Group Title: differential impact of death on family stress levels as determined by stage of the family life cycle /
Title: The Differential impact of death on family stress levels as determined by stage of the family life cycle /
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Title: The Differential impact of death on family stress levels as determined by stage of the family life cycle /
Physical Description: xiii, 218 leaves : ill. ; 29 cm.
Language: English
Creator: Harvey, Elizabeth Anne, 1947-
Publication Date: 1994
Copyright Date: 1994
 Subjects
Subject: Bereavement -- Psychological aspects   ( lcsh )
Death -- Psychological aspects   ( lcsh )
Family   ( lcsh )
Counselor Education thesis Ph.D
Dissertations, Academic -- Counselor Education -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis (Ph. D.)--University of Florida, 1994.
Bibliography: Includes bibliographical references (leaves 202-216).
General Note: Typescript.
General Note: Vita.
Statement of Responsibility: by Elizabeth Anne Harvey.
 Record Information
Bibliographic ID: UF00099557
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 002012616
oclc - 32522326
notis - AKJ9954

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THE DIFFERENTIAL IMPACT OF DEATH ON FAMILY STRESS LEVELS
AS DETERMINED BY STAGE OF THE FAMILY LIFE CYCLE















By

ELIZABETH ANNE HARVEY















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA













This dissertation is lovingly dedicated
to members of my family:



To Sharon,
beautiful sister,
still missed


To Mom,
who gave me life
and so much more--
love for music and word games
and learning


To Rothi,
who was like a sister to me
and such a wonderful role model


To Rock and Todd,
dear nephews,
whose lives were cut tragically short


To Grandpa,
who gave us permission to eat dessert first


and to my dad and brothers,
whose losses far exceed my own








Copyright 1994

by

Elizabeth Anne Harvey













ACKNOWLEDGMENTS

I would like to extend my deepest thanks to those family members, friends, and

colleagues who have given me support and encouragement throughout the process of

designing, implementing, and writing this dissertation. I am so grateful to have had the

opportunity to be mentored by Dr. Peter A. D. Sherrard from the beginning of my graduate

program. He has served as advisor, teacher, supervisor, and chair of my committee. His

patience, encouragement, and feedback have been invaluable. And to Dr. David Miller,

whose door was always open and whose words of wisdom were so concise, I will be

forever grateful for all the times he trusted my knowledge more than I did. Dr. Ellen

Amatea has been a tremendous source of encouragement throughout the doctoral program,

pointing me towards valuable resources, offering insight and prompt feedback when

needed. And to Dr. Jaber Gubrium, a most congenial member of my committee, I am

thankful for the vote of confidence.

Words cannot begin to express my gratitude to Anne Seraphine, astute statistician,

without whom I cannot even imagine completing this project. I am also grateful to fellow

doctoral students Carol Jordan and Valerie Thomas; their friendship has meant so much.

Our monthly get-togethers for feedback and support have been immensely helpful to me.

To my weekly reunion group who has cheered and prayed me through many passages the

last 3 years, my warmest thanks for keeping me accountable in all that I do.

To the Hospice of North Central Florida, I am so thankful to have the opportunity

to do the work I do. I am also very grateful for the staff support from Ray Dean and

Valerie Bowie while I was engaged in collecting data requiring their time and skills, which

they so patiently and promptly provided, and to the 84 families who agreed to participate in

iii








this study. I feel very privileged to have met each one. Without them, this study would

not have been possible. My deepest appreciation goes out to them for opening their hearts

and homes to me. I learned more from these families than I could ever express in words.

Last, but certainly not the least, I am blessed to have had the love and support of

my husband, John, throughout this whole graduate school experience. We have given new

meaning to the word "flexible," especially during the last 9 months as I entered the data

collection phase and began writing the results. He has been a sounding board for

theoretical wonderings and research design and protocol, pushing and prodding when I just

wanted to give up and, in addition, has become a wonderful cook. I am especially thankful

to him for the many hours he spent at his computer providing all the graphics included in

this dissertation.













TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS............................................. ..................... iii

LIST OF TABLES.............................................................................viii

LIST OF FIGURES ........................................ .... ....................... x

KEY TO ABBREVIATIONS.................................................................. xi

ABSTRA CT ........................... ............................................ xii

CHAPTERS

1 INTRODUCTION ...................................................... 1

Scope of the Problem .. ..................................... .................... 2
Theoretical Framework ................ .... ........................ 3
Need for the Study .......................................................... ........... 8
Purpose..................................................................................... 12
Variables to be Measured.............................................................. 13
Research Questions .............................................. .................. 14
Definition of Terms .................................................................. 15
Organization of the Study ........................................... .............. 18

2 REVIEW OF THE LITERATURE ................................................... 19

Introduction .......................................................................... 19
Sociocultural Influence .................................................................. 20
Frequency of Death ........................................ .............. 22
Ramifications for Family Therapy ........................................... 23
From Individual to Family Impact......................................... .......... 23
Individual Perspective ........................................ ............ .. 23
Family Perspective............................................................ 25
Empirical Research.............................. .............................. 26
Death as a Stressor Event........................................................ 30
Individual Perspective ....................................... ............ .. 30
Family Perspective............................................................ 30
The Effect of Stress on the Family ................................ .................. 32
Demands for Change..................................... ................. 32
Demand Overload ............................................................ 32
Reestablishing Balance ................. .............. ..................... 33







Impact of Death on the Family......................................................... 34
Symptoms Produced........................................................... 35
Adaptational Factors .......................................................... .. 44
Family Systems, Stress, and the Family Life Cycle ................................ 47
Family Systems................................................................ 47
Family Life Cycle .............................. ...................... .. 48
Family Stress ..................................................... ........... 50
Family Stress and the Life Cycle............................................ 51
Family Life Spiral Model .............................. ..................... 54
Predictions .................................................... ....................... 63
Other Variables Impacting Death that May be Expected to Vary by
Life Cycle Phase................................. ............... .................... 64
Social Support ................................................... ........... 65
Cohesion and Adaptability ............................ ...................... 69
Communication.................... .......................... 73
Conclusion .......................... ........ ..... ....................... 78

3 METHODOLOGY ........................................................ 80

Statem ent of Purpose ........................................................ 80
H ypotheses......................... .. ................... ... .. .. ........... 81
Delineation of Relevant Variables ................................ ................... 82
Dependent Variable.......................... ..................... 82
Independent Variables ............................. ..................... .. 82
Data Analysis ............................ .. .... ........ ............... ..... 84
Description of the Population ........................... ...................... 84
Sampling Procedures .......................................................... 86
Subjects............................. ............................. 90
Data Collection.................................................... 92
Instrumentation ....................................................... .................... 93
Family Inventory of Life Events and Changes (FILE)...................... 93
Stage of the Family Life Cycle ................................................. 96
Family Environment Scale (FES) ............................................ 96
Family Index of Regenerativity and Adaptation--General (FIRA-G) ..... 98
Family Adaptability and Cohesion Evaluation Scale (FACES-I) ......... 99

4 DATA ANALYSIS AND RESULTS.................... ......................... 102

Analysis Procedures ...................................................................102
Analysis Results ................................................... .. 105
Hypotheses Testing ................................................................. 124
Chapter Summary .......................................... ........... .... 128

5 DISCUSSION...................... .. .................. ............ 129

Overview of the Study ................................ ........ .......... 129
Research Sam ple ....................................................................... 130
Relationship Between Quadrants in the Model and Family Stress............... 133
Relationship Between Quadrants and Expressive Communication .............. 145
Relationship Between Quadrants and Cohesion................................. 147
Relationship Between Quadrants and Adaptability ............................... 149







Relationship Between Quadrants and Social Support............................... 153
Summ ary of Quadrant Effects ........................................................ 153
Relationship Between Communication and Stress ............................... 154
Relationship Between Cohesion and Stress ...................................... 154
Relationship Between Adaptability and Stress.................. .................. 155
Relationship Between Family Subtypes and Amount of Stress .................. 157
Relationship Between Social Support and Stress .................................. 164
Summary of Predictor Variables for Stress .................. ................... 165
Relationship Between Cohesion and Communication ........................... 166
Relationship Between Adaptability and Communication ........................... 166
Family Life Spiral M odel................... ..... .............. ........ ................ 167
Recommendations............................... ......... 170
Implications for Therapy ................. ................... 170
Lim stations of the Study ..................................................... 171
Suggestions for Further Study .............................................. 173
Chapter Summ ary ................................................ .............. .. 175

