement programmes and bereavement outcome measurements t o e v a l u a t e e f f i c a c y of v a r i o u s s t r a t e g i e s . E x p l o r e h e l p - s e e k i n g behaviours t o a s c e r t a i n a p p r o p r i a t e s t r a t e g i e s f o r encouraging p a r t i c i p a t i o n by those deemed most a t - r i s k . A c t i v e l y engage i n p o l i c y and programme development i n c l u d i n g funding and s t a f f i n g components at both the d e p a r t m e n t a l / i n s t i t u t i o n a l and m u n i c i p a l / p r o v i n c i a l government l e v e l s . While the i d i o s y n c r a t i c nature of the bereavement experience may make i t d i f f i c u l t t o r i g o u r o u s l y d e s i g n e v a l u a t i v e s t u d i e s with uniform measures and methods, i t i s important t o i n c o r p o r a t e r e s e a r c h i n t o p r a c t i c e i n o r d e r t o expand knowledge and t o l e g i t i m i z e c l a i m s f o r f u n d i n g and programme development. Two other areas t h a t r e q u i r e a t t e n t i o n were b r i e f l y touched upon i n t h i s study. The p l a c e f o r r i t u a l 248 and symbolism i n today's world i s an important c o n s i d e r a t i o n . As w e l l , the whole aspect of " c r e a t i v e " g r i e v i n g — wi t h c r e a t i v e i n t e r v e n t i o n — bears a t t e n t i o n . CONCLUSION G r i e f a f f e c t s a l l of us at one time or another. Some of us, because of f a c t o r s i n our l i v e s — i s o l a t i o n , low s o c i a l support networks, few or es t r a n g e d f a m i l y members, age, sex, poor h e a l t h — w i l l be.at g r e a t e r r i s k than o t h e r s . While g r i e v i n g i s a n a t u r a l p r o c e s s , some p h y s i c a l and mental d i s t u r b a n c e s are normal but may be u n s e t t l i n g and d i s r u p t i v e . Unsupported g r i e f r e a c t i o n s can r e s u l t i n h i g h e r i n c i d e n c e of d i s e a s e (heart d i s e a s e , cancer, h i g h b l o o d p r e s s u r e , a n x i e t y and depression) and r e l a t e d v i s i t s t o p h y s i c i a n s , h o s p i t a l i z a t i o n , need f o r c o u n s e l l i n g a s s i s t a n c e , or p s y c h i a t r i c i n t e r v e n t i o n . Support, reassurance and knowledge w i l l h e l p d e t e r development of p a t h o l o g i c a l g r i e v i n g c o m p l i c a t i o n s . The f i n d i n g s of the study imply t h a t i n d i v i d u a l s w i t h bereavement i n t e r v e n t i o n have b e t t e r g r i e f r e s o l u t i o n than do i n d i v i d u a l s without the i n t e r v e n t i o n . They a l s o s u b s t a n t i a t e c o n t e n t i o n s t h a t not everyone r e q u i r e s 249 bereavement intervention. The strength of the study i s derived from the mixed strategy approach which involves the d i s c i p l i n e of p r i o r protocols as well as rigorous adherence to grounded theory p r i n c i p l e s . Various r i s k factors are also described i n the study that e f f e c t : e l d e r l y males, young women i n t h e i r twenties, and r i s k for i n d i v i d u a l s with either too short or too long a preparation time for the death of a family member. The timing of the i n v i t a t i o n to the bereavement support group may also be a c r i t i c a l factor for consideration. The group without bereavement follow-up indicated that at the time of i n v i t a t i o n they did not f e e l that the support group was necessary. When analyzing the g r i e f r e s olution of t h i s group, i t i s observed that t h e i r i n i t i a l assessment of not requiring any further support may have been questionable for most of them. One i n d i v i d u a l had, i n fact, sought priva t e counselling but had not resolved some f a i r l y major g r i e f issues. Continued contact at three months i n t e r v a l s with those refusing to p a r t i c i p a t e may circumvent bereavement rela t e d d i f f i c u l t i e s . 250 P r e v e n t i v e i m p l i c a t i o n s of bereavement i n t e r v e n t i o n f o r s u r v i v o r s must not be underestimated — r i s k f a c t o r s , as mentioned above, can l e a d t o h o s p i t a l i z a t i o n . Not o n l y can t h e r e be p e r s o n a l h e a l t h i m p l i c a t i o n s but: p o s s i b l e income l o s s r e s u l t i n g from decreased p r o d u c t i v i t y i n the work p l a c e through absenteeism or i n a b i l i t y t o c o n t i n u e i n a work r o l e ; the l o s s of f a m i l y through breakdown; f a i l u r e at s c h o o l and behaviour problems w i t h c h i l d r e n ; p o s s i b l e s u i c i d e . E f f e c t i v e bereavement f o l l o w - u p has long-term s i g n i f i c a n c e and circumvents t h e s e t r a g i c events and t h e i r concomitant anguish. I t i s important t o c o n s i d e r the c o s t - e f f e c t i v e n e s s of i n t e r v e n t i o n and t o j u s t i f y program d e d i c a t e d s t a f f and f u n d i n g . I t i s incumbent upon programme i n i t i a t o r s t o f u l l y d e d i c a t e s t a f f t o the p a l l i a t i v e programming. As we have observed, s o c i e t a l changes i n f l u e n c e f a m i l y c o n f i g u r a t i o n and subsequent co p i n g and problem s o l v i n g s t r e n g t h s . To s a f e g u a r d the i n t e g r i t y of the i n d i v i d u a l and the f a m i l y u n i t , a p p r o p r i a t e s t a f f must be r e a d i l y a v a i l a b l e t o a c t i v e l y i n t e r c e d e when ne c e s s a r y . F u l l r i s k assessment and c o n t a c t with a l l p a l l i a t i v e p a t i e n t s and f a m i l i e s r e q u i r e s e x t e n s i v e work on the p a r t of the program s o c i a l worker. Through c o n s o l i d a t i n g r i s k assessment with a c t i v e 251 i n t e r v e n t i o n , the s o c i a l worker can f a c i l i t a t e f a m i l y s t r e n g t h e n i n g through c r e a t i v e g r i e v i n g i n which f a m i l y r i t u a l and new t r a d i t i o n s can be developed. Enhanced s o c i a l support networks may be v i t a l t o the s u r v i v a l of the i n d i v i d u a l . The impact of s o c i a l change must not be underestimated. The p o p u l a t i o n i s aging due t o lower b i r t h r a t e s combined wit h b e t t e r housing, n u t r i t i o n and h e a l t h f a c t o r s . I l l n e s s and d i s e a s e are h e l d i n abeyance f o r l o n g e r and l o n g e r p e r i o d s of time thus extend i n g d i s e a s e t r a j e c t o r y . I m p l i c a t i o n s of l a r g e numbers of f r a i l e l d e r l y c o h o r t s , with aging and/or d i s p e r s e d f a m i l i e s , hampers the development of i n f o r m a l support networks. Family s i z e and m o b i l i t y , and w e l l as the i n c r e a s e d numbers of s i n g l e parent f a m i l i e s a l s o l i m i t s the f a m i l y support network and t h r e a t e n s i n d i v i d u a l s u r v i v a l . The r i s k assessment must i n c o r p o r a t e f a m i l y / s o c i a l / r e l i g i o u s support s t r u c t u r e s , p a s t h i s t o r y of c r i s i s response and r e s u l t a n t r e p e r t o i r e of coping mechanisms; the s o c i a l realm of community-based focus of h e a l t h support s e r v i c e s and a v a i l a b i l i t y of home c a r e g i v e r s and support networks; and, f l e x i b l e , i n d i v i d u a l l y determined bereavement foll o w - u p i n t e r v e n t i o n . 252 "Family s t u d i e s are c r i t i c a l . . . because the f a m i l y focus i s a d e f i n i t i v e f e a t u r e o f h o s p i c e c a r e " (Dush, 1988, p.17). S o c i a l work e x p e r t i s e and u n d e r s t a n d i n g o f network s t r e n g t h s and needs, of f a m i l y dynamics, of i n t e r p e r s o n a l s t r e s s o r s and coping a b i l i t i e s a m e l i o r a t e the g r i e v i n g p r o c e s s through a p p r o p r i a t e i n t e r v e n t i o n s t r a t e g i e s . Bereavement support enhances s o c i a l networks and l e g i t i m i z e s the g r i e v i n g experience and ex p e r i e n c e of l o s s . C h a r a c t e r i s t i c s of h o s p i c e / p a l l i a t i v e care fch-r-eugn i n t e g r a t i o n of bereavement w i t h i n the d y i n g e x p e r i e n c e and a c t i v e involvement of f a m i l y and p a t i e n t i n d e t e r m i n i n g i n t e r v e n t i o n . The f a m i l y i s the " u n i t o f c a r e " both as a f a m i l y c o n f i g u r a t i o n and as i n d i v i d u a l members w i t h i n d i v i d u a l needs. C o n t i n u i t y of care i s v i t a l t o f a c i l i t a t e on-going assessment of p s y c h o - s o c i a l c l i e n t needs, t o f o s t e r awareness of d e v e l o p i n g r i s k r e l a t e d problems, and t o i n t e r c e d e and r e f e r t o other p r o f e s s i o n a l b o d i e s when nec e s s a r y . Government focus on community-based h e a l t h promotion and p r e v e n t i o n must c o n s i d e r t h a t e f f o r t s toward i n d i v i d u a l s e l f - s u f f i c i e n c y and independence are c o n t i n g e n t upon r e s o u r c e a l l o c a t i o n and enhancement of the p r o f e s s i o n a l support s t r u c t u r e s — such t h a t f a m i l y and s o c i a l s t r u c t u r e s can then be strengthened. 