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.

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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.

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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.

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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.

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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.

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Osterweis, M., Solomon, F., & Green, M. (Eds.). (1984). Bereavement: Reactions, conseguences, and care. Washington, DC: National Academy Press.

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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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80

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

81

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)

82

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

83

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