APPENDICES

A LETTER TO FAMILIES .................................. ........ ................. 176

B FAMILY MEMBER SELECTION PROTOCOL ......... ......................... 177

C STAGE OF THE FAMILY LIFE CYCLE....................................... 178

D FAMILY INVENTORY OF LIFE EVENTS AND CHANGES (FILE) ......... 182

E FAMILY ENVIRONMENT SCALE (FES) ....................................... 185

F FAMILY INDEX OF REGENERATIVITY AND ADAPTATION--
GEN ERA L (FIRA-G).................................................... 187

G FAMILY ADAPTABILITY AND COHESION EVALUATION SCALES
(FACES-II) ......... .. ........ ... .................. 190

H DEMOGRAPHIC QUESTIONNAIRE.............................. ....... 194

I LINEAR SCORING AND INTERPRETATION FOR FACES-II ............... 196

J LETTER OF INSTRUCTION TO FAMILIES PARTICIPATING BY MAIL 197

K COMPOSITION OF PARTICIPANT FAMILIES ............................... 199

REFERENCES............................................... 202

BIOGRAPHICAL SKETCH.............................................. ................. 217













LIST OF TABLES


Table Page

1 Comparative Norms for Family Pile-up Over the Family Life Cycle ............... 52

2 Table of Analyses ....................................................................... 85

3 Comparative Breakdown by Ethnicity for Population Subsamples ................ 88

4 Representation of Sample Across Family Life Cycle ................................ 91

5 Breakdown by County for Patient Census and Research Sample................. 92

6 Regression Model Testing Quadrant. Cohesion. Adaptability, Communication,
Social Support, and Relative and Friend Support with Family Composite
Score for Stress as Outcome Variable ......................... .................. 106

7 Means, Discrepancies, and Standard Deviations for Instruments ............... 107

8 Regression Model Testing Quadrant and Discrepancy Scores on
Communication, Social Support, Relative and Friend Support, Cohesion,
and Adaptability with Stress Discrepancy Scores as Outcome Variable ....... 108

9 Regression Model Testing Quadrant and Discrepancy Scores on Cohesion,
Adaptability, Communication, Social Support, and Relative and Friend
Support with Family Composite Score for Stress as Outcome Variable....... 110

10 Regression Coefficients and t-values for Interaction Model for Quadrant and
Discrepancy Scores on Cohesion, Adaptability, Communication, Social
Support, and Relative and Friend Support with Family Composite Score for
Stress as Outcome Variable ........................................................ II

11 ANOVA for Relationship Between Family Subtypes and Stress ............... 114

12 ANOVAS for Types of Stressors by Quadrant ................................... 115

13 ANOVA for Individual Stress Scores by Individual's Stage in the Family Life
C ycle.......................... .............. ............................... ....... 117

14 Individual Stress Scores by Individual Stage of the Family Life Cycle........... 118

15 Regression Model Testing Quadrant, Cohesion, and Adaptability with
Communication as Outcome Variable ............................................ 120







16 Regression Model Testing Quadrant and Discrepancy Scores on Cohesion
and Adaptability with Communication Discrepancy Scores as Outcome
Variable ........................................... 122

17 ANOVAS for Social Support, Relative and Friend Support, Cohesion,
and Adaptability by Quadrant.................................................... 123

18 Results of Hypotheses Testing ..................................................... 125

19 Top Stressors for Families ................... .... ..................... ................ 136

20 Top Ten Stressors by Quadrants ................ ........... ........... 138

21 Family Subtypes by Quadrant .................................... ................... 158

22 Family Types by Quadrant.................................... ..................... 163













LIST OF FIGURES


Figure Page

1 Fam ily Life Spiral M odel........................ .. .........................................

2 Quadrants of the Family Life Spiral Model.......................................9

3 Cohesion in Normal Families Across the Life Cycle ............................... 71

4 Operationalized Model .................... ................... ................. 87

5 Operationalized Model with Results of Hypotheses Testing...................... 104

6 Interaction Between Family Stress Scores and Communication Discrepancy
Scores by Quadrant .......................... .................. 113

7 Stress Mean Weighted Sums by Individual Stage on Family Life Spiral
M odel ................... .... ....... ........... .... .............. 119

8 Family Stress by Quadrant.......................... ................................. 134

9 Cohesion Mean Scores by Quadrant .......................................... 148

10 Cohesion Mean Discrepancy Scores by Quadrant................................. 150

11 Adaptability Mean Scores by Quadrant............................. ................. 151

12 Adaptability Mean Discrepancy Scores by Quadrant ............................. 152

13 Cohesion and Stress Mean Discrepancy Scores by Quadrant ................... 156

14 Family Subtypes for Total Sample ............................................. 159

15 Stress Mean Scores for Family Subtypes ........................................ 160

16 Family Subtypes by Quadrant ....................... ...................... 162













KEY TO ABBREVIATIONS


CF Centrifugal--outward focus and orientation

CP Centripetal--inward focus and orientation

FACES-II Family Adaptability and Cohesion Evaluation Scales

FES Family Environment Scale

FILE Family Inventory of Life Events and Changes

FIRA-G Family Index of Regenerativity and Adaptation--General













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE DIFFERENTIAL IMPACT OF DEATH ON FAMILY STRESS LEVELS
AS DETERMINED BY STAGE OF THE FAMILY LIFE CYCLE

By
Elizabeth Anne Harvey

April, 1994

Chairperson: Peter A. D. Sherrard
Major Department: Counselor Education

The purpose of this study was to determine if there are points in the family life cycle

when the death of a member creates more stress than usual. The stages of the family life

cycle covering three generations were differentiated into four quadrants depicting

interrelated developmental phases within the Family Life Spiral Model: centripetal (CP),

including birth, childbearing, and grandparenthood: centripetal--centrifugal (CP--CF),

including middle years of childhood, settling down, and planning for retirement:

centrifugal (CF), encompassing adolescence, 40s reevaluation, and retirement: and

centrifugal-centripetal (CF--CP), incorporating marriage/courtship, middle adulthood,

and late adulthood. Eighty-four Hospice families were assessed 1 year after the death of

their loved one to determine the stress they had experienced in the past year. Levels of

cohesion, adaptability, expressive communication, and social support were also measured.

There were no differences between quadrants on stress levels, communication, and

social support. Differences were found between quadrants (p<.05) on levels of cohesion

and adaptability, with CP families the highest and CF families the lowest. Analyses by








stage of the family life cycle determined that the settling down stage evidenced significantly

greater stress.

Cohesion was a significant predictor of stress with low cohesion accompanied by

high stress. An indirect relationship between quadrants and stress was found when

cohesion was controlled. There were differences between family subtypes with Very

Connected-Very Flexible families having the least stress. As levels of cohesion and

adaptability decreased, stress increased. Differences by quadrant were found for

discrepancy scores on cohesion and adaptability, with CF families more discrepant than CP

families. A positive relationship was found between cohesion discrepancy scores and

stress discrepancy scores. As communication discrepancy increased for CP-CF families.

so did their stress; the reverse was true for CF families--as communication discrepancy

increased, stress levels decreased. Social support and adaptability were not found to be

predictors of stress. Increased adaptability predicted increased communication.

Although stress measures by quadrant were not significant, there were differences

on other measures that tended to confirm the theory behind the Family Life Spiral Model.

Differences by stage of the life cycle were found, and further studies are in order.














CHAPTER 1
INTRODUCTION


The father came back from the funeral rites.
His boy of seven stood at the window, with eyes wide open and a
golden amulet hanging from his neck, full of thoughts too difficult for his
age.
His father took him in his arms and the boy asked him, "Where is
mother?"
"In heaven." answered his father, pointing to the sky.

