OLDER ADULT BEREAVEMENT: A COMPARISON
OF BEREAVED PARENTS AND SPOUSES
by
B. JANETTEE HENDERSON, B.A.
A THESIS
IN
HUMAN DEVELOPMENT AND FAMILY STUDIES
Submitted to the Graduate Faculty of Texas Tech University in
Partial Fulfillment of the Requirements for
the Degree of
MASTER OF SCIENCE
Approved
December, 1993
12 ACKNOWLEDGMENTS
0 Afi,)^ My deepest appreciation to Dr. Jean P. Scott, chair of
my thesis committee, for her continued encouragement and
support on this project. She has served as an excellent
role model, eloquently combining the polished skills of a
researcher with the warm and unconditional regard of a
trusted counselor. My heartfelt thanks also go to my
committee members. Dr. Joyce Munsch for her expertise in
the area of social support and her careful attention to
detail, and Dr. Ed Glenn for his kind support of this project
from the very beginning and his thought provoking advice.
I am deeply indebted to those persons who chose to
participate in this research. Their willingness to share
their pain and grief experience made this project possible.
Finally, I am most grateful to my husband, Dean, for his
constant love and encouragement throughout this program of
study. His "whatever it takes" attitude has allowed me to
pursue my dream. Many thanks also go to family and friends
who believed in me and supported me in reaching this goal.
11
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ii
ABSTRACT v
LIST OF TABLES vi
CHAPTER
I. INTRODUCTION 1
II. LITERATURE REVIEW 12
Adaptation Model 12
Social Support and Bereavement
Outcomes 18
Loss of An Adult Child 23
Complicated Grief 25
Hypotheses 27
III. METHODS 31
Subjects 31
Measures 32
Procedures 41
Analyses 43
IV. RESULTS 45
Recruitment and Description of
the Sample 4 5
Hypotheses 1 and 2 50
Hypotheses 3 and 4 51
Social Support 53
Total Loss History 55 111
V. DISCUSSION
Double ABCX Model of Family Adaptation
Differences Between Bereaved Parents and Spouses
Differences Between Bereaved Parents
Limitations of the Study
Implications for Future Research
REFERENCES
APPENDICES
A. QUESTIONNAIRE
B. SCREENING QUESTIONNAIRE
C. INSTRUCTIONS FOR MAILED QUESTIONNAIRE
D. LOCAL SOCIAL SERVICES RESOURCE LIST
64
64
68
70
71
72
74
81
92
93
94
IV
ABSTRACT
The Double ABCX Model of Family Adaptation was used to
study the grief experience of older adults who had suffered
the loss of an adult child (Group 1) or spouse (Group 2).
As hypothesized, results indicated a poorer health status
outcome and a higher grief intensity level for Group 1 in
comparison to Group 2. Contrary to expectations. Group 1
revealed lower depression and social withdrawal scores
compared to Group 2. In addition, bereaved parents with a
low number of network sources of support were compared with
bereaved parents with a high number of network sources of
support. As predicted, parents with a high number of sources
of support reported less social withdrawal, significantly
less depression, and a significantly better health outcome.
Hypothesis 4, which predicted a lower grief intensity level
for parents with a high number of support sources, was not
supported. Implications for future research are also
discussed.
LIST OF TABLES
1. Cronbach' s Alpha Values 44
2. Recruitment Sources of Study Participants.... 56
3. Demographic Characteristics of a Sample of Older Bereaved Parents and Spouses 57
4. Means and Standard Deviations of Dependent and Independent Variables 59
5. Discriminators of Bereaved Parents Versus Bereaved Spouses 61
6. Discriminators of Low Versus High Sources of Social Support for Bereaved Parents 62
7. Cell Means and Standard Deviations of Discriminators of Low Versus High Sources of Social Support for Bereaved Parents 63
VI
CHAPTER I
INTRODUCTION
Of all the wonders that I yet have heard. It seems to me most strange that men should fear; Seeing that death, a necessary end. Will come when it will come.
Seemingly little has changed in the three centuries
since Shakespeare penned these lines. Death continues to
hold apprehension, if not fear, for many of us. Social
thanatologists Leming and Dickinson (1985) have noted that
based on the reactions of most people to death-related
topics "it appears that in contemporary society, death
discussions are considered in bad taste and something to be
avoided" (p. 3). DeSpelder and Strickland (1992) concur,
"Death has always been the central question of human
experience, although it is one that, for the greater part
of the twentieth century, most Americans have tried in
various ways to avoid" (p. 5).
Kubler-Ross (1969) in her landmark book On Death and
Dying went so far as to characterize our attitudes toward
death and dying as death denying. In support of this
argument. Brown (1988) has identified the "death
specialists" that our society has created in order to
remove all responsibility for dealing with death on a
personal level. Among those cited are hospitals to house
the very ill and dying, morticians to take care of the
necessary preparations of the body prior to burial, and
funeral directors to handle the actual details of the
burial.
Perhaps part of our distaste and distancing of death
is related to the acute physical and emotional suffering it
involves. Death is indeed considered a major stressor by
most individuals and their families and may result in a
crisis situation. Bowen (1976) has explored the potential
stress that a family may experience due to a death or other
loss in the family unit. Based on multigenerational family
research, Bowen identified the "Emotional Shock Wave" as:
...a network of underground "aftershocks" of serious life events that can occur anywhere in the extended family system in the months or years following serious emotional events in a family. It occurs most often after the death or the threatened death of a significant family member, but it can occur following losses of other types, (p. 339)
According to Hoxlingsworth and Pasnau (1977) death
possesses two unique characteristics that can contribute to
the development of a crisis situation. One, the absolute
finality of death and one's inability to retrieve the loss.
And, two, the likelihood that one remains comparatively
inexperienced in coping with death due to its relative
infrequency and the uniqueness associated with each death.
Death can be viewed as both a personal and a family crisis,
that is, each survivor must bear the pain associated with
the loss and the family unit as a whole must also cope with
and adapt to the death.
The bereavement literature is consistent in its
reports of the many difficulties that survivors endure due
to the death of a family member. It has been debated as to
which loss is the most devastating (e.g., loss of spouse,
child, parent, sibling, or other close relative); however,
it is generally agreed that an attachment loss (i.e., death
of child, spouse, or parent) is more problematic than a
nonattachment loss (i.e., death of sibling, grandchild, or
close friend) (Gass, 1989; Owen, Fulton, & Markusen, 1982;
Raphael, 1983; Sanders, 1980).
The most researched topics in the bereavement
literature have been widowhood and the parental loss of a
young child. There appears to be a paucity of literature
concerning parents who lose an adult child. As noted by
Rando (1986), "Interestingly, even in the literature on
bereaved parents, there is lictle about the loss of an
adult child" (p. 230).
There are several reasons why this area of bereavement
has not been adequately explored. Moss, Lesher and Moss
(1986) have noted the overall unwillingness of mental
health providers and social scientists to explore the
anguish connected to bereavement. Specifically, they have
speculated that the immense pain associated with the death
of anyone's child only adds to the desire to avoid the
issue. In addition, the authors have suggested that
perhaps due to the perceived infrequency of child death, it
has not been considered a topic meritorious of research.
The death of a child at any age may be seen as an
"off-time" event. The trauma associated with the loss is
greater than with an "on-time" death because it is
considered "unnatural" and upsetting to the flow of the
expected life cycle. Several authors have concluded that
the loss of a child is the most painful and longest lasting
grief experienced by most people (Gorer, 1965; Rando, 1984;
Rosen, 1988; Videka-Sherman & Lieberman, 1985). Based on
the observations of a self-help group. The Compassionate
Friends (TCF), Klass (1985) noted that one apparently never
gets over being a bereaved parent. Klass suggests that
"when your parent dies, you lose your past; when your child
dies, you lose the future" (p. 361). In a later article,
Klass and Marwit (1988) observed that "the resolution of
parental grief usually includes a sense that the world is
never what it once seemed to be" (p. 46).
Grief reactions to the loss of a family member may
vary in many different ways. Some factors affecting the
survivor's response to loss are: (a) the type of loss
(attachment, nonattachment or other); (b) the relationship
of the bereaved to the deceased; (c) the manner in which
the family member died; (d) the age of the deceased; (e)
the age of the survivor; and (f) whether or not the death
was sudden or anticipated. It should be noted that whether
the death is sudden or prolonged may affect the degree of
stress at the actual time of death; however, the grief work
for an anticipated death is just as stressful as that for a
sudden death; it simply occurs at a different time in the
grief process (Crosby & Jose, 1983).
Abnormal grief has been described in various ways and
given numerous labels, for example, morbid grief, chronic
grief, pathological grief, unresolved grief, complicated
grief, delayed grief, absent grief, inhibited grief, or
conflicted grief. The term most used at the present would
appear to be "complicated bereavement" in keeping with the
latest designation of the Diagnostic and Statistical Manual
III-R of the American Psychiatric Association (APA, 1987).
Whatever name one may choose, the outcome is the same,
namely, poor resolution of the loss. This, in turn, leads
to an impairment in the daily functioning of ;.he bereaved
individual.
Abnormal grief differs from normal grief in both its
intensity and duration. It may result from the loss of any
dearly held object; however, those suffering an attachment
loss (e.g., loss of a child) are considered the group most
at risk for a maladaptive outcome. Among the factors
affecting the successful or unsuccessful resolution of a
loss are: (a) the timing of the death (off-time, sudden, or
unexpected); (b) the type of death (attachment or
nonattachment); (c) prior losses, especially unresolved
ones; (d) the support of family members and the social
network; and (e) the status of the relationship between the
deceased and the bereaved at the time of death (level of
ambivalence and/or dependence). Rando (1986) has argued,
"The characteristics of relationships that lead to
unresolved grief are typically found in parent-child
relationships" (p. 55). For example, the death of a child
is both an attachment loss and an off-time death. Also, if
the child was an adolescent at the time of death there may
have been a high level of ambivalence in the parent-child
relationship. Conversely, if the child was an adult at the
time of death there may have been a high degree of
dependence in the relationship. Taking any of these
factors into account, it may be clearly seen that bereaved
parents are particularly susceptible to unresolved grief.
The symptoms of normal versus abnormal grief are not
so far apart as once believed. "The attempt to make a
sharp distinction between normal and pathological grief has
been largely replaced ... by a greater awareness of
individual and cultural differences in the expression of
grief" (DeSpelder & Strickland, 1992, p. 236). On the
other hand, according to Raphael (1983), "The levels of
morbid outcome or pathological patterns of grief are known
in only a few instances, but they may represent at least
one in three bereavements" (p. 64). Consider also Rando's
(1986) claim that "New criteria are mandated for
identification of pathological parental bereavement, since
the normal experience of parental grief so closely
resembles that commonly accepted as unresolved,
pathological, or abnormal" (p. 56).
As pointed out by several authors, psychological shock
is a normal immediate response to an overwhelming loss
(Figley & Sprenkle, 1978; Lazarus & Folkman, 1984; Rando,
1984). As the shock wears off, denial steps in to act as a
therapeutic buffer, allowing the bereaved to slowly over
time realize the impact of the loss, thereby, preventing
emotional overload. However, if the use of avoidance
mechanisms persists and there is no movement toward
confrontation of the loss and the eventual reestablishment
of emotional and social functioning in an ongoing manner,
then unresolved grief may be diagnosed.
It is important to note the idiosyncratic nature of
grief, that is, each individual will proceed through the
grief process at his or her own pace. A definite time
limit for each phase is impossible to determine, however
broad limits may be set. A progression from avoidance to
confrontation to reestablishment must occur in order for
normal grief resolution to take place (Rando, 1984). "The
duration of a grief reaction seems to depend upon the
success with which a person does the grief work, namely,
emancipation from the bondage to the deceased, readjustment
to the environment in which the deceased is missing, and
the formation of new relationships" (Lindemann, 1944, p.