253 Thus, enhancing coping c a p a c i t y t r a n s l a t e s i n t o community- based s e r v i c e s t h a t would "provide the s k i l l s and the community support needed by people", and i n c l u d e s r e c o g n i t i o n o f "the importance o f en s u r i n g t h a t i n f o r m a l c a r e - g i v e r s have access t o the support they need" (Epp, 1986, p.4). A broad range o f government, p r i v a t e and v o l u n t a r y / n o n p r o f i t agency and v o l u n t e e r programmes are seen as r e i n f o r c i n g i n d i v i d u a l i n t e g r i t y and autonomy. Demographic changes t h a t may pr e c l u d e t h i s approach must be co n s i d e r e d . By emphasizing f i n a n c i a l a s p e c t s o f h e a l t h c a r e s e r v i c e s , "the m a l d i s t r i b u t i o n o f ta s k s , r e s p o n s i b i l i t i e s and c o n t r i b u t i o n s " are obscured, as are the d i r e c t consequences (McNiven, 1986, p.321). P a l l i a t i v e care i s a c o l l a b o r a t i v e , s h a r i n g model o f care t h a t empowers the i n d i v i d u a l and f a m i l y . A core component o f t h i s model of care, bereavement i n t e r v e n t i o n , o f f e r s hope and "a re s p e c t f o r the h e a l i n g r e s o u r c e s w i t h i n each person" (Katz and Seth, 1987, p.132). Bereavement i n t e r v e n t i o n has been shown t o i n f l u e n c e p o s i t i v e g r i e f r e s o l u t i o n through the p r o v i s i o n of s o c i a l support, i n f o r m a t i o n , v a l i d a t i o n , c a r i n g concern and p r o f e s s i o n a l c o u n s e l l i n g . Concerted e f f o r t must be made t o i n t e r p r e t the language 254 and i d e o l o g y of p o l i c i e s and the concomitant i m p l i c a t i o n s f o r implementation. In t h i s way f a m i l y i n t e g r i t y w i l l be enhanced post-bereavement through f u l l y funded and a p p r o p r i a t e l y s t a f f e d p a l l i a t i v e programming — of which bereavement i n t e r v e n t i o n i s an i n t e g r a l p a r t . 255 BIBLIOGRAPHY ADAMS, J.E. and E. Lindemann. (1974) "Coping w i t h l o n g -term d i s a b i l i t y " , i n G.V. Coelho, D.A. Hamburg, J.E. Adams (eds), Coping and A d a p t a t i o n . New York: B a s i c Books AJEMIAN, I. and B. Mount (eds) 1980 The Royal V i c t o r i a H o s p i t a l Manual on P a l l i a t i v e / H o s p i c e Care. New York: ARNO P r e s s . ALLISON, H., J . G r i p t o n and M. Rodway. 1983 " S o c i a l S e r v i c e s as a Component of P a l l i a t i v e Care w i t h Terminal Cancer P a t i e n t s " , S o c i a l Work i n H e a l t h Care 8 (4) Summer: 29-44. ANDERSON, H., H. A. Goolishan, and L. Windermand. 1986 "Problem Determined Systems: Towards T r a n s f o r m a t i o n i n Fa m i l y Therapy" i n J o u r n a l of S t r a t e g i c and Systemic  T h e r a p i e s , V o l . 5 (4), Winter 1986 pp. 1-13. BARNES, D. 1987 "Previous L o s s e s : F o r g o t t e n but Not Resolved" i n M.A. Morgan (ed.), Bereavement: H e l p i n g  the S u r v i v o r s . London, O n t a r i o : King's C o l l e g e . BELENKY, M.F., B.McVicker C l i n c h y , N. Rule Goldberger and J.M. T a r u l e . 1986 Women's Ways of Knowing. New York: B a s i c Books BEREZA E. 1988 "Dying wishes: I m p l i c a t i o n s f o r bereavement i n t e r v e n t i o n " Canadian M e d i c a l A s s o c i a t i o n J . 139, December 1: 1094-1097. BERG, D.N. and K.K. Smith. 1988 The S e l f i n S o c i a l I n q u i r y B e v e r l y H i l l s : Sage BODIN, A r t h u r M. 1981 "The I n t e r a c t i o n a l View: Family Therapy Approaches of the Mental Research I n s t i t u t e " i n Handbook of Family Therapy, e d i t e d by A. S. Gurman and D. P. K n i s k e r n . New York: Brunner/Mazel Pub. 256 BOWLBY, John. 1980. Attachment and Los s : Volume 3. London: Penguin Books. BRANCH, K., D.A. Hooper, J . Thompson and J . C r e i g h t o n . 1984 Guide t o S o c i a l Assessment: Framework f o r A s s e s s i n g  S o c i a l Change. Boulder, C o l o . : Westview P r e s s BRENNER, P.R. 1985 "Hospice a p p l i c a t i o n s o f f a m i l y systems t h e o r y " . Am. J . Hospice Care , November/December 1985: 13-16. BRITISH COLUMBIA: 1987 M i n i s t r y o f H e a l t h S t e e r i n g Committee. DRAFT Report " P a l l i a t i v e Care/Hospice Care" S t r a t e g y Paper. 1988 Guaranteed A v a i l a b l e Income F o r Need A c t "GAIN f o r S e n i o r s " GAIN R e g u l a t i o n s , Schedule A, S e c t i o n 2 (2) (3) (6), J u l y 1990 Toward a B e t t e r Age Report of the B r i t i s h Columbia Task Force on Issues o f Concern t o S e n i o r s : A p r i l . CAINE, Lynn. 1974 Widow New York: W i l l i a m Morrow and Co. CAMERON, J . and B. B r i n g s . 1980 "Bereavement Outcome F o l l o w i n g P r e v e n t i v e I n t e r v e n t i o n : A C o n t r o l l e d Study" i n Ajemian and Mount (eds.) The Royal V i c t o r i a  H o s p i t a l Manual on P a l l i a t i v e / H o s p i c e Care. New York: ARNO P r e s s . CAMERON, J . and CM. Parkes. 1983 "Terminal c a r e : e v a l u a t i o n of e f f e c t s on s u r v i v i n g f a m i l y o f c a r e b e f o r e and a f t e r bereavement" i n Postgraduate M e d i c a l  J o u r n a l (February) 59: 73-78. CANADA: NATIONAL HEALTH AND WELFARE 197 9 Report o f the S p e c i a l Senate Committee on RetirementAge P o l i c i e s : Retirement without Tears, I n f o r m a t i o n Canada, Ottawa, 1979 257 CANADA: NATIONAL HEALTH AND WELFARE 1981 " G u i d e l i n e s f o r E s t a b l i s h i n g Standards f o r S p e c i a l S e r v i c e s i n H o s p i t a l s , P a l l i a t i v e Care S e r v i c e s i n H o s p i t a l s " . H e a l t h S e r v i c e s D i r e c t o r a t e : H e a l t h S e r v i c e s and Promotion Branch. 1982 P a l l i a t i v e Care i n Canada. P o l i c y , P l a n n i n g and Inf o r m a t i o n Branch. 1987 B a s i c F a c t s on S o c i a l S e c u r i t y Programs, Ottawa: M i n i s t e r o f Supply and S e r v i c e s , March 1988 Monthly S t a t i s t i c s : Income S e c u r i t y Programs, Ottawa: M i n i s t e r of Supply and S e r v i c e s , August CANADIAN CANCER SOCIETY 1977 Proceedings: Symposium on  Coping With Cancer Toronto, O n t a r i o . A p r i l 24-26, 1977. CAPRA, F. 1982 The Turn i n g P o i n t New York: Bantam Books. CASSEM, N.H. 197 6 "The F i r s t Three Steps Beyond t h e Grave" i n V. R. V i n e (ed.). Acute G r i e f and the F u n e r a l . S p r i n g f i e l d , I l l i n o i s : C h a r l e s C. Thomas Pub. CONWAY, P. 1988 "Losses and G r i e f i n O l d Age". S o c i a l Casework: the J . of Contemporary S o c i a l Work. 69 (9). DE HOYOS, G., A. De Hoyos and C. B. Anderson. 1986 " S o c i o c u l t u r a l D i s l o c a t i o n : Beyond the Dual P e r s p e c t i v e " i n S o c i a l Work, V o l . 31, 1986 pp. 61-67. DELUDE, L o u i s e . 1978 Women and Aging: A Report on the Rest  of Our L i v e s , Ottawa: M i n i s t e r o f Supply and S e r v i c e s , A p r i l 1981 Pension Reform with Women i n Mind, Ottawa: M i n i s t e r of Supply and S e r v i c e s , March. DOWNIE, N.M. and R.W. Heath. 1970. B a s i c S t a t i s t i c a l  Methods New York: Harper and Row. 258 DUHL, B. S. and F. Duhl. 1981 " I n t e g r a t i v e F a m i l y Therapy" i n Handbook of F a m i l y Therapy, e d i t e d by A. S. Gurman and D. P. K n i s k e r n . New York: Brunner/Mazel Pub. DUNLOP, M. 1985 Understanding Cancer Toronto: I r w i n Pub. DUSH, D.M. 1988 "Trends i n Hospice Research and P s y c h o s o c i a l P a l l i a t i v e Care". The Hospice J . 4 (3): 13-28 ECKHARDT, K.W. and M.D. Ermann. 1977 S o c i a l Research  Methods. New York: Random House ERICKSON, G e r a l d D. 1984 "A Framework and Themes f o r S o c i a l Network I n t e r v e n t i o n " i n Family P r o c e s s V o l 23, June 1984. pp. 187-205 FISHER. J.D., B.A. Goff, A. Nadler and J.M. Chinsky. 1988 " S o c i a l P s y c h o l o g i c a l I n f l u e n c e s on Help Seeking and Support from P e e r s " i n G o t t l i e b (ed.) S o c i a l Networks  and S o c i a l Support B e v e r l y H i l l s : Sage pp.267-303. FREDERICK, J.F. and N.J. F r e d e r i c k . 1985 "The Hospice E x p e r i e n c e : P o s s i b l e E f f e c t s i n A l t e r i n g the B i o c h e m i s t r y of Bereavement". The Hospice J . 1 (3): 81-97. FUCHS EBAUGH, E.R. 1988 Becoming an Ex: The P r o c e s s of  Role E x i t . Chicago: U n i v e r s i t y of Chicago P r e s s . FYKE, K.J., P. P a l l a n and D.W.M. Ju z w i s h i n . 1988 The  V i c t o r i a H e a l t h P r o j e c t . Canadian H e a l t h Care Management: Community and I n s t i t u t i o n a l R e l a t i o n s Chapter. GASS, K.A. and A.S. Chang 1989 " A p p r a i s a l s of Bereavement, Coping, Resources and P s y c h o s o c i a l H e a l t h D y s f u n c t i o n i n Widows and Widowers" Nu r s i n g Research. 38 (1): 31-36. GENTLES, Ian (ed.) 1982 Care f o r the Dying and t h e Bereaved Toronto: A n g l i c a n Book Centre 259 GLASER, B.G. 1978 T h e o r e t i c a l S e n s i t i v i t y M i l l V a l l e y : S o c i o l o g y P r e s s . GLASER, B.G. and A.L. S t r a u s s . 