The boy raised his eyes to the sky and long gazed in silence. His
bewildered mind sent abroad into the night the question, "Where is
heaven?"
No answer came: and the stars seemed like the burning tears of that
ignorant darkness.
--Tagore, from The Fugitive


"The fear of death is our deepest terror and the loss of a loved one our most

profound sorrow" (Walsh & McGoldrick, 1991, p. xix). Of all life experiences, death

presents the most painful adaptational challenges for every surviving member (Holmes &

Rahe, 1967) and for the family as a system, with "reverberations for all other relationships"

(Walsh & McGoldrick, 1991, p. xv). Many families, of course, have the necessary

adaptational skills to weave the loss of a family member into the tapestry of their lives and

have no need of intervention from mental health professionals. Others, however, do not

adapt as well to the stress of loss for a variety of reasons; often their loss exacerbates the

multitude of problems they already face. This study addresses the impact of death on

families in terms of their levels of stress depending upon where they are in the family life

cycle.









Scope of the Problem

A body of literature exists promoting theoretical premises about the impact of death

on individuals (Freud, 1917; Lindemann, 1944; Osterweis. Solomon, & Green, 1984;

Rando, 1988; Schumacher, 1984; Volkan, 1970: Wortman & Silver, 1989). Extensive

research has been undertaken to test those individually oriented theoretical premises

(Bowlby, 1961, 1980: Eisenstadt, 1978: Elizur & Kaffman. 1983; Fleming & Adolph,

1986: Kranzler, Shaffer, Wasserman, & Davies, 1990: Parkes, 1964, 1970a, 1970b,

1975; Parkes & Weiss, 1983; Volkan, 1974).

Some individual theorists began to see the individual's reaction to death within the

context of their family and acknowledged the importance of assessing both individual and

family (Rando, 1984; Sanders, 1989). Given the lack of systemic assessment devices,

however, families were initially assessed by measuring the individual family members'

reactions to the death (Bass, Noelker, Townsend, & Deimling, 1990; Helmrath & Steinitz,

1978; Huygen. van den Hoogen, van Eijk, & Smits, 1989; Lewis, Beavers, Gossett, &

Phillips, 1976; Schwab, 1990; Tietz, McSherry, & Britt, 1977; Wahl, 1970).

Although numerous family theorists and therapists have postulated hypotheses

based on clinical observations of families (Aleksandrowicz. 1978; Arnold & Gemma.

1983; Bolton, 1984; Bowen, 1976; Brown, 1988: Coleman. 1980; Coleman & Stanton,

1978; Crosby & Jose, 1983; Gelcer, 1983; Goldberg, 1973: Haley, 1973, 1980;

Hare-Mustin, 1979; Herz, 1980; Howe & Robinson, 1975: Imber-Black, Roberts, &

Whiting, 1988: Lamberti & Detmer, 1993; McGoldrick & Walsh, 1983; Moody & Moody,

1991; Paul. 1967; Paul & Grosser, 1965; Raphael, 1983; Reilly, 1978; Rolland, 1988a;

Rosen, 1988-1989, 1989, 1990a, 1990b; Simos, 1986; Solomon & Hersch, 1979;

Stanton. 1978, 1980; Vollman, Ganzert, Picher, & Williams, 1971; Walsh & McGoldrick,

1987, 1991), very little research has been carried out on the impact of death on the family

as a unit (Bass & Bowman, 1990; Cohen, Dizenhuz, & Winget, 1977; Coleman, Kaplan,









& Downing, 1986; DeFrain, 1991; Hadley, Jacob, Miliones, Caplan, & Spitz, 1974;

Jordan, 1991-1992; Ponzetti, 1992; Reiss, Gonzalez, & Kramer, 1986; Shanfield,

Benjamin, & Swain, 1984; Sprang, McNeil, & Wright, 1992-93; Vess, Moreland, &

Schwebel, 1985-1986; Walsh, 1978; Weber & Fournier, 1985).

The summary results of the above research efforts studying the impact of death on

families indicate that a family's inability to mourn its losses is often at the heart of clinical

complaints, even when death is not the presenting problem (Walsh & McGoldrick, 1991).

"Symptoms reflect a family's difficulty in adapting to loss and moving on, whether the

problem is addiction, disturbed behavior of a child or adolescent, anxiety, phobias or

compulsions, marital conflicts, depression, or the inability of family members to leave

home or commit themselves in relationships" (Walsh & McGoldrick. 1991, p. 51).

As family assessment tools have become more widely formulated and tested, their

ability to be used as valid research instruments has increased to the point that the

interactions and interrelationships of family members can now be assessed with reasonable

objectivity. This allows a more accurate depiction of the family as a dynamic system,

enabling the therapist to work more effectively with the family as a unit.

Theoretical Framework

At the heart of family systems assessment is the identification of the developmental

stage of the family in the family life cycle, originally seen as a linear model. The family life

cycle is composed of stages from birth through adolescence, launching and coupling,

childbearing and rearing, middle age and "empty nest," to retirement and old age (Carter &

McGoldrick, 1988; Duvall & Miller, 1985).

The developmental tasks that are normative for families at various stages of the life

cycle offer the context for ongoing assessment and diagnosis of family problems.

Symptoms and stressors, both present and past, are viewed in light of the family's

developmental stage (Carter & McGoldrick, 1988; McCubbin & Thompson, 1991; Olson,









1988; Olson, McCubbin, Barnes, Larsen, Muxen, & Wilson, 1983). Each stage of the

family life cycle has tasks and stressors that are specific to that stage and normative at that

point in time. Stressors that occur off-time, that is, at an unexpected point in the life cycle,

or a pile-up of stressors within a short period of time have been postulated to tax families'

adaptive capabilities severely (McCubbin & Thompson, 1991).

McCubbin and Patterson (1983) have extended Hill's ABCX family crisis model

(1958) to include this pileup of life events experienced by the family and have developed an

instrument, the Family Inventory of Life Events and Changes (FILE), to document

quantitatively life events and changes in the family system as well as for individual

members (McCubbin & Thompson, 1991). This instrument can be useful in predicting the

family's vulnerability as a result of the pileup of stressors. A family's ability to adapt to a

crisis and achieve a new level of balance depends on the reciprocity of the family's

functioning. When the demands of the family unit are not satisfactorily met by the family's

capabilities, negative consequences will present through evidence of deterioration or

breakdown in the family unit, relationships within the family unit, and/or the psychological

and physical health of family members (McCubbin & Thompson, 1991).

t Clinicians and researchers alike have theorized and documented that certain stages

of the family life cycle are associated with higher levels of stress than others under

normative conditions (Carter & McGoldrick, 1988; Olson et al., 1983). For example,

families with young preschool children and school-age children experience a higher degree

of stress than "empty nest" families, but the most stressful stages of the family life cycle

appear to be adolescence and the launching stages (Olson et al., 1983).

Combrinck-Graham (1983, 1985) has taken the linear family life cycle model and

transformed it into a continuous spiral to show the impact of the interlocking of the

generations on developmental tasks. This spiral represents three generations of family

evolution with families oscillating between periods when they are centripetal (CP) or









centrifugal (CF) depending on the focal tasks required of them at those stages of the family

life cycle. Figure 1 illustrates the configuration of Combrinck-Graham's Family Life Spiral

Model.

Typically, an individual will experience three oscillations in a lifetime, spanning six

developmental stages of the family life cycle: one's own childhood (CP) and adolescence

(CF), the birth (CP) and adolescence (CF) of one's children, and the birth (CP) and

development (CF) of one's grandchildren. Each oscillation is approximately 25 years in

length, producing a new generation with each full oscillation. These oscillations appear to

provide opportunities within the family context for family members to work and rework

issues of intimacy in the CP stages and self-actualization in the CF stages.

The CP stages are those with an inner orientation requiring intense bonding and

cohesion (early childhood, child rearing, grandparenting). During CP periods the

individual and the family's life structure emphasize the internal dynamics of family life.

External boundaries are tightened while internal boundaries may be more diffuse to enhance

communication and teamwork. The CF stages are those with an outer orientation

addressing the challenges and opportunities in the environment. Developmental tasks that

emphasize personal identity and autonomy (adolescence, midlife, retirement) are

emphasized. The external family boundary is loosened, and distance among family

members increases as they attend to extrafamilial concerns.