143).
According to Lindemann (1960), if the first phase
(which usually lasts about six weeks) does not get resolved
properly then the grief may be viewed as pathological and
psychosomatic disorders and disturbances in social
interaction are likely to occur. Lazare (1979) has
suggested that if symptoms and behaviors following a death
continue beyond six months to one year, a diagnosis of
unresolved grief is warranted. Parkes (1970) has
identified the average period of normal grief as being from
1 year to 18 months. However, Rosen (1988) has noted that
in the case of child loss, normal reaction times are hardly
ever observed. "Although there are undoubtedly individuals
and families who are able to resolve such a loss in a
reasonably brief period, the usual period of grief is quite
protracted" (p. 189). Likewise, Osterweis, Solomon and
Green (1984) have found parental grief to be especially
complicated and long lasting.
Symptoms commonly associated with normal grief
reactions in a newly bereaved individual can be later
diagnosed as a complicated grief reaction if the symptoms
persist and resolution of the loss is not achieved within a
reasonable period of time. These include: (a) depression
(Lazare, 1979; Lindemann, 1944; Owen, Fulton & Markusen,
1982; Rando, 1984, 1986; Raphael, 1983; Rosen, 1988;
8
Sanders, 1980; Videka-Sherman & Lieberman, 1985; Zisook &
Lyons, 1990); (b) somatic distress (Lazare, 1979;
Lindemann, 1944; Parkes, 1965; Raphael, 1983; Sanders,
1980); and (c) social withdrawal (Fish, 1986; Lazare, 1979;
Lindenann, 1944; Raphael, 1983; Worden, 1991).
Several clinicians have acknowledged the notion that
past unresolved grief experiences can affect the level of
adaptation achieved in dealing with a current death, for
example, "Previous unresolved losses generally hinder
effective grief resolution" (Rando, 1984, p. 47). Also,
"...patients in acute bereavement about a recent death may
soon upon exploration be found preoccupied with grief about
a person who died many years ago" (Lindemann, 1944, p.
144). In dealing with an older adult population the
likelihood that they have experienced a number of prior
losses increases the potential for an unresolved grief
issue.
The importance of social support in mediating the
grief process has been noted by several authors. According
to DeSpelder and Strickland (1992), "Social support may
well be the key to helping the bereaved mitigate the
potentially harmful effects of grief with respect to
heightened mortality or morbidity following loss" (p. 247).
Worden (1991) states "Grief is really a social process and
is best dealt with in a social setting in which people can
support and reinforce each other in their reactions to the
loss" (p. 69). The author goes on to note that the absence
of a social support network may cause disruption m the
resolution of the loss, leading to a complicated grief
reaction. Raphael (1983) also observes that "the most
powerful influence for the majority of bereaved people will
be the influence of the family and social network" (p. 47).
Recently, Walsh and McGoldrick (1991) have published
the first book devoted solely to the study of death and its
impact on the family unit. Given the depth and breadth of
the subject, death as a topic for theory building,
research, and intervention strategies is an area too long
neglected by family therapists, gerontdogists, family life
educators, and thanatologists.
The present study proposes to explore the process of
parental bereavement in the case of adult child loss. The
problem proposed by this project may be summarized by the
following research questions:
1. Do older bereaved parents suffering the loss of an
adult child reveal a greater number or greater severity
level of symptoms commonly associated with a
complicated grief outcome?
2. Do parents experiencing grief resulting from the death
of an adult child differ in grief outcomes from those
experiencing grief associated with other types of
deaths?
10
3. Is social support a significant predictor of healthy
resolution following an attachment loss?
Moss et al. (1986) state "The death of an adult child
and its impact on elderly parents has been relatively
unexplored and it deserves greater attention" (p. 216).
This statement would appear to be self-evident in view of
the fact that the greatest advances in life expectancy "are
coming in the oldest years, in the 80-plus group" (Carlson,
1992, p. 12). As a result, we may expect more older
parents to experience the devastating loss of an adult
child in the future. Due to the possibility that some of
these bereaved parents will suffer unresolved grief as a
result of the death of their adult child, and given the
deleterious effects the loss may have on their physical and
emotional health, it seems prudent for family studies and
mental health professionals to examine this neglected area
of parental bereavement.
11
CHAPTER II
LITERATURE REVIEW
The extant bereavement literature concurs that the
death of a loved one is a trying and stressful event under
any circumstances. According to Figley (1983), death is a
catastrophic life experience leading to high levels of
stress. Likewise, Lazarus and Folkman (1984) have
acknowledged that "the most damaging life events are those
in which central and extensive commitments are lost" (p.
33). Death has been conceptualized and treated in the
theoretical literature as a crisis or stressor event for
which coping and eventual adaptation are required. In the
following sections, an individual model of adaptation to
bereavement is presented based on the Double ABCX Model of
Family Adaptation (McCubbin & Patterson, 1983) (see Figure
1). Literature related to variables in the model and
outcome variables are also discussed.
Adaptation Model
A stress model is useful for looking at death as the
most devastating stressor experienced by most individuals.
Hill's (1958) ABCX family crisis model was one of the first
attempts to isolate the variables responsible for the
diverse outcomes found across individuals in adaptation to
stressful situations. In the original ABCX model the "a"
12
factor represents the initial stressor, the "b" factor
represents the existing resources, the "c" factor is the
subjective appraisal of the stressor and its impact, and
the "x" factor represents the resulting crisis if the
family is unable to maintain stability in light of the
stressor.
Using Hill's original ABCX model as the floor plan,
McCubbin and Patterson (1983) expanded the model to include
post-crisis factors (Figure 1). These are: (a) the
additional hardships and strains which result directly from
the initial stressor ("A" factor); (b) the crucial
psychological, personal, and social resources which are
developed over time to assist in management of the crisis
("B" factor); (c) the reappraisal of the crisis in an
attempt to find meaning in the crisis situation ("C"
factor); (d) the range of coping strategies employed (the
mediating factor); and (e) the possible variation of
adaptation outcomes based on the above mentioned variables
("X" factor). These factors directly affect the outcome of
a family crisis over time. For example, a prior unresolved
loss issue may be seen as a pileup stressor or hardship
that a recent death may reactivate, while the solicitation
of emotional support from family members and/or the
community may be viewed as an attempt to gain access to new
resources.
13
McCubbin and Patterson (1983) described the "aA"
factor, the pileup of stressors, as the hardships and
demands experienced by the family following the impact of a
major stressor, such as a death in the family. They
identified five diverse types of demands which add to the
pileup effect: (a) the initial stressor and its hardships,
(b) normative transitions, (c) prior strains, (d) the
consequences of family efforts to cope, and (e) ambiguity,
both intra-family and social. In the case of bereavement,
the focus of this study, prior losses were explored as a
pileup factor.
The "bB" factor represents the existing resources
(e.g., role flexibility, religious beliefs, and
friendships) and the expanded resources which are renewed
or generated to specitically assist in dealing with the
demands of the crisis situation or the resulting pile-up
(e.g., counseling or self-help groups, personal enhancement
opportunities, and reallocation of roles and
responsibilities). For the purpose of this study, social
support as a resource was explored.
The "cC** factor is inclusive in that it not only
includes the meaning given to the initial stressor, but
encompasses the appraisal of the total crisis situation,
including appraisal of the pileup factors, the existing and
expanded resources, and possible means to reestablish
equilibrium. Coping is the mediating factor between the
14
"aA", "bB", and "cC" variables and determines the level of
adaptation ("xX" factor) to the crisis situation (Figure
1). Due to the emphasis on the interaction of the
variables making up the "cC" factor with the goal of
reestablishing equilibrium, this model can be said to
represent a systemic view of family adaptation. The "cC"
factor of the model was not addressed in this study.
Coping, defined as "constantly changing cognitive and
behavioral efforts to manage specific external and/or
internal demands that are appraised as taxing or exceeding
the resources of the person" (Lazarus & Folkman, 1984, p.
141), is seen as a mediating process as opposed to a stage.
According to the authors, coping serves two major
functions. One, to manage or change the difficulty causing
the distress (i.e., problem-focused coping). And, two, to
regulate the emotional response to the problem (i.e.,
emotion-focused coping). In bereavement, as in other
highly stressful situations, both coping strategies may be
used and may involve adaptive or maladaptive techniques.
Coping strategies commonly seen in bereavement situations
include shock, disbelief, denial, anger, crying, substance
abuse, impulsive behavior, and rationalization. The key as
to whether or not the strategies are adaptive or
maladaptative appears to be the time frame in which they
occur (Lazare, 1979; Lindemann, 1944; Parkes, 1970; Rosen,
1988).
15
Adaptation, as defined in the Double ABCX model,
describes the outcome of family post-crisis adjustment and
runs along a continuum from bonadaptation to maladaptation.
Adaptation, in the case of bereavement, should not be
confused with complete resolution of the loss. "Rather, it
involves finding ways to put the loss in perspective and to
move on with life" (Walsh & McGoldrick, 1991, p. 8).
According to Fish (1986) "The loss of a child is more like
dismemberment than a bruise, requiring adaptation to an
irretrievable loss....As one adapts to the loss of a limb,
so one adapts to the loss of a child, but there is no
restoration to a point of prior normalcy" (p. 417). In
addition. Pine and Brauer (1986) state "Acceptance of the
loss does not necessarily mean getting over it, but rather
coping with it" (p. 66). In McCubbin and Patterson's
model, successful resolution of the loss would fall in the
sphere of bonadaptation, distinguished from maladaptation
by a "balanced 'fit' at the member-to-family and the
family-to-community levels" (McCubbin & Patterson, 1983, p.
20). In other words, the level of adaptation may be seen
as the end product of the grief process, with
reestablishment corresponding to bonadaptation and grief
"resolution," while being stuck in the avoidance or
confrontation phases would be related to maladaptation and
complicated grief.
16
Appraisal of the stressful event is also seen as a
critical factor in the outcome. Lazarus and Folkman (1984)
define cognitive appraisal as the "evaluative cognitive
processes that intervene between the encounter and the
reaction" (p. 52). Three appraisal processes were
identified: (a) primary appraisal (the judgment that an
encounter is irrelevant, benign-positive or stressful); (b)
secondary appraisal (judgment concerning what might and can
be done about the situation); and (c) reappraisal (an
altered appraisal based on new information). In addition,
the authors identified two personal characteristics that
are important determinants of appraisals, that is, (a)
commitments (i.e., what is important or has meaning for an
individual) and (b) beliefs (e.g., what the individual
believes about personal control over events or their
beliefs in a Higher Power). Situation factors influencing
appraisal include: (a) novelty, (b) predictability versus
event uncertainty, (c) temporal factors, (d) ambiguity, and
(e) timing of the stressor in the life cycle.
In the present study, the occurrence of the adult
child's death in the aging years stage (Hill & Rodgers,
1964) is expected to negatively impact the parent's
appraisal of the event. For example, in addition to the
developmental tasks of achieving integrity and working
toward disengagement (Erikson, 1959) appropriate to this
age group, parents suffering the death of an adult child
17
are confronted with the issue of decreased abilities and
choices for reinvestment in new relationships deemed
essential for the successful completion of grief work by
Lindemann (1944). This is but one of the several unique
factors identified by Rando (1986), discussed later in this
chapter, that serve to complicate the grief process of
older parents who lose an adult child.