1967 The D i s c o v e r y o f  Grounded Theory. Chicago: A l d i n e A t h e r t o n GOLDBERG, M i c h a e l , Sr. 1988 R e g a i n i n g D i g n i t y , "An examina-t i o n of s u b s i s t e n c e c o s t s and the adequacy of income a s s i s t a n c e r a t e s (GAIN) i n B r i t i s h Columbia", Vancouver: SPARC, May. GOTTLIEB, B.H. (ed.) 1988 M a r s h a l l i n g S o c i a l Support B e v e r l y H i l l s : Sage Pub. GUEST, Dennis. 1985 The Emergence of S o c i a l S e c u r i t y i n  Canada, U n i v e r s i t y of B r i t i s h Columbia P r e s s , Vancouver, 2nd ed. HALEVY-MARTINI, J . , E.M. Hemley-Van Der Velden, L. Ruhf, and P. S c h o e n f e l d . 1984 "Process and S t r a t e g y i n Network Therapy" F a m i l y Process 23: 521-533. HANEN, M.P., M.J. O s i e r and R.G. Weyant. 1979 Science,  Pseudo-Science and S o c i e t y . Waterloo, Ont.: W i l f r e d L a u r i e r U n i v e r s i t y P r e s s . HANSEN, J.C. (ed.) 1985 H e a l t h Promotion i n Family Therapy R o c k v i l l e , Maryland: Aspen Pub. HANSARD. 1975 House of Commons Debates, V o l . V I : May 29, June 16. HINTON, J . 1967 Dying Markham, Ont.: Penguin Books HOEHNE, D i e t e r . 1986 " S e l f Help and S o c i a l Change" i n Cunningham (ed.) S o c i a l Movements/Social Change Toronto: Between the L i n e s . HOSPICE DEVELOPMENT AND TECHNICAL ASSISTANCE GROUP 197 8 C r i t e r i a and Standards f o r HSA Approval f o r a Hospice  Program of Care. Bethesda, MD: Elm S e r v i c e s , Inc. 260 HUDSON, J.E. 1988 The Hospice Response t o Contemporary  Western A t t i t u d e s on Death and Dying U n i v e r s i t y o f Toronto: F a c u l t y o f S o c i a l Work. HUNTER, David. 1985 "On t h e Boundary: F a m i l y Therapy i n Long-Term I n p a t i e n t S e t t i n g " i n Fam i l y Process V o l . 24, September 1985 pp. 339-355 ILLICH, Ivan. 1976 L i m i t s t o Me d i c i n e . London: Penguin Books IMBER-BLACK, Evan. 1986 " F a m i l i e s , L a r g e r Systems and the Wider S o c i a l Context" i n J o u r n a l o f S t r a t e g i c and  Systemic T h e r a p i e s , V o l . 5 (4) Winter, 1986 pp.29-35. IMBER-BLACK, E., J . Roberts and R.A. Whiting. 1988 R i t u a l s  i n F a m i l i e s and F a m i l y Therapy. New York: W.W. Norton INTERNATIONAL WORK GROUP IN DEATH, DYING AND BEREAVEMENT. 197 9 "Assumptions and P r i n c i p l e s U n d e r l y i n g Standards f o r Terminal Care" Essence 3 ( 1 ) : 31-36. JENKINS, H. 1989 "The f a m i l y and l o s s : a systems framework". P a l l i a t i v e M edicine 3 (2) A p r i l 1989: 97-104. KARPEL, Mark A. (ed.) 1986 F a m i l y Resources: The Hidden  P a r t n e r i n Family Therapy New York: G u i l f o r d P r e s s KARPEL, M.A. and E.S. S t r a u s s 1983 F a m i l y E v a l u a t i o n New York: Gardner P r e s s . KEITH, R. 1981. "Acute G r i e f and S u r v i v o r E x p e c t a t i o n s " i n O.S. M a r g o l i s e t a l (eds.) Acute G r i e f NewYork: Columbia U n i v e r s i t y P r e s s . KERR, Michael E. 1981 "Family Systems Theory and Therapy" i n Handbook of F a m i l y Therapy e d i t e d by A. S. Gurman and D. P. K n i s k e r n . New York: Brunner/Mazel Pub. KERTZER, D.I. 1989 " L a s t i n g R i t e s : The Power of R i t u a l " Family Therapy Networker 13 (4): 21-29. 261 KLASS, D. and B. Shinners, 1981. "The Role of a P r o f e s s i o n a l i n a S e l f - H e l p Group f o r the Bereaved" i n P a c h o l s k i and C o r r (eds.) New D i r e c t i o n s i n Death  E d u c a t i o n and C o u n s e l l i n g . KIRSCHNER, D. A. and S. K i r s c h n e r . 1986 Comprehensive  Fa m i l y Therapy: An I n t e g r a t i o n o f Systemic and  Psychodynamic Treatment Models New York: Brunner/Mazel Pub. KIVOWITZ, A.L. 1988 Being M i s s e d and M i s s i n g : an I n t e r a c t i o n a l Element of S p e a r a t i o n / I n d i v i d u a t i o n " C l i n i c a l S o c i a l Work J . 16 (3): 261-269. KURTZ, L.F. and T.J . P o w e l l . 1987 "Three Approaches t o Understanding S e l f - H e l p Groups", S o c i a l Work w i t h  Groups 10 (3), F a l l : 69-80. LAMERS, W.M. 1988 "Hospice Research: Some R e f l e c t i o n s " . The Hospice J . 4 (3): 3-12. LAUER, M.E., R.K. Mulhern, M.J. S c h e l l and B.M. Ca m i t t a . 1988 "Long-Term Follow-up o f P a r e n t a l Adjustment F o l l o w i n g a C h i l d ' s Death a t Home or H o s p i t a l " Cancer 63 (5): 988-994. LAZARSFELD, P.F., A.K. P a s a n e l l a and M. Rosenberg. 1972 C o n t i n u i t i e s i n the Language of S o c i a l Research. New York: The Free P r e s s . LEVIN, S. B., J . B. Raser, C. N i l e s and A. Reese. 1986 "Beyond Family Systems - Toward Problem Systems: Some C l i n i c a l I m p l i c a t i o n s " i n J o u r n a l o f S t r a t e g i c and  Systemic T h e r a p i e s , V o l . 5 (4) Winter 1986 pp.62-69. LEWIS, C.S. 19 61 A G r i e f Observed. London: Faber LINDEMANN E. 1944 "Symptomology and management of acute g r i e f " B r i t i s h J o u r n a l o f P s y c h i a t r y 101: 141-149 MARRIS, P e t e r . 1986 Loss and Change. London: Routledge, Kegan P a u l . 262 MASTERMAN, S.H. and R. Reams. 1988 "Support Groups f o r Bereaved P r e s c h o o l and School-Age C h i l d r e n " . Am. J .  O r t h o p s y c h i a t r y . 58 (4): 562-570. McHORNEY, C A . and V. Mor. 1988 " P r e d i c t o r s of Bereavement D e p r e s s i o n and I t s H e a l t h Consequences" M e d i c a l Care 26 (9): 882-893. McINTYRE, E i l e e n L. G. 1986 " S o c i a l Networks: P o t e n t i a l f o r P r a c t i c e " i n S o c i a l Work V o l . 31 (6) November-December, 1986. McNIVEN, C R . 1986 " S o c i a l P o l i c y and Some Aspects o f Neoconservative Ideology i n B r i t i s h Columbia" i n R. M i s h r a (ed.) The Welfare S t a t e i n C r i s i s . New York: St. M a r t i n ' s P r e s s . MILES, M.B. and A.M. Huberman 1984 Q u a l i t a t i v e Data  A n a l y s i s Newbury Park: Sage Pub. MILLS, C Wright. 1961 The S o c i o l o g i c a l Imagination New York: Grove P r e s s . MITCHELL, M a n z e l l . 1986 " U t i l i z i n g V o l u n t e e r s t o Enhance Informal S o c i a l Networks", S o c i a l Casework: The J o u r n a l  of Contemporary S o c i a l Work, May: 290-298 MITROFF, I . I . and R.H. Kilmann 1978 M e t h o d o l o g i c a l Approaches to S o c i a l S c i e n c e San F r a n c i s c o : J o s s e y -Bass MOOS R.H. (ed.) 1986 Goping With L i f e C r i s i s : An  I n t e g r a t e d Approach New York: Plenum Press MORGAN, J.D. (ed.) 1986 C h i l d r e n and Death Pr o c e e d i n g s of the 1985 King's C o l l e g e Conference. London, Ont.: King's C o l l e g e . 1987 Bereavement: H e l p i n g the S u r v i v o r s Proceedings of thel987 King's C o l l e g e Conference. London, Ont.: King's C o l l e g e . 263 NASON, F. 1983 "Diagnosing the H o s p i t a l Team", S o c i a l  Work i n Hea l t h Care 9 ( 2 ) : 25-43 Winter N a t i o n a l C o u n c i l of Welfare. 1988 Po v e r t y L i n e s : E s t i m a t e s Ottawa:Minister o f Supply and S e r v i c e s , A p r i l 1988a Poverty P r o f i l e , 1988: A Report, Ottawa: M i n i s t e r of Supply and S e r v i c e s , A p r i l NEY, P.G. 1987 " G r i e f Work f o r A d o l e s c e n t s : How the Family P h y s i c i a n Can Help" P s y c h i a t r y i n Canada 1 (3): 93-101. OBERSHAW, R i c h a r d 1977 "Grief/Bereavement". Source unknown, pp. 72-75. ONTARIO ASSOCIATION OF PROFESSIONAL SOCIAL WORKERS 198 6 "Role o f S o c i a l Work i n H e a l t h " . Toronto, Ont. OSTERWEISS, M. 1988. " P e r c e p t i o n s Not Yet Matched by Research" J . P a l l i a t i v e Care. 4 ( 1 ) ( 2 ) : 78-80. OSTERWEISS, M., F r e d r i c Solomon, and M o r r i s Green, (eds) 1984 Bereavement: R e a c t i o n s , Consequences and Care. Committee f o r the Study o f H e a l t h Consequences o f the S t r e s s o f Bereavement: I n s t i t u t e o f Medicine. Washington, D.C: N a t i o n a l Academy P r e s s . 0'TOOLE, D.R. 1987 "Hospice Bereavement S e r v i c e s i n the U n i t e d S t a t e s : F a c t o r Fancy" i n J.D. Morgan (ed.) Bereavement: H e l p i n g the S u r v i v o r s . London, O n t a r i o : King's C o l l e g e . PALMER, E. and J . Watt. 1987 L i v i n g and Working w i t h the  Bereaved. C a l g a r y : D e t s e l i g E n t e r p r i s e s PANCOAST, D.L., P.Parker and C. F r o l a n d . 1983 R e d i s c o v e r i n g S e l f - H e l p : I t s Role i n S o c i a l Care B e v e r l y H i l l s : Sage Pub. 264 PARADIS, L.F. (ed.) 1987 S t r e s s and Burnout Among P r o v i d e r s C a r i n g f o r t h e T e r m i n a l l y and T h e i r F a m i l i e s New York: Haworth P r e s s . PARKES, C o l i n Murray. 1971 " P s y c h o - S o c i a l T r a n s i t i o n s : A F i e l d f o r Study" i n S o c i a l S c i ence and Medicine, 5: 101-115. 1972 Bereavement: S t u d i e s of G r i e f i n A d u l t L i f e . Markham, Ont.: Penguin Books 1975 "Determinants o f outcome f o l l o w i n g bereavement." Omega 6: 303-323 PARKES, C M . 1980 "Bereavement C o u n s e l i n g : Does i t Work?" B r i t i s h M e d i c a l J o u r n a l 281: 3-6 198 6 "Models o f Bereavement Support" Concurrent S e s s i o n B15, 6th World Congress on the Care of the T e r m i n a l l y 111, Montreal, Canada September 27 -October 1, 1986. PARRY, J.K. 1987. S o c i a l Work Theory and P r a c t i c e w i t h the  T e r m i n a l l y 111 New York: The Haworth P r e s s . PATTON, M.Q. 1989 Q u a l i t a t i v e E v a l u a t i o n Methods Newbury Park, C a l i f : Sage Pub. PEGG, P.F., and E. Metze 1981 Death and Dying: A  Q u a l i t y o f L i f e . Bath: Pitman P r e s s PITKEATHLEY, J i l l . 