Neither CP nor CF defines a pathological condition but only describes the

relationship focus and style of the family at particular stages of the family life cycle.

Symptom formation, however, often occurs when the situation in the family is out of phase

with the focal developmental tasks of the family members, such as the death of a child

interrupting the child-rearing phase of the family life cycle.

Losing an immediate family member is a painful event at any time in the life cycle

(Combrinck-Graham, 1983). When Combrinck-Graham developed the Family Life Spiral
















Grandparenthood
Childbearing
Childbirth

Late Middle Marriage Middle Years Settling Plan for
Adulthood Adulthood Courtship of Childhood Down Retirement


SAdolescence / /


Figure 1. Family Life Spiral Model


Source: A developmental model for family systems. Family Process, 24, 139-150.
L. Combrinck-Graham, 1985.









Model in 1983, she hypothesized that because death is experienced as a departure, its

occurrence may be more upsetting for a family that is not CF; the family might respond to a

member's death by tightening their external boundaries even more. She also speculated

that if the predominance of force is CP at a time in the family life cycle when the family

should be coming apart, the family is likely to experience nonnormative stress.

Additionally, she hypothesized that healthy families are those who are able to adjust their

structure to meet the ever-changing needs of their members throughout the oscillations over

the life cycle.

Rolland (1988a) observed that both chronic illness and death exert a CP pull on the

family system. This pull increases as the level of incapacitation or risk of death increases.

Progressive diseases over time are more CP in terms of their effect on families than

constant course illnesses. The addition of new demands as an illness progresses keeps a

family's energy focused inward; a constant course disease, on the other hand, allows a

family to enter or resume a more age- or stage-appropriate phase of the life cycle. Family

members facing chronic illness and death must work together to manage the situation,

frequency of contact among members is increased, time for activities and contacts outside

the family is minimized, and when death occurs, family members congregate to

memorialize the life of the deceased person. In contrast to Combrinck-Graham's original

hypothesis, Rolland hypothesized that if the death coincides with a CF period in the family,

the impact would be more severe at that time, affecting the developmental tasks of all the

family members. Young adults may be forced to shelve their differentiation from the

family in lieu of needing to fill roles vacated by the deceased and, therefore, have their

launching delayed. Midlife adults may be forced to delay or pass up new career

opportunities. If death occurs at a CP period, although less severe in its impact according

to Rolland, the effects may be to prolong temporarily this phase or cause families to

become stuck at this point of development.









Rosen (1990a, 1990b) noted that both CP and CF forces are at work at every stage

of the family life cycle, although one tends to dominate. Crises have a powerful CP force

at any stage, pulling the family together to manage the crisis. Sometimes that CP pull does

not produce healthy results in the family, causing the family to close and rigidify both its

internal and external boundaries, making it difficult for the family to receive help from the

outside and for family members to help each other. Combrinck-Graham, Rolland, and

Rosen all hypothesize that the CP force of death at a CP stage may have "additive effects,"

resulting in arrested development or symptomatic regression as it impedes the family's

progress through the necessary stages of its life cycle. When the CP pull occurs at CF

stages, it may interfere with the natural momentum of the family's development and the

achievement of necessary individuation tasks of those stages (Rosen, 1990a, 1990b).

The Family Life Spiral Model has the potential of being a helpful diagnostic tool if

the theory behind its conception can be tested. There is clinical documentation that both CP

and CF forces are normative over the course of the family life spiral, but there has been no

empirical testing of the model in terms of how death affects families at the various phases,

which this study proposes to do. For purposes of this study, the Family Life Spiral Model

will be divided into four quadrants as delineated in Figure 2: the CP quadrant,

encompassing birth, childbirth, and grandparenthood; the CP->CF quadrant,

encompassing childhood, settling down, and planning for retirement; the CF quadrant,

encompassing adolescence, 40s reevaluation, and retirement; and the CF-4CP quadrant,

encompassing marriage/courtship, middle adulthood, and late adulthood.

Need for the Study

The impact of loss at various stages in the family life cycle, and on the family as a

functional unit, needs to be studied so that higher risk stages, if any, can be identified.

Then different interventions that were appropriate to each stage of family development

could be developed and tested. Targeting bereavement services for families that are


















CP


S Grandparenthood
Childbearing
( Childbirth -

iddle Marriage~ / Middle Years Settling Plan for
lthood Courtship \ of Childhood Down Retirement


X' Adolescence 1


s Reevaluation


Retiremen
Retirement ^-"


40
/
/
/ 40'
a' Ni
a''*s
a'^ ^~


CF


Figure 2. Quadrants of the Family Life Spiral Model


LJ.
0


Late M
Adulthood Adu
\


0
-'
t
0
-n









predisposed to more serious consequences may prevent a deleterious effect on the family

unit when a loved one dies. Early or predeath interventions may be more beneficial and

effective than postdeath bereavement interventions, partially because the dying person may

be a key figure in the resolution of difficulties (Bass & Bowman, 1990).

Systemic impact of loss has been virtually unexplored with experimental research,

and family therapy must move beyond clinical impressions if therapeutic potential is to be

maximized. Loss has implications for how the family adapts to later experiences, and even

for family members not directly related to the member who has died. "Patterns set in

motion around the death of a family member have both immediate impact and long-term

ramifications in family development over the course of the life cycle and across many

generations" (Walsh & McGoldrick, 1991, p. xviii). The events surrounding a family

death have the potential for producing growth and development as well as for setting the

stage for immediate distress or long-term dysfunction. Families influence how the death is

experienced and the legacies that are passed on. "By attending to family processes,

clinicians can promote healthy adaptation to loss and strengthen the family unit to meet

other life challenges" (Walsh & McGoldrick, 1991, p. xviii).

Quantitative studies in the area of death reactions in families are scarce. Thinking

that notes the systemic effects of events that occur within families is relatively recent and

has not yet generated the variety of assessment tools needed for family research. Although

theory abounds about the ramifications of death on the family unit, research beyond the

formulation and testing of clinical hypotheses with individual families presenting for

therapy has been virtually nonexistent. Possibly this area of research has been thwarted by

the plethora of variables that have been hypothesized to affect the impact of death on

families and the difficulty of controlling for them in order to isolate the effects of one

particular variable.









Rosen (personal communication, November, 1991) has suggested that a true

experimental design testing the differences in intervention strategies for CP or CF families

would be appropriate. However, the first step is to test the predictive validity of the

theoretical model by seeing if there are differences among family responses that reflect the

stage of the family life cycle in which the death occurs. This study takes this first step.

Although a key issue related to this theoretical model is the notion that death has a

CP pull on families, that question was not addressed directly in this study; answering that

question would require a longitudinal prospective study that would assess the family prior

to the diagnosis of the fatal illness, since chronic illnesses themselves are believed to have a

CP pull. In addition, the family would need to be observed over a period of time postdeath

to measure the impact of death on their subsequent development. Obtaining such a sample

is, of course, logistically difficult and impractical.

Another drawback to family assessment and family research is capturing the

family's perception as opposed to individuals' perceptions of their families. Family

members often do not agree with each other in describing their family system (Olson,

1989); therefore, it is important to assess multiple family members in order to construct a

more realistic picture of the family system out of the areas of agreement or disagreement

among them (Keeney, 1983). It is also important, both conceptually and methodologically,

to find ways to combine various family members' perspectives without losing too much of

the individual perspective (Larsen & Olson, 1990). Mean scores are appropriate for some

families but have the effect of modifying extreme differences in others; standard deviations

are a better measure in those latter instances. Composite scores are appropriate for some

instruments (McCubbin & Thompson, 1991). For others, family discrepancy scores or

incongruency scores indicate the relative levels of agreement among family members as to

their perceptions of the dynamics in their family (Olson et al., 1983). Whereas mean

scores conceal individual differences, discrepancy scores highlight the differences. In









some instances, discrepancy scores can be complementary to mean scores, providing a

fuller picture of the family as a whole. However, even the best methodology may leave

critical gaps in representing the "true" family dynamics; for example, only those family

members who agree to participate and only those who are old enough or not too old, able to

read, and are not handicapped in some physical or emotional way will be represented when

objective self-report assessments are the tools of choice (Larsen & Olson, 1990).

