The experience of grief after bereavement: a phenomenological study with implications for mental health counseling. (Research).
Grief over the death of a loved one presents one of the most frequent and challenging problems mental health counselors face with their clients. Death of loved ones is possibly the most penetrating loss individuals experience: it is a physical, emotional, and spiritual loss (James & Friedman, 1998). Grief, our emotional response to loss, is the entire range of naturally occurring human emotions that accompany loss. The authors' position is that mental health counselors could improve their grief counseling skills from reading first person accounts of the experience of grief.
Few would disagree with Parkes' (1996) contention that bereavement results in emotional, cognitive, physical, and behavioral responses. The impact of loss through death is noted on the Social Readjustment Rating Scale (Holmes & Holmes, 1970), which was designed to measure cumulative stress over a given period of time. The norm group which was used in developing the scale, although almost exclusively composed of men, contained all major cultural groups in the United States. On the scale, the death of a spouse ranks first out of 43 stressful events followed by the death of a family member which ranks 5th and the death of a close friend ranking 17th. Clearly, mental health counselors need to be prepared to work with clients on their adjustment to the loss of their loved ones through death.
FACTORS INFLUENCING THE GRIEVING PROCESS
A variety of factors affect the bereavement experience, including how one is related to the deceased (e.g., parent, child, partner, or friend; Bonanno, 1999; Leahy, 1993; Meshot & Leitner, 1993), the type of death (Drenovsky, 1994; Ginzburg, Geron, & Solomon, 2002; Levy, Martinkowski, & Derby, 1994; Stamm, 1999), historical approaches to bereavement (Leming & Dickinson, 1994; Smart, 1993), societal influences (Leming & Dickinson), cultural norms (Klapper, Moss, Moss, & Rubinstein, 1994; Stroebe, 1992), the quality of relationship with the deceased (Meshot & Leitner; Rubin, 1992), and the age of the deceased (Klapper et al.; Moss, Moss, Rubinstein, & Resch, 1993). In addition, various aspects of bereaved individuals influence their reaction to loss such as personal vulnerability (Bonanno, 1999; Van Baarsen, Van Duijn, Smit, Snijders, & Knipscheer, 2002), personality traits (Goodman, Black, & Rubinstein, 1996), their age (Gilbar & Dagan, 1995; Levy et al.; Meshot & Leitner), social behavior (Van Baarsen et al.) and familial patterns in dealing with grief (Book, 1996; McGoldrick, 1995). Some have suggested that certain variables have differential effects depending on the stage of bereavement (Richardson & Balaswamy, 2001). For example, loss-oriented variables such as circumstances of death (e.g., type of death) have been found to be more crucial in the early stages of loss whereas restoration variables such as investing in social activities are more relevant in later stages.
When considering the variables which impact the experience of bereavement, it is no surprise that one's relationship with the deceased greatly influences an individual's emotional response to the loss (Meshot & Leitner, 1993; Rubin, 1992). For instance, one's association (i.e., kinship tie) to the deceased has a notable effect on one's reaction to a loss. Reactions vary depending on whether one has lost a parent, sibling, child, partner, co-worker, or friend; different relationships evoke different responses. Losing a spouse is different from losing a parent. The death of a twin is a loss that involves its own unique issues. Losing a friend is likely very different from losing a sibling. The quality of the emotional attachment to the deceased acts as an additional variable in one's response to death. The nature of the bond influences the intensity of one's grief and one's adjustment to a loss (Levy et al., 1994; Meshot & Leitner; Moss, Resch, & Moss, 1997; Rubin).The role of the deceased, whether that of family scapegoat, hero, or main provider, has a notable effect on the grieving process. Bereaved individuals who had a more positive relationship with the deceased reported more intense grief than do those with a less positive one (Bonanno, 1999; Moss, Rubinstein, & Moss, 1997).
Regarding type of death, one's reaction to a death is greatly influenced by the manner in which the death occurs. Deaths can be categorized as natural anticipated (e.g., cancer), natural unanticipated (e.g., heart attack), accidental, homicidal, or suicidal (Range, Walston, & Pollard, 1992; Silverman, Range, & Overholser, 1994). Although there is some evidence that type of death is unrelated to resolution of grief (Campbell, Swank, & Vincent, 1991), there is much evidence that type of death does influence the grief experience or reaction (Drenovsky, 1994; Ginzburg et al., 2002; Levy et al., 1994; Silverman et al.).
The aforementioned variables may account for some of the incongruencies found in the literature on grief and bereavement. For example, researchers have found that the duration of grief varies widely (Levy et al., 1994). There are also divergent views on which grief responses are most adaptive. Although some researchers have found that talking about their feelings and reactions to a loss is necessary for a healthy adjustment (Lindemann, 1944; Worden, 1982), other professionals contend that this is unnecessary for (Bonanno, 1999; Stroebe, 1992) or even detrimental to a healthy adjustment (Wortman & Silver, 1989). Some researchers advocate for stage-based approaches to grief (Kavanaugh, 1972; Kubler-Ross, 1969, 1975; Parkes, 1996), while others favor task-based approaches (Attig, 1996; Corr, 1992; Lindemann, 1944; Rando, 1993; Worden, 1982).