1989 I t ' s My Duty I s n ' t I t ? : The P l i g h t  of C a r e r s i n our S o c i e t y London: Souvenir P r e s s . RANDO, T. A. 1984 G r i e f , Dying and Death: C l i n i c a l  I n t e r v e n t i o n s f o r C a r e g i v e r s . Champaign, 111.: Research Press 1986 Loss and A n t i c i p a t o r y G r i e f . Toronto: Lexington Books 1988 Bereavement. Toronto: L e x i n g t o n Books 265 RAPHAEL, B. 1980 "A P s y c h i a t r i c Model of Bereavement C o u n s e l i n g " i n Mark B. Schoenberg (ed.) Bereavement  C o u n s e l i n g : A M u l t i d i s c i p l i n a r y Handbook Westport, C o n n e c t i c u t : Greenwood P r e s s . 1982 The Anatomy o f Bereavement. New York: B a s i c Books. REIDY, M., L. Levesque and M. P a y e t t e . 1987 "A Paradigm S h i f t i n N u r s i n g Care" i n E.M. Bennett (ed.) S o c i a l  I n t e r v e n t i o n : Theory and P r a c t i c e . Queenston, Ont.: Edwin M e l l e n P r e s s RICCI, C a r l o and Mara S e l v i n i - P a l a z z o l i . 1984 " I n t e r a c t i o n a l Complexity and Communication" i n Family  P r o c e s s V o l . 23 (2) June 1984 p 169. RICE, J . and D. R i c e . 1986 L i v i n g Through D i v o r c e : A Developmental Approach t o D i v o r c e Therapy. New York: G u i l f o r d P r e s s . ROLLAND, J.S. 1989 "Chronic I l l n e s s and The F a m i l y L i f e C y c l e " i n B. C a r t e r and M. McGoldrick (eds.) The  Changing L i f e C y c l e : A Framework f o r F a m i l y Therapy, Boston: A l l y n and Bacon. ROSSMAN, P a r k e r . 1977 Hospice New York: A s s o c i a t i o n P r e s s ROY, P.E. and H. Sumpter. 1983 "Group Support f o r t h e R e c e n t l y Bereaved" H e a l t h and S o c i a l Work pp.230-232. SANDLER, I., J.C. Gersten, K. Reynolds, C A . K a l l g r e n amd R. Ramirez. 1988 "Using Theory and Data t o P l a n Support I n t e r v e n t i o n s : Design o f a Program f o r Bereaved C h i l d r e n " i n B.H. G o t t l i e b (ed.) M a r s h a l l i n g S o c i a l  Support: Format, Processes and E f f e c t s . B e v e r l e y H i l l s : Sage Pub. SATIR, V i r g i n i a 1988 The New Peoplemaking Mountain View, C a l i f o r n i a : S c i ence and Behavior Books, Inc. 266 SCHNEIDER, John. 1984 S t r e s s , Loss, and G r i e f R o c k v i l l e , Maryland: Aspen Pub. SCHOENBERG, M. B. e t a l , (Eds) 1974 A n t i c i p a t o r y G r i e f New York: Columbia U n i v e r s i t y Press 1980 (ed.) Bereavement C o u n s e l i n g : A M u l t i d i s c i p l i n a r y  Handbook. Westport, C o n n e c t i c u t : Greenwood P r e s s SCHWARTZ, P. and J . O g i l v y 197 9 The Emergent Paradigm: Changing P a t t e r n s o f Thought and B e l i e f . Menlo Park: SRI I n t e r n a t i o n a l . SHANNON, Mary. 1989 "Health Promotion and I l l n e s s P r e v e n t i o n : A B i o p s y c h o s o c i a l P e r s p e c t i v e " i n H e a l t h  and S o c i a l Work, February: 32-40. SHERA, Wes 1987 H e l p i n g Networks: An Annotated B i b l i o g r a p h y . U n i v e r s i t y of V i c t o r i a : School o f S o c i a l Work. SHNEIDMAN, E.S. 197 6 Death: Current P e r s p e c t i v e s P a l o A l t o , C a l i f o r n i a : M a y f i e l d Pub. SIEGEL, Sidney. 1956 Nonparametric S t a t i s t i c s f o r the  B e h a v i o u r a l S c i e n c e s . New York: McGraw H i l l . SILVERMAN, P. 1980 Mutual Help Groups: O r g a n i z a t i o n and  Development B e v e r l y H i l l s : Sage Pub. 1982 Mutual Help: Widow t o Widow Programs B e v e r l y H i l l s : Sage Pub. SONTAG, Susan. 1977 I l l n e s s as a Metaphor New York: F a r r a r , S t r a u s s and Giroux. STANTON, M. Duncan. 1984 "Fusion, Compression, D i v e r s i o n , and the Workings of Paradox: A Theory of Th e r a p e u t i c / S y s t e m i c Change" i n Family P r o c e s s V o l . 23 (2) June 1984 pp. 135-163 267 STRAUSS, Anselm. 1987 Q u a l i t a t i v e A n a l y s i s f o r S o c i a l  S c i e n t i s t s Cambridge: Cambridge P r e s s . SUDNOW, Dav i d 1967 P a s s i n g on: The S o c i a l O r g a n i z a t i o n of  Dying Englewood C l i f f s , New J e r s e y : P r e n t i c e - H a l l Inc. TATELBAUM, Judy. 1980 The Courage t o G r i e v e : C r e a t i v e L i v i n g , Recovery, and Growth Through G r i e f New York: L i p p i n c o t t and C r o w e l l Pub. TOSELAND, R. W. , J . Palmer-Ganeles and D. Chapman. 1986 "Teamwork i n P s y c h i a t r i c S e t t i n g s " i n S o c i a l Work, V o l . 31 (1), January-February 1986. TURNER, F r a n c i s , ed. 197 9 S o c i a l Work Treatment: I n t e r l o c k - i n g T h e o r e t i c a l Approaches, 2nd e d i t i o n . London: The Free P r e s s , C o l l i e r M c M i l l a n Pub. VACHON, M. L. S. 197 6 " G r i e f and bereavement f o l l o w i n g the death of a spouse." Canadian P s y c h i a t r i c A s s o c i a t i o n  J o u r n a l 21: 35-44. 1981 "Type of death as a determinant i n acute g r i e f " . In 0. S. M a r g o l i s e t a l (eds) Acute G r i e f :  C o u n s e l i n g the Bereaved. New York: Columbia U n i v e r s i t y P r e s s 1982 " G r i e f and Bereavement: the Family's E x p e r i e n c e B e f o r e and A f t e r Death." In Ian G e n t l e s , (ed) Care f o r the Dying and the Bereaved Toronto: A n g l i c a n Book Centre 1988 " C o u n s e l l i n g and psychotherapy i n p a l l i a t i v e / h o s p i c e c a r e : a review". P a l l i a t i v e  M e dicine 2 (1): 34-50. and S. K. S t y l i a n o s . 1988 "The Role of S o c i a l Support i n Bereavement" J . S o c i a l Issues 44 (3): 175-190. VANDECREEK, L. 1988 "Sources of Support i n C o n j u g a l Bereavement". The Hospice J . 4 (4): 81-92. 263 WALSH, Froma, Ed. 1982 Normal Family P r o c e s s e s . New York: G u i l f o r d P r e s s . WALTERS, M., B. C a r t e r , P. Papp and 0. S i l v e r s t e i n . 1988 The I n v i s i b l e Web: Gender P a t t e r n s i n Family  R e a l t i o n s h i p s . New York: G u i l f o r d Press WALTON, I. 1987 "Terminal care o f the e l d e r l y and bereavement c o u n s e l l i n g " The P r a c t i t i o n e r 231: 869-873. WASOW, M. and D. H. Coons. 1987 "Widows and Widowers o f Alzheimer's V i c t i m s : T h e i r S u r v i v a l A f t e r Spouses' Death" J o u r n a l o f Independent S o c i a l Work Winter 2 ( 2 ) : 21-33. WASSERMAN, H. and H.E. D a n f o r t h . 1988 The Human Bond:  Support Groups and Mutual A i d New York: S p r i n g e r WEINBERG, Nancy. 1985 "The H e a l t h Care S o c i a l Worker's Role i n F a c i l i t a t i n g G r i e f Work: An E m p i r i c a l Study", S o c i a l Work i n H e a l t h Care 10 (3) S p r i n g :107 -117. WEIZMAN, S.G. and P. Kamm 1985 About Mourning: Support  and Guidance f o r the Bereaved. New York: Human Sciences P r e s s . WOODY, J.D. and R.H. Woody. 1988 " P u b l i c P o l i c y i n L i f e -T h r e a t e n i n g S i t u a t i o n s : A Response t o Bobele" J .  M a r i t a l and Family Therapy 14 (2): 133-137. WORDEN, J . W i l l i a m . 1982 G r i e f C o u n s e l i n g and G r i e f Therapy: A Handbook f o r the Mental H e a l t h P r a c t i t i o n e r . New York: S p r i n g e r Pub. Co. and Mary Vachon. 1984 " G r i e f and Bereavement" F i f t h I n t e r n a t i o n a l Seminar on Terminal Care, Concur-ren t One Day Seminar, Montreal, Canada. Sunday, September 30, 1984. 269 WYNNE, Lyman C. 1984 "The E p i g e n e s i s o f R e l a t i o n a l Systems: A Model f o r Understanding F a m i l y Development" i n F amily Process Vol.23 (3) September 1984 pp. 297-315 YALOM, I.D. and S. Vinogradov. 1988 "Bereavement Groups: Techniques and Themes". I n t . J . Group  Psychotherapy 38 (4), October 1988: 419-457. MacLENNAN, B.W. " D i s c u s s i o n of 'Bereavement Groups'" pp. 453-457 STONE, W.N. "Commentary on 'Bereavement Groups'" pp.447-451 YELAJA, Shankar A. ed. 1985 An I n t r o d u c t i o n t o S o c i a l Work P r a c t i c e i n Canada, Scarborough, O n t a r i o : H o l t , R i n e h a r t and Winston ZALOT, G.N. 1989 " P l a n n i n g a R e g i o n a l P a l l i t i v e Care S e r v i c e s Network" J . P a l l i a t i v e Care 5 (1): 42-46 ZAUTRA, A. and I. Sand l e r . 