Purpose

The purpose of this study was to test several of the predictions generated by the

theory behind the Family Life Spiral Model in terms of how the crisis event of death

impacts families at different points in the family life cycle. When there is a death in the

family, is there a differential impact reflecting the phase of the life spiral? The importance

of this study rests in its ability (a) to differentiate phases (i.e., quadrants) of the Family Life

Spiral Model, (b) to determine if phase of the life spiral is indeed a significant variable

influencing the perceived impact of death on family members, and (c) to discern which

phase of the life spiral may be at higher risk for symptomatic reactions to the stressor of

death.

This author believes that there are now family assessment tools that allow the

measurement of the impact of death on families and the identification of the most significant

of the variables and that there are statistical programs now available that can control for

variation influenced by other independent variables so that the variance attributable to stage

of the life spiral can be isolated. The tools used to do the assessments in this study were

self-report instruments of a retrospective nature. Although there are drawbacks to both

retrospective and self-report assessments, such as the accuracy of an individual's memory

and perception and the influence of social desirability, the advantages outweigh the

disadvantages in this study because it was the composite of the family members'









perceptions of the changes that had occurred in their family over the course of a year that

was considered essential.

The population was drawn from family members of patients served by the Hospice

of North Central Florida, an area encompassing 11 counties. The variable, nature of death,

was controlled for, inasmuch as admission to Hospice requires a diagnosis of a terminal

illness and a prognosis of 6 months or less to live; thus, death was expected and was not a

sudden event that occurred without warning. Because the ramifications for the family were

likely to occur over a period of time after the death (Hadley et al., 1974), assessments were

made at 1 year postdeath and were a composite of the family's reflections of events that

occurred in their family since the death of their loved one.

Variables to be Measured

In addition to stage of the life spiral as the primary independent variable, several

other variables that also influence the impact of death on families were measured.

Differences were expected between phases of the family life spiral on these variables: the

adaptability and cohesion of the family, the family's degree of expressive communication.

and the degree of social support the family utilized when adapting to the stressor of death.

Adaptability and cohesion were measured by the Family Adaptability and Cohesion

Evaluation Scales (FACES-I); expressive communication was measured by the Family

Environment Scale (FES), Expressiveness subscale; social support was measured by two

subscales from the Family Index of Regenerativity and Adaptation-General (FIRA-G), the

Social Support subscale and the Relative and Friend Support subscale.

The instrument used to measure the dependent variable, FILE. was designed strictly

as a retrospective self-report assessment tool. Many of the items pertain to the objective

assessment of behaviors and events in the family's life over the year past; others refer to

changes requiring a subjective judgment as to their occurrence (McCubbin & Thompson,

1991). Each family member fills out a FILE, and a composite is made for all of the family









members who are assessed. The differences in members' perceptions of their family

situation are also measured and represented by family discrepancy scores. The other

instruments used in this study were also self-report tools assessing family members'

perceptions of ongoing styles of interaction within their families. They, too, were designed

to be filled out by each member and a composite made for all members. It is believed that

this multiple perspective on the family, a form of "double description" (Bateson, 1979),

produces a more accurate representation of the family as a system than one individual's

perception of their family.

Research Questions

Little empirical research has been carried out on the impact of death on families, and

none has been done with phase of the life spiral as the independent variable. Since the

family life spiral is a primary lens through which families are assessed and theoreticians

believe this to be a significant variable determining how death impacts families, testing the

significance of this appears to be an appropriate target for a research study. Because there

are other variables believed to be of importance in assessing a family's vulnerability to

adjusting to a loss and because those variables are expected to vary by phase of the life

spiral, those variables were also measured. The goal of this study was to expand the body

of knowledge used to explain the impact of death on families and to determine which

phases of the family life spiral may be at the greatest risk for experiencing undesirable

outcomes. To this end, the following research questions were posed:

1. Is there a difference in impact, both in degree of stress and type of stress,

reported by family members at different phases of the family life spiral when there is a

death in the family?

2. How do the levels of disagreement among family members at CF phases

compare with other phases of the family life spiral?









3. Do family members at different life spiral phases differ in terms of reported

levels of expressive communication, social support, family cohesion, and family

adaptability?

Definition of Terms

For the purpose of this study, key constructs and terms are defined as follows:

Adaptability. Family adaptability is defined as the extent to which the family

system is flexible and able to change its power structure, role relationships, and

relationship rules in response to situational and developmental stress (Olson et al., 1985).

For the purposes of this study, adaptability was determined by the adaptability score from

FACES-II.

Centrifugal. The term centrifugal, originating in the field of physics, implies a

moving away from the center. Applied to families in a metaphorical sense, CF phases of

the Family Life Spiral are those with an outer orientation and developmental tasks that

emphasize personal identity and autonomy. Stages of the family life cycle when these tasks

predominate are adolescence, midlife, and retirement. The external family boundary is

loosened, and distance between family members increases as family members begin to

expect gratification from, and put their trust in, activities and relationships outside the

family unit (Beavers, 1982).

Centripetal. Also originating out of physics, the term centripetal implies a moving

towards the center. The CP phases are those with an inner orientation requiring intense

bonding and cohesion, such as early childhood, child rearing, and grandparenting.

According to Beavers (1982), CP families look predominantly within the family for

gratification and tend to be more trusting of family members than outsiders. During CP

periods the individual and the family's life structure emphasize internal family life.

External boundaries are tightened while internal boundaries may be more diffuse to enhance

communication and teamwork.









These forces then, CF and CP, are in opposition to each other, an opposition that

generates the oscillation characteristic of the family life spiral. It is expected that both

forces operate simultaneously throughout the life spiral but that a different force

predominates at each life cycle stage depending upon the developmental tasks the family is

facing as they progress through the life cycle.

Cohesion. Family cohesion assesses the degree to which family members are

separated from or connected to their family and is defined as the emotional bonding that

family members have toward one another. Cohesion incorporates concepts of emotional

bonding, boundaries, coalitions, time space, friends, decision making, interests, and

recreation (Olson et al., 1985). For the purposes of this study, cohesion was determined

by the cohesion score from FACES-II.

Communication. In this study, communication is defined as the extent to which

family members are encouraged to act openly and to express their feelings directly with one

another. Communication was measured by the expressiveness subscale from FES for this

study.

Family. For purposes of this study, a family is described as being a group of two

or more persons living together who are related by blood, marriage, or adoption

(McCubbin & Thompson, 1991).

Family life cycle. This is a term used to describe the normal development of

families in the management of tasks and events related to the entry and departure of

individuals from the household (Carter & McGoldrick, 1988). Child rearing is the element

around which the family life cycle is organized. Various lineal models of the family life

cycle exist that organize the developmental schema into any number of stages--5, 7, 8, or

24 (Carter & McGoldrick, 1988; Duvall & Miller, 1985: Olson et al., 1983). Traditionally,

the lineal models have mapped the developmental progression of a three-generational family









system that is understood as an ever-renewing system in which new generations are added

and others die out; individual life cycles evolve within the context of the family life cycle.

Family life cycle stage. This is the stage in which each family perceives

themselves to be based on the chronological age of children present in the home. For

families whose children are all launched, stage is determined by age of oldest

grandchildren, if 5 or under; or on the developmental tasks the members are working on if

all children have been launched and there are no grandchildren, or oldest grandchildren are

over 5.

Family Life Spiral Model. This is a model developed by Lee Combrinck-Graham

(1983, 1985) in which she transformed the traditional lineal models into a spiral model that

suggests an ongoing movement throughout time, the life of the family continuing on as

new generations are added. It consists of four phases that are simultaneously experienced

from three different positions within the family life spiral (see Figure 1). The model

portrays the recursions inherent in the life cycle as one oscillates from CP phases to CF

phases again and again and again.

Family Life Spiral phase. In this study, this term denotes the four different phases

(CP. CP--CF, CF, CF--CP) that families pass through over and over again throughout

time as generations are added and others deleted. The artificial boundaries separating the

phases are the quadrants. and these terms are used interchangeably in this study. Each

phase or quadrant incorporates three stages of the family life cycle simultaneously

experienced by three generations within the family. When a family is at a CP phase of the

family life spiral, it is assumed that they are operating in a CP style, with characteristics as

defined previously, and the same is assumed for each of the other phases.

