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Loss, change, and the family : implications for social work practice Saunders, Diana 1978

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LOSS, CHANGE, AND THE FAMILY: IMPLICATIONS FOR SOCIAL WORK PRACTICE Diana Saunders School of Social Work The University of British Columbia u Submitted as partial requirement for the degree of Master of Social Work Submitted to: Dr. Kloh-Ann Amacher Dr. Anne Furness July 23, 1978 Loss, Change, and the Family; Implications for Social Work Practice Table of Contents I. Introduction II. Reactions to Loss (individual, family) A. Stages of Dying: The Grieving Process B. Loss of a Family Member as a Result of Death --C. Losses Due to the Process of Separation and/or Divorce D. Losses Due to the Aging Process E. The Concept of Grieving Applied to Other Losses .p, -F. Some Issues for the Family as a System III. Implications for Social Work Practice IV. Implications for Social Policy V. Conclusion Introduction "Everything that happens to us graduations, marriage, childbirth, divorce, getting or losing a job affects us" (Sheehy, 1977, p.29). Life is full of transitions and changes. Some of these, such as the transitions that occur between developmental stages, are internal changes. Others, such as the transitions that occur as a result of our interactions in the social environment, are external changes. In many ways, life is a series of changes and adjustments. How we cope with loss and change has far-reaching implications for each of us. At times, the coping is relatively painless; at other times, it shakes the very core of our being and disrupts the meaning of our lives. Social work is a profession committed to a better understanding of the individual in his social context. Our professional goals include helping people to maximize their personal and social potential and to cope with problems in living. It seems appropriate, therefore, that we undertake an analysis of how the change process affects individuals, families, and communities. Since the basic social unit, in this author's opinion, is the family, our discussion is presented from a family perspective. - 2 -Since all change involves a loss of things as they were whether this is seen as positive or negative our discussion is presented in the context of trying to achieve a better understanding of the reactions to and implications of loss. "The fear of loss, loss, and separation are beginning to be recognized as important underlying dynamics in much pathology seen in clinical work" (Simos, 1977, p.337), so that our discussion has relevance to social work practice. This is not to presume that loss and change are necessarily negative experiences. Indeed, a major implication for social work practice seems to be the potential for growth in the experience of dealing with loss and change. We will begin with an examination of reactions to loss. Included here will be a consideration of the stages of dying and the grieving process as well as the loss of a family member as a result of death. We will then consider losses due to the process of separation and/or divorce, which has particular relevance due to the increasing incidence of divorce in our society. Losses due to the aging process will also be addressed. We will then apply the concept of grieving to other losses and also consider some issues for the family as a system. We will conclude by considering some additional implications for social work practice and for social policy. Reactions to Loss (individual, family) Stages of Dying: the Grieving Process: Elizabeth Kubler-Ross describes five major stages in the grieving process. While much of her work has focussed on the dying patient, and therefore grief as it relates specifically to death, Kubler-Ross's ideas and concepts have increasingly been applied to other kinds of losses as well. It would be useful at this point, therefore, to review some of her material regarding the stages of dying. Kubler-Ross points out that these stages apply to the terminally ill patient between the point of awareness and actual death. In her more recent work, Kubler-Ross also states that these stages apply to the family of the terminally ill patient during the period of anticipatory grief and again during the period of grief following death. In general, Kubler-Ross finds that the family members tend to lag behind the individual in terms of stages and this causes turmoil within the family. She points out that practitioners need to be particularly sensitive to those family members lagging behind. Staff members working with families and individuals experiencing terminal illness often go through the same process and'stages. Kubler-Ross points out, however, that these stages are not absolute and -4-not everyone goes through the same stages in the same order. The first reaction may be a temporary state of shock or numbness. When this dissipates the initial stage of denial is likely to occur. The denial stage is important and serves the necessary function of cushioning the impact of the inevitability of the death or loss. When the person is no longer able to maintain denial, this is replaced by the next stage. The second stage in the dying process, according to Kubler-Ross, is the stage of anger or rage. This stage is very difficult to cope with from the point of view of family, staff, and other people coming into contact with the person. The person resents the fact that others remain healthy and alive while he or she faces death. Anger is displaced onto the environment and may be manifested in obnoxious behavior. The normal reaction to this is to get angry and act out anger in return a response that further intensifies the situation. Kubler-Ross points out the importance of trying to understand the purpose of this stage and viewing it as progress. It is important that the person be allowed to express the anger. In dealing with staff and family members, it should be pointed out that the person is angry at others for what they represent, namely -5-life, energy, functioning. The stage of anger and rage is typically followed by the third stage, which is one of bargaining. This is an attempt to postpone the inevitable. The fact of death is accepted but the person attempts to bargain typically with God 'for more time. Kubler-Ross points out that this stage looks peaceful but it is not. It is more of a temporary truce that allows for a remobilization of strength. The fourth stage in the dying process is one of depression. Rather than being an abnormal reaction, this stage is a sign of strength and courage an indication that the person is facing up to the situation. It is important to recognize the person's need to mourn and to allow this to happen. There is a