1983 " L i f e Events Needs Assessments: Two Models f o Measuring P r e v e n t a b l e Mental H e a l t h Problems" P r e v e n t i o n i n Human S e r v i c e s 2 (4): 35-58 Summer. APPENDIX I Sampling Frame 271 APPENDIX I Sampling Frame: D i s p r o p o r t i o n a t e S t r a t i f i e d Random Sampling The samples f o r the study were drawn from a p o p u l a t i o n of f o r t y - f o u r (44) i n d i v i d u a l s h a v i n g P a l l i a t i v e Care e x p e r i e n c e . I t was hoped t o d e r i v e two samples o f f i f t e e n t h a t would be comparable w i t h i n age and sex s t r a t a so t h a t matching c o u l d be f a c i l i t a t e d f o r p a i r e d t e s t s . To t h i s end the p o p u l a t i o n was f i r s t d i v i d e d i n t o those h a v i n g bereavement i n t e r v e n t i o n and those not h a v i n g bereavement i n t e r v e n t i o n . The number of i n d i v i d u a l s h a v i n g the bereavement i n t e r v e n t i o n was t e n (10), thus the t o t a l p o p u l a t i o n was sampled. The remaining p o p u l a t i o n of t h i r t y - f o u r (34) i n d i v i d u a l s — those not h a v i n g bereavement i n t e r v e n t i o n — was then sampled through s t r a t i f i e d random sampling u s i n g d i s p r o p o r t i o n a t e sampling r a t i o s . These r a t i o s were based upon the s t r a t i f i c a t i o n of the bereavement i n t e r v e n t i o n sample. In t h i s manner, i t was hoped to m a i n t a i n homogeneity 272 w i t h i n age s t r a t a by sex wherever p o s s i b l e , and r e s u l t e d i n d i f f e r e n t i a l sampling between the s t r a t a . Homogeneity between the s t r a t a was not a concern, however i t s h o u l d be noted t h a t the c h a r a c t e r i s t i c s o f the t o t a l p o p u l a t i o n (44) i n d i c a t e d a f a i r l y homogeneous p o p u l a t i o n . Response Rate: F i v e (5) males and t e n (10) females, from which s i x p a i r s were matched f o r the q u a n t i t a t i v e a n a l y s i s : two (2) daughters, f o u r (4) widowers, and s i x (6) widows. S t r a t i f i c a t i o n by Age and Sex f o r two p o p u l a t i o n s -h a v i n g bereavement i n t e r v e n t i o n and those w i t h o u t : 273 - those With I n t e r v e n t i o n Without I n t e r v e n t i o n Age T o t a l Female Male Female Male < 39 4 1 1 2 -40 - 49 3 - 1 1 1 50 - 59 9 2 - 5 2 60 - 69 12 4 - 5 3 > 70 16 - 1 6 9 N = 44 7 3 19 15 D i s p r o p o r t i o n a t e sampling based upon the bereavement i n t e r v e n t i o n sample c h a r a c t e r i s t i c s : Age N=10 F M S=10 Q , *o S=15 N F =34 M F =15 M R a t i o < 39 1 1 2 20 3 2 - 2 - 1:1 40 - 49 1 1 10 1-2 1 1 1 1 1:1 50 - 59 2 2 20 3 5 2 2 1 1:2 50 - 69 4 4 40 6 5 3 4 2 2:3 > 70 1 1 10 1-2 6 9 1 1 1:7 T = 7 3 10 100 15 19 15 10 5 APPENDIX II Cameron and Brings Questionnaire and Selected Questionnaire Excerpts 275 CAMERON ZAND BRINGS  BEREAVEMENT ANNIVERSARY QUESTIONNAIRE Date of i n t e r v i e w Group C o n t r o l # The f i r s t g r o u p i n g o f q u e s t i o n s are very g e n e r a l q u e s t i o n s about your deceased f a m i l y member and your awareness o f h i s / h e r i l l n e s s p r o c e s s . Name of p a t i e n t Age Length of I l l n e s s Date of Death Name of K.P M a r i t a l s t a t u s R e l a t i o n s h i p t o p a t i e n t Age How many years m a r r i e d t o p a t i e n t ? F i r s t marriage? Time l a p s e between your awareness o f the impending death and the a c t u a l death? D i d you d i s c u s s the impending death w i t h the deceased person? Had the p a t i e n t made a w i l l ? , When? Had the wishes f o r f u n e r a l arrangements been d i s c u s s e d ? When? 276 I would now l i k e t o ask you about your f a m i l y and your c u r r e n t r e l a t i o n s h i p w i t h i t . Are t h e r e c h i l d r e n ? Ages and sex Where do they l i v e ? Who now l i v e s w i t h you? Is t h i s a new arrangement s i n c e the death? Are your r e l a t i o n s w i t h o t h e r members of your household c l o s e r unchanged more d i s t a n t than b e f o r e the death? To whom do you f e e l c l o s e s t now? For K.P. o t h e r than spouse - i s t h i s d i f f e r e n t than from b e f o r e the death? How has t h i s changed ? C h i l d r e n / Family (when no c h i l d r e n ) / F r i e n d s (when no family) Do your c h i l d r e n / f a m i l y / f r i e n d s t a l k about (the dead person) to you t o each o t h e r Do they do t h i s more or l e s s than they d i d d u r i n g the f i r s t months? 277 Do you t a l k t o your c h i l d r e n / f a m i l y / f r i e n d s about (the dead person)? Do you f i n d y o u r s e l f doing t h i s more or l e s s than i n the f i r s t month? Has t h e i r behaviour p a t t e r n changed s i n c e the death? In what way? Has t h e i r schoolwork/occupation performance a l t e r e d ? In what way? Do you f e e l c l o s e r t o them than you d i d p r i o r t o the bereavement? Is t h e r e a n y t h i n g e l s e about your c h i l d r e n / f a m i l y / f r i e n d s t h a t you would l i k e t o share w i t h me? The next s e t of q u e s t i o n s are concerned w i t h your h e a l t h s t a t u s both p r i o r t o and s i n c e your bereavement. H e a l t h Since Bereavement During t h i s year, has your h e a l t h been b e t t e r or worse than b e f o r e your bereavement? 278 D u r i n g t h i s year, have you sought p r o f e s s i o n a l h e l p from a Doctor P s y c h i a t r i s t C o u n s e l l o r / S o c i a l Worker How many times? D i d you i n t h e year p r i o r t o the death? P l e a s e e x p l a i n Are you e a t i n g any b e t t e r than you d i d immediately a f t e r the bereavement? Are you s l e e p i n g b e t t e r ? Do you take s l e e p i n g p i l l s ? T r a n q u i l l i z e r s ? D i d you b e f o r e the death? For how long? Compared t o the time b e f o r e the death, do you now: Drink more l e s s the same Smoke more l e s s the same Have you g a i n e d weight l o s t s t a y e d the same Compared t o the time immediately a f t e r the death, do you f e e l more depressed l e s s depressed about the same Would you now share w i t h me any changes t h a t have o c c u r r e d i n your l i f e over the p a s t year? 279 L i v i n g Arrangements Have you changed your l i v i n g arrangements t h i s year? I f so, when d i d you make the changes? Do you now t h i n k t h i s was a wise d e c i s i o n ? Finances Has your income a l t e r e d d u r i n g the year? Do you f i n d i t d i f f i c u l t t o budget and manage f i n a n c e s ? Do you f i n d i t necessary t o work i n order t o supplement you income? Occupation D i d you work b e f o r e the death? D i d you t e m p o r a r i l y cease t o work d u r i n g the p e r i o d of i l l n e s s and death? For how long? Do you now work? Do you enjoy your work? R e l i g i o n Do you c o n s i d e r y o u r s e l f a r e l i g i o u s person? Do you t h i n k t h a t your f a i t h has hel p e d you d u r i n g your bereavement? 280 D i d your r e l i g i o u s f e e l i n g or p r a c t i c e change at the time of the death? Have you r e t u r n e d t o r e l i g i o n a f t e r b e i n g away f o r a time? Have you r e t u r n e d t o t a k i n g p a r t i n church a c t i v i t i e s ? D i d you r e c e i v e support and h e l p from your own m i n i s t e r , p r i e s t , r a b b i or whoever was a p p r o p r i a t e ? Cemetery Do you ever v i s i t the grave of (the dead person)? Do you make frequent v i s i t s t o the grave? Does t h i s h e l p you? A n n i v e r s a r y How d i d you spend the day? D i d you v i s i t the grave? D i d you f e e l v ery depressed? What d i d you t h i n k about and remember? Were you alone? 281 P a l l i a t i v e Care U n i t (For those w i t h P.C.U. e x p e r i e n c e only) Have you r e t u r n e d t o the P.C.U.? I f so, was i t f o r a s p e c i f i c purpose or j u s t t o v i s i t ? How many times have you been back d u r i n g the year? D i d you f e e l comfortable? D i d you a t t e n d the December meeting? I f so, d i d you enjoy the evening? D i d i t h e l p you p l a n f o r the h o l i d a y season? How many c o n t a c t s have you had wit h the P a l l i a t i v e Care S t a f f d u r i n g the year? Were thes e s e l f or s t a f f i n i t i a t e d ? Bereavement Support D i d you/Do you belong t o a bereavement support group? D i d someone ask you t o j o i n or was i t s e l f - i n i t i a t e d ? I f you were asked t o j o i n a group and you chose not t o , what were your reasons f o r not p a r t i c i p a t i n g ? 282 Would you wish t o p a r t i c i p a t e i n a group now? Who sponsored the group? H o s p i t a l Agency Club Church F a m i l y S e r v i c e s Other Do you s t i l l a t t e n d the meetings? I f no, how many months post bereavement d i d you at t e n d ? How o f t e n did/do you a t t e n d these meetings? What has h e l p e d the most? In r e f l e c t i n g over the past year, what are your g e n e r a l impressions about the f o l l o w i n g : Do you f e e l any c l o s e r t o your f r i e n d s s i n c e bereavement? Have you made any new, c l o s e r e l a t i o n s h i p s t h i s year? What do you f e e l about the p o s s i b i l i t y of re-marriage? Do you ever t h i n k about t h i s ? Do you f i n d y o u r s e l f g r i e v i n g any l e s s now than you d i d e a r l i e r ? 283 Do you ever f e e l g u i l t y because you are not w o r r y i n g as much now? Do you f e e l t h a t you have more understanding and sympathy f o r other people's problems s i n c e your bereavement? Have you begun t o r e t u r n t o any former a c t i v i t i e s which you had abandoned f o r a time? Have you begun any new a c t i v i t i e s ? Do you go out more than you did? Have you begun t o make p l a n s f o r the f u t u r e ? When d i d you d i s p o s e of p e r s o n a l belongings? Do you keep reminders such as photographs where you can see them? Have you e x p e r i e n c e d any o t h e r l o s s d u r i n g the year? I f yes, p l e a s e e x p l a i n I f you had t o t r y t o s i n g l e out any one t h i n g , what would you say was the h a r d e s t t h i n g t o bear t h i s year? 284 Were t h e r e some p o s i t i v e t h i n g s t h a t o c c u r r e d d u r i n g t h i s year? Do you now have a c l e a r e r image of (the dead person) i n your mind than you d i d a f t e r the death? Do you o f t e n f i n d y o u r s e l f t e a r f u l now? I f yes, i s i t d i f f e r e n t from when you were f i r s t bereaved? In what way? Who or what do you t h i n k has h e l p e d you the most d u r i n g t h i s year? Is t h e r e a n y t h i n g e l s e t h a t you wish t o share? _285 Do you wish t o make an appointment t o d i s c u s s t h i s f u r t h e r , or do you wish t o r e c e i v e i n f o r m a t i o n about bereavement support groups? Thankyou. 