Most of the research on bereavement has been done using quantitative methods (Henschen & Heil, 1992; Hogan, Morse, & Tason, 1996). Edmonds and Hooker (1992) suggested that a qualitative approach would "more clearly articulate the voices of the bereaved respondents without the framework imposed by the researchers" (p. 315). Therefore, the present study was designed to use phenomenological methods to provide a deeper and clearer understanding of the general bereavement experience. With a goal to understand better what it is like for an individual to experience the death of a loved one, particularly what the experience of grief is like, the research question for the study invited bereaved participants to describe their experience of grief after the death of a loved one. A thematic structure of the experience of grief was used to identify the common patterns that emerged from such an experience.
Participants were individuals who volunteered to be interviewed after hearing a brief description of the study. In accordance with Polkinghorne's (1989) recommendation, the researcher attempted to select volunteers with diverse experiences regarding variables such as period of time since the death, relationship to deceased, and type of death in hopes that these variables would increase the richness of the data. Nine Caucasian adults, five females and four males, who had experienced the death of a family member or loved one volunteered for the study. They ranged from 44 to 77 years of age. The period of time since their loved one's death ranged from one week to 28 years prior to the interview. The deceased individuals were spouses, parents, siblings, children, and friends of the participants. The deceased person's age at the time of their death ranged from 3 years and 10 months to 89 years of age. Causes of death included various forms of cancer, a heart attack, an aortal aneurysm, an auto accident, a rare disease, heart conditions, stroke/pneumonia, AIDS, and drowning.
Open-ended and unstructured interviews were conducted by the senior author. Each interview began with the following statement: "Tell me about your experience of grief after the death of a loved one." Subsequent statements or questions represented attempts to obtain clarification or elaboration regarding the participant's experience. Interviews were participant-centered in the sense that participants controlled the direction of the interview, including the subject matter and range of topics discussed. The interviewer, prior to the study, participated in a bracketing interview on the same topic to identify her experiences, reactions, and thoughts regarding the experience of grief after the death of a loved one. The interviewer's responsibility was to avoid injecting her experiences into the interview content shared by the participants. Likewise, the interviewer's responses were limited to minimal encouragers, summaries of content, clarifications, and requests for elaboration on the content shared by the participants. Thus, there was no preplanned agenda of questions to be covered in the interview. Interviews were discontinued when no new material and themes were forth-coming from the participants. In other words, the number of participants interviewed in the study was guided by the repetition of content and themes. Interviews lasted between 45 and 90 minutes.
Following the interviews, the sessions were transcribed. Each transcript was read to members of a research group with one member reading the interviewer's part and one member reading the participant's part. Members of the research group, reading along with the readers, worked to find agreement on the thematic structure emerging from each participant's transcript. Themes were supported by identifying a set of exemplary quotes for each theme. Individual summaries of the participants' interviews were compiled and validated for accuracy by each participant.
Certain patterns in the interviewing process seem noteworthy. Of the nine participants, five (i.e., three females and two males) chose to discuss the death of more than one person. Of the four participants who focused almost exclusively on the death of one person, it seemed significant that two (i.e., one male and one female) were the participants who had lost a spouse and the other two were the participants who had lost a child (i.e., one male and one female.) Several participants made statements about the interview itself or about their reason for participating. One participant stated, "I think it's very important for people to share and that's why I agreed to come, and I would hope that down the road, someone else would come and reach their hand out to someone who is suffering because I reached out to help them." Many stated during or after the interview that it was helpful for them in some way. One participant said, "You've made me think about some things I hadn't thought about in a while." Another stated, "I think it's good for me to talk about it. I haven't been this loquacious about it for some time." After signing his summary form, this participant also wrote, "I trust that your project will prove to be helpful to a number of people as it was for me to participate."
The goal of this research was to provide a description of the thematic structure of the experience of grief for bereaved individuals, with participants being asked to describe their experience of grief after the death of a loved one. The five most prominent themes found in the interviews were as follows: (a) Coping, (b) Affect, (c) Change, (d) Details, and (e) Relationship, which were posed on the background of Time (see Figure). Based on these five themes, a simple outline of the experience of grief after bereavement might contain the following components:"Someone I cared about died ... This is the kind of person they were ... Our relationship was like this ... This is what happened and how they died ... This is how I felt ... This is how I coped with their death ... Their death changed me in these ways."