tendency to attempt to "cheer up" the person and to point out that things "are not so bad". We cannot tolerate the mourning and, therefore, tend to stop the process. In dealing with the stage of depression, it is helpful to remember that the dying person is losing everyone and everything he has ever loved. First the person mourns past losses, things not done, wrongs committed, then enters a state of preparatory grief, getting ready for the approaching death. As. the separation process continues, a decathexis becomes evident. This stage is -6-often a silent one with the person growing increasingly quiet and not wanting visitors. Often the person will want to spend time with one silent, caring, comfortable person. It is important during this stage to work with the family, since the family is often not at the same stage at the same time and might have difficulty coping with the person's need to begin to separate. It is helpful to point out that the person can't achieve acceptance if he or she does not separate. The final stage in the dying process, according to Kubler-Ross, is one of acceptance. This is not a resignation, which implies bitterness or defeat, but rather is a state almost devoid of feelings. The terminally ill person is often weak and tired at this point and is neither happy nor unhappy. Kubler-Ross points out the similarity of this acceptance stage to the beginning of life. Hope usually persists through all these stages. Fear of death is universal but we can learn to cope better with it. Kubler-Ross points out that dying is something we do continuously, not just at the end of our physical lives. Each new stage of our development involves a loss. For example, when we enter adulthood we experience the loss of our childhood. Preparation for these transitions and the -7-accompanying feelings of loss can help to resolve the ambivalence and maintain the thread of continuity. The stages of dying apply equally to any significant change such as retirement, moving, changing jobs, divorce and change is a regular occurrence in human existence. While the stages of the dying process described by Kubler-Ross have been widely accepted in recent years, some have challenged this conceptual framework. Bugen (1977) suggests a theoretical conception of grief that is not tied to a fixed order of emotional states or stages. His model is intended to apply only to conventional grief in response to death and he identifies two dimensions as prime predictors of the intensity and duration of bereavement. These two dimensions are closeness of relationship and the mourner's perception of preventability of the death. Bugen proposes that a variety of emotional states exist during the grieving process and he challenges the need to order these as stages. He suggests five theoretical weaknesses and inconsistencies to "stage" concepts of grieving: 1) that the emotional states blend dynamically and are not separate entities, 2) that they are not successive, 3) that it is not necessary to experience every stage, 4) the intensity and duration of any one stage may vary among those who grieve, -8-and 5) there is little empirical evidence to substantiate the theory of stages (Bugen, 1977). Bugen proposes that a range of grief reactions exists along the two dimensions from intense and prolonged grief reaction, where the relationship was central and the mourner perceived the death as preventable, to mild and brief, where the relationship was a peripheral one and the mourner per-ceived the death as unpreventable. Bugen suggests that positive movement occurs in the intervention in two ways: 1) an individual may move from a belief in preventability to a belief in unpreventability or 2) the individual may shift a relationship with the deceased from centrality to peripherality (Bugen, 1977). Freud states that "mourning is regularly the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as fatherland, liberty, an ideal, and so on" (Freud, 1957, p.125). Freud looks upon any interference with the grieving process as potentially harmful, the expectation being that it will be overcome in time. Some of the characteristics of grief, according to Freud, are feelings of pain, loss of interest in the outside world in „so far as it does not recall the dead one loss of capacity to adopt any new -9-love object, turning from every active effort that is not connected with thoughts of the dead (Freud, 1957, p.125). The factor that distinguishes normal mourning from melancholia according to Freud, is the absence of a fall in self-esteem. In grief the world becomes poor and empty; in melancholia it is the ego which becomes so (Freud, 1957). The work which mourning performs, according to Freud, is to help the mourner gradually detach from the lost person. The Loss of a Family Member as a Result of Death: Our society encourages us to deny rather than to deal with the aging process and with death. When an individual or family experiences the loss of a family member through death, therefore, the normal pain of mourning can be intensified by the lack of preparation and experience. Kubler-Ross suggests that by making dying a taboo subject and keeping children away from people who are dying or have died, we create an unnecessary fear (Kubler-Ross, 1975). In a sense, we create problems in our culture by not helping to prepare people for the inevitable. According to Kubler-Ross, "death is as much a part of human existence, of human growth and development as, being born...Growing is the human way of living, and death is the final stage in the -10-development of human beings" (Kubler-Ross, 1975, p.x-xi). Our society does not appear to share this perspective. Colin Murray Parkes, who has done extensive research in the area of grief in adult life, points out that apart from grief two other factors always contribute to the overall reaction to a bereavement. These two factors are stigma and deprivation (Parkes, 1975). Stigma is related to the change in attitude that takes place in society when a person dies. For example, the widow finds that people who were previously friendly and approachable become strained and uncomfortable in her presence. It is almost as if the widow becomes tainted with death. Mourning is often treated as a weakness and self-indulgence rather than a psychological necessity. Some societies have a more explicit taboo on bereaved people. The Shuswap in British Columbia, for example, seclude widows and widowers and consider their presence to be unlucky. In other cultures, ritual suicide is the custom following a bereavement. The factor of deprivation, according to Parkes, is one involving loss of essential psychological "supplies" that were previously provided by the lost person. Parkes points out that the individual