286 EXCERPTS I. Cemetery To account f o r changes i n f u n e r a l and b u r i a l p r a c t i c e , the s e c t i o n on "Cemetery" r e q u i r e d a d d i t i o n a l p r o b i n g t h a t would e l i c i t r i t u a l behaviour other than " v i s i t i n g t he grave". Here a q u e s t i o n was added a s k i n g i f t h e r e i s "a s p e c i a l p l a c e t h a t reminds you of (your f a m i l y member) t h a t you v i s i t ? " . The responses were a p p r o p r i a t e f o r the number of i n d i v i d u a l s whose f a m i l y member was cremated (70% of the sample), and f o r some, the degree of g r i e f r e s o l u t i o n , q u i t e c r e a t i v e . Cemetery Do you ever v i s i t the grave of (the dead person)? Yes 4; No - 9; No answer - 1 I f not, why? Cremated, ashes s c a t t e r e d - 8 I n t e r r e d i n Manitoba - 1 No answer - 1 Do you make frequent v i s i t s t o the grave? P e r i o d i c - 3 R e g u l a r l y - 1 287 Respondent: I have a very p e r s o n a l r e l i g i o u s b e l i e f . My w i f e wished f o r cremation and no f u n e r a l . I c o u l d n ' t do t h a t . I v i s i t the grave o f t e n . I t h e l p s . Respondent: "My daughter became h y s t e r i c a l at the thought of s c a t t e r i n g the ashes i n the ocean — she s a i d she f e l t l i k e she was 'pushing him away'. I r e a l i z e d i t was important t o her t o have him i n t e r r e d so we d i d . And we have p l a n t e d a rhododendron a t h i s s i t e — i t was h i s f a v o u r i t e p l a n t . ( I f cremated and not i n t e r r e d ) Is t h e r e a s p e c i a l p l a c e t h a t reminds you of your f a m i l y member t h a t you v i s i t ? Not r e a l l y - 2 Yes - 6 Would you be w i l l i n g t o share t h i s with me? Examples of responses: Respondent: "I can always go and s t a n d i n my c l o s e t . . . ( l a u g h t e r ) . . . you see, I d i d n ' t know what t o do w i t h him f o r the l o n g e s t time, so I kept him i n my c l o s e t ! " 288 Respondent: "The Parks Board wouldn't a l l o w me t o i n t e r the ashes at the t e n n i s c o u r t s i n S t a n l e y Park, but I cheated and took a p i n c h [of ashes] over, and now I can go and watch a good game of t e n n i s w i t h him!" Respondent: "My f r o n t room i s f u l l o f p l a n t s g i v e n t o me when my husband was dying. Now they are blooming and d o i n g w o n d e r f u l l y . T h i s , i n a way, keeps him a l i v e f o r me. Being i n t h a t room makes me f e e l c l o s e t o him. " Respondent: "Her ashes were s c a t t e r e d i n the ocean. T h i s g i v e s the c h i l d r e n a co n n e c t i o n w i t h l i f e r a t h e r than p l a c e — f r e e i n g them t o move on i n t h e i r l i v e s -- the ocean i s always t h e r e " Respondent: "I l i k e t o go and s i t on a bench o v e r l o o k i n g the s e a w a l l where we walked. He l i k e d t o s i t t h e r e when he was too weak t o do the walk anymore. We've d e d i c a t e d the bench i n h i s name t o the m u n i c i p a l i t y . There's a n i c e l i t t l e garden t h e r e t o o . " 289 I I . Bereavement Support D i d you/Do you belong t o a bereavement support group? Yes - 8; No - 7 D i d someone ask you t o j o i n o r was i t s e l f - i n i t i a t e d ? Some asked me - 15 I f you were asked t o j o i n a group and you chose not t o , what were your reasons f o r not p a r t i c i p a t i n g ? Not a j o i n e r - 1 Didn't need i t - 4 Not ready - 1 Saw a t h e r a p i s t - 1 Would you wish t o p a r t i c i p a t e i n a group now? No - 7 For p a r t i c i p a n t s : Who sponsored the group? H o s p i t a l - 8 Do you s t i l l a t t e n d the meetings? Yes - 4 No - 4 I f no, how many months pos t bereavement d i d you attend? < 3 months - 4; > 3 months - 4 290 How o f t e n did/do you a t t e n d t h e s e meetings? R e g u l a r l y - 6; P e r i o d i c a l l y - 2 What has h e l p e d the most? The bereavement group p a r t i c i p a n t s expressed needs b e i n g met t h a t i n c l u d e d : s o c i a l support, openness and acceptance, the normalcy of the bereavement e x p r e s s i o n ( i e . not going c r a z y ) , s h a r i n g and v a l i d a t i o n of e x p e r i e n c e , p e r c e p t i o n of growth i n o t h e r s and s e l f , p e r m i s s i o n t o t a l k about the death and about s e l f , a v a i l a b i l i t y of i n f o r m a t i o n from which t o d e f i n e own g u i d e l i n e s f o r g r i e v i n g , and the p r o v i s i o n of a refuge and support. "The bereavement group has been a source of my s a n i t y " . 291 I I I . G e n e r a l Impressions I f you had t o t r y t o s i n g l e out any one t h i n g , what would you say was the hardest t h i n g t o bear t h i s year? The death - 2 Respondent; " I t f e e l s l i k e I have been c a s t i n t o the middle of the ocean without a l i f e j a c k e t " ; Respondent; " I t i s a deep abyss out of which you must c r a w l " Other: "I miss the phone c a l l s — she used t o c a l l everyday". " G r i e f was so p a i n f u l , I hadn't a n t i c i p a t e d how much i t would HURT". "The " F i r s t s " were the h a r d e s t . " " T h i s f a l l — w i t h the r a i n ... i t was j u s t l i k e l a s t f a l l b e f o r e she d i e d , ... wet and d r e a r y . I t brought i t a l l back, ... a l l t h a t p a i n " . "I miss HIM. I'm d i s a p p o i n t e d and angry t h a t we c o u l d n ' t do a l l the t h i n g s we had plan n e d t o do when he r e t i r e d " . "Going back t o England and t e l l i n g h er f a m i l y about her death — i t kept the g r i e f f r e s h " . " F a t h e r ' s Day" "My b i r t h d a y ! I'd prepared myself f o r every o t h e r s p e c i a l o c c a s i o n d u r i n g the year and f o r g o t about my b i r t h d a y — and no one e l s e knew 'cause I don't t e l l people when i t i s — and t h e r e I was al o n e ! I t r e a l l y caught me o f f guard." "I miss the s h a r i n g and companionship". "The a n n i v e r s a r y date of the death". "At the b e g i n n i n g everything; was h a r d . . . mostly I guess, other than him, were a l l the p l a n s we made f o r h i s r e t i r e m e n t " . Were t h e r e some p o s i t i v e t h i n g s t h a t o c c u r r e d d u r i n g t h i s year? Nothing was p o s i t i v e - 3 For example: "I can't t a l k about t h i s y e t . For me he i s n ' t dead y e t " . Improved r e l a t i o n s h i p / g r e a t e r c l o s e n e s s w i t h my c h i l d r e n - 4 293 I n c r e a s e d independence - 4; G r e a t e r r e s i l i e n c e - 3 C l o s e r f r i e n d s - 6; Good neighbours - 4 New pet - 1; New a c t i v i t i e s - 3 Return t o Church r o o t s - 1 Comments i n c l u d e d : "I'm managing r e a l l y w e l l I d i d the v e g e t a b l e garden f o r the f i r s t time t h i s year. I t ' s a l s o b e t t e r now t h a t I see my daughter t u r n i n g the c o r n e r " [ r e s o l v i n g i s s u e s ] . "I have a wonderful f r i e n d who has l i s t e n e d and l i s t e n e d — she's always t h e r e and always a c c e p t i n g " . "I had a new g r a n d c h i l d born i n September — i t was a b i t t e r s w e e t experience — wonderful f o r me, sad t h a t my husband missed i t " . "My neighbours have been so c o n s i d e r a t e and t h o u g h t f u l . " "I'm do i n g t h i n g s I've never done b e f o r e . I never had c l o s e f r i e n d s , now I have new f r i e n d s t h a t I do new t h i n g s w i t h " . "I hadn't a n t i c i p a t e d how much freedom t h e r e i s t o b e i n g alone — freedom t o do what I want, when I want. I t 294 was a s u r p r i s e " . "The s a i l i n g has brought the f a m i l y c l o s e r t o g e t h e r — we share time and space t o g e t h e r and are a l s o c l o s e t o my w i f e / t h e i r mother t h i s way". " I t r e a l l y h e l p e d me t o see t h a t I c o u l d h e l p o t h e r s ( i n the bereavement group)". "I don't l e t l i t t l e t h i n g s b u i l d up anymore. The death h e l p e d t h a t way — time i s too s h o r t " . APPENDIX III Cameron and Brings G r i e f and Adjustment Inventories 296 Group Control# G r i e f Inventory 1. P h y s i c a l H e a l t h (as p e r c e i v e d by respondent) U n d e s i r a b l e weight change 1 U n d e s i r a b l e e a t i n g p a t t e r n change p e r s i s t s 1 U n d e s i r a b l e s l e e p p a t t e r n change p e r s i s t s 1 Uses s l e e p i n g p i l l s ( s i n c e b e r e a v e m e n t / i l l n e s s ) ... 1 Uses t r a n q u i l l i z e r s ( s i n c e b e r e a v e m e n t / i l l n e s s ) ... 