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Theme 1: Coping--Having Faith You Can Deal With It Will Get You Through It
All nine participants talked about what they did to cope with the loss of their loved one. Coping appeared to be the most prominent of the five themes in that there were more statements regarding this theme than any other. The Coping theme represents the participants' descriptions of how they coped with the death of their loved ones. Participants frequently described certain behaviors or things that were 'helpful.' Some participants distinguished those things that helped them get through it from those that hindered them or were unhelpful. On the whole, this theme reflected the active aspect of the grieving process because participants talked primarily about what they did in order to cope with or adjust to their loss. Participants made reference to various coping mechanisms they employed. Transcript examples include:
Your own faith that you can get through and can deal with it and just rely on that--that's what will get you through it ... I think going back to your routine life as quickly as you can possibly do it--I think that was the thing that was really my saving grace ... Canoeing is my release; that was my escape; I could hit the river. On those weekends after she died, I was out a lot because that was my way of coping ... My therapist had me to write letters to my mother and my daddy and he had me write letters to myself. It was really good. He was into the Gestalt stuff, and it was amazing how effective that was; that was very helpful.
The participants shared numerous examples of coping mechanisms or helpful behaviors. Examples of cognitive strategies were optimism, intellectualization, positive self-talk, compartmentalization, and avoidance. Participants also noted that certain attitudes and perspectives were helpful in dealing with a loss. Several participants noted benefits of individual therapy, support groups, and psychotropic medication. Spiritual resources such as beliefs, prayer, and Bible verses were also sources of comfort for some participants. Most participants noted that support from family and friends was helpful and appreciated, including listening, attending the funeral, helping with practical responsibilities, and verbal expressions.
A variety of behavioral strategies or activities were described as being helpful, including reading, remembering the good times, getting back into a routine, and attending funerals. Physical exercise, being alone, and talking about the deceased were also reported by participants as helpful. Specifically, participants stated that reminiscing about positive memories of the deceased was helpful. Regarding funerals, the consensus among participants was that attending the funeral of a loved one was helpful. They stated that funerals provided a sense of closure, reminded them that many people cared about their loved ones, provided them an opportunity to be with family and close friends, and helped them to accept the loss. Physical activities such as exercise, raking leaves, and canoeing were mentioned as examples of helpful coping mechanisms. Getting back into the routine and having a job were also described as beneficial.
Several participants expressed their belief that there are different ways of grieving and stated that it is important for people to decide for themselves what is most helpful for them in dealing with their loss. In noting differences between what is helpful for different people, some participants noted familial differences in bereavement responses. Another participant emphasized the need for bereaved individuals to grieve in whatever way is most helpful to them. For instance, some participants found it helpful to talk about their grief while others viewed talking about it as unnecessary.
Regarding social support, some participants described their process of learning to accept support from others even though they initially resisted it. Most participants noted ways in which support from others was helpful to them, particularly support from family, friends, or professionals. Participants distinguished between support that was helpful and support that was not. Listening, bringing food, and giving constructive advice were described as helpful by some participants.
On the other hand, trying to dictate how someone grieves and pressuring people to "get over it" were unhelpful as was the discomfort of others with the death. Several participants reported that, at some point, they became aware that certain coping mechanisms they had been using were unhealthy. For instance, trying to be strong for others became too heavy a burden for some participants. Alcohol and avoidance were helpful for one participant initially, but she later became depressed and realized these behaviors were maladaptive. "Wearing tragedy on one's sleeve too long" was described by one participant as unhelpful.
Theme 2: Affect--We Miss Him Desperately
The participants' Affect or emotional response to the deterioration and death of their loved ones was another prominent theme in the interviews. All nine participants described how they felt and reacted to the death. Participants reported having a variety of feelings and reactions. Responses included:
That's the thing about people dying, you don't think it's fair and you're upset; you're mad at them ... It's clearly for me the worst thing I've ever gone through, absolutely awful, unmitigatedly painful ... To some extent I was relieved when she died ... I felt like I had to fill my mother's shoes immediately, just being all things to all people, just this innate drive that so much was expected of me ... It's just missing him, you know, and lately I've missed him a lot. The enthusiasm and the joy that my son had was contagious and, no matter how bad a day you had, you come home, he's got his little arms out and he hugs your neck and it just made everything alright. And we miss that desperately.
The most commonly reported feelings were sadness and a sense of responsibility. Every participant reported either crying or feeling sad, sometimes for themselves, sometimes for the deceased individual, and sometimes for other bereaved individuals. Along with sadness, the other feeling most commonly reported among participants was a sense of responsibility. Participants felt responsible in various ways for the person who was dying. This sense of responsibility has to do with the numerous decisions participants had to make related to the deceased during their illness and death. Many felt responsible for spending time with the person during their illness, for taking care of them, for planning their funeral, and for taking charge of practical matters after their death. This involved crucial decisions about medical care, funeral arrangements, and other practical matters such as the deceased's belongings and finances. Participants also had to make decisions about coming to be with their loved ones during their illness or near the time of their death. At times, participants felt responsible for other bereaved individuals and felt the responsibility of other obligations. Many expressed their concern for other family members or friends and stated that they tried to be strong for them. Participants were also aware of other responsibilities and obligations in their lives related to work, relationships, parenting, and finances; these were sometimes neglected as they dealt with the loss.