Impact of Death. The impact of death in this study is defined in terms of the

changes in the life of the family in the year postdeath. These changes encompass the

stresses of intrafamily and marital relationships, pregnancy and childbearing, financial and









business strains, work-family transitions, illness and family caregiving strains, losses

(other than the death of the Hospice patient), transitions in and out of the family, and family

legal violations (McCubbin & Thompson, 1991). For the purposes of this study, the

impact of death was measured by FILE.

Nature of death. Nature of death in this study is anticipated, as opposed to sudden

and unexpected with no time to prepare. (This is distinguished from timing in the life

cycle, when unexpected would refer to age of deceased at time of death.) For participants

in this study, the death of their family member had been anticipated and was not sudden

and unexpected.

Social support. Social support is defined here as the family's perception of the

degree to which they view relatives, friends, and the community as a source of emotional

and network support to them in the management of their stressors and strains (McCubbin &

Thompson, 1991). For the purposes of this study, social support was measured by two

subscales from FIRA-G, the Social Support subscale and the Relative and Friend Support

subscale.

Organization of the Study

Chapter 2 of this study is a review of the related literature. Following Chapter 2 is

a delineation of the methodology in Chapter 3, containing a statement of the purpose of the

study, hypotheses, delineation of relevant variables, data analysis, description of the

population, subjects, sampling procedures, data collection, and instrumentation. Chapter 4

is a presentation of the results of the statistical analyses of the data. Chapter 5 includes a

discussion of the results, implications for therapy, limitations of the study, and suggestions

for further study.














CHAPTER 2
REVIEW OF THE LITERATURE


And ever has it been
that love knows not its own depth
until the hour of separation.
--Kahlil Gibran


Introduction

To live is to lose. One can simply not escape loss (Viorst, 1986). One of the most

difficult events we confront in the life cycle is the loss of a loved one through death. When

a close family member dies, the lives of the individuals as well as the life of the family as a

unit are dramatically changed. Most family members acknowledge that life will never be

the same. For many, life takes on a much deeper meaning with the perspective that life is a

beautiful gift, however fragile. Coming to terms with the fullness of the life cycle's

evolutionary process from birth to death is one of the most painful adaptational tasks we

face.

Survivors' lives are irrevocably altered by their encounter with loss (Bowlby,

1980). Researchers have shown that one of the greatest stressors for individuals is the

death of a family member (Hare-Mustin, 1979; Holmes & Rahe, 1967). Although the

finality of death seems to bring the life cycle to a standstill, life does continue after a loss.

Just as birth connects one human to another in the shared life cycle, so does death connect

the deceased and the survivors (Walsh & McGoldrick, 1987). Not only is the family's life

cycle greatly influenced by death, but the family's response to death is greatly influenced

by their life cycle development (Bowen, 1976; Herz, 1980; Herz-Brown, 1990; Rosen,









1990a, 1990b: Walsh & McGoldrick, 1987, 1991). Death impacts the family as a unit as

well as each of its members who have a different relationship with the deceased. "When

links in the familial chain are broken by separation or death, disturbing social and

psychological disruptions are often created" (Raphael, 1984, in Sanders, 1989, p. 147).

And the impact of death continues to reverberate throughout the family system (Bowen,

1976), sometimes for generations as an unresolved legacy (Paul, 1967, 1974; Paul &

Grosser, 1965).

Sociocultural Influence

One of the reasons families in American culture have a difficult time adapting to the

death of a close family member is that they often have little prior experience with death,

making adaptation difficult. Death in the home used to be a natural occurrence.

Postmortem preparation and funeral rituals took place in the home, thus being integrated

directly into family life. Families essentially had no choice but to face the pain of the end of

their loved one's life. As the geographical distance between family members increased and

medical practice and technology developed, individuals were encouraged to be admitted to

hospitals or institutions for care of life-threatening conditions. This was reinforced by the

institution of Medicare and Medicaid in 1965, and the family was removed from direct

hour-by-hour contact with the process of dying (McCusker, 1983; Mor & Hiris, 1983).

This "antiseptic" approach to death may have proved more harmful than helpful, for it is in

our family experience that we learn how to face death. Recent generations of children have

found themselves in middle age never having seen a corpse or attended a funeral, with no

previous opportunity to incorporate a meaningful concept of death into their concept of life

(Pattison, 1977).

In 1984, 90% of the deaths in the U.S. occurred in a hospital or other health-care

institution (Vital Statistics of the U. S., 1991). Two factors contributing to this high rate

are the increased geographical mobility and distance between family members, as well as









the involvement of more and more women in the work force, making it difficult for family

members to care for terminally ill and dying members. There are indications of a shift in

this tendency as more home-care programs like Hospice are made available (McCusker,

1983; Mor & Hiris, 1983), enabling the terminally ill to die at home. By 1988 the

percentage of deaths in the hospital had dropped to 75% (Vital Statistics of the U. S.,

1991) and in 1992 the estimate was 70% based on local figures (A. S. Beckner, personal

communication, October 14, 1992).

At the beginning of the 19th century life expectancy was slightly over 34 years; by

the beginning of the 20th century it had increased to 47 years; and now as the 20th century

draws to a close, life expectancy is nearing 75 years of age (U.S. Bureau of the Census

cited in Hargrave, 1992: Walsh & McGoldrick, 1987). Previously, children could expect

to witness the death of a parent before they grew up and left home and certainly were more

likely to witness the death of siblings to childhood illnesses (Scott & Wishy, 1982, cited in

Walsh & McGoldrick, 1987). Now a person's first experience with death of a close family

member is often the loss of a parent when the child is middle aged.

Death of a family member in our culture appears to cause greater psychological

impact than in other cultures (Rando, 1984). Our increasingly smaller families and our

increased geographical separation from extended family tend to breed family systems with

overidentification and overdependence. Emotional attachments to particular people become

the norm and make for a higher vulnerability to stress. The nuclear family's bond far

outweighs that of the extended family network, and so dependency needs are relegated to a

smaller circle (Sanders. 1989). The emotional investment becomes more focused and

intense, and there are fewer members to share the loss.

Our culture places great emphasis on preparing ourselves materially for death (Paul

& Grosser, 1965). The life insurance industry, the social security system, programs for

economic security of survivors via trusts and wills, and prepaid burial plans are all









evidence of our willingness to prepare ourselves financially for the eventuality of our own

death. However, we take very little care to prepare ourselves psychologically and may not

even commemorate or ritualize the death of a loved one, perhaps to avoid the psychological

pain assumed to be associated (Imber-Black et al.. 1988), or possibly because of our

deceptive emphasis on rationality (Paul & Grosser. 1965).

Frequency of Death

Estimates of I-year incidence rates of bereavement range from 5% to 9%

(Osterweis et al., 1984), amounting to an estimated 13,000,000 to 20,000,000 people who

experience the death of an immediate family member annually (Vital Statistics of the U. S.,

1991). It is estimated that 12,000,000 people lose a parent every year; 800,000 lose a

spouse; and 400,000 deaths are children under 25. Two and a half million of those who

lose a parent are children under the age of 18; 99% of those deceased parents are fathers

(Barth, 1989; Osterweis et al., 1984; Walsh & McGoldrick, 1987). In a key study of

normal families across the life cycle (Olson et al., 1983), researchers found that 19% to

23% of the 1000 couples interviewed had lost a parent or close relative in the preceding

year. In view of this being a percentage based on the couple's response, it is in close

proximity to the upper end of the estimate by Osterweis et al. (1984).

Although death is in some ways always expected, in that the only guarantee in life

is that we will die, it does not occur with sufficient frequency to be considered a normal

everyday occurrence in the life of a family. Therefore, its occurrence does not provide a

situation wherein a family can call on previous adaptive skills to help them through.