1 F e e l s h e a l t h has d e t e r i o r a t e d s i n c e bereavement ..1 T o t a l 2. P s y c h o l o g i c a l H e a l t h a) G r i e f i n d i c e s p r e s e n t a f t e r one year: P i n i n g and s e e k i n g 1 Sense of presence 1 Death wish or s u i c i d e 1 T e a r f u l n e s s 1 Anger 1 G u i l t 1 R e s t l e s s n e s s / t e n s i o n 1 A v o i d a n c e / b l o c k i n g 1 Sub-Total 297 b) I n d i c e s of poor adjustment: No change i n g r i e f s i n c e bereavement 1 F e e l s very depressed 1 Uncomfortable with reminders 1 V i s i t s t o grave very d i s t r e s s i n g 1 Haunted by i n t o l e r a b l e death memories on bereavement a n n i v e r s a r y 1 A v o i d i n g new a c t i v i t i e s / r e l a t i o n s h i p s 1 H y p e r a c t i v e (postponing) 1 Lacks c o n c e n t r a t i o n , a b i l i t y t o f o l l o w t h r u .. 1 Experiences p a n i c a t t a c k s 1 I s o l a t i o n 1 Sub-Total c) I n d i c e s of maladaptive adjustment: Engages i n l i f e endangering behaviour 1 (Increased smoking, d r i n k i n g etc.) Death wish 1 More depressed now than e a r l i e r 1 I s o l a t i o n r e : s o c i a l withdrawal 1 H o s t i l e toward o t h e r s 1 No f u t u r e o r i e n t a t i o n , today only 1 Marked sense of presence 1 Has symptoms of dead p e r s o n 1 F a i l u r e t o see Dr. r e : d e t e r i o r a t i n g h e a l t h .. 1 Sub-Total T o t a l Grand T o t a l (l+2a,b,c) Comments: 298 Adjustment Inventory 1. Physical Health Appetite normal 1 Weight normal or desired 1 Sleeping habits normal 1 Health related to bereavement now resolved ... 1 Has sought professional help with health related problems appropriately 1 Total 2a. Psychological Health Grieving less, no g u i l t 1 Feels less depressed/saddened than at time of bereavement 1 Comfortable with reminders of deceased 1 Memories of deceased h a p p y / r e a l i s t i c 1 Clearer image of deceased person 1 Sub-Total b. Behavioural/Social Sphere Resumed old a c t i v i t i e s 1 Engaging i n new a c t i v i t i e s / r e l a t i o n s h i p s 1 Personal expression of independence 1 Planning ahead for the future 1 Sub-Total Total Grand Total (l+2a,b) Comments: APPENDIX IV Code Book for SPSS:X Analysis Code Book 300 1 - 4 CID C l i e n t I d e n t i f i c a t i o n Number AGE 7 SEX 8 REL 9 CHILD 11-12 MAR 13-14 PREP 15 HEALTH 16 RELIG 17 FSUPP 18 SSUPP 1 = Male 2 = Female R e l a t i o n s h i p t o Deceased 1 = Spouse 2 = c h i l d Number of c h i l d r e n / s i b l i n g s Number of years m a r r i e d Number of Months 111 b e f o r e Death (awareness of not g e t t i n g b e t t e r ) H e a l t h Risk 1 = n i l / l o w 2 = poor h e a l t h s i n c e death, r e s o l v e d 3 = poor h e a l t h s i n c e death, u n r e s o l v e d 4 = poor h e a l t h p r i o r , c o n t i n u i n g 5 = poor h e a l t h and/or o t h e r R e l i g i o s i t y 1 = n i l 2 = s p i r i t u a l 3 = p e r s o n a l , no church 4 = church Family Support 1 = n i l / l o 2 = some/moderate 3 - h i g h S o c i a l Support 1 = n i l / l o 2 = some/moderate 3 = h i g h 301 20-21 GRIEF G r i e f Score 22-23 ADJUST Adjustment Score 25 BG Bereavement Group 1 = Yes; 0 = No To ensure c o n f i d e n t i a l i t y , i d e n t i f i a b l e p e r s o n a l i n f o r m a t i o n — age, sex, r e l a t i o n s h i p t o the deceased, number of years m a r r i e d — p e r t a i n i n g t o the respondents has been removed from the Raw Data M a t r i x . Raw Data M a t r i x A01J 2 031322 0705 1 A02J 3 112132 0510 1 A03J 3 095431 0911 1 A04J 1 032432 0212 1 A05J 3 042233 0912 1 A07M 2 063411 1109 1 A08M 2 081133 0212 1 A09M 1 051433 0113 1 COIF 2 241322 1405 0 C02F 2 132213 0610 0 C06F 2 724121 0506 0 C08F 1 241422 0014 0 CUM 9 135411 2001 0 C13M 2 111133 0414 0 C14A 1 182322 0510 0 302 APPENDIX V A b s t r a c t o f Comments u t i l i z i n g W i l l i a m Worden's Four Tasks o f G r i e v i n g 303 I n t e r v i e w A b s t r a c t  u s i n g W i l l i a m Worden's Four Tasks of G r i e v i n g , 1982 Task I A c c e p t i n g the r e a l i t y of the l o s s : (absence o f : d e n i a l , s e a r c h i n g , m i n i m a l i z i n g , s e l e c t i v e f o r g e t t i n g ) Cancer i s s t r e s s - r e l a t e d , t h e r e f o r e you need t o i n c o r p o r a t e a h e a l t h y l i f e s t y l e . There was a m i s d i a g n o s i s , t h e r e was no time. I don't know how l o n g he was s i c k , I can't remember. We d i d n ' t t a l k , we d i d n ' t want t o t h i n k t h a t he wouldn't get b e t t e r . The death was brought on and aggravated by the treatments. The d o c t o r s d i d n ' t g i v e us enough i n f o r m a t i o n . Death i s "an a c t of God" G r i e f was so p a i n f u l . I hadn't a n t i c i p a t e d how much i t would h u r t . I was numb and very angry. We t r u s t e d the d o c t o r s and the treatment was wrong. They gave us wrong a d v i c e . I d i d n ' t understand what was happening. There was a t e r r i b l e numbness t h a t l a s t e d f o r ages and ages and then one day i t was over. I t was gut-wrenching and p a i n f u l . I t r a v e l e x t e n s i v e l y . Her image i s s t i l l t h e r e , i t i s so empty. 304 There were good days and bad days. The whole year was hard. I t ' s harder now. There was n o t h i n g p o s i t i v e about the y e a r . I d i d n ' t want t o g i v e up hope. I was shocked when he d i e d . T a l k i n g about him made me sad, so I d i d n ' t want t o dw e l l on him. His job k i l l e d him — the s t r e s s caused him t o become i l l . To me he's not dead y e t . I t w i l l be another year b e f o r e I can t a l k about i t . The f i n a l i t y of i t i s the h a r d e s t . G r i e f i s a deep abyss out of which you must c r a w l . I can't t a l k about i t as I have a bad stomach and i t makes me very s i c k . I t was l i k e b e i n g c a s t out i n t o the ocean without a l i f e j a c k e t . His s u f f e r i n g i s over. He s u f f e r e d t e r r i b l y . I had t o move. We b u i l t the house t o g e t h e r , her presence was everywhere. I l o s t p a r t of myself. The hardest t h i n g was buying the c o f f i n . The memory of the death i s hard — i t wasn't him. I don't remember how l o n g he was s i c k -- I've b l o c k e d 305 i t out, i t was so p a i n f u l . The treatments were so hard on him we d i d n ' t have any q u a l i t y time. He d i e d a t home. He waited u n t i l everyone was t h e r e and then p e a c e f u l l y s l i p p e d away. I t was a g i f t . He knew the baby was b e i n g born. He waited u n t i l u n t i l she was born and he heard her c r y on the phone. He s a i d "That's my grand-daughter" and then s l i p p e d i n t o a coma and d i e d t h r e e days l a t e r . The time we had was p r e c i o u s - h i g h l y p o s i t i v e and c l o s e . 306 Task I I E x p e r i e n c i n g the p a i n o f g r i e f : (absence o f : n e g a t i n g f e e l i n g s , a v o i d i n g p a i n f u l thoughts, i d e a l i z i n g the dead, s t o i c i s m ; concerns r e : l e t t i n g go of anger, f e a r s , g u i l t , l o s s as p a r t of s e l f , avoidance, r e l i v i n g / r e w o r k i n g the death event) I t ' s none of the d o c t o r s ' damn b u s i n e s s how my h e a l t h i s . My f r i e n d s asked me not t o move away. I don't need a n y t h i n g ( a l c o h o l , t r a n q u i l l i z e r s ) , I don't need any c r u t c h e s . My w i f e kept a s k i n g me t o take her away from a l l t h i s . You have t o move ahead. There's n o t h i n g you can do — he's gone and you have t o move on. I thought I was doing so w e l l and then I went t o the d e n t i s t and he found I had seven c r a c k e d t e e t h — a l l w i t h i n the l a s t year! A l l t h o s e l o s t dreams and e x p e c t a t i o n s t h a t have t o be worked through. I used t o v i s i t the grave when I needed t o work out a problem, i t ' s l e s s now. I'm w a i t i n g f o r the oth e r shoe t o drop. The boys f o l l o w Mom's l e a d — t h e y ' r e managing w e l l . I f e e l too o l d . I t ' s nobody e l s e ' s b u s i n e s s . My w i f e was so s c a r e d . 307 I gave the c l o t h e s away — i t made me f e e l needed. There are some u n r e s o l v e d i s s u e s t h a t need t o be addressed. I t ' s not time y e t . We p l a y e d the game and kept up the p r e t e n s e — I deeply r e g r e t t h a t . I wished I c o u l d go t o o . What r i g h t d i d she have t o go and l e a v e me? She was my soul-mate. P a i n over time i s d i f f e r e n t — i t becomes more l i k e n o s t a l g i a . I remember the image of him at t h e end -- i t ' s hard. The wrenching p a i n has now been r e p l a c e d by p e r i o d i c sadness. I never wanted to be a "poor me p e r s o n " . The c h i l d r e n were ab l e t o cope. They must. I needed to get on with i t . I observed a r i t u a l mourning p e r i o d j u s t b e f o r e the a n n i v e r s a r y . I needed t o check out my emotions. I haven't r e a l l y c r i e d yet — I don't t h i n k I've a l l o w e d myself t o f e e l i t y e t . I e x e r c i s e r e g u l a r l y — I keep i n f i g h t i n g t r i m . I haven't d i s m i s s e d him from my l i f e . I t ' s more n a t u r a l and easy t o speak of him now. 308 The n i g h t s are s t i l l v e ry d i f f i c u l t . I wear h i s sweater f o r s e c u r i t y — i t s m e l l s of h i s a f t e r s h a v e . V i s i t i n g the grave was p a i n f u l a t f i r s t , now i t ' s okay. I t ' s h a r d t o con c e n t r a t e at t i m e s . I was i n s t r e s s o v e r l o a d (on the a n n i v e r s a r y of the death) and can't remember a n y t h i n g we d i d . The s t i f f upper l i p t h i n g — i t f i t s . I won't wallow i n s e l f p i t y . I t doesn't take men long t o f i n d someone e l s e . L a s t f a l l was wet and dreary, j u s t l i k e when she was s i c k and dying. I t brought i t a l l back. I don't have time t o d e a l w i t h i t r i g h t now. I t ' s h a r d l i v i n g alone — i t ' s d e f i n i t e l y d i f f e r e n t without a mate. 309 Task I I I A d j u s t i n g t o the Environment without Deceased: ( c o n s i d e r a t i o n s o f : r o l e l o s s , d e v e l o p i n g new s k i l l s , l o n e l i n e s s and r e a c h i n g out t o o t h e r s , s e l f - c o n f i d e n c e , t a k i n g i n i t i a t i v e ) I used t o walk everyday with my wif e — I s t i l l c a n't walk those pathways and have had to make new one's f o r myself. I am c o l l e c t i n g s t o r i e s and v i g n e t t e s about her from her f r i e n d s and am c o m p i l i n g a book f o r our son — my wi f e f e a r e d t h a t he would f o r g e t her. I meditate and use c r e a t i v e v i s u a l i z a t i o n . I am proud o f my r e s i l i e n c e . People expected me t o "get over i t " w i t h i n two months. My son t r i e s t o boss me but I can handle i t . He's not t h e r e , he's everywhere. The bereavement group a l l o w s me t o t a l k about myself -- t o say t h i n g s I c o u l d never say to my f r i e n d s . I don't l i k e e a t i n g by myself. My f r i e n d s expect me t o be "over i t " by now. S i t t i n g a t home i s n ' t good. You have t o make an e f f o r t t o get out. I t ' s e a s i e r now. I have a new dog — she's my. dog. She's wonderful. She f i l l s the h o l e and gets me out f o r my e x e r c i s e . He's not coming back. Things have t o be t h i s way. I now have f r i e n d s of my own. 310 I don't f i t anywhere — I'm not a couple, I'm not an anything. I miss the sharing. I f e e l alone and scared. I address issues now — there's no time to l e t things b u i l d up. I've learned not to be so uptight about things. I've created my own guidelines to handle my bereavement. I need to be whole for the children. We make a point of eating together every day. I've re-established a friendship with an o l d f r i e n d . I grieve for the children's l o s s . I thought I would manage better. I t ' l l work out i n time. I have one very close f r i e n d . I'm very shy — i t ' s hard for me to reach out to others, to speak up i n a group. The experience of the new grandchild i s bittersweet — he's not here to enjoy i t . My neighbours of many years provide me a sense of s e c u r i t y . Time heals. It takes time. It's lonely. My small dog keeps me company. 311 The a n n i v e r s a r y was the end of the f i r s t year — t h e end of a l l the " f i r s t s " I'm r e v e r t i n g back t o my o l d independence and am becoming i n c r e a s i n g l y s e l f d i r e c t i v e . I miss the s h a r i n g — "wouldn't "M" have l o v e d t h i s " The bereavement group i s a refuge — t h e r e I know I'm not going n u t t y . I f e e l the experi e n c e has s o f t e n e d me — I'm not so hardnosed. My daughter i s becoming b o l d e r — t r i e s t o boss me l i k e her mother d i d . I miss the p h o n e c a l l s . I'm ab l e t o reach out t o more my f r i e n d s now. I f e e l so alone, not j u s t l o n e l y — as though I don't f i t . I t ' s hard a l o n e . I'm t r y i n g t o venture out on my own now. I've l e a r n e d new s k i l l s at work and f o r the f i r s t time I've put i n the v e g e t a b l e garden — my husband used t o do t h a t . My problems are minor compared t o o t h e r s . The " F i r s t s " are the h a r d e s t . I had two years t o l e a r n how t o do t h i n g s . He l e f t me a wonderful l e t t e r — i t has been such a s o l a c e t o me. We p l a n t e d h i s f a v o u r i t e shrub on the a n n i v e r s a r y the r e s t of the day was v e r y hard. There has been n o t h i n g p o s i t i v e about the p a s t yea I t u r n e d the c o r n e r at Christmas. I'm no lon g e r p a r t of a c o u p l e . I t ' s hard t o meet new people, e s p e c i a l l y when o l d f r i e n d s are a l l c o u p l e s . I'm l o n e l y and alone . I f e l t abandoned when everyone went away. I've s t a r t e d g o i n g out more. I miss him — the person. I'm not t h a t o l d . There are some advantages t o b e i n g s i n g l e . 313 Task IV Withdrawal and reinvestment of energy i n new  a c t i v i t i e s / r e l a t i o n s h i p s : (concerns r e : never marrying again, i n a b i l i t y t o l o v e someone e l s e , l e t t i n g go, no p a i n f u l memories) The thought o f remarriage s c a r e s me. The thought of another f a m i l y overwhelms me. The s m e l l was gone — I used t o s m e l l the c l o t h e s and then I found the s m e l l was gone — i t was time t o l e t go. We spread the ashes i n the sea — the sea s i g n i f i e s c o n n e c t i o n w i t h l i f e . I t ' s a b e a u t i f u l world -- t h e r e ' s a l o t t o do and see and c h e r i s h . I'm so proud of how w e l l the c h i l d r e n are doing. I went t o a p s y c h i c who p r e d i c t e d " l o t s of fun and dancing i n the year t o come" — I'm l o o k i n g forward t o i t . I'm open t o remarriage — I'm not t h a t o l d and t h e r e are advantages t o b e i n g m a r r i e d . Everyone i s d i f f e r e n t — t h e r e ' s no way t o h e l p everyone. I'm too o l d t o c o n s i d e r remarriage. Remarriage would be a b e t r a y a l of her. I have l o t s t o do — no time f o r remarriage r i g h t now. I'm t r a v e l l i n g and doing t h i n g s I d i d n ' t get the chance t o do with my husband. I am s t i l l d i s t r e s s e d over l a c k of r e s o l u t i o n b e f o r e the death. I f I r e m a r r i e d I would always compare the second with the f i r s t . I've r e t u r n e d t o my church and am making new f r i e n d s . The memories are s t i l l p a i n f u l . I'm p l a n n i n g t o s e l l the house i n a year or two and t r a v e l . I have a wonderful c l o s e f r i e n d who w i l l l i s t e n and l i s t e n . I'm l o o k i n g forward t o the new baby. I have new f r i e n d s and new a c t i v i t i e s — i t ' s e x c i t i n g . Time was a r e a l g i f t . I t was a r e l i e f , the year was over. I'd made i t and now I can go on. Things and p l a c e s get b u i l t i n t o your l i f e . There's a time to f i n i s h up t h i n g s . I have more freedom now. There's more t o l i f e than worrying about d y i n g . I p l a n t o remarry. I'm d a t i n g now — " r e h e a r s i n g " . APPENDIX VI Abstract of Time Connotations 316 Time Conn o t a t i o n s : 1 - time l i n e , p e r i o d o f time, time frame 2 - o c c a s i o n , d u r a t i o n of time r e l a t i n g t o c e r t a i n e x p e r i e n c e s 3 - c o n d i t i o n a l , c h o i c e of pr o p e r moment - f u t u r e 4 - t u r n i n g p o i n t , t i m i n g , at r i g h t moment - past Without Bereavement I n t e r v e n t i o n 2 Two years of s u f f e r i n g f o r us both. 3 I t ' s not time yet - x3 1 No time t o t a l k . 3 Don't have time t o d e a l with i t r i g h t now. 1/2 Looked a f t e r [deceased] f o r over s i x years, now t h e r e ' s n o t h i n g . 1/2 I l l n e s s of two years e q u a l l e d the r e t i r e m e n t o f two y e a r s . 1 Had time t o prepare, t o l e a r n the t h i n g s I need t o know. 2/3 I t ' l l be another year b e f o r e I can t a l k about i t . 1 Time i s a r e l e a s e . 1 He had time t o take c a r e of t h i n g s b e f o r e he d i e d . 1 There was no q u a l i t y time. 3 He waited u n t i l everyone was t h e r e and then he d i e d . 4 Christmas was a t u r n i n g p o i n t f o r me. 317 With Bereavement I n t e r v e n t i o n 4 The year was over, now I can go on. 4 There's a time t o l e a v e . 3 He s t a y e d a l i v e u n t i l she was born. 1 Doesn't take men long b e f o r e they f i n d someone. 1 Time was a r e a l g i f t . 1 My husband had time t o take care of e v e r y t h i n g . 2 Hardest time was my b i r t h d a y . 2 We c o u l d go t o the h o s p i t a l anytime t o be w i t h him. 2 We d i s c u s s t h i n g s r i g h t away — t h e r e ' s no time t o l e t t h i n g s b u i l d up. 1 There was no time t o d i s c u s s t h i n g s , t o work through the f e a r and anger. 3 I ' l l have time t o i n d u l g e myself a f t e r . . . 1 There may have been more time f o r us i f t h e r e hadn't been a m i s d i a g n o s i s . 4 P a i n changed a f t e r t h a t time. 1 Time h e a l s . 1 I w i l l work i t out i n time. 1 The time of her i l l n e s s was very c l o s e . 4 The s m e l l was gone, i t was time. 4 The p a i n was gone. 4 I t was time to s t a r t a g a i n . 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0097997/manifest

Comment

Related Items