gets, little support from society following the loss of a loved one. Marriage, for -11-example, has been an integral part of our culture, yet little is done by society to ensure that the functions that marriage performs are adequately carried out after its dissolution. Some cultures offer alternative ways of approaching death that seem more adaptive for the individual and for family members. Among the Alaskan Indians, for example, dying people exhibit more of a willfulness about their death and participate in its planning. In some villages, the entire village turns out to participate and to prepare the funeral. Jewish tradition also confronts death directly. A tradition of never leaving the bedside during a terminal illness tends to avoid the issue of guilt of the family should the person have died alone. The community also shares in the responsibility of the bedside vigil. The deathbed confessional often includes a confrontation of the family with an ethical will. This deals with issues such as family unity and loyalty to religious traditions rather than the distribution of material possessions and provides a certain continuity for the family. The guide-lines for mourning are based on having the mourner face the reality of death. Characterized by realism and -12-simplicity, the Jewish tradition prescribes that the mourner express grief openly. Following the death, the focus shifts to the mourners and there is a sharing of memories of the past. The prescribed open expression of grief is painful but necessary and occurs in the context of emotional support from friends and community. Parkes describes seven features that seem to be major aspects of many bereavement reactions. These include: 1) a process of realization, 2) an alarm reaction, 3) an urge to search for and find the lost person in some form, 4) anger and guilt, 5) feelings of internal loss of self or mutilation, 6) identification phenomena (adoption of traits, mannerisms, or symptoms of the lost person), and 7) pathological variants of grief (Parkes, 1975, p.213). Kubler-Ross applies her stages both to anticipatory grief and to grief that occurs following death. Har work with the family focusses on opening up communication, dealing with practical matters, and helping the family to understand the separation stage prior to the death. After the death occurs, she feels the worker should be available to help the family go through the grieving stages. -13-Eisenstadt (1978) conducted a study of parental loss and genius and found early orphanhood to be characteristic of a group of occupationally eminent people. He used a parental loss profile, which specifically related to parental loss by death. While this study seems to have some problems in terms of research strategy, some interesting preliminary findings are described. Death of a parent in childhood is recognized as a major traumatic event. The trauma includes not only the loss of the deceased parent but also the changed relationships with surviving family members (Eisenstadt, 19 78). Eisenstadt feels the findings of his study lead to the conclusion that parental loss by death explains some similarities between the genius and the psychotic. He sees the bereavement reaction as an impetus for creative effort or, if the crisis is not mastered, as an impetus for emotional problems. Some of the similarities that he describes between an outstanding successful, creative individual and a disturbed, psychotic individual include "a certain vulner-ability and poor ego defenses...a great energy investment in themselves and what the self produces...disturbed personal relationships... an apparent ease of regression to more childlike behavior" that is more easily controlled by -14 -the creative person (Eisenstadt, 1978, p.221). Again, he explains these similarities in terms of parental loss through death in the person1s early years. The death of a child can be one of the most devastating of losses to bear. Gorer conducted a study in Great Britain of people who had lost a child and concluded that such a loss, particularly if the child was fully grown, is "the most distressing and longlasting of all griefs" (Parkes, 1975, p.148). Somehow a child's death goes against the nature of things. In the context of the family, it is expected by parents that their children will outlive them and provide generational continuity. Parkes (1975) feels that in previous centuries when the loss of a child was a fairly common occurence, parental grief was less extreme. He feels this may relate to the factor of expectation of loss. "In a society in which the death of a child is statistically rare we are particularly likely to be unprepared for those that do occur" (Parkes, 1975, p.148). Guest (1976) in a novel called Ordinary People addresses some of the issues facing a modern-day family experiencing the death of a child. One of the fairly common outcomes that she analyzes is the rift in the spouse relationship that sometimes develops. While it might seem -15-that the sharing of a common, intense grief would bring the couple closer together, it is not unusual for the death of a child to precipitate a crisis in the marriage re-lationship. Parents and siblings, as Guest portrays, experience feelings of guilt that may be destructive. Regarding the parents, perhaps the fact that each spouse needs so much emotionally at a time when the other is drained of emotional resources and unable to give, is a factor. Any family tragedy has the potential for triggering a family breakup. Losses Due to the Process of Separation and/or Divorce: Divorce is a critical event which affects the entire family system and the functioning and interactions of its members (Hetherington, Cox, and Cox, 19 76) . Hetherington | and others conducted a two year longitudinal study of the impact of divorce on family functioning and the development of children. This research indicated that at least one member of the family reported distress or exhibited dis-rupted behavior, particularly during the first year following divorce (Hetherington, Cox, and Cox, 1976) . The research al so indicated that disorganized and disrupted functioning seemed to peak at one year and to be stabilized by two years following divorce. Two years seems to be the standard -J -16-predicted time period for working through the emotional >! turmoil of a separation or divorce. ' Until recently, research and intervention have seemed to focus on the effects of separation and divorce on the adults involved and to neglect the impact of the experience on the children. It is becoming increasingly recognized that divorce is stressful for most children and constitutes a potential developmental interference in a general, non-clinical population. While some children flourish