Certainly the majority of deaths do not result in a debilitating impact on families. Some

families rise to the challenge of coping with this experience, and some family members

actually do better, appropriately growing and differentiating from the family as it used to be

(Tietz et al., 1977). A third of all major bereavements, however, result in problems for

which professional help may be required (Raphael. 1983; Sanders, 1989).









Ramifications for Family Therapy

The family therapy field has paid a lot of attention to certain issues affecting

families: physical and sexual abuse, impact of divorce, substance abuse, and eating

disorders. However, there has been relatively little attention paid to the impact of death on

families. Walsh and McGoldrick (1991) initiated a landmark treatise on the impact of death

on families as observed in the clinical setting. Others have had input also in highlighting

this as an area in need of our attention as family systems therapists (Bowen, 1976; Brown,

1988; Herz Brown, 1988; Paul & Grosser, 1965; Rolland, 1988a, 1988b; Rosen, 1990a:

Walsh, 1988). However, death is more than just another content issue for families. A

significant loss represents the symbolic death of the family as they had experienced it

(Greaves, 1983). Death modifies a family's structure and demands a reorganization of the

family system that will guarantee its viability in the future. The individual's reaction cannot

be isolated from that of the family as a whole. For the individual the disruption in behavior

and personality functioning is symptomatized through grief and mourning (Lindemann,

1944; Rubin, 1986). Each person's response, whether functional or not, has

consequences for each of the other family members. The impact of loss on the family,

characterized through impact on their function and relationships to one another, can only be

appropriately examined in light of the entire interactional system (Rubin, 1986; Walsh &

McGoldrick, 1991).

From Individual to Family Impact

Individual Perspective

Sigmund Freud's "Mourning and Melancholia" (1917) is the 20th century's first

major treatise on the effects of death on adult survivors and was written from an individual

psychodynamic perspective, focusing on the psychological process of detaching from the

lost object. Another psychiatrist, Erich Lindemann (1944), studied the impact of death on

family members and relatives who survived the loss of a member in the 1942 Boston









Cocoanut Grove nightclub fire. Although most of his observations had to do with

individuals' reactions, one of his predictions about the type and severity of the grief

reaction was based on his observation that the overall makeup of the family network was

more predictive of the reaction than was the individual's coping mechanisms for stressful

situations. "Not infrequently the person who passed away represented a key person in a

social system, his death being followed by disintegration of this social system and by a

profound alteration of the living and social conditions for the bereaved" (Lindemann, 1944,

p. 146).

Freud's hypotheses about the importance of the mother-child relationship and

consequent separation anxiety in human development became the central focus of Bowlby's

(1961, 1980) research on the relationship between attachment and loss in infancy and

childhood. His findings indicated that early childhood loss resulted in disturbed patterns of

attachment behavior, eventually leading to chronic stress and severe depression.

Distinguishing pathological grief from normal grief reactions became the focus of other

psychodynamic grief research as well (Volkan, 1970, 1974).

Subsequent bereavement studies addressed age or relationship to the deceased

(Cain, Fast, & Erickson, 1964; Eisenstadt, 1978; Fleming & Adolph, 1986; Johnson &

Rosenblatt, 1981; Kranzler et al., 1990; Moody & Moody, 1991; Norris & Murrell, 1987;

Parkes, 1964, 1970b, 1975; Raphael, Cubis, Dunne, Lewin, & Kelly, 1990; Sanders,

1986, 1989; Schumacher, 1984), gender (Glick, Weiss, & Parkes, 1974; Parkes, 1970a),

ethnicity (Carter & McGoldrick, 1988; Rosenblatt, Walsh. & Jackson, 1976),

symptomatology upon clinical presentation (Zisook & Lyons, 1989-90), or type of illness

or death (Binger, Ablin, Feuerstein, Kushner, Zoger, & Mikkelsen, 1969; Bolton. 1984;

DeFrain, 1991; Williams & Stafford, 1991). These studies, some anecdotal and clinical

observations and others of an experimental design, focused on the individual. Later

researchers focused on the dyad, for example, the effects on marital couples of the loss of a









child (Brubaker, 1985; Feeley & Gottlieb, 1988-89; Helmrath & Steinitz, 1978; Lauer,

Mulher, Wallskog, & Camitta, 1983: Rando, 1983; Schwab, 1992; Shanfield et al.,

1984). Finally, Raphael (1983) and Parkes (1987-1988) both organized extensive reviews

of the bereavement literature.

Family Perspective

Eventually, some of these same psychodynamic researchers began to note the

influence on the family of the death of a loved one. Paul and Grosser (1965), after

acknowledging the dearth of literature on the family's resolution of grief and the few

studies based on empirical research, recorded clinical observations of schizophrenic

patients and their families, which suggested an association between the onset of

schizophrenia and the disruption to the family's equilibrium because of a previous death

and described the subsequent difficulties of some families to adapt to the changing role

demands on family members.

In 1974, Paul, on the basis of clinical impressions, hypothesized that there is a

direct relationship between the maladaptive response to the death of a loved person and the

permanence of symbiotic relationships within the family. Suffering a significant loss many

years previously with little empathy within the bereaved system seemed to produce family

styles that were unresponsive to further losses and disappointments. The family may try to

keep one of its members in an inappropriately dependent position or as a scapegoat to

maintain the family equilibrium. It was this observed fixation in the mourning process that

prompted Paul to intervene with a corrective grief experience he called "operational

mourning" to free the family members from their inability to be empathic with one another.

Evans (1976) and Aleksandrowicz (1978) both noted in discussing clinical cases

that extensive individual psychiatric work with symptomatic children had not alleviated the

presenting symptomatology, presumably because the families had not coped with the

mourning process after the death of a close family member. It was clear that a loss affects









all members of the family and that one person's mourning affects everyone else in the

family.

Pattison (1977) suggested that how the family responds to a death has more impact

than the event itself. If the family incorporates and embodies the cultural denial of death

and fails to integrate it appropriately within the family or if the family deals with the death

by avoiding discussion of it or mystifying it, psychopathology for the children will be

much more likely to occur.

Parkes and Weiss (1983), through anecdotal accounts, began to observe that

bereavement seldom affects only one survivor. The entire family of the deceased person

could be traumatized sufficiently by the loss to create estrangement between family

members. Defensive reactions impede attempts to establish new alignments within the

family; anger and anxiety by ambivalent survivors is sometimes inflicted upon other family

members close to them. Consequently, the family may cease to be supportive and acquires

the potential to be destructive.

With a family systems orientation, theorists began to stress the importance of going

beyond a psychoanalytic viewpoint in order to recognize and treat the stress on the entire

family system when death of a close family member occurs (Hare-Mustin, 1979). Death

was seen to be the precursor of underlying problems, including an increase in family

conflicts, school problems for children, role confusion, isolation of the family or

individuals, or overdependency of one member upon another.

Empirical Research

A few researchers began to try to capture a family's reaction to death by measuring

the individual members within the family. Lewis et al. (1976) noted some dramatic

differences in families they were studying with regard to the interplay between physical

illness and the family system. Families who discussed death in a personalized way in

constructing a story ending to a taped vignette of a dying person had a significantly higher









number of days in which no family member was ill, suggesting that there was a

relationship between a family's openness in discussing death, the amount of empathy they

showed, and their own physical well being.

Psychiatric help was needed for at least one family member in half of the 23

families participating in a study of families who had lost a child to leukemia (Binger et al.,

1969) and in 25% of families of cystic fibrosis children who died (Kerner, Harvey, &

Lewiston, 1979). There was a high incidence of emotional and health problems in parents

of the cystic fibrosis children and an unexpectedly high incidence of incomplete mourning

as indicated by weekly visits to the grave 2 years postdeath or maintenance of the child's

room as a shrine. Siblings of cystic fibrosis patients (Kerner et al., 1979) had fewer

adjustment problems than siblings of leukemic patients (Binger et al., 1969), possibly due

to the length of the illness and no hope of cure in cystic fibrosis patients.

Tietz et al. (1977) interviewed disadvantaged families who had lost a child 1 to 3

years earlier due to cancer to assess the psychological ramifications of the death. In

addition to clinical depression in a significant number of the parents and psychosomatic

complaints in both children and adults in the families, they observed school achievement

problems and behavior problems in the surviving siblings.