Other feelings that were reported by most of the participants were surprise/shock, anger, missing the deceased, pain, relief, pleasure, guilt, depression, and ambivalence. Some participants likened the death of a loved one to losing part of themselves or a part of their identity. Other responses mentioned less frequently included a sense of helplessness or lack of control, regret, loneliness, a sense of injustice, and hoping. Feelings of pleasure or happiness, unexpected by the participants, were salient for them, particularly when they occurred for the first time after a loss. The first experience of laughter or humor following a loss was described by some participants. Even examples of humorous situations were reported during the grieving period. Some noted humorous moments and memories and others remembered times of feeling happy. Related to this theme were stimuli that triggered these feelings and reactions. Eight of the nine participants mentioned particular stimuli or reminders that triggered these emotions and reactions. Music, places, smells, objects, and activities were some of the triggers mentioned.
The deceased's quality of life was also an important factor in influencing participants' emotional responses to death. Quality of life refers to the participants' impression of how positive the deceased's life was. A good quality of life was perceived as one that was fulfilling, happy, and involved minimal pain. Quality of life was often associated with feelings such as relief, sadness, or acceptance. One participant stated that it was easier for him to accept his younger sister's death because of her difficult life; however, he was sad about the quality of her life. On the other hand, he was less sad about his older sister's death because she had a good life. Many participants were aware of the lost potential associated with death and had a poignant sense of "What could have been." Although participants' reflections on lost potential were frequently associated with sadness, they were also associated with feelings of anger, injustice, and loss.
Theme 3: Change--The Drive I Had for Life Is Totally Changed.
Participants were aware of various ways in which they had changed as a result of their loss. Seven of the nine participants discussed how they changed as a result of the death. Many participants reported changes in their perspective and gave powerful examples of how their outlook on life changed. These examples included changes in values and priorities. For many, their loss emphasized to them those things that matter the most. Participants also reported changes in behavior, different ways of relating to others, and growth or maturity that occurred as a result of their experience of bereavement.
The drive I had for life is totally changed ... I'm not saying that I am in any way, shape, or form ready to die, but you know, there are worse things. I'm not afraid of it anymore ... I know I have especially come to grips with knowing that it's not me who's in control ... At this point, whether or not you get a haircut is not nearly as important as it was a year ago. There are too many big battles; you still talk about those sorts of things, but you think more the bigger picture, you really do ... After my husband died, I was forced to become an independent person ... The priorities in your life are changed by a tragedy, by a death, and 1 think the depth in the grieving just emphasized to me the right path for me. The grieving process just kind of emphasized what really makes my heart and soul come alive.
As a result of their loss, participants reported having a greater appreciation for each day, putting a higher priority on time with loved ones, and being less concerned with trivial things. One aspect of clarifying and strengthening values for participants was distinguishing the important things in life from the trivial. Participants reported paying closer attention to the "big picture" and to the "big scheme of things" and less attention to the trivial or unimportant things. Accordingly, many reported valuing time with family and loved ones more after their loss.
Certain behaviors and ways of relating also changed for participants. Many reported personal growth and changes in habits. For one participant, her fear of death diminished because of her experience of bereavement. One participant talked about learning through his bereavement experience to "celebrate each day." Others talked about greater faith or spiritual understanding as a result of their loss. Personal growth was demonstrated by participants' reports of greater maturity, increased independence, and less concern about what others think. Oftentimes, participants reported valuing their relationships more after bereavement. The bereavement experience also increased their sensitivity to other bereaved individuals. Finally, participants noted changes in their way of dealing with grief over time. Some compared their current way of dealing with their loss to their previous way of dealing with it. Less favorable changes were also reported, some of which were temporary and others which were more enduring. For example, some participants experienced unpleasant physical sensations, health problems, or poor self-care after their loss, but these negative effects dissipated with time. Enduring negative changes reported by participants included a diminished "drive for life" and a fear of establishing other close relationships because of anticipated future losses.
Theme 4: Details--I Could Tell You Exactly What I Was Doing the Night He Died.
The Details theme might best be summarized as the participants' stories of their losses and what happened. Much of this theme related to the circumstances of the death, including details of the deterioration and death of loved ones. Eight of the nine participants shared details relevant to the process of dying. Of course, in cases where death occurred suddenly, descriptions were limited to the details of the death. Memories were vivid for most participants with regard to the death and to events leading up to it. Many participants recounted specific conversations and events in detail around the time of the death.
It's amazing that dates and conversations and missed phone calls are still very vivid in my mind. I could tell you exactly what I was doing, what we were talking about, where I was, what I was eating on the night that she died ... We were at the hospital, and I would sit in the chair according to the direction of Daddy's head while he was sleeping so that when he woke up, he would see me there ... He had lost an incredible amount of weight and his skin was very sallow and very green almost. There were days when he didn't get out of bed ... Periodically I had to give permission--I had one leg cut off and then the other leg because she was diabetic ... At the very end she said to me, "I can't fight anymore," and I said, "You don't have to." ... He said, "You don't have a lot of time, so what do you want to say to your father?" And I said, "There's only one thing I want to say, and that's that it's okay for him to leave us." And the minister said, "Well, do you think you can do that?" And I said, "No, I can't."
One noteworthy component of participants' stories was receiving the news regarding prognoses or death. They recalled phone calls, events, and conversations in vivid detail. The time at which they realized or found out that the end was near was also salient for participants. Another prominent aspect of this theme was the time near the end, in which participants talked about the last hours or days with the person who was dying. This often included descriptions of last moments and last words with the deceased. Some participants spent time with and took care of their loved ones during this time. In describing the deceased individual's deterioration and death, many participants also talked about crucial decisions that had to be made regarding medical care and funeral arrangements. These were clearly important aspects of their experience.
Theme 5: Relationship--He Would Walk Into a Room and the Room Would Light Up.
The Relationship theme is characterized by descriptions of who the deceased individuals were and what the participants' relationship with them was like. All nine participants shared personal characteristics of the deceased person and described their relationship with them. This theme is composed of the participants' reflections on the deceased individuals, including descriptions of their personality, the nature of the relationship with them, and various memories that illustrate these components. Some participants provided explanations for talking about their relationship with the deceased and for recounting stories about them. One participant stated that talking about memories is enjoyable for her: "We had some fun. Still do, talking about 'em." Another participant, after talking for a lengthy period of time about who his deceased parents were and what his relationship with them was like, explained, "The reason I gave all this other background is to say my feelings at the end don't make sense if you didn't have some idea of the past." Following are a few examples:
My Daddy loved me, he would do anything in the world for me, but at the same time, the only way he could feel good about himself--he had such low self-esteem--was to put everybody else down ... She was a role model; I never heard her say anything unkind about anybody ... He was a big influence because he was also a stabilizing factor ... We used to fight in the kitchen ... She got up every morning and made up all the beds from scratch ... He would walk into a room and the room would light up. It's just the way he was--a warm, bright child ... She would tell me if she thought I had a bad idea and I could trust her judgment. I've lost someone I could communicate with and talk to about things that I could talk to no one else about.
In describing their relationship with the deceased, participants talked about shared experiences, the amount of time spent together, how they related, the role of the deceased in their life, and the role they had in the deceased's life. Admiration and appreciation for the deceased were often evident as participants described loved ones; at other times, sadness and anger were associated with these descriptions. Participants spent considerable time describing the character and personality of the deceased. Their admiration of the deceased was evident in these descriptions. One father proudly noted how bright and warm his son was. A widower talked about his wife's quick wit. One participant stated that his parents would do anything for him. A daughter shared her admiration for her father's big heart and his skills in woodworking. Some participants balanced out their admiration for the deceased with recognition of the deceased's weaknesses or dysfunctions. One participant talked about her father's disorganization and her friend's tendency to burn bridges. Another talked about his mother's "neurotic-bordering-on-sometimes-psychotic" tendencies. One participant talked about his sister's tendency to do things that embarrassed others. One man commented on his wife's "sharp tongue." Participants shared memories of conflicts as well as of bonding moments.
Some participants noted how the relationship impacted their experience of grief. One participant, in comparing his responses to the losses of three siblings, said that the loss of his older sister was hardest for him because he was closest to her. He stated that he was less able to help with her funeral arrangements because of the severity of his grief. One participant described very different roles that his two sisters had had; his older sister was an initiator and planned family gatherings. His younger sister received care from others and was supported financially by the state and by family members. Another participant reported that he cried when his father died but that he did not cry when his mother died. He attributed this to his relationship with them: "I had a better relationship with my father ... I felt like I had lost a friend. But with my mother, I didn't feel like I had lost a friend." A widow talked about how her husband had taken care of her before he died and how, in contrast, she later took care of her partner before he died. She explained that this was one of the reasons she missed her husband more than her partner. Various participants described the deceased individual as their best friend. One participant referred to her deceased friend as a "stabilizing factor or a guiding factor" in her life. Another stated that her mother was her "sounding board." Another participant talked about how he took care of his parents and felt responsible for them until they died. Clearly, the role of the deceased in the participant's life and the participant's role in the deceased's life are significant aspects of the relationship theme.
Three participants made reference to their ongoing relationship with the deceased; some even stated that the deceased are with them and a part of them:
He's very much with me. I'm my father down to a T. Just the way I do things, I am my father's child and I consider that very special and he's always with me. Daddy is much closer to me, even now, he's always there ... I think that so much of what I am and who I am--I think so many of my habits of thought, so many of my ways of feeling and thinking about things were influenced by my wife. I think she will always constitute one of the most important parts of who I am.