following^ a divorce, particularly if the family situation had been characterized by tension and conflict, most children experience some degree of difficulty in coping with the change. Since the parents are undergoing stress themselves, the quality of parental functioning may be lowered at the very time the children are in need of special support, reassurance, and understanding. Children rarely have any decision-making power regarding the separation and, indeed, when they are put in the position of having to decide between one parent or the other are likely to be caught in 1 a loyalty bind. Typical feelings on the part of the child : are helplessness, guilt, confusion, and anxiety. j In their own confusion about how to deal with the children regarding the separation and divorce, parents sometimes provide little clarifying information. In this -17-context the child faces the loss, to varying degrees, of the absent parent. It is quite common for a child, partic-ularly a younger one, to feel that he is responsible for j the departure of the absent parent. The relationship with the custodial parent, whether good or not, is usually J different following the separation and represents another ji i1 kind of loss for the child. All family members also experience the loss of the "intact" family and there may I be considerable fantasizing and yearning for a return to I 1 the way things were. Another loss frequently experienced is that of the comfort and support of a familiar environment, such as a house, neighborhood, school, friends. Krantzler (19 73) defines divorce as "an emotional crisis triggered by a sudden and unexpected loss" (Krantzler, 19 73, p.30). As do other theorists and researchers, he uses a grief model to conceptualize the divorce process. Inherent in this model is the idea that the crisis provides an opportunity to improve on the past and create a new life. In order for this to occur, Krantzler feels it is necessary to recognize that a relationship has died, that there will be a period of mourning, and a slow, painful emotional readjustment (1973). He also feels the pain usually affects each spouse equally regardless of who initiated the separation. - 1 8 -The adults in this situation are likely to experience a sense of loss and abandonment as well as a sense of failure. Feelings of guilt, rejection, anxiety, and lone-liness are common. Again, the emotional turmoil is likely to occur at the very time one's coping mechanisms are being pushed to the limit. Relationships with the children are also changing. When children are involved, one parent usually faces the adjustment of becoming essentially a single-parent, while the other is coping with the loss of day to day parenting. It becomes increasingly apparent that the marital relationship may be severed but the parental relationship continues for life. Some kind of ongoing contact is necessary when a relationship is main-tained with the children by the absent parent. There may be, in addition, economic and legal battles and a fairly rapid change in the standard of living. Both adults must adjust to becoming single again, which in a couple-oriented society can be difficult. Often the reality of the new situation suffers in comparison to some of the myths of "freedom" regarding single life. Krantzler describes the loss as triggering a kind of disruption of identity. The process of separation and/or divorce, therefore, is stressful for the entire family. There are some common -19-losses, such as the loss of the intact family, a house, a neighborhood, and some individual or subsystem losses, such as the loss of a spouse or a parent. It is clear that there are many parallels between the separation experience and the bereavement experience. Indeed, many refer to the "death" of a relationship and a grieving process when describing reactions to a separation. In our discussion, it is important to stress that it is "normal" for an emotional crisis to occtar as a result of a separation and/or divorce. This is a pre-dictable life crisis. The unfortunate fact is that too often we are not prepared for what is in many ways predictable. There are practice implications here that will be addressed later in our discussion. Losses Due to the Aging Process: An increase in life-expectancy has been accompanied by changes in family life partly due to the age of technology such as increased mobility and more isolated living arrangements. At a time when the over 65 group of our population has been growing, many of the previous support systems, such as the extended family, have become less available. At the same time, in our youth-oriented -20-culture, the problems and concerns of people in the latter part of the life cycle have often been minimized or ignored. The aging process itself, which is a lifelong process and the normal course of development, is often denied in our culture. This has implications for how adequately people in our society are prepared to cope with losses and changes associated with the aging process. Streib (19 75) points out that when we consider the family in the latter part of the life cycle, we need to rethink the notion of the autonomous family. This idea is contrary to the North American tradition of minimal inter-ference into family life, a notion that fails to recognize the diminishing support systems previously available to the nuclear family. At present many of our interventions tend to be crisis-oriented rather than developmentally-focussed or preventative. Streib points out that autonomy and independence are sometimes difficult to attain, partic-ularly under conditions of economic or medical crisis, and some notion of shared functions must be considered. This idea, developed by Litwak (Streib, 1975) , is that formal organizations and families must coordinate their efforts and share functions in meeting problems or crises which older families face. -21-Hill (1978) identifies three categories of possible losses in old age: physical losses, social/emotional losses, and intellectual losses. Physical losses include such things as sight, hearing, continence, and changes in appear-ance. Social/emotional losses include a sense of belonging, status, and roles. Included here are close relationships and associations, independence, finances and control of funds, housing choices and alternatives, and lifestyles. Intellectual losses include such things as memory loss, ( confusion, disorientation, slower reaction time, and diminished sense of mastery (Hill, 197 8). Streib (19 75) suggests four major resources that contribute to the strength of older families: physical health, emotional health, economic resources, and social resources. These resources correspond with the categories of possible losses described by Hill. There