There are several kinds of resources discussed in the
literature that are applicable in the case of bereavement,
namely social (e.g., family, friends, co-workers,
neighbors, and voluntary associations), personal (e.g.,
finances, education, and health), and psychological (e.g.,
mastery, self-esteem, and self-denigration). The existing
and new social resources interact to form the social
support component seen by McCubbin and Patterson (1983; as
the most important aspect affecting the outcome of the
crisis situation. This is due to the ability of the social
support network to assist the family in being more
resistant to major stressors and also in helping the family
more easily and quickly recover from crises and return to a
state of equilibrium.
Social Support and Bereavement Outcomes
The importance of social support as a mitigating
factor in the healthy resolution of grief has been noted by
several authors. According to Worden (1991) the absence of
18
a social network may cause disruption in the resolution of
a loss and contribute to a complicated grief reaction.
Raphael (1983) has also reported that the most important
influence for the majority of grieving individuals will be
their families and social network.
As noted by Arseneault (1986) "The term social support
is currently used to denote a variety of supportive
interactions" (p. 204). This is readily apparent in a
cursory review of the extant literature on social support.
For example, according to Vachon and Stylianos (1988)
social support can be broken down into four elements: (a)
emotional support (actions that are self-esteem enhancing),
(b) appraisal support (feedback on one's behavior or
attitudes), (c) instrumental support (tangible assistance),
and (d) informational support (advice or knowledge that
assists in problem solving). Dimond and Jones (1983)
report agreement on four slightly different components of
social support, i.e., communication of positive affect,
social integration, instrumental behavior or material aid,
and reciprocity. Similarly, Wills (1985) has identified
four supportive functions of interpersonal relationships:
(a) esteem support (b) informational support (c)
instrumental support, and (d) social companionship.
According to Walker, MacBride and Vachon (1977) "An
individual's support network may be defined as that set of
personal contacts through which the individual maintains
19
his social identity and receives emotional support,
material aid and services, and information and new social
contacts" (p. 35). Yet another distinction in social
support concerns the provider, i.e., an informal network,
typically composed of family, friends, neighbors, and
coworkers, or a formal source, such as volunteer or
government agencies (Arseneault, 1986). When all is
considered, social support in essence may be defined as
psychological or material aid given to others by
individuals or organizations (i.e., social network
associates) based on need or upon request.
Widowhood has been the most widely researched topic in
the bereavement literature. As a result, more is known
about the importance of social support and social networks
on the well-being of widows than any other bereaved group.
Schuster and Butler (1989) found that social support
and social networks did significantly impact the mental and
physical health of their widowed sample. Results included
the finding that it was the quantity of instrumental and
emotional support that was primarily responsible for the
effect on widows' mental health. Another important finding
was that the support received at the time of bereavement
had a greater influence on the widows' current level of
mental health than current support or current assessments
of network closeness and frequency of contact. Also,
instrumental support was identified as being more
20
predictive than affective support of the long-term mental
health of widows.
Bankoff (1983) found that the source of support made a
difference in the well-being scores for two groups of
widows. Although the crisis loss phase widows (those
widowed 18 months or less) received more support from their
children than from any other network associates, only the
support from the widow's parents and their widowed or
otherwise single friends was positively related to their
overall well-being. For the transition phase widows (those
widowed between 19 and 35 months), it appeared that a
larger number of network associates were capable of being
effective supporters. The widow's highest level of
well-being came from association with their widowed or
otherwise single friends; however, support received from
their parents, children, and neighbors was also positively
associated with their overall well-being.
Lowenstein and Rosen (1989) found that for a sample of
Jewish women widowed from 6 months to 6 years the size of
their informal network and the extent of their satisfaction
with it was significantly related to a better physical
health outcome, while the inclination to participate in
social activities was significantly related to less
depression. Morgan (1989) asked a group of 39 women and 2
men, widowed from 6 to 18 months, which aspects of their
social networks they felt were critical in restructuring
21
their lives following conjugal bereavement. Results from
six separate focus groups showed that non- family
relationships were mentioned not only more often, but also
more favorably than family relationships. In the nonfamily
portion of the network, friends had a large number of
positive mentions (55.9%), and others (e.g., doctors and
pastors) were also assigned a large number of positive
mentions (57.85%). The largest number of positive
mentions, however, was attributed to the widowhood support
group (84.6%).
Based on these studies it can be concluded that the
size of the social network, the source of the support, the
frequency of contact, the timing of the support, and the
type of support provided are all important variables
affecting a grief response. A review of the bereavement
literature has indicated that: (a) emotional support, (b)
instrumental support, (c) informational support, and (d)
social companionship are considered important dimensions of
social support following a death in the family (Lowenstein
& Rosen, 1989; McCubbin & Patterson, 1983; Pine & Brauer,
1986; Rando, 1984; Raphael, 1983; Schuster & Butler, 1989;
Worden, 1991). These four components of social support
were examined in the present study. Also, social support
from both formal and informal network sources was examined.
22
Loss of an Adult Child
There is a dearth of empirical studies addressing the
issue of parental bereavement among older parents who lose
an adult child. In general, "The studies of parental
bereavement have been very few in number and have been
limited in their scope or have been included as a secondary
part of a larger study" (Levav, 1982, p. 24). This is
especially true for adult child loss.
Rando (1986), one of the few authors to write
specifically about the older parent who loses an adult
child, explored the unique issues that separate parents who
lose a grown child from those who lose a younger child.
Among the factors mentioned are: (a) difficulty accepting
the death because the child has successfully survived the
perils of early childhood and adolescence and "should"
easily be able to live out a long life as an adult; (b)
developmental issues of aging and loss of control; (c)
lifespan concerns of retirement, loss of same age siblings
or friends, and widowhood; (d) loss of meaning and sense of
generativity critical to successful aging (Erikson, 1950);
(e) loss of financial, psychological, social or physical
caregiver; (f) decreased abilities and choices for
reinvestment in new relationships; (g) a reduced social
support network due to loss of spouse, friends, or
coworkers; (h) lack of validation of their loss as they are
not considered the primary grievers (family of procreation
23
is considered primary griever); and (i) social
discrimination, that is, society's view that "old" people
are used to death and grief, and therefore they should be
less affected by the loss. Moss et al. (1986) mention the
increased risk of institutionalization that elderly
bereaved parents may face as a result of losing an adult
child caregiver. Raphael (1983) depicted the adult child
as:
a representative of the parent beyond the parent's death, symbolic of the parent's immortality - the only way the parent can go on into the future as he ages. So to lose this adult child would be to lose the continuity of the line, the denial of death that he [adult child] meant for the parent, (p. 234)
Rando (1986) also discusses secondary losses, that is,
those losses that accrue as a result of the death. For a
parent who loses an adult child these may include: (a) fear
of losing contact with a beloved in-law and/or
grandchildren; (b) concern that the grandchildren will
forget their natural parent in the event of re-marriage or
moving away; (c) seeing living reminders of their child in
the looks and actions of grandchildren; (d) having to
assume caretaking responsibilities for grandchildren; (e)
seeing the end of the family name if there is no one else
left to carry it on; and (f) loss of someone to entrust
with family heirlooms. All of these factors may be
considered pileup stressors for the older bereaved parent.
In short, there are a number of factors that can
impact the grief response of older parents mourning the
24
loss of an adult child. In addition to those mentioned
above are: (a) the age of the bereaved parent at the time
of the loss, (b) the cause of death, (c) whether or not the
death was anticipated or sudden, (d) the personal resources
available to the bereaved, and (e) the support of family
members and the social network.
Complicated Grief
According to Worden (1991), individuals who have
experienced a complicated grief reaction in the past will
have an elevated risk of having a complicated reaction in
the present. This is in agreement with the writings of
several other authors (Lindemann, 1944; Rando, 1984;
Raphael, 1983).
Lazare (1979) identified 13 tentative diagnostic clues
to unresolved grief. The author has pointed out that while
any singular clue may be insufficient grounds for a
diagnosis of unresolved grief, the presence of any clue
should be taken earnestly and the possibility of unresolved
grief seriously considered. Clues to unresolved grief are:
1. An inability to discuss the death without
experiencing it anew and the grief reaction is severe.
2. A prior history of delayed or extended grief.
3. Recurrent discussions of loss issues in formal
interview situations.
25
4. An unwillingness to move or release possessions
that belonged to the deceased.
5. Complaints of ill-defined somatic distress, or
development of physical symptoms similar to those of the
deceased.
6. A change in social relationships after the death.
7. Past history of subclinical depression.
8. A feeling of recency concerning the death even
though it may have occurred several years ago.
9. A pattern of searching behavior emerges.
10. Inexplicable sadness reoccurring at the same time
over a period of years (e.g., holidays or anniversary of
death).
11. Somatic distress centered in the upper half of the
sternum.
12. Avoidance of rxtuals or activities associated with
religion and/or death.
13. Feelings of guilt, self-reproach and anxiety
attacks.
To this list Worden (1991) has added:
1. A relatively insignificant event sets off a major
grief reaction.
2. A drastic change in lifestyle following a death.
3. An attempt on the part of the bereaved to imitate
the personality or behavior of the deceased.
26
4. Tendency of the bereaved toward self-destructive
behavior.
5. An unfounded fear about death or certain
illnesses, such as the one the deceased succumbed to.
As noted earlier, depression is one of the primary
symptoms associated with a complicated grief reaction.
Examination of the "clues" provided by both Lazare and
Worden cited above indicate the importance of the presence
of depression in diagnosing complicated grief. The
association between depression and complicated bereavement
has also been acknowledged in the Diagnostic and
Statistical Manual III-R (1987) of the APA. The main
differences between the two are: (a) unlike clinical
depression, a grief reaction does not usually involve the
loss of self-esteem; and (b) any guilt involved in a grief
reaction is typically associated with some definite aspect
of the loss situation rather than the generalized overall
sense of guilt associated with major depression. Thus,
while depression and grief both have similar subjective and
objective characteristics, they are distinctly different
conditions.
Hypotheses
Death is a family affair; no one lives or dies in a
vacuum. Thus, it is important to evaluate the influence of
a death on the whole family system. However, on the other
27
hand, grief resulting from a death is a highly personal
matter. Not all bereaved family members will suffer the
loss in the same way, nor will they resolve it at the same
time. For example, a sibling may grieve intensely for a
dead brother or sister, but the grief of the parent may be
even more intense and much longer lasting. "In short,
death demands both personal adjustment and interpersonal
adaptation" (Bengston & Treas, 1980, p. 418).
The focus of the present study is the personal
subsystem or individual bereaved parent. The Double ABCX
Model of Family Adaptation will be used to study
participants' adaptation response to bereavement. The loss
of an adult child as experienced by an older parent would
seem to fit the variables associated with the Double ABCX
model quite well due to the overwhelming nature of the
crisis resulting from the death and the importance of
personal resources, social support, and the impact of pile-
up factors on the healthy resolution of the loss.
The following hypotheses were examined:
1. Older parents suffering the loss of an adult child
will have significantly higher scores on measures of
depression and social withdrawal, and a significantly lower
score for health status in comparison to bereaved persons
who have lost a spouse.
28
2. Older parents suffering the loss of an adult child
will report significantly higher grief intensity levels in
comparison to bereaved persons who have lost a spouse.
3. Older bereaved parents with a greater number of
network sources of support will have significantly lower
scores on measures of depression and social withdrawal, and
a significantly higher score for health status in
comparison to those who report a lower number of network
sources of support.
4. Older bereaved parents with a greater number of
network sources of support will report significantly lower
grief intensity levels in comparison to those who report a
lower number of network sources of support.