The words bereaved individuals used to describe their experience of bereavement have been examined in order to better understand the experience of grief after bereavement. In addition to learning from the language of bereaved individuals, Corr and Doka (2001) suggest that "counselors, caregivers, and educators would do well to listen to the language that clients, patients, and students use in describing their responses to death-related encounters" so that they "can examine that language, learn from it, mirror it when appropriate, or correct and guide it to improved usage when necessary" (p.195). Clinicians may help bereaved individuals cope with early negative feelings by inviting them to talk about the death and the circumstances surrounding it (Richardson & Balaswamy, 2001). In fact, several of the participants in this study remarked that they enjoyed and/or benefited from participating. Participation in this study may have been helpful for various reasons. Teaching others about something is one of the most effective ways to learn about it (Thompson & Rudolph, 2000). It may be that describing one's experience of grief is similar to teaching others about it. Therefore, the participants may have learned more about their grief experience through the interviewing process. One participant shared,
Coming here was a chance to reflect upon all three of them (i.e., his deceased siblings) as well as to talk to you. This has made me think about how I have dealt with it, coped with it on a different level than just intellectualize what I already knew.
This comment implies that he learned more than he "already knew" by participating in the interview. The remainder of this article includes a discussion of the five themes in relation to previous literature and implications for mental health practice.
The theme of Coping is consistent with previous literature in resembling an aspect of grieving proposed by Attig (1996) and corresponding to task-based approaches to grieving. Coping addresses the active nature of the grieving process rather than the passive view of grief as something that happens to someone (Attig; Corr, 1992). Participants mentioned numerous things that they did in order to cope with their loss. There is also evidence that the coping efforts of bereaved individuals change over time (Van Baarsen et al., 2002). Some participants in this study reported changes in their coping style over time.
Social support is an important component of the Coping theme and the literature on bereavement. Perceived social support, as opposed to actual social support, is associated with better adjustment to bereavement (Bonanno, 1999). Although support from others was an important aspect of coping in the present study, it is different from the other aspects of coping which involved task-based action on the part of participants. Participant descriptions of what was helpful regarding social support seemed to suggest that some form of companion therapy (Whiting, Planney, & Balog, 2000), which involves mutual sharing and support, would be beneficial. Participants talked about the value of having others listen sympathetically, having support from people who accept the way they want to grieve and not tell them what they should do, talking to others who have been through similar experiences, and reminiscing about the deceased with others. Participants also expressed an interest in helping other bereaved individuals. For example, they talked about trying to be strong for other bereaved individuals and about helping them deal with their grief.
In terms of coping, participants also described behaviors which were unhelpful. Many of the behaviors that participants viewed as unhelpful were similar to Leming and Dickinson's (1994) list of unhealthy grief reactions, including avoiding funerals, abusing alcohol, not accepting support from others, and rushing into major life changes. The participants' distinctions between healthy and unhealthy coping mechanisms may reflect a novel finding related to bereavement. Some coping mechanisms might be labeled as growth-oriented or proactive while others are survival-oriented or reactive. Growth-oriented mechanisms would be those that bereaved individuals describe as consistently helpful and adaptive; while survival-oriented mechanisms are those that might be helpful temporarily but maladaptive if employed long term. Examples of growth-oriented mechanisms might be therapy, physical exercise, and talking about the loss; examples of survival-oriented mechanisms would be avoidance and alcohol use. Participants noted that, while these survival-oriented mechanisms may have helped them survive or get through the worst time, they were neither helpful nor healthy in the long run. In addition, some researchers believe that talking about feelings is necessary for a healthy adjustment (Stroebe, 1992; Worden, 1982), though others have shown that talking about feelings or working through them is not necessary for a healthy adjustment (Stroebe) or is detrimental (Wortman & Silver, 1989). Similarly, participants had different opinions about whether talking about their loss or crying was helpful. However, most indicated that it was helpful for them to talk about their loss and the feelings associated with it. The results from the research were consistent with the existing literature in suggesting that while there are certain commonalities in what is helpful for bereaved individuals, there are also individual differences.
The Affect Theme is also consistent with previous literature. The most frequently reported emotional responses were similar to Kubler-Ross' (1969) stages of denial, anger, and depression; Kavanaugh's (1972) stages of shock, guilt, and relief; and Parkes' (1996) stages of numbness, pining, and despair. Although participants rarely used words such as acceptance, disorganization, and bargaining, they often described behaviors, thoughts, and feelings that were consistent with those reactions. In contrast, fewer participants reported having the cognitive responses mentioned by Parkes and the physical symptoms mentioned by Worden (1991). In addition, the present findings were not compatible with Scharlach and Fredriksen's (1993) contention that anxiety and fear, along with sadness and depression, are the most prominent responses to the death of a loved one. Fear and anxiety were not frequently reported by participants in this study. It may be that the sense of responsibility that was described by participants in this study is a manifestation of anxiety for bereaved individuals. The literature on bereavement contains little about this perceived sense of responsibility, though, in one study, middle-aged adults who lost a parent reported an increased sense of responsibility (Scharlach & Fredriksen).
Although it is apparent that the deceased's quality of life impacts the response to bereavement, the literature on bereavement seems to focus on certain quality of life variables and to neglect others. As stated earlier, participants in this study indicated that a good quality of life was one that was happy, fulfilling, and involved minimal pain and suffering. The pain and suffering aspect have been at least partially examined in studies which explore the influence of death circumstances on grief response (Drenovsky, 1994; Ginzburg et al., 2002; Stamm, 1999). For example, type of death is linked to the amount of suffering which influences the perceived quality of life, and subsequently, the emotional response. In one study, amount of suffering was linked to decreased well-being after a death (Richardson & Balaswamy, 2001). In contrast, few if any studies have examined how a bereaved individual's perception regarding the amount of fulfillment or happiness in the deceased's life affects the experience of grief.
Participants' overall descriptions of their feelings and of the general grieving process might be characterized as disequilibrium; the death of a loved one disrupted the balance in their life. Participants talked about needing to get back into their routine and how structure helped. One said, "You've got to have a sense of normalcy." One of participants' tasks was to reestablish balance or equilibrium in their lives which is consistent with Kavanaugh's (1972) final stage of reestablishment.
The Change theme is also consistent with previous literature. For example, Hogan et al. (1996) found that bereaved individuals often report being different after their loss. The changes in participants were generally constructive and pertained to personal growth, values, priorities, and behaviors. Positive changes and personal growth have been reported in other studies as well (Edmonds & Hooker, 1992; Henschen & Heil, 1992; Salahu-Din, 1996).
Regarding the Details theme, participants talked about how their loved ones died. The way an individual dies, often referred to as circumstances of loss or type of death, clearly impacts the grieving process (Levy et al., 1994; Range et al., 1992; Silverman et al., 1994); and the differential effects of gradual, expected deaths and sudden, unexpected deaths are also considered important (Leming & Dickinson, 1994). However, there is an aspect of this theme that is surprising. The research question required participants to talk about their experience of grief after the death of a loved one. Therefore, any details shared which occurred before the death might be considered unnecessary. It was expected that participants would spend some time talking about the cause of death and to provide a brief description of the death. However, eight of nine participants went into extensive detail about the time before the death and described the death and/or deterioration of their loved one. Based on this, we might surmise that the telling of their story may have been an attempt by the participants to help others understand their grief. In other words, telling someone what happened helps them to better understand one's grief response. It is also possible that for many participants, telling their story may have been simply an end in itself, in other words, that merely telling their story was helpful for them. This is consistent with Richardson and Balaswamy's (2001) contention that talking about the circumstances surrounding a loss is helpful.
The Relationship theme can also be considered a somewhat surprising result, given the research question, because one's relationship with the deceased is a pre-bereavement variable. Researchers have examined (a) how the nature of one's bond with the deceased influences the intensity of grief and one's overall reaction to a loss (Bonanno, 1999; Levy et al., 1994; Moss, Rubinstein et al., 1997) and (b) the deceased's relationship with and role in the life of the bereaved (McGoldrick, 1995; Meshot & Leitner, 1993; Moss et al., 1993; Rubin, 1992). Less attention has been given to the personality of the deceased and how that affects one's experience of loss. Nonetheless, it is considered healthy when the bereaved remembers and discusses both positive and negative aspects of the relationship (James & Friedman, 1998) and the deceased's personality (McGoldrick), as some of these participants did. In addition, some participants talked about their ongoing relationship with the deceased individual, which is considered to be healthy (Klapper et al., 1994; Moss et al., 1993). Overall, it is very meaningful that participants went into extensive detail about their relationship with deceased individuals because this information was not directly solicited. Sharing memories and stories of the deceased is a way of coming to terms with a death (McGoldrick). It is likely that talking about the deceased individual and one's relationship with him or her serves several purposes: (a) it is enjoyable; (b) it is helpful; and (c) it helps others understand one's experience.
IMPLICATIONS FOR MENTAL HEALTH COUNSELORS
Several implications for mental health counselors may be drawn from the research. Reading the first person accounts of the grieving process should help counselors become more empathetic, sensitive, and helpful to their clients as a result of their understanding of bereavement issues. Levy et al. (1994) suggested that knowing how bereaved individuals "experience their present circumstances and future prospects and make sense of them should make for a much more finely tuned approach to helping, as well as understanding" (p. 85). The fact that participants found the interview experience helpful in terms of processing the experience, gaining perspective, and sharing memories of the deceased has implications for the counseling process.
Young and Black (1997) pointed out that the needs of those bereaved by death should be a major concern for all mental health professionals. The total cost of these unmet needs from human suffering, chronic health problems, and economic losses is incalculable. As mentioned previously, grief and bereavement issues affect everyone and surface in nearly all types of counseling situations. Compounding the problem for mental health counselors and their clients is the fact that many people have not yet received a healthy preparation for coping with death and bereavement. Our research results indicate that bereavement is a critical life event that has the potential for positive as well as negative effects. The International Work Group on Death, Dying, and Bereavement (1992) concluded that unnecessary suffering, loss of dignity, alienation, and diminished quality of living result when people fail to understand and appreciate that death, dying, and bereavement are fundamental and pervasive aspects of the human experience (i.e., death is a part of life). This failure to understand and appreciate the significance of death and bereavement will likely be central to bereavement problems brought to mental health counseling.
It was quite clear from this research that coping with death and bereavement is often a very individual matter even though aspects of each theme were common to all nine participants, regardless of gender. Mental health counselors who adapt their counseling to the clients' preferred coping styles will likely be more successful than those who expect clients to adapt to the mental health counselor's preferred counseling orientation. This matching may be especially true when working with bereavement issues. As noted in the data, some participants preferred affective coping methods, while others preferred behavioral, or cognitive coping methods. Clients who have a preference for an affective coping style may prefer a person-centered orientation to counseling because it allows them to control the direction and content of the session. Mental health counselors would do well to let their affectively oriented clients assume the role of teacher while the professional becomes the student. In teaching mental health counselors, clients will learn more about their own bereavement process. The mental health counselor's role as the student is limited to taking periodic oral quizzes on what the client is teaching. These quizzes will be summaries of what the mental health counselor is learning regarding the content of the client's message, the type and strength of the feelings related to the content, and the client's expectations and goals. Whiting et al. (2000) described this type of person-centered counseling as companioning and learning from others. Companioning emphasizes walking alongside, but not leading; it is listening but not analyzing or advising. In a similar vein, Nouwen (1975) wrote that people who have given others hope and strength in times of need were not the advice givers, but were those who were able to convey their understanding of others experiences--experiences such as bereavement which are part of the human condition. In our solution-oriented world, wanting to alleviate pain without sharing it can be likened to wanting to save a child from a burning house without risk of injury. Person-centered counseling is particularly helpful to those needing to proceed at their own pace while working through expression of feelings associated with bereavement. Grieving is a process that cannot be accelerated. The person-centered nature of the phenomenological interview in concert with the non-directive nature of person-centered counseling allows clients to express their individuality regarding bereavement issues.
On the other hand, some participants acknowledged that they were only able to feel better after having made behavioral changes in their lives. Such examples included activities that helped them to make adjustments in their daily routines as they worked to restore a sense of equilibrium to their lives. A reality therapy approach to working with behaviorally oriented clients would seem to be appropriate. More cognitively oriented clients would be helped by some of the thought-restructuring techniques used in rational emotive behavior therapy and other cognitive-behavioral methods. For example, techniques such as reframing would be helpful in the acceptance and recognition of the loss, and in moving from the present pain stage to ways of preserving and finding meaning in the good memories surrounding the life of the lost loved one. Clients may find that their long-term, irreconcilable grief becomes manageable when they realize that the choice of never having had the relationship (i.e., and no grief) is a distant second to their first choice of having enjoyed the time they were able to have with their loved one. Such a restructuring of thinking would likely be helpful to clients who have reached an impasse in moving toward a healthy adjustment to their loss.
Finally, other clients may come to counseling with unfinished business related to their deceased loved one. Several of the Gestalt methods would be possibilities for helping clients obtain the closure needed to move on with their lives. For example, the client who regrets and feels guilty for never having told his father that he loved him (while the father was still living), may find help in dialoguing with his father using the empty-chair method. Letter writing, another Gestalt intervention, was mentioned as helpful by one of the participants.
Whiting (2001) distinguished between two paths that bereaved individuals typically take: toward reconciliation or toward complicated grief. Reconciliation is defined as writing the loss into one's life story by doing a variety of adaptive behaviors. Such behaviors include surviving, remembering, accepting, changing perspective, accepting reality, honoring the past, and creating the next chapters of one's life story. Failure to move toward the reconciliation phase results in complicated grief, which is grief that is prolonged, postponed, displaced, or suppressed. Clearly, the mental health counselor's role would be to assist those clients who are experiencing either simple or complicated grief in making the transition to reconciliation by helping them move from a relationship of the present to a relationship of the past, this is, a relationship replete with memories worthy of preservation.
In conclusion, limitations of the study and implications for future research should be considered. Phenomenological research is designed to study how individuals experience certain events in their lives. These experiences do not necessarily generalize beyond the participants' involved in the study. The goal of our research was to identify the structure of the participants' experience of grief. Future research on the topic of grief and bereavement could be directed toward comparing differences in the grieving experience between cultural groups, age groups, and those who experience complicated grief and those who experience reconciliation.
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Elizabeth D. Muller, Ph.D., is staff psychologist at Baylor University, Waco, TX. E-mail: firstname.lastname@example.org. Charles L. Thompson, Ph.D., is a professor in the Educational Psychology and Counseling Department, The University of Tennessee, Knoxville. E-mail: email@example.com
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|Author:||Thompson, Charles L.|
|Publication:||Journal of Mental Health Counseling|
|Date:||Jul 1, 2003|
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