is a complex interrelationship among these resources so that an absence of one or more can bring about a severe dislocation in the life of the person, while an abundance of any resource can greatly alleviate stress caused by a lack of others. In considering some of the special problems and patterns of family life that exist in old age, sex-related factors are important to keep in mind. A factor due to the differential -22-death. rate, for example, is that a man is much more likely to have another person in his household in times of trouble or crisis, while a woman is more likely to need to turn to outsiders or bureaucratic organizations for assistance (Streib, 1975) . Harris and Associates (1977) found that most older people feel their condition in life is better economically and socially than the general public believes it to be, but added that the term "most" is deceptive since millions of older people in the United States live below the poverty line. Streib (1975) makes the important point that the amount of income an individual receives may not be as important as whether he perceives it as "enough". It seems that poverty is most certainly a serious problem facing older families today but we should also keep in mind that one can be poor in other areas than money. It also appears that, in general, certain subgroups particularly the elderly poor do have a harder time coping with the problems of old age. In terms of the emotional loss of family, Streib suggests that research findings indicate that the picture is not so bleak as is sometimes believed in terms of the family's "failure" to meet the needs of older members in industrial society. He says that it would be inaccurate to -23-hold to the stereotyped picture that many older Americans are abandoned by their adult children. This is not to deny that some older people are lonely, isolated, and neglected. Mutual help patterns are present in many families, however, and an almost universal finding is that older people desire "intimacy at a distance". v Our discussion of loss of a family member as a result of death is particularly applicable to older people. The elderly often face a succession of bereavements due to the loss of friends and loved ones. It is at this stage in life that one's own mortality becomes increasingly more evident and the individual must come to terms with his own impending death. These bereavements are likely to occur at a time when other losses such as the physical, social/emotional, and intellectual losses discussed prev-iously are probable. The pain and the crisis, therefore, is compounded and coping mechanisms are pushed to their limits. A crucial point to consider in planning and implementing services is that the troubles of older families are often long-term in nature and are better characterized as a process rather than as an event. This has implications in terms of the structure of our current service delivery -24-systems which often tend to be crisis-oriented rather than preventative. One of the most serious and difficult problems faced by society in relation to old people is that of helping them maintain some satisfying place in the community and with it a sense of self-worth. In order to do this, it is necessary that we more clearly recognize both the needs and potential contribution of this group. A range of community-based services and opportunities for the elderly is essential in order to meet their needs on an ongoing basis and in an efficient and humane manner. Interventions should also be considered in the context of mutual helping at various points in the life cycle, such as Foster Grandparents, a program that provides supports to young families and meaningful activity and social interaction for older adults. There is a potential for reciprocity that is exciting for all concerned. "Helping" need not be a one-way transaction. Given the long-term and recurrent nature of their difficulties, an integration of services for older families is also essential. -25-The Concept of Grieving Applied to Other Losses: We have discussed how the concept of grieving might be applied to losses such as separation and divorce and the aging process. Let us now consider how this concept applies to other kinds of loss. Tenbrinck and Brewer (1976) describe the stages of parental reaction to recognition of retardation in a child as similar to the stages put forth by Kubler-Ross. They point out, however, that with the awareness of mental retardation there is unending grief and chronic sorrow. 'j^ TChe loss reaction does not end relatively quickly as it does with the finality of death. The role of the family is important to the retarded child and these authors warn that problems of communication should not be neglected. Tenbrinck and Brewer have found this adaptation of Kubler-Ross' s concept of the stages of dying useful in dealing with the chronic sorrow and unending grief of parents of handicapped children. Peter Marris (1975) presents an interesting analysis of the sense of loss that accompanies serious personal and social change. He proposes that bereavement represents one aspect of social change "the irretrievable loss of the familiar" (Marris, 1975, p.26). He defines grief as -26-...the expression of a profound conflict between contradictory impulses to consolidate all that is still valuable and important in the past, and preserve it from loss, and at the same time, to re-establish a meaningful pattern of relationships, in which the loss is accepted... If the process is aborted, from too hasty a readjustment or too unchecked a clinging to the dead, the bereaved may never recover. (Marris, 1975, p.35) According to Marris, individuals have a need to maintain continuity in goals and relationships what he describes as a conservative impulse. The continuity of life cannot be re-established until the nature of the disruption is made clear (Marris, 1975). In a discussion of slum clearance in the West End of Boston, Marris compares bereavement and social change. This urban renewal project involved the destruction of a neighborhood and the d i s p e r s a l of i t s r e s i d e n t s . Both Marris and Parkes refer to a study by Fried regarding the effects of this urban renewal project on residents of the West End. Fried (Parkes, 1975) found that for the majority of residents contacted, it was accurate to describe their reactions as expressions of grief. . . .These are manifest in the feelings of painful loss, the continued longing, the general depressive tone, frequent symptoms of psychological or social or dramatic distress, the active work required in adapting to the altered situation, the sense of helplessness, the occasional expression of both -27-direct and displaced anger, and tendencies to idealize the lost place...46% gave evidence of a fairly severe grief reaction or worse. (Parkes, 1975, p.220) Intensity of grief was found to be correlated with "the measured area of physical life-space that had been lost" (Parkes, 1975, p.221) . One of the more striking of Fried's findings is that many respondents described their reactions in terms of physical mutilation. "I felt like my heart was taken out of me...Something of me went with the West End..." (Parkes, 1975, p.222). Parkes points out that these people seemed to experience a loss of self and a psychological mutilation. Marris feels we can understand a change of home, like bereavement, as a potential disruption of the meaning of life. It is not only a neighborhood that is lost, but significant others and a whole way of life. To add to the difficulties of this loss of community, according to Marris, was the fact that rehousing of the West End residents was carelessly handled. The transition was abrupt and no process analogous to mourning was provided. Parkes feels more research is needed in the area of comparing how reactions to other losses resemble the reaction to bereavement. His own research regarding the reactions of amputees to the loss of a limb illustrates one such -28-effort. While the complete results of the study were not available at the time of his writing, Parkes compared the amputee to the bereaved in the seven aspects of bereavement previously discussed. He concluded that the "psychosocial transition from being an intact person to being an amputee is a painful and time-constiming process which is, in many ways, similar to the transition from married person to widow or widower" (Parkes, 1975, p.220). He feels it is quite justifiable to consider these situations as parts of the same field of study. Parkes points out that the similarity in reactions to loss of a loved one, loss of a limb and loss of a neighbor-hood seems to indicate that anticipatory preparation might be useful. He adds, however, that is not enough to institute new ways of helping the homeless, the crippled, or the bereaved. Any plan for change should include an attempt to under-stand and provide for the psychosocial effects of the change. Thus the decision to remove a leg should be made in full awareness of the patient's prospects of making a successful adjustment to life as an amputee; plans for slum clearance should be made in full awareness of the probable effects of relocation upon the population to be resettled; the decision to send a man to prison should be made only after there has been an attempt to predict the probable effects of this action upon the man and his family. (Parkes, 1975, p.225) -29-Soitie Issues for the Family as a System: Bowen (19 66), in describing the family as a system, points out that a change in one part of the system is followed by compensatory change in other parts of the system. It is useful in considering the effects of loss and change on the family to use a systems perspective. As in any group, the family or the system as a whole is greater than the sum of its parts. There is an energy generated by the interactional process that gives the group in this case the family a life of its own. The family is more than a collection of its individual members. In this regard, we can also say that the effects of loss or change on the family as a whole are different from the effects on the individual. From this point of view, the stage concepts of grieving perhaps do not go far enough in analyzing grief reactions. The literature regarding the differences in the grieving process for families as opposed to individuals is extremely limited and this area needs to be further explored. One of the issues for the family as a system following a loss, for example, is dealing with the changed relationships within the family group. The loss of a family member, whether through death or separation, results in role changes -30-and a restructuring of the family and this process can have a tremendous long-ranging impact. The systems framework is potentially useful for practitioners working with families and individuals who are experiencing or have experienced loss. The concept of differentiation (Bowen, 1966)•, for example, might help in predicting reactions to anticipated loss or explaining reactions to actual loss. When the structure of a family or dyad is characterized by fusion rather than differentia-tion, change would be expected to be seen as a serious threat. A crisis situation is likely to be created by a shift in fusion. In the systems framework, dysfunction is seen as a reflection of an active emotional system as a reaction to how the family is organized in dealing with the problem (Freeman, 1977) . At times how the system deals with problems becomes an even bigger problem. This has implications in terms of intervention strategies of helping families to restructure and deal with change. The concept of triangles is also useful in intervening with families and in conceptualizing how families deal with change. There are functional triangles and dysfunctional triangles, the difference being a matter of degree. -31-Triangling in a system is a stabilizing process, the purpose being to maintain the status quo. Two "insiders" spending much time talking about an "outsider" serves to reduce tension (Freeman, 1977). There are many triangles operating within a system, so that the loss of one member disrupts the balance of the emotional system. Another issue for the family as a system in regards to loss is what Bowen (1966) describes as the projection process. This is the process by which parental problems are transmitted to their children. Another intergenerational issue arises when a bereaved person idealizes the lost loved one and does not accept the loss. This involves a denial of the ambivalent feelings and might result in their expression through displacement. For example, a child who resembles the lost person might have these feelings displaced onto him. This is an extension of the searching process, that is, there is a searching for and finding in another similar qualities and traits of the lost person. Toman (1969) seems to consider this transmission process from an even broader perspective. He considers family constellation to include sibling position and early losses for the individual as well as all patterns of sex, rank, and final losses for the person's siblings, parents and ancestors (Toman, 196 9). -32-Implications for Social Work Practice In the course of our discussion, we have seen that loss is a universal lifelong experience that extends over all stages of the life cycle. While a thorough discussion of loss at every stage of development is beyond the scope of the present discussion, we have tried to illustrate a variety of kinds of losses at various stages. Simos points out that "the fear of loss, loss, and separation are beginning to be recognized as important underlying dynamics in much pathology seen in clinical work" (Simos, 197 7, p.337). She adds that some losses are subtle and are unrecognized as such, partly due to large gaps in the education of clinicians. It is important that the clinician understand what constitutes normal grief in order to avoid misinterpreting it as "pathological" behavior. It is also important to recognize that if griet is not expressed at the time of loss, the feelings can hang on for years. This is particularly relevant in the context of Toman's notion of transmission of loss from generation to generation. Simos f e e l s t h a t defenses a g a i n s t g r i e v i n g are o f t e n unrecognized as such. Not every l o s s , however, r e s u l t s i n -33-a grief reaction. Early losses and reactions set the pattern for later reactions to separation and loss (Simos. 1977). Childhood and old age are periods of particular vulnerability to the damaging effects of loss. Clinicians should have insight into their own defenses against loss, grief, and pain in order to best help their clients. I t i s a l s o i m p o r t a n t f o r p r a c t i t i o n e r s t o r e c o g n i z e t h e p o t e n t i a l f o r g r o w t h t h a t i s p r e s e n t i n a l o s s o r c r i s i s s i t u a t i o n . S t r e s s c a n be an i m p e t u s f o r p o s i t i v e c h a n g e a n d a s t r e n g t h e n i n g l i f e e x p e r i e n c e . K u b l e r - R o s s s a y s t h a t b y f a c i n g a p r o b l e m , w h e t h e r o r n o t we a r e a b l e t o s o l v e i t , we w i l l grow. O f t e n an e x p e r i e n c e t h a t i s "forced" upon us such as the loss of a job, a divorce—-can be the impetus to a positive life change. Living without change is not living and it is often a willingne ^ to risk the unknown that helps us to discover our inner selves (Kubler-Ross, 1975). At the practice and planning level, practitioners should be aware of the need for developing and supporting crisis intervention and preventative programs. There is a need for educational programs, beginning perhaps in the elementary schools, regarding predictable life crises and stresses over the life cycle and how to cope with these. -34-Too often our social service programs are totally crisis-oriented with little focus on preventative issues. In previous sections, we have touched on some of the specific kinds of interventions that should be available. For example, services are needed for children and families experiencing separation and/or divorce and there is a need for comprehensive community services on an integrated basis for older families. Implications for Social Policy Consideration of some broad implications of fragmented services in general has stimulated interest in Canada and the United States in the need for developing an area of family policy. At present, family policy is broad and falls under the jurisdiction of many departments. Consequently, the question has been raised of whether families might better be served by an integration of social policies affecting the family. There are both legal and ideological constraints, however, on family policy-making in Canada and the United States (MacDonald, 197 8). In Canada, for example, split jurisdiction between federal and provincial governments -35-impedes policy development and makes coordination difficult since family policy tends to fall between departments and there is a division of government responsibility. An area of family policy might more adequately address a social policy issue mentioned above, namely, the need for community programming that is geared to meeting a wide-range of family needs over the course of the life cycle. A major issue is that of funding for preventative programs. While budget limitations are recognized and acknowledged, a reassessing of priorities seems in order. In this author's opinion, our society cannot afford not to provide services of a preventative nature. It is not only a matter of dollars and cents but of the cost in human suffering when preventative and educational programs are not available. An aspect of ideological constraint on family policy-making in North America is rooted in the tradition of minimal interference into family life. As discussed previously this ideology contributes to a philosophy of crisis-oriented, rather than preventative, programs and policies. While it would be foolhardy to deny the need for crisis-oriented services, there is also a pressing need for other kinds of services. There are many instances, such as the family in the latter part of the life cycle, where autonomy and inde--36-pendence are difficult to attain. It seems imperative, as well, that we broaden the concept of resources as a social utility as a right. The need for the provision of formal and informal supports to the nuclear family needs to be more adequately researched and addressed. It has been suggested that the mass media should become a more significant resource (Streib, 1975). The media is in a position to provide information regarding community resources, to offer emotional and interactional resources, and to educate the general public. In regards to our present discussion, the possibilities of reaching out to people who are experiencing significant loss and change in their lives are almost limitless. The provision of high quality documentaries on topics such as aging, separation, divorce, and death would provide a community service. This would be educational and preventative and help to stimulate interest in areas of concern to most people. The media would not be a substitute for direct services, but would be a supplement to available services. Marris (1975) points out that in social planning, we need to differentiate those changes where a sense of bereavement is likely to be provoked. In urban development, for example, the social implications of breaking up extended -37-family groups, isolating older people, bankrupting small business, are often ignored. The moment of transition tends to be abrupt and no process comparable to mourning is provided. C Marris (1975) also points out that loss disrupts our /ability to find meaning in experience and grief represents the struggle to retrieve this sense of meaning. In slum clearance, however, any restoration of a familiar pattern is often deliberately frustrated and continuity is, therefore, broken. Marris feels negative reactions are more likely when slum clearance is used as an instrument of social change, rather than merely as physical development. Marris suggests that the process of reform must always expect and even encourage conflict. There is a natural tendency to resist change and the irretrievable loss of the familiar provokes an ambivalent response. The conflict reaction dramatizes the transition and allows expression of ambivalent feelings (Marris, 1975). He adds that the process of reform must also respect the autonomy of different kinds of experience. Time and patience are required if anything resembling a reasonable adjustment is to be made. (19 75) feels that the knowledge we now have regarding how people react to loss and change "imposes upon the planner the obligation to take full account of how his decisions will affect the population or individuals concerned, and to do all that he can to ensure that any planned change leads to growth and maturation rather than dislocation and ill health" (Parkes, 1975, p.225-226). Conclusion In the course of our discussion, we have seen that | loss is a universal, lifelong experience that extends over| 1 all stages of the life cycle. Our discussion has contributed, hopefully, to our understanding of the change process and how this affects individuals, families, and communities. Since change is the normal course of development, it is in our best interest that we attempt to educate ourselves in this area and to increase our mastery of the unfamiliar. We have seen that stress can be an impetus for positive change and a strengthening life experience. It is an opportunity to improve on the past." This is not to deny the -39-pain and anguish that accompanies a major loss or signif-icant life change. By recognizing the growth potential of such experiences, however, we increase the potential for re-establishing a sense of continuity in our lives and for making sense of what we have experienced and, hopefully, mastered. As practitioners, it is imperative that we have an understanding of what constitutes a normal grief reaction and how to deal with it. In clinical practice, social policy-making, and social planning, we need to differentiate those changes where a sense of bereavement is likely to be provoked and to take into account how decisions will affect the population or individual involved. .We can no longer deny that research into the effects of change is an essential area of study. Willingness to look at the problems of grief and grieving instead of turning away from them is the key to successful grief work in the sufferer, the helper, the planner, and the research worker. L ' (Parkes, 1975, p.226) -40-References Bermann, E. Scapegoat: The impact of death-fear on an A m e r i c a n f a m i l y . Ann A r b o r : U n i v e r s i t y o f M i c h i g a n P r e s s , 1973. * Bower:, M. The use of family theory in clinical practice. Comprehensive Psychiatry, Volume 7, 1966, pp. 345-373. Bugen, L.A. Human grief: A model for prediction and i n t e r v e n t i o n . A m e r i c a n J o u r n a l o f O r t h o p s y c h i a t r y , 47(2), A p r i l 1977, pp.196-206. Cohen, P., Dizenhuz, I.M., & Winget, C. Family adaptation to terminal illness and death of a parent. Social Casework, 58(4), April 1977, pp. 223-228. Eisenstadt, J.M. Parental loss and genius. American Psychologist, 33(3), March 1978, pp.211-223. Freeman, D. Personal communication. Vancouver, B.C., 1977. Freud, S. Mourning and melancholia. In John Rickman (ed.) A general selection from the works of Sigmund Freud. Garden City, N.Y.: Doubleday, 1957. Goldman, J. & Coane, J. Family therapy after the divorce: D e v e l o p i n g a s t r a t e g y . F a m i l y P r o c e s s , 16(3), September 1977, p p . 357-362. G r e e n b e r g , L.I. T h e r a p e u t i c g r i e f work w i t h c h i l d r e n . S o c i a l C a s e w o r k , 56(7), July 1975, p p . 396-403. Guest, J. Ordinary people. New York: Ballantine Books, 1976. Hetherington, E.M., Cox, M., & Cox, R. Divorced fathers. The Family Coordinator, 25(4), October 1976. Hill, M. Aspects of older people requiring special help or understanding. Unpublished document, Vancouver, B.C., March 19 78. Hozman, T . L . & F r o i l a n d , D . J . F a m i l i e s i n d i v o r c e : A p r o p o s e d model f o r c o u n s e l l i n g t h e c h i l d r e n . The F a m i l y C o o r d i n a t o r , 25(3), J u l y 1976, p p . 271-276. -41-References K a l t e r , N. C h i l d r e n of d i v o r c e i n an o u t p a t i e n t p s y c h i a t r i c p o p u l a t i o n . American J o u r n a l of O r t h o p s y c h i a t r y , 47(1), January 1977, pp. 40-51. K e l l y , J . B . & W a l l e r s t e i n , J . S . B r i e f i n t e r v e n t i o n s w i t h c h i l d r e n i n d i v o r c i n g f a m i l i e s . American J o u r n a l of O r t h o p s y c h i a t r y , 47(1), January 1977. K r a n t z l e r , M. C r e a t i v e d i v o r c e : A new o p p o r t u n i t y f o r p e r s o n a l growth. New York: M. Evans & C o . , 1973. K u b l e r - R o s s , E . Death i n a death denying s o c i e t y . From Death and Dying, P a r t I , The U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B . C . , 1971. (Videotape) / ' K u b l e r - R o s s , E . Death: The f i n a l stage of growth. Englewood C l i f f s , N . J . : P r e n t i c e - H a l l , 1975. K u b l e r - R o s s , E . F i v e s t a g e s of d y i n g . From Death and Dying, P a r t I I , The U n i v e r s i t y o f B r i t i s h Columbia, Vancouver, B . C . , 1971. (Videotape) Kubler-Ross, E. On death and dying. New York: Macmillan, 1969. K u b l e r - R o s s , E . Quest ions and answers on death and d y i n g . New York: C o l l i e r Books (Macmil lan) , 1974. L e a d e r . A . L . F a m i l y therapy for d i v o r c e d f a t h e r s and others out of the home. S o c i a l Casework, 54(1), January 1973, p p . 13-19. MacDonald, J. Personal communication. Vancouver, B.C., 1978. M a r r i s , P. Loss and change. Garden C i t y , N . Y . : Anchor P r e s s , 1975. > P a r k e s , C.M. 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, O n t a r i o : Penguin Books, 1975. Sheehy, G. P a s s a g e s : P r e d i c t a b l e "cr ises of a d u l t l i f e . New York: Bantam Books, 1977. -42 -References Simos, B.G. Grief therapy to facilitate healthy restitution. Social Casework, 58(6), June 1977, pp. 337-342. Streib, G.F. Older families and their troubles. In W.C. Sze (Ed.) Human life cycle. New York: Jason Aronson, 1975. Tenbrinck, M.S. & Brewer, P.W. The stages of grief experienced by parents of handicapped children. Arizona Medicine, 33(9), 1976, pp.712-714. Toman, W. Family constellation: Its effects on personality and social behavior. New York: Springer Publishing, 1969. Wallerstein, J.S. & Kelly, J.B. Divorce counselling: A community service for families in the midst of divorce, American Journal of Orthopsychiatry, 47(1) , January 1977, pp. 4-22. 


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