29
& B EXJSTINQ &
^EW RESOURCES
O A
PILEUP
COPING
POST-CRISIS o PERCEPTION OF
X^aA4bB
BONADAPTATK)N
ADAPTATION
A X MALADAPTATION
Figure 1
Individual Model of Factors Affecting Adaptation Following Attachment Loss Based on Double ABCX Model of Family
Adaptation (McCubbin & Patterson, 1983).
30
CHAPTER III
METHODS
Subjects
Subjects were all older adults who had suffered the
death of an adult child or a spouse within the past five
years. For the purposes of this study, an older adult was
operationally defined as a person at least 55 years of age.
An adult child must have been at least 21 years of age at
the time of death in order to meet the requirements of the
study. All deaths took place between 1988 and 1993 and all
subjects were volunteers.
Bereaved parents suffering the death of an adult child
are a small portion of the overall population due to the
relatively low death rates for adult children. According
to the U.S. National Center foi Health Statistics (1992),
the expected number of deaths for those 21 years of age is
1.10 per 1,000, and increases to only 4.85 per 1,000 for
those 50 years of age. In addition, acceptance rates for
bereavement research are usually low (Stroebe & Stroebe,
1989). According to Stroebe and Stroebe (1989) studies with
the highest rates are those which utilize "credible
sources," for example, hospital or medical personnel,
ministers, or persons sharing the same experience. An
alternate method of locating bereaved parents involves the
followup of obituary information. However, this method
31
also fails to yield a random sample, and can be problematic
in several ways, for example, not all deaths are published
in local obituaries, and published obituaries may not
reflect local deaths or the location of surviving parents.
In this study, subjects were drawn from several
different sources, including local churches, retirement
communities, bereavement support groups, senior volunteer
programs. Meals on Wheels Program, and Hospice. In
addition, several participants were recruited through word
of mouth from other subjects.
Measures
Dependent Measures
Adaptation to bereavement was assessed using four
variables: grief intensity level, depression, social
withdrawal, and health status.
Grief intensity level. The Texas Revised Grief
Inventory (TRIG) was developed by Faschingbauer, DeVaul,
and Zisook (1977) at the University of Texas Medical Center
in Houston. This self-report instrument consists of 21
items designed to "quantify grief reactions" at two
distinct time periods: (a) at the time the person died
(Part I, 8 items), and (b) currently (Part II, 13 items).
According to Faschingbauer (1981) "the TRIG appears to
provide information regarding a person's progress through
the various stages of grief by combining Parts I and II"
32
(p. 10) and can be useful in identifying complicated grief.
A five-point Likert scale is used to respond to each
question, ranging from completely true (5) to completely
false (1). A higher score indicates a higher grief
intensity level. The TRIG also collects demographic and
other data relevant to the death (e.g., time since the
death). The last item offers an unstructured opportunity
for the respondent to communicate any "special thoughts and
comments." The calculation of TRIG scores involves the
summing of the Likert values indicated for each item on the
two scales and yields a past behavior score (Part I) and a
present feelings score (Part II). A higher score
represents a poorer grief adjustment pattern. The median
correlation of the 13 items comprising the present feelings
score is .69, the alpha coefficient is .86, and the split
half reliability of the 13 items is .88. TRIG norms and
95% confidence intervals for two TRIG subsamples
(networking sample and replication sample) are available
(Faschingbauer, 1981). In the present study Cronbach's
alpha on Part II was .85.
Self-report quantitative instruments to measure grief
are new additions to the more established data gathering
methodologies of the standardized interview or the use of
rating scales combined with behavioral observations.
Currently two scales exist which seek to quantify grief
reactions. The Texas Revised Grief Inventory (1977) and
33
the Grief Experience Inventory (GEI) (Sanders, 1980).
Whereas the TRIG is a brief instrument requiring
approximately 10 minutes to complete, the GEI is a more
extensive measure modeled after the Minnesota Multiphasic
Personality Inventory (MMPI) assessing 12 separate grief
factors. Due to its brevity and its ability to identify
complicated grief, the TRIG was chosen for this study.
Part I of the TRIG was included in the questionnaire
(Appendix A) as item number 26 and Part II was contained in
item number 27. Item numbers 18 through 25 are also from
the TRIG. Only Part II containing questions relevant to
present feelings was used for the analyses in this study.
Depression. The Center for Epidemiologic Studies
Depression Scale (CES-D) (Radloff, 1977) is a brief 20 item
multiple choice instrument used to identify the presence of
depressive symptomatology in the general population.
According to Radloff and Locke (1986) the CES-D was not
designed to distinguish specific types of depression (e.g.,
bipolar vs. unipolar) nor to discriminate between primary
and secondary depressive disorders. Rather the purpose of
the CES-D was to establish the presence and severity of
depressive symptomatology in the adult nonpsychiatric
population. Scale items were identified from a combination
of items drawn from previously validated measures of
depression (e.g., Beck, Ward, Mendelson, Mock, & Erbaugh,
1961; Dahlstrom & Welsh, 1960; Raskin, Schulterbrandt,
34
Rearig, & McKeon, 1969; Zung, 1965). The clinical
literature and factor analytic studies were used to select
the following major components of depressive
symptomatology: depressed mood, feelings of guilt and
worthlessness, psychomotor retardation, loss of appetite,
and sleep disturbance (Radloff, 1977). The scale was
intended to identify current state and to be sensitive to
changes in state by inquiring as to how often the symptoms
occurred during the past week. In an attempt to disrupt
response set and to measure the presence or absence of
positive affect, four items were worded in the positive
direction (i.e., items 4, 8, 12 and 16). Items are scored
on a four point scale (0 to 3) used to describe the
frequency of occurrence of the event during the prior week
as follows:
1. Rarely or none of the time (less than 1 day),
2. Some or a little of the time (1-2 days),
3. Occasionally or a moderate amount of time (3-4
days),
4. Most or all of the time (5-7 days).
The weights for the four positive items are reversed, with
lower frequency scoring higher. Scores can range from 0 to
60, with higher scores reflecting both more depressive
symptoms and the persistence of symptoms. Severity is
determined by the number of symptoms weighted by the
frequency of their occurrence during the past week. The
35
CES-D is objectively scored by summing the selected choices
to arrive at a single score. A score of 16 or above is
recommended to identify individuals who are "at risk" for
clinical depression (Radloff, 1977; Radloff & Locke, 1986).
In order to attain a score of 16 or more an individual must
select a majority of the symptoms presented in the CES-D
for a few days in the last week or select at least 6 of the
symptoms for a majority of the time during the last week.
The CES-D has the advantage of being tested with a
diverse number of populations, including community samples,
geriatric out-patients, psychiatric in-patients and
psychiatric out-patients. Another plus is its simplicity
and ease of administration. In addition, the test can
usually be completed within 10 minutes. In the original
probability samples of households intended to be
representative of two communities (Kansas City, Missouri
and Washington County, Maryland) test-retest reliability
estimates for the CES-D yielded moderate correlations (.40
or above). Coefficient alpha of .80 or above was revealed
for all subgroups. Cronbach's alpha for the present study
was .90.
Comparison of a community sample with five psychiatric
samples (i.e., acute depressives, recovered depressives,
drug addicts, alcoholics, and schizophrenics) by Weissman,
Sholomskas, Pottenger, Prusoff, and Locke (1977) revealed
substantial evidence for the concurrent validity of the
36
CES-D. Support for the measure was based on the following
findings: (l) the CES-D was able to adequately
differentiate the psychiatric patients from the community
normals; (2) the acutely depressed patients indicated more
symptoms than the other psychiatric patients; (3) the
depressed subgroups within each psychiatric grouping
revealed higher scores than the nondepressed patients
within each of the respective groupings; (4) the acutely
depressed patients tested out higher than the recovered
depressives; and (5) correlations between the CES-D and
other depression measures (e.g., clinician ratings, the
Hamilton and the Raskin Depression Scale, and the Symptom
Checklist (SCL-90) were high. In addition, the
discriminant validity of the instrument was supported by
the low correlation of the CES-D with the variables of age,
sex, and social class.
A recent study by Williamson and Schulz (1992)
revealed "the mean CES-D score for at-risk subjects (24.09)
was close to the 27-point level shown by Schulberg et al.
(1985) to be a very good predictor of clinical depression"
(p. P371). Likewise, Thomas, Kelman, Kennedy, Ahn, and Yang
(1992) found the CES-D to accurately measure the absence of
depression in a sample of 1,855 elderly community residents
at two separate time points.
Due to its ability to consistently ascertain the
presence or absence of depressive symptomatology,
37
especially in an older adult population, the Center for
Epidemiologic Studies Depression Scale was the instrument
of choice for this project. Its brevity and ease of
administration were also considered advantages in the
present study.
Social withdrawal. As mentioned earlier, several
authors have included social withdrawal as one of the
symptoms commonly associated with complicated grief.
However, a suitable measure to tap this dimension of
bereavement was not found. As a result, the 5 items
contained in questions 36 and 39 of the questionnaire, used
to assess social withdrawal in this study, were taken from
Worden (1991) who has suggested that social withdrawal
following a death involves an overall loss of interest m
others and the outside world. Each item is scored based on
a five-point Likert-type scale ranging from strongly
disagree (0) to strongly agree (4). A higher score
indicates a greater level of social withdrawal. In the
present study a coefficient alpha of .85 was obtained for
the scale measuring social withdrawal at the present time.
A conceptual distinction between the social withdrawal
of the participant from family and friends (social
withdrawal measure) and the withdrawal of family and
friends from the participant, as indicated by their lack of
representation in the number of present supportive network
38
contacts (total sources of support index), was confirmed by
the low correlation between the two measures (r(108) =
-.09, n.s.).
Health status. Health status was evaluated using a
three-item index (items 9, 10 and 11). The overall
self-rating of health at the present time consists of four
options, ranging from (1) poor to (4) excellent. The
self-report of present health compared to five years ago
consists of three options, ranging from (1) worse to (3)
better. The extent to which health problems stand in the
way of performing desired activities consists of three
options, ranging from (1) a great deal to (3) not at all.
Responses are added together for a total health score.
Higher scores indicate better health. This three item
index was used recently in a study of older, rural adults
by Scott and Roberto (1985). Inter-item consistency was
.76 using Cronbach's alpha. Reliability using Cronbach's
alpha was .68 in the present study.
Independent Variables
Prior losses. Respondents were asked to identify all
the prior losses they had experienced (item 12 of the
questionnaire). The losses were then divided into
attachment and nonattachment categories. Each category was
summed for an attachment, nonattachment, and total combined
39
score. Higher scores reflect a greater number of pileup
factors contributing to a complicated bereavement outcome.
Social support. The items used to assess subject's
report of their support network and the amount of social
support provided (items 28 through 35 of the questionnaire)
are similar to those used by Ricketts (1989) to examine
parental grief in the case of the unexpected death of an
older child. The total number of present network sources
of support was summed to provide a Total Sources of Support
Index. In addition, the present amount of social support
provided by the most helpful member of the network (based
on the 19 options presented in item number 35 of the
questionnaire) was also summed, resulting in a Total Amount
of SoCj.al Support Index.
Th3 total amount of social support received was
further subdivided into four separate dimensions of social
support. This resulted in four subscales as follows: (a)
emotional support (e.g., shared personal experience), (b)
instrumental support (e.g., provided transportation), (c)
informational support (provided needed information), and
(d) social companionship (e.g., provided distractions).
The alpha coefficients for these indices may be found in
Table 1.
40
Procedures
Local ministers, a support group for bereaved parents
and hospice personnel were contacted regarding the
identification of potential study participants. Each of
these sources provided the researcher with the names and
telephone numbers of persons they felt met the eligibility
requirements of the study. Most of the church members had
been notified in advance and were expecting phone contact.
A phone call was made to each individual to answer any
remaining questions and to confirm participation.
In addition, a screening questionnaire (Appendix B)
suitable for mass distribution was designed for use by
agencies agreeing to participate but who did not wish to
release names and telephone numbers of potential subjects
directly to the researcher. The screening questionnaire
was used to ascertain whether persons had lost a spouse or
a child in the last five years and whether or not they
would be willing to participate in the study.
Approximately 800 screening forms were mailed out to
persons involved in a senior volunteer program. Fifty
forms were distributed to a local support group for
bereaved spouses, 130 forms were distributed to the local
Meals on Wheels office, and 30 forms were distributed at a
retirement community. Following return of the screening
questionnaire and determination of eligibility for the
41
study, a phone call was made to each person to answer any
remaining questions and to confirm participation.
Each participant was given the option of being
interviewed in person, having the information dropped off
personally, or having it mailed. A total of 53% (57) of
the interviews were completed orally and the remaining 47%
(51) were completed and returned by the participants.
Widowed persons responded to a questionnaire identical to
the one used by bereaved parents, except for rewording to
reflect the loss of a spouse rather than of an adult child
For those questionnaires delivered in person participants
were asked to call the researcher when they had been
completed so that a pickup time could be arranged. For
mailed questionnaires a cover letter containing
instructions for completion and return was included
(Appendix C). Phone calls were made to discuss missing
information and to follow-up non-returned materials.
A list of available community resources was provided
to each participant in the study (Appendix D). The
following services were identified:
(a) The Psychology Clinic at Texas Tech University,
(b) The Family Therapy Clinic at Texas Tech
University,
(c) Charter Plains Hospital,
(d) THEOS-Support group for widowed persons,
42
(e) Compassionate Friends-Support group for bereaved
parents.
Analyses
Cronbach's alpha was used to assess the reliability of
the Texas Revised Grief Inventory, the Center for
Epidemiologic Studies Depression Scale, the social
withdrawal scale, and the health index. The alpha
coefficients for these measures may be found in Table 1.
For Hypotheses 1 and 2 a discriminant analysis was
used to assess the differences between the groups on
depression, social withdrawal, grief intensity level, and
health status. For Hypotheses 3 and 4 a discriminant
analysis was used to assess the differences between the low
and high sources of support groups of bereaved parents on
depression, social withdrawal, grief intensity level, and
health status.
43
Table 1
Cronbach's Alpha Values
Health Index .68
Texas Revised Inventory of Grief Part II (TRIGII)
Social Withdrawal Scale - Present
Center for Epidemiologic Studies Depression Scale (CES-D)
Total Amount of Social Support Index
Emotional Support Subscale
Informational Support Subscale
Instrumental Support Subscale
Social Companionship Support Subscale
. 85
. 8 5
. 9 0
. 86
. 8 4
. 66
. 64
e . 48
44
CHAPTER IV
RESULTS
Recruitment and Description of the Sample
Participants for the study were recruited from
churches and community agencies in a southwestern city of
200,000 persons and several smaller surrounding
communities. Referrals from local churches accounted for
the majority of the participants (38.0%), while 5.6% lived
in retirement communities, 5.6% were Meals on Wheels
recipients, 16.7% were members of a bereavement support
group, 7.4% were active members of senior volunteer
programs, 11.1% were referrals from Hospice, and 15.7% were
referred by other study participants.
A total of 120 names were supplied and 115 screening
questionnaires were returned for a potential subject pool
of 235 persons. However, a number of potential
participants did not meet the study requirements.
Disqualifying reasons included: (a) subject being too young
when the child or spouse died; (b) child being too young at
time of death; (c) death was over five years ago; (d)
subject had overlapping losses (i.e., both spouse and adult
child had died in the last five years); or (e) subject did
not indicate loss of adult child or spouse on the screening
questionnaire. In addition, several persons were not able
to be contacted. The most common problem was a change of
45
address or unlisted telephone number. Also the list of
names provided by Hospice included several persons who had
died since the time of the target loss.
Following review for study eligibility, a final
potential subject pool of 154 subjects was identified. Of
this number, 30% refused to participate and the remaining
70% were included in the study (see Table 2). Reasons
given for refusal (when individual was personally
contacted) included: (a) present health (e.g., awaiting
surgery); (b) scheduling conflict (e.g., vacations or
visiting relatives); and (c) unwillingness to talk about
the death or fill out a questionnaire that would require
thinking about the death.
A total of 108 bereaved persons participated in the
project, 53 bereaved parents and 55 bereaved spouses.
Of the total, 20.4% were men and 79.6% were women. The age
range was from 55 to 93 with a mean of 71.2 years. The
sample was primarily Caucasian (95.4%), with
African-Americans making up 2.8%, and others making up
1.8%. The overall education level of the sample was 12.9
years. Slightly over half of the subjects were retired
(54.6%), 13.9% continued to work fulltime, 9.3% worked
parttime, and 22.2% indicated they were housewives.
Of those retired, most had been retired for 5 to 9 years
(32.2%). Only 5.1% had been retired 1 year or less, 13.6%
had been retired 2 to 4 years, 18.7% had been retired 10 to
46
15 years, 10.2% had been retired 16 to 20 years, and 20.2%
had been retired over 20 years.
The demographic characteristics of the bereaved parent
and spouse groups are presented in Table 3. As may be
seen, there were no significant differences between the
groups, except on income where parents reported higher
incomes than surviving spouses (t(98) = 2.28, p < .05).
Income was determined by asking participants to check the
appropriate range that represented their annual income.
The lowest range was from $1,000 to $4,999 and the upper
range was $50,000 or more. The mean range for annual
income for the total sample was between $20,000 and
$29,999.00. Eight participants did not disclose their
income.
There were no significant differences between the
bereaved parents or bereaved spouses on their total loss
histories (t(106) = -.17, n.s.) nor on their individual
attachment (t(96) = 1.02, n.s.) or nonattachment loss
(t(106) = -.81, n.s.) histories. T-tests revealed no
significant differences between the groups on their age at
the time the loss was experienced (t(106) = .48, n.s.), nor
on the time since the death (t(106) = -1.05, n.s.). Also
the groups did not reveal differences based on whether the
deaths were sudden versus slow (A^(l, N = 108) = .13, n.s.)
or expected versus unexpected {^{1, N = 108) = .13, n.s.).
47
There were no differences between the groups on
depression (t(lOO) = -1.52, n.s.), social withdrawal
(t(lOO) = -1.72, n.s.), or health (t(106) = -.44, n.s.).
However, the groups did differ significantly on grief
intensity level with bereaved parents scoring higher than
bereaved spouses (t(106) = 1.95, p < .05). The means and
standard deviations for these variables are presented in
Table 4.
A measure of diversity across the network based on
persons identified as helpful at the present time was also
developed. If participants indicated that they received
help from only one category (i.e., professionals, family
members, or nonfamily members) they received a value of
one, if they indicated that they received help from two of
the above mentioned categories they received a value of
two, and if they indicated they received help from all
three categories they received a value of three. Analysis
revealed no significant differences between the bereaved
parents and spouses groups across the networks to which
they were connected (A^(2, N = 104) = .10, n.s.).
Analyses were also conducted to determine any
differences between the low and high support groups of
bereaved parents based on the number of network sources of
support. T-tests revealed no significant differences
between the two groups on their total loss histories
(t(49) = -.32, n.s.) nor their individual attachment
48
(t(51) = .41, n.s.) or nonattachment loss histories
(t(51) = -.59, n.s.). There were no significant
differences between the groups on their age at the time the
loss was experienced (t(51) = .74, n.s.), nor on the time
since the death (t(51) = .33, n.s.). Also, the groups did
not reveal differences based on whether the deaths were
sudden versus slow (A^d, N = 53) = .23, n.s.) or expected
versus unexpected (A^(l, N = 53) = .10, n.s.).
In addition, there were no significant differences
between the groups on social withdrawal (t(22) = .93, n.s.)
or grief intensity level (t(29) = .19, n.s.). However, the
groups did differ significantly on depression with the high
support group scoring lower than the low support group
(t(51) = 2.61, p < .01). Also, the groups differed
significantly on health status with the high support group
reporting better health than the low support group (t(51) =
-2.27, p < .05).
The leading cause of death for adult children was
cancer (26.4%) followed closely by AIDS (20.8%). Heart
attack or stroke accounted for 13.2% of all adult child
deaths, 7.5% died as the result of a brain tumor, aneurysms
accounted for 5.7% and 11.3% died as a result of other
illnesses. Suicide was given as the cause of death for
3.8% and murder was also responsible for 3.8% of the
deaths. Accidents claimed the lives of 7.5% of the adult
children.
49
Heart attack or stroke was the primary cause of death
for spouses (52.7%) followed by cancer (32.7%). A brain
tumor was responsible for 1.8% of all deaths and 12.7% died
as a result of other illnesses.
Hypotheses 1 and 2
Hypothesis 1 predicted that older parents suffering
the loss of an adult child would have significantly higher
scores on measures of depression and social withdrawal, and
a significantly lower score for health status in comparison
to bereaved spouses. Hypothesis 2 predicted that older
bereaved parents would report significantly higher grief
intensity levels in comparison to bereaved spouses. Both
hypotheses were tested with a multivariate discriminant
analysis in order to see if a set of variables including
income, depression, grief intensity, social withdrawal, and
health could significantly discriminate between the two
bereaved groups. Income was entered on the first step
followed by depression, grief intensity, social withdrawal,
and health. The Wilks' lambda selection method was chosen.
The analysis revealed overall significance for the
combination of discriminating variables (Wilks' lambda =
.85, p < .01). The discriminant function was weighted
largely by grief intensity level (-.99) and depression
(.75). Taking all variables together, persons in the
parent group were distinguished from the spouses group by
50
having higher grief, a lower health status, less social
withdrawal, less depression, and higher income (see Table
5). The findings provided partial support for Hypothesis 1
and fully supported Hypothesis 2. Overall the ability of
the variables to separate the groups was modest, accounting
for only 15% of the total variance existing between the two
groups.
Hypotheses 3 and 4
Hypothesis 3 predicted that bereaved parents with a
greater number of network sources of support would have
significantly lower scores on measures of depression and
social withdrawal, and a higher score for health status in
comparison to bereaved parents with a lower number of
•\etwork sources of support. Hypothesis 4 predicted that
the bereaved parent group with a greater number of network
sources of support would report a significantly lower grief
intensity level in comparison to the bereaved parent group
with a lower number of network sources of support.
The total number of supportive sources reported by
bereaved parents at the present time ranged from 0 to 11
with a mean of 6.0. The groups were divided at the median,
with the low support group made up of those parents who
reported 0 to 5 (n=18) supportive sources and the high
support group made up of those parents who reported 6 to 11
(n=35) supportive sources.
51
Both hypotheses were tested with a multivariate
discriminant analysis in order to determine if a set of
variables including depression, grief intensity, social
withdrawal, and health could significantly discriminate
between the low and high support groups of bereaved
parents. Discriminant analysis revealed overall
significance for the combination of discriminating
variables (Wilks' lambda = .81, p < .05).
The discriminant function was largely represented by
depression (.83) followed by grief intensity (-.55). On
the whole, persons in the high support group were
distinguished from the low support group by having
significantly higher health status, significantly less
depression, and less social withdrawal (see Tables 6 and
7). These findings supported Hypothesis 3. However, the
analysis also revealed that bereaved parents with a greater
number of network support sources actually reported a
higher grief intensity level, thus Hypothesis 4 was not
supported. Overall the ability of the variables to
separate the bereaved parents groups was modest, accounting
for only 19% of the total variance existing between the two
support groups.
Interestingly, when the low versus high support groups
were divided so that the low group encompassed from 0 to 6
supportive sources (n=32) and the high group encompassed
52
from 7 to 11 supportive sources (n=21) discriminant
analysis did not meet established criteria for significance
(Wilks' lambda = .83, p = .06). The findings, while not
significant, were in the direction predicted by Hypothesis
3, that is, persons with a greater number of support
sources had better health, less depression, and less social
withdrawal. However, Hypothesis 4 was not supported as
those parents with a high number of support sources
continued to report a greater grief intensity.
Social Support
The total amount of social support received from the
most helpful person in the network at the present ranged
from 3 to 16 for the bereaved parents group with a mean of
9.55. The group? were divided at the median, the low level
support group being comprised of persons who received from
3 to 9 helpful behaviors (n=23) while the high level
support group encompassed those persons who received from
10 to 16 helpful behaviors (n=26).
A discriminant analysis using the outcome variables of
depression, grief intensity, social withdrawal, and health
did not discriminate between the low versus high social
support groups based on the amount of social support
received by bereaved parents (Wilks* lambda = .96,
^ _ 30). Of the dimensions of social support examined
(emotional, instrumental, informational, social
53
companionship) emotional support is considered to be
particularly beneficial following a loss. However, a
discriminant analysis using the four outcome variables
failed to discriminate between low and high emotional
support groups or any of the other dimensions of social
support (Wilks' lambda = .96, p = .73).
In addition, the sources of support were divided into
three subcategories: (a) professionals (e.g., doctor,
religious leader, funeral director); (b) family members
(e.g., spouse, mother, son); and (c) nonfamily members
(e.g., friend, neighbor, co-worker). With respect to these
subcategorizations of the network based on the most helpful
person, the bereaved parents group did not identify any
professional as the most helpful person at the present
time. Two parents indicated that they no longer needed any
help and therefore listed no one as most helpful at the
present time. Nonfamily members received 28% of the
mentions as the most helpful person and family members
received the highest number accounting for 68% of all
mentions. Friends were the most frequently mentioned
nonfamily members (17%) and spouses were the most mentioned
family members (36%).
When asked if anyone had disappointed them in
providing support following the loss of their child
bereaved parents most often indicated that no one had
54
disappointed them (73%). However, if someone was
mentioned, he/she was most often a family member (19%).
Only one parent indicated he/she was disappointed in a
professional (2%) and 6% mentioned disappointment in the
support provided by nonfamily members (6%).
Total Loss History
As may be expected at this point in the life cycle of
the participants most had experienced multiple losses,
ranging from a low of 2 to a high of 11 with a mean of
5.20. The groups were divided at the median with those
having 2 to 4 losses being considered the low loss history
group and those having 5 to 11 losses being considered the
high loss history group. A discr...minant analysis based on
these two loss history groups failad to reveal significant
differences in the groups according to the outcome measures
(Wilks' lambda = .84, p = .07).
55
Table 2
Recruitment Sources of Study Participants
Potential Source Subjects Refused Participated
Local Churches 43 2 41
Senior Volunteer Program 22 14 8
Support Group -Spouses 15 3 12
Support Group -Parents 7 1 6
Retirement
Community 12 6 6
Meals on Wheels 17 11 6
Hospice 17 5 12
Participant Referrals 21 4 17
Totals 154 46 108
(30%) (70%)
56
Table 3
Demographic Characteristics of a Sample of Older Bereaved Parents and Spouses
Characteristic Bereaved Bereaved Test of Parents Spouses Significance
Current age(X)
Education level(X*)
71.40 71.07 n. s
Gender
(1) Male
(2) Female
Race
(1) White
(2) Black
(3) Hispanic
(4) Other
Employment Status
(1) Fulltime
(2) Parttime
(3) Retired
(4) Housewife
(9.74)^ (8.0)
12.94
(3.89)
22.6
77.4
94.3
1.9
1.9
1.9
12.89
(3.07)
18.2
81.8
96.4
3.6
0.0
0.0
2 0 . 8
7 . 5
4 9 . 1
2 2 . 6
7 . 3
1 0 . 9
6 0 . 0
2 1 . 8
n. s
n. s
n. s
n. s
57
Table 3
Continued
Bereaved Bereaved Test of Characteristic Parents Spouses Significance
Years Retired n.s.
(1) 1 year or less 1.7 3.4
(2) 2 to 4 years 8.5 5.1
(3) 5 to 9 years 11.9 20.3
(4) 10 to 15 years 6.8 11.9
(5) 16 to 20 years 5.1 5.1
(6) over 20 years 10.1 10.1
Income
(1) $ 1,000-$ 4,999 2.1 1.9 p < .05
(2) $ 5,000-$ 9,999
(3) $10,000-$14,999
(4) $15,000-$19,999
(5) $20,000-$24,999
(6) $25,000-$29,999
(7) $30,000-$34,999
(8) $35,000-$39,999
(9) $40,000-$44,999
(10) $45,000-$49,999
(11) $50,000 or more
2 . 1
8 . 5
1 0 . 6
1 2 . 8
1 7 . 0
2 . 1
8 . 5
8 . 5
0 . 0
2 . 1
2 7 . 7
1.9
1 7 . 0
1 7 . 0
1 1 . 3
2 0 . 8
7 . 5
5 . 7
3 . 8
1 .9
1 .9
1 1 . 3
^Standard deviations are in parentheses.
*p < .05.
Note. Bereaved parents N=53 and Bereaved spouses N=55.
58
Table 4
Means and Standard Deviations of Dependent and Independent Variables
Variable
Depression
Parents
Spouses
Grief Intensity
Parents
Mean
10.42
13.33
45.19
Spouses
Social Withdrawal
Parents
Spouses
Health Status^
Parents
Spouses
Total Loss History
Parents
Spouses
Attachment Loss History
Parents
Spouses
Nonattachment History
Parents
Spouses
41.27
6.92
7.87
7.02
7.16
5.17
5.24
3.38
3.20
1.79
2.04
Standard Deviation
8.50
11.27
10.67
10.16
3.68
4.27
1.77
1.69
2.16
1.82
1.02
.76
1.58
1.54
Test of Significance
n.s.
p < . 05
n.s.
n. s
n. s
n. s
n. s
59
Table 4
Continued
Standard Test of Variable Mean Deviation Significance
Age at Time of Loss n.s.
Parents 69.49 9.86
Spouses 68.67 7.93
Time Since Loss n.s.
Parents 2.77 1.78
Spouses 3.13 1.71
Sudden Versus Slow Death n.s
Parents 1.40 .49
Spouses 1.53 .50
Expected Versus Unexpected n.s
Parents 1.38 .49
Spouses 1.51 .50
^Assessed by inquiring about participants present health status, change in health over the past 5 years, and extent of activity restriction due to health. High scores represent better health.
Note. N=108
60
Table 5
Discriminators of Bereaved Parents Versus Bereaved Spouses
Standardized Discriminant Coefficients Factor 1**
Step Variable Bereaved Parents vs. Bereaved Spouses
1. Income -.42
2. Depression .75
Grief Intensity -.99
Social Withdrawal .42
Health .38
**Wilks' lambda = .85, p < .01
Note. N=100
Group Centroids
Bereaved Parents -.44
Bereaved Spouses .39
61
Table 6
Discriminators of Low Versus High Sources of Social Support for Bereaved Parents
Standardized Discriminant Coefficients Factor 1*
Variables Low vs. High Sources of Social Support
Depression .83
Grief Intensity -.55
Social Withdrawal .24
Health -.49
Group Centroids
Low sources of social support .66
High sources of social support -.34
*Wilks' lambda = .81, p < .05
Note. N=53
62
Table 7
Cell Means and Standard Deviations of Discriminators of Low Versus High Sources of Social Support for Bereaved Parents
Variable Mean Standard Deviation
Depression
Low 12.16 9.19
High 7.76 6.70
Grief Intensity
Low 45.84 11.94
High 44.19 8.58
Social Withdrawal
Low 7.56 4.30
High 5.81 1.75
Health
Low 6.53 1.81
High
Note. N=53
7.76 1.45
63
CHAPTER V
DISCUSSION
This study examined the bereavement experiences and
outcomes resulting from the loss of an adult child and from
loss of a spouse. The Double ABCX Model of Family
Adaptation guided the selection of variables and
development of hypotheses. Partial support for Hypothesis
1 was found. Hypotheses 2 and 3 were supported and
Hypothesis 4 was not supported. This chapter will address
the following issues in regard to the theoretical model and
hypotheses: (a) the "fit" of the study results and the
factors of the Double ABCX Model of Family Adaptation; (b)
the differences between bereaved parents and bereaved
spouses; and (c) the differences between groups of bereaved
parents based on a low versus high number of network
sources of support. Also the limitations of the present
study and directions for future research will be discussed
in this chapter.
Double ABCX Model of Family Adaptation
Prior losses can act as pileup ("aiA" factor) in the
Double ABCX Model, contributing to the difficulty in
resolving the loss. In the present study a discriminant
analysis based on a low versus high number of total losses
failed to reveal significant differences in the outcome
64
measures. Findings did not support prior total losses as a
pileup factor. Perhaps the summation of one's total loss
history does not accurately tap unresolved loss
experiences. It may be that indices based on the salience
of the loss or the role the deceased played in the life of
the survivor would provide a better measure of the impact
of prior losses as a pileup factor.
Social support was examined as the resources factor
("bB") of the model. The findings do indicate that those
bereaved parents with a greater number of sources of
support from their network experienced less depression,
less social withdrawal, and a better current health status.
These findings support the bereavement literature regarding
the importance of social support as a resource capable of
influencing the grief response of bereaved individuals
(Baiikoff, 1983; DeSpelder & Strickland, 1992; Lowenstein &
Rosen, 1988; Morgan, 1989; Raphael, 1983; Worden, 1991).
However, these same parents also experienced a greater
grief intensity level. Thus it would appear that social
support, in the case of an adult child's death, can help
mitigate some negative outcomes, but not others. It may be
that a greater number of network sources of support
reflects a greater need for the support they can provide.
This premise is supported by the findings of a recent study
by Greene and Feld (1989) in which "the hypothesis that
social support coverage would have a generally beneficial
65
main effect on the well-being of elderly women was not
supported" (p. 45). The authors concluded that perhaps the
widows in their study actually attracted a large number of
supporters specifically because they did have problems. It
may be speculated that this is the case in the present
study for those parents reporting a high grief intensity
level reflective of a poor resolution to the loss.
Based on the results of the present study it would
appear that social support may mitigate against depression,
social withdrawal, and poor health, but is not an adequate
resource for negating the effects of an intense grief
reaction following the loss of a child. Rather, it would
appear that the results support the premise that depression
and grief are distinctly different conditions. In this
study a hiyn level of depression was associated with
poorer heal-h. This is in agreement with the elevated
somatic distress component of depression (American
Psychiatric Association, 1987). Grief, on the other hand,
would appear to encompass a greater range of emotional
distress, evidenced by the questions on the TRIGII relating
to still wanting to cry, getting upset, missing the person
who died, or being preoccupied with thoughts of the
deceased. Support from one's network may not be a critical
resource in coping with the unique intrapsychic experience
of grief over the loss of a child.
66
Inasmuch as the adaptation to the loss of a child or
spouse may be thought of as an on-gomg process, adaptation
of the study participants to their respective losses would,
for the most part, appear to be in the area of
bonadaptation. That is to say, those bereaved persons who
agreed to participate would appear to have "readjusted" to
their new environment in which the deceased is missing and
to have formed new relationships. In response to item 1 of
the TRIGII (i.e., I am unable to accept the death of the
person who died) 67.9% of bereaved parents indicated
"Completely False" and only 7.5% indicated "Completely
True." For those who had lost a spouse 61.8% indicated
"Completely False" and only 7.3% indicated "Completely
True."
However, in keeping with the comments of several
authors mentioned earlier (Fish, 1986; Klass, 1985; Klass &
Marwit, 1988; Pine & Brauer, 1986;), it should be noted
that many bereaved persons expressed their belief that the
world would never be the same without their loved one, that
they thought about the deceased every day, and that the
death was something they would "never get over." In
response to item h of the TRIGII (i.e., No one will ever
take the place in my life of the person who died) 96.2% of
bereaved parents responded "Completely True" and none
responded "Completely False." Likewise, 74.5% of bereaved
spouses indicated "Completely True" and one indicated
67
"Completely False." Many also discussed the daily ups and
downs of losing a child or spouse. The down times seemed
to especially revolve around shared holidays, family
gatherings, and personal anniversaries (e.g., birthdays,
wedding anniversaries, or date of death).
In summary, it would appear that the Double ABCX Model
of Family Adaptation can provide a useful framework for
examining the grief experience of older adults coping with
the loss of either an adult child or spouse. However,
further effort is needed to evaluate the salience of "aA",
"bB", and "cC" factors for those older persons who have
lost a child.
Differences Betw-̂ en Bereaved Parents
and Spouses
In support of the bereavement literature and
Hypothesis 2 bereaved parents evidenced greater grief
intensity levels than bereaved spouses. Also, as predicted
by Hypothesis 1, bereaved parents indicated a poorer health
status than bereaved spouses.
In contrast to the prediction of Hypothesis 1 bereaved
spouses revealed a higher score on depression and social
withdrawal than bereaved parents. These findings are in
agreement with the widowhood literature which suggests that
the loss of a life partner creates a vacuum in the life of
the survivor resulting in an elevated risk of depression
(Gallagher, Breckenridge, Thompson, & Peterson, 1983;
68
Parkes & Brown, 1972; Thompson, Breckenridge, Gallagher, &
Peterson, 1984). Bereaved spouses must not only suffer the
loss of a primary support relationship, they many times
must cope with a disruption in their established
interpersonal and support networks (Hansson & Remondet,
1988). Such disruption could be speculated to lead to an
increased level of social withdrawal.
This premise is borne out in the present study by the
experience of several widowed persons. Several bereaved
spouses shared stories in which they felt they had been
abandoned by their longtime couple friends. They were hurt
by being excluded from previously shared activities with
their former friends, but felt helpless to do anything to
change the situation. As one widow so poignantly pointed
out, "I can't bring back (the deceased) simply so I can
enjoy our travel club trips again ca.. I?"
Also bereaved spouses were more likely to mention that
they had been disappointed in the support they received
following their loss than were bereaved parents. In all,
38% of bereaved spouses indicated disappointment with
someone in their support network compared to 26% of
bereaved parents who made such mentions. Also 13% of
bereaved spouses mentioned another bereaved spouse as the
person most helpful to them at the present time, whereas
none of the bereaved parents listed another bereaved parent
69
(other than their spouse) as the person most helpful to
them.
Given the possible disruption in their network due not
only to the loss of a primary support member but also to
the lack of support from other network members, the
increased social withdrawal of bereaved spouses in
comparison to bereaved parents may be understandable. The
lack of support and increased social withdrawal may, in
turn, further increase their susceptibility to depression.
The bereaved parent group also revealed a
significantly higher income than the bereaved spouse group
(t = 2.28 (98), p < .05). This was due largely to the fact
that more parents were still employed than widowed persons
thus increasing their annual earnings. This income
differential between married and widowed persons is
consistent with income reported in other literature
(Heinemann & Evans, 1990).
Differences Between Bereaved Parents
According to the bereavement literature, social
support is an important resource in arriving at a healthy
resolution to the loss. This is supported in the present
study in that those bereaved parents with a higher number
of support sources reported significantly less depression
and less social withdrawal than those parents with a lower
number of support sources. In addition, those with a
70
higher number of support sources also reported
significantly better health. These findings provided
support for Hypothesis 3.
On the other hand, having a high number of support
sources did not appear to protect bereaved parents from
also having a high grief intensity level. It should be
noted that the presence of a high grief intensity level
does not by itself indicate the presence of complicated
grief. It may be that social support does indeed aid
bereaved parents in avoiding a complicated grief reaction.
However, social support (or anything else for that matter)
may not mitigate the intrapsychic pain and resulting grief
experience of losing a child.
Limitations of the Study
Several limitations of the present study should be
noted. First, the sample was not random nor was it
representative of all bereaved parents or spouses. The
sample was recruited from a number of different sources,
all of which may be said to involve a certain amount of
social interaction and hence social support. Care should
be taken in generalizing the results of the present study
inasmuch as all subjects were volunteers willing to be
queried about a sensitive and personal topic and all were
involved in some type of supportive network.
71
Second, the study used a cross-sectional design thus
limiting speculation about individual changes in the grief
experience over time. Issues of timing in the use of
resources, coping, and grief resolution could not be
adequately addressed in this study. Third, the sample size
was small and limited to those bereaved persons who had
experienced the loss of a child or spouse in the last five
years. These factors further limit the generalizability of
the results.
Implications for Future Research
Overall bereavement research is in its infancy. There
is a great need for additional research in all facets of
the bereavement experience. However, longitudinal research
is especially needed as we strive to understand more about
the grief process and its effects over time on bereaved
individuals. Such research will aid in assessing the
effects of grief on the long-term physical and mental
health of survivors.
As noted earlier, most of the bereavement literature
has focused on widowhood. With the graying of America
there is an increasing need for research directed at
helping parents cope with the death of an adult child. A
pressing concern is the number of adult children who die as
a result of AIDS. In this small study alone, 11 of the 53
parents interviewed attributed the cause of their child's
72
death to AIDS. Clearly, this is an area in need of
increased attention by researchers.
This study included only a few of the many possible
variables affecting the grief response of older adults. In
this regard, there is a need for investigation of other
factors identified by the Double ABCX Model of Family
Adaptation. For example, further exploration of pile-up
factors affecting the grief experience is called for, as is
future research directed at the survivor's perception of
the death.
A final concern involves the risk factors for a
complicated grief outcome. With an aging population it is
imperative that we determine those most at risk for a
maladaptive grief response and identify those factors which
will help alleviate the negative physical and psychological
outcomes associated with complicated grief.
73
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Faschingbauer, T. R., Devaul, R. A., & Zisook, S. (1977). Development of the Texas Inventory of Grief. American Journal of Psychiatry. 134. 696-698.
Figley, C. R. (1983). Catastrophes: An overview of family reactions. In C. R. Figley & H. I. McCubbin (Eds.), Stress and the family: Vol. 2. (pp. 3-20). New York: Brunner/Mazel.
Figley, C. R., & Sprenkle, D. H. (1978). Delayed stress response syndrome: Family therapy indications. Journal of Marriage and Family Counseling. 4, 53-60.
Fish, W. C. (1986). Differences in grief intensity in bereaved parents. In T. A. Rando, (Ed.), Parental loss of a child (pp. 415-428). Champaign, IL: Research Press.
Gallagher, D. E., Breckenridge, J. N., Thompson, L. W., & Peterson, J. A. (1983). Effects of bereavement on indicators on mental health in elderly widows and widowers. Journal of Gerontology, 38, 565-571.
Gass, K. A. (1989). Health of older widowers: Role of appraisal, coping, resources, and type of spouse's death. In D. A. Lund (Ed.), Older bereaved spouses: Research with practical applications (pp. 95-110). New York: Hemisphere Publishing.
Gorer, G. (1965). Death, grief and mourning. New York: Doubleday.
Greene, R. W., & Feld, S. (1989). Social support coverage and the well-being of elderly widows and married women. Journal of Family Issues, 10/ 33-51.
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Hansson, R. 0., & Remondet, J. H. (1988). Old age and widowhood: Issues of personal control and independence. Journal of Social Issues. 44(3), 159-174. ~
Heinemann, G., & Evans, P. (1990). Widowhood: Loss, change, and adaptation. In T. Brubaker, (Ed.), Family relationships in later life (pp. 142-168). Newbury Park, CA: Sage.
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Hill, R., & Rodgers, R. (1964). The developmental approach. In H. Christensen (Ed.), Handbook of marriage and the family (pp. 171-211). Chicago: Rand McNally.
Hollingsworth, C. E., & Pasnau, R. 0. (1977). Psychotherapy for the bereaved. In C. E. Hollingsworth & R. 0. Pasnau (Eds.), The family in mourning: A guide for health professionals (pp. 145-158). New York: Grune & Stratton.
Klass, D. (1985). Bereaved parents and the compassionate friends: Affiliation and healing. Omega. 15. 353-373.
Klass, D. , & Marwit, S. J. (1988). Toward a model of parental grief. Omega, 19, 31-50.
Klaus, M. H., & Kennell, J. H. (1976). Maternal-infant bonding. St. Louis: The C. V. Mosby Co.
Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.
Lazare, A. (1979). Unresolved grief. In A. Lazare (Ed.), Outpatient psychiatry: Diagnosis and treatment (pp. 498-512). Baltimore: Williams & Wilkins.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Leming, M. R., & Dickinson, G. E. (1985). Understanding dying, death, and bereavement. New York: Holt, Rinehart and Winston.
Levav, I. (1982). Mortality and psychopathdogy following the death of an adult child: An epidemiological review. Israeli Journal of Psychiatry & Related Sciences, 19, 23-38.
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Lindemann, B. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-148.
Lindemann, E. (1960). Psycho-social factors as stressor agents. In J. M. Tanner (Ed.), Stress and psychiatric disorder (pp. 13-16). Oxford, England: Blackwell Scientific Publications Ltd.
Lowenstein, A., & Rosen, A. (1989). The relation of widows' needs and resources to perceived health and depression. Social Science & Medicine. 29, 659-667.
McCubbin, H. I., & Patterson, J. M. (1983). The family stress process: The double ABCX model of adjustment and adaptation. In H. I. McCubbin, M. B. Sussman, & J. M. Patterson (Eds.), Social stress and the family: Advances and developments in family stress theory and research (pp. 7-37). New York: Haworth Press.
Morgan, D. L. (1989). Adjusting to widowhood: Do social networks really make it easier? The Gerontdogist, 29, 101-107.
Moss, M. S., Lesher, E. L., & Moss, S. Z. (1986). Impact of the death of an adult child on elderly parents: Some observations. Omega, 17, 209-218.
National Center for Health Statistics, U. S. Department of Health and Human Services. (1992). Expectation of life and death. Statistical abstract of the United States (112 ed.). Washington, DC: U. S. Department of Commerce, Bureau of the Census.
Osterweis, M., Solomon, F., & Green, M. (Eds.). (1984). Bereavement: Reactions, conseguences, and care. Washington, DC: National Academy Press.
Owen, G., Fulton, R., & Markusen, E. (1982). Death at a distance: A study of family survivors. Omega, 13, 191-225.
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Parkes, C. M. (1970). The first year of bereavement: A longitudinal study of the reaction of London widows to the death of their husbands. Psychiatry, 31, 444-467.
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Parkes, C. M., & Brown, R. j. (1972). Health after bereavement: A controlled study of young Boston widows and widowers. Psychosomatic Medicine. 34, 449-461. ~
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Radloff, L. S., & Locke, B. Z. (1986). The community mental health assessment and the CES-D Scale. In M. Weissman, J. Myers, & C. Ross (Eds.), Community surveys of psychiatric disorders. New Brunswick, NJ: Rutgers University Press.
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APPENDIX A
QUESTIONNAIRE
Please complete each question by checking the 'appropriate response item or by writing a response in the space provided, Your responses will remain confidential.
Name
Address
Telephone. Date of Birth ./.
3.
4.
5.
6.
Gender Female Male
Race White BlacJc Hispanic. Other
Marital Status Single Married Widowed Divorced Separated
Length of present marital status in years
Years of school completed
Employment Status Employed full-time. Employed part-time. Retired Housewife
7. xf ] 1 2 5 10 16 Ov«
retired, how year or less - 4 years - 9 years - 15 years - 20 years »r 20 years
long
Annual 1,000 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000
Income - 4,999 - 9,999 - 14,999 - 19,999 - 24,999 - 29,999 - 34,999 - 39,999 - 44,999 - 49,999 or more
9. Rate overall health at present Excellent. Good Fair Poor
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10. Present health compared to health five years ago Better About the same Worse
11. How much your current health affects your activity level
Not at all A little (some) A great deal
12. Please check each type of loss you have experienced and indicate the age of the person at the time of death and the year the death occurred.
IF DECEASED, AGE AT IN WHAT YEAR DID IifiSS QLL TIME QZ DEATH? DEATH OCCUR?
.Mother
.Father
.Brother(s)
.Sister(s)
.Spouse(s)
.Child(ren)
.Grandchild(ren)
.Other Family
.Close Friend(s)
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13. I have strong rel igious beliefs Agree. Strongly agree Disagree Strongly disagree.
14. I attend church Frequently - at least once a week Occasionally - at least once a month Seldom Never
15. I was years old when the death occurred
16. I viewed the death as Mildly Stressful. Very Stressful Overwhelming, I couldn't do anything
17. I feel as if I should have been able to prevent the death Yes No
18. Cause of death
19. The death was Sudden. Slow
20. The death was Expected. Unexpected.
21. I attended the funeral of the person who died True False
22. I feel that I have really grieved for the person who died True False
23. I feel that I am now functioning about as well as I was before the death True
False
24. I seem to get upset each year at about the same time the person died True
False
25. Sometimes I feel that I have the same illness as the person who died True
False
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26. Think back to the time your child died and answer all of these Items about your feelings and actions at that time by indicating whether each item i« Completely True, Mostly True, Both True and False, Mostly False, or completely False as it applied to you after this person died. Check the best answer.
COMPL. MOSTLY TRUE & MOSTLY COMPL, TBUE TRUE FALSE FALSE FALSE
a. After this person died, I found it hard to get along with certain people.
b. I found it hard to work well after this person died.
c. After this person's death I lost interest in my family, friends, & outside activities.
d. I felt a need to do things that the deceased had wanted to do.
e. I was unusually irritable after this person died.
f. I couldn't keep up with my normal activities for the first 3 months after this person died.
g. I was angry that the person who died had left me.
h. I found it hard to sleep after this person died.
27. Now answer all of the following items by checking how you presently feel about this person's death. Do not look back at your prior answers.
COMPL. MOSTLY TRUE & MOSTLY COMPL TRUE TRUE FALSE FALSE FALSE
a. I still want to cry when I think of the person who died.
b. I still get upset when I think about the person who died.
c. I cannot accept this person's death.
d. Sometimes I very much miss the person who died.
e. Even now it's still painful to recall memories of the person who died.
f. I am preoccupied with thoughts (often think) about the person who has died.
84
COMPL. MOSTLY TRUE & MOSTLY COMPL TRUE TRUE FALSE FALSE FALSE
g. I hide my tears when I think about the person who died. _
h. No one will ever take the place in my life of the person who died. _
i. I can't avoid thinking about the person who died. _
j. I feel it's unfair that this person died. _
k. Things and people around me still remind me of the person who died..
1. I am unable to accept the death of the person who died. _
m. At times I feel the need to cry for the person who has died. _
28. Please indicate by checking the appropriate category the frequency of help you received from the following persons in the month immediately following your child's death.
About Several No Once Times
Contact A Month A Month Weekly Daily
Spouse
Religious Leader
Mother
Father
Sister
Brother
other Relatives
Friends
Co-Workers
Neighbors
Doctors
Self-help Group
Nurses
85
About Several No Once Times
Contact A Month A Month Weekly Daily
Funeral Director
Other Bereaved Parents
Mental Health Professional
Other
29. Who was the most helpful to you in helping you deal with the death of your child in the month immediately following the death?
_(from list above)
30. If a relative was listed as the most helpful, please give his/her specific relationship to you.
31. What types of help did the most helpful person listed above offer?
Please check all that apply
Opportunity to talk Expressed concern Was a good listener Was there when I needed them Provided me with a- new way of seeing things Offered to lend me money Helped me get involved in social activities again Provided needed information Talked to me about religion Provided transportation Shared personal experience Spoke highly of my lost loved one Avoided criticism Helped with household tasks Provided distractions Helped me with things that needed to be done Gave me advice Encouraged me to recover Other
86
32. Please indicate by checking the appropriate category the frequency of help you presently receive from the following persons.
Spouse
Religious Leader
Mother
Father
Sister
Brother
Other Relatives
Friends
Co-Workers
Neighbors
Doctors
Self-help Group
Nurses
Funeral Director
Other Bereaved Parents
Mental Health Professional
Other
About No Once
Contact A Month
Several Times
A Month Weekly Daily
33. Who is presently the most helpful to you m helping you deal with the death of your child?
_(from list above)
34. If a relative was listed as the most helpful, please give his/her specific relationship to you.
87
"• ^ISov/SHr?' "•'" ""̂ "• "'°" "•̂ •""̂ "•"<"> l " " " Please check a l l that apply
Opportunity to talk . Expressed concern
Waa a good l i s tener Was there when I needed them of?«i**!**.'"',*'^i^ * "*'' '̂̂ y °^ seeing things Offered to lend me money 2! iS?2 ?• '^5 involved in soc ia l a c t i v i t i e s again Provided needed information Talked to me about rel ig ion Provided transportation Shared personal experience Spoke highly of my lost loved one Avoided cr i t i c i sm Helped with household tasks Provided dis tract ions Helped me with things that needed to be done Gave me advice Encouraged me to recover Other
36. Please indicate how much you agree with each of the fo l lowing statements concerning your a c t i v i t i e s m the month following your ch i ld ' s death.
Strongly Not Strongly Disagree Disagree Sure Agree Agree
a. I stopped watching t e l e v i s i o n .
b. I withdrew from family and f r i e n d s .
c. I stopped reading newspapers and magazines.
d. I found it difficult to go out.
e. I lost interest in the outside world.
37. Was there anyone who disappointed you in providing support? If so, please indicate their relationship to you from the list above m question #27.
38. In what way were you disappointed?
88
39. Please indicate how much you agree with each of the following statements concerning your present activity level.
Strongly Not Disagree Disagree Sure Agree
Strongly Agree
a. I still do not watch television.
b. I am withdrawn from family and friends.
c. I have stopped reading newspapers and magazines.
d. I still find it difficult to go out.
e. I have lost interest in the outside world.
40. Below is a list of the way you might have felt or behaved. Please indicate how often you have felt this way during the last w«ek.
During the last week:
a. I was bothered by things that usually don't bother oe.
b. I did not feel like eating; my appetite was poor.
c. I felt that I could not shake off the blues even with help from my family or friends.
d. I felt that I was just as good as other people.
e. I had trouble keeping my mmd on what I was doing.
f. I felt depressed. g. I felt that everything I
did was an effort. h. I felt hopeful about the
future. 1. I thought my life had been a
failure, j. I felt fearful.
Rarely or none of the time (less than 1 day)
Some or little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
Most or all of the time (5-7 days)
89
Rarely or none of thm time (less than 1 day)
Some or little of the tiioe (1-2 days)
Occasionally or a moderate aaount of tia« (3-4 days)
Host or all of the time (5-7 days)
k. My sleep was restless. 1. I was happy. m. I talked less than usual. n. I felt lonely. o. People were unfriendly. p. I enjoyed life. q. I had crying spells. r. I felt sad. s. I felt that people disliked
me. t. I could not get 'going
, I
41. What has changed in your life since the death of your child?
42. What meaning have you been able to make out of the death of your child?
90
43. How has the death of your child been different from other deaths you have experienced?
44. Are there any other comments you would like to make?
Thank you for your participation in this project. Your time, effort, and willingness to share this information is gratefully acknowledged and appreciated.
91
APPENDIX B
SCREENING QUESTIONNAIRE
The purpose of this survey is to better understand the grief experience of older adults. Please complete the questions below concerning the deaths of family members that you have experienced. Your responses will be treated confidentially. I hope you will choose to become a part of this important project. After completing the following questions, please return this form to: Janettee Henderson, 6907-B Hartford Avenue, Lubbock, TX 79413 by April 15 m order for it to be processed in a timely manner.
Name
Address:
Telephone:.
Female Male / / Date of Birth
Please check each type of loss you have experienced and indicate the age of the person at the time of death and the year the death occurred.
IF DECEASED, AGE AT IN WHAT YEAR DID LOSS OF: TIME QZ DEATH? D£AIH OCCVR?
.Mother
.Father
_Brother(s)
_Sister(s)
.Spouse(s)
Child(ren)
Other family member :— (specify relationship . '
yes I would be willing to be interviewed in more depth about the losses I have experienced,
no Your time and willingness to participate m this survey is greatly appreciated. ^ janettee Henderson
Texas Tech University
92
APPENDIX C
INSTRUCTIONS FOR MAILED QUESTIONNAIRES
Enclosed please find a consent form, a questionnaire and a stamped return envelope for your use m participating in the bereavement research project at Texas Tech University. It will take approximately 45 minutes of your time to fill out the questionnaire. Please answer all questions using either a pencil or ball point pen. Please complete this form using only your own thoughts.
It is very important that you sign and return the consent form. Once data collection is complete the actual questionnaires will be destroyed. Only group data will be compiled. No names or identifying information will be used in the completed report.
If in the process of completing this information you experience any distress, a list of local mental health services and bereavement self-help groups is enclosed for your use.
Please return the enclosed information in the next week so that the project can proceed in a timely manner. Again, I appreciate your cooperation in learning more about the grieving process of seniors. If you have any questions, please feel free to call mf* at 806/793-9458.
B. Janettee Henderson Texas Tech University
6907-B Hartford Avenue Lubbock, TX 79413
93
APPENDIX D
LOCAL SOCIAL SERVICES RESOURCE LIST
The Psychology Clinic at Texas Tech University 742-3737
The Family Therapy Clinic at
Texas Tech University 742-3074
Charter Plains Hospital 744-5505
THEOS - Support group for bereaved spouses Contact: Kathy Taylor 792-3615
Compassionate Friends - Support group for bereaved parents Contact: Jan Thompson 747-3924
94
PERMISSION TO COPY
In presenting this thesis in partial fulfillment of the
requirements for a master's degree at Texas Tech University or
Texas Tech University Health Sciences Center, I agree that the Library
and my major department shall make it freely available for research
purposes. Permission to copy this thesis for scholarly purposes may
be granted by the Director of the Library or my major professor. It
is understood that any copying or publication of this thesis for
financial gain shall not be allowed without my further written
permission and that any user may be liable for copyright infringement.
Agree (Permission is granted.)
i\MS.-<^\7, \-> . \ A (̂ brvZZXZ? ., f\l t^y^'d^y\:.^-tv<-^
Student^'s Signature Date
Disagree (Permission is not granted.)
Student's Signature Date