In a retrospective study of families who had experienced the death of a child with

cancer 7 to 9 years previously, many of the parents and siblings were still experiencing

pained loss at the time of the study (McClowry, Davies, May, Kulenkamp, & Martinson,

1987). The empty space created by the child's death was a characteristic noted by many of

the participants, and different patterns of grieving were noted with the family's response to

that empty space.

Norris and Murrell (1987) conducted a longitudinal study to determine differences

in health and stress levels for families who experienced loss of an immediate family

member and those who experienced no losses. These researchers found no significant









difference in health effects, but they did note a sharp, significant increase in psychological

distress, regardless of prebereavement stress. There were no significant differences

between losses due to chronic illness and expected death and sudden unexpected losses,

suggesting that anticipatory grieving did not alter adaptation.

In another study, however, family members were found to have significantly

increased morbidity rates following the death of one of their members (Huygen et al.,

1989). The increase in serious morbidity was still significant 4 years after a death in the

family. Morbidity levels were higher after deaths from acute illnesses than death from

chronic illnesses. Families with prior history of nervous symptoms showed elevation of

morbidity in the period before the loss; after the death, the difference gradually decreased,

suggesting that bereavement may cause a shift in the system that changes the function of

these behaviors.

Raphael et al. (1990) longitudinally studied the adjustment of adolescents who had

suffered parental loss and found higher levels of general health problems, more neuroses,

introverted personalities, impulsive behavior, and more negative views of their school

performance. Interestingly, losses due to death were not significantly distinguished from

losses by separation or divorce.

A study of the effects of all deaths in a family over four generations of a family's

history (Jordan, 1991-1992) showed different effects on family functioning for men and

women. A husband's stress and loss history was found to predict his spouse's and child's

level of satisfaction with the family and, in turn, the satisfaction level for the couple and the

family as a whole, whereas the reverse was not true for wives. The wife's traumatic loss

history was correlated positively with her husband's current level of symptoms, not her

own, which speaks to the notion of reciprocity in marital functioning. Women with high

levels of traumatic loss seemed to become caretakers of men with high levels of

psychological symptomatology, allowing the wife to "overfunction" and the husband to









"underfunction." Traumatic losses may have served as growth catalysts for the women

since much of grief work involves affiliative tasks, traditionally more characteristic of

women's roles. Other intriguing findings of this study were that wives with greater stress

and loss histories were in couples that had greater husband-wife discrepancies in their

perceptions of the family. They were significantly different from nonclinical couples in that

they had more difficulty in achieving shared consensus about the family and had lower

levels of actual and ideal cohesion and adaptability. Jordan noted that the damaged

worldview of a family with traumatic or multiple losses may have a deleterious adaptive

effect transmitted generationally with children adopting parents' views that loss,

abandonment, and suffering are the norm setting the stage for "self-fulfilling prophecies"

that create difficulties in subsequent intimate relationships.

In an effort to assess generational effects, Ponzetti (1992) compared the reactions of

parents and grandparents to the death of a child. Parents felt a significantly greater degree

of shock, disbelief, and numbness than grandparents, although both generations

experienced some physical symptoms following the child's death. There was a significant

difference between parents and grandparents on their need to talk about the death, with

parents feeling that need much more often; gender differences were also significant with

mothers and grandmothers reporting the need to talk more than fathers and grandfathers.

The bereavement of parents and grandparents was different in that parents' reactions

centered on their child, whereas the grandparents' concerns were for their children (the

parents of the deceased child). This study emphasizes the importance of assessing family

members outside the nuclear family when a death occurs.

Family members who had survived the murder of one of their members were

studied by Sprang et al. (1992-1993). Those who were found to grieve extensively were

women, nonmarried, those with lower incomes, infrequent users of social supports, and

those more religiously inclined.









The empirically based research studies on the impact of death on families cited

above were largely carried out retrospectively through questionnaires or interview

processes and the additive results of individual assessment tools. Findings were primarily

noted in the areas of morbidity, psychological distress, behavioral disturbances, gender

differences, social support, and generational differences.

Death as a Stressor Event

Individual Perspective

Death of a family member is a universal event that researchers agree is one of the

most difficult and stressful life cycle changes families face (Dohrenwend & Dohrenwend,

1974; Holmes & Rahe, 1967). The death of one's spouse is listed as the single greatest

stressor on Holmes and Rahe's Social Adjustment Rating Scale (Holmes & Rahe, 1967).

Death of a child also creates such significant stress for couples that marital discord erupts

and may end in divorce, further disrupting these families (Kaplan et al., 1976; Tietz et al.,

1977). For a young child or adolescent the stress of losing a parent can produce high

amounts of behavior disturbance within 6 months of the death (Kranzler et al., 1990) and

can have lifelong impact on their development (Eisenstadt, 1978; Elizur & Kaffman, 1983;

Johnson & Rosenblatt, 1981; Solomon & Hersch, 1979; Weber & Foumier, 1985). Loss

of siblings, grandparents, and other close relatives, too, can be quite stressful, depending

on the nature of the relationship (Binger et al., 1969; Cain et al., 1964; Schumacher,

1984).

Family Perspective

As the American family has decreased in size and increased its geographical

distance from extended family members, emotional attachments to individual nuclear family

members have become the norm. This makes the family more vulnerable to stress when

the death of one of its members occurs (Rando, 1984). Death is a stressor event that

produces a significant amount of change in the patterns of family life, altering previous









subsystem dyads, alliances, and coalitions (Rando, 1984; Reiss, 1981). When a loved one

dies, it is difficult, if not impossible, for the subsystems and boundaries of the family to

exist as they did before the death (Lamberti & Detmer, 1993). If the husband-father or

wife-mother dies, two subsystems (spousal and parental) are affected. The death of a child

affects the family's subsystems just as profoundly. The sibling subsystem has lost a

member. A parent may move in to the sibling system to fill the void and "become" a child,

or a child may move into the parental subsystem to "parent" the parent, which complicates

the spousal subsystem. Extended family members may also be pulled in, all in an effort to

reestablish equilibrium in the family unit (Detmer & Lamberti. 1991).

The immediate effects of the loss of a loved one are felt by those who are close to

that person, but eventually the effects of the loss reverberate throughout the whole system

of family relationships transgenerationally, necessitating changes in interconnectedness and

relationships (Detmer & Lamberti, 1991). The death of a husband will affect his siblings

(same generation) and his parents (older generation) and potentially grandparents and

grandchildren (Detmer & Lamberti, 1991). The reactions of those close to the dead family

member initiate a cycle of change in others. Stress is generated not only in the immediate

impact on those close to the deceased but also as a result of the reactions that are produced

in the rest of the family system (Gelcer, 1986). Valeriote and Fine (1987) differentiate

between the primary effects of a loss (the immediate impact on those who are close to the

dead person) and the secondary effects which are the result of changes produced at the

primary level.

Bereavement will affect the family system in many ways. The death of a
member means the system is irrevocably changed. Interlocking roles,
relationships, interactions, communications, and psychopathology and
needs can no longer be fulfilled in the same way as before the death. The
family unit as it was before dies, and a new family system must be
constituted. The death will be a crisis for the family unit as well as for each
individual member and each component subsystem. The family view of
itself, the family myth, may be impossible to maintain, and all that it
avoided may have to be confronted. The threat to the integrity of the family








unit may come not only through the change that loss of a family member
brings, but also because that member may have occupied a key role in
maintaining the system, or perhaps in regulating it in a crisis. Others may
be unable to take over [the deceased's] roles and responsibilities. While the
threat to its integrity may make family boundaries close over, individual
members and the system itself may, in contradiction, desperately need the
support and care of other systems. (Raphael, 1983, p. 54)
The vulnerability of the family will be mediated by its ability to receive support, requiring

the family system to be open to extended family and friends outside the immediate family

(Detmer & Lamberti, 1991).

The Effect of Stress on the Family

Demands for Change

Theories about stress and families originated in the field of sociology. Hill (1949)

was one of the first to examine why stressor events such as losses, illness, or separation

produced such a variety of differences in families' abilities to adapt. Families tended to be

more stressed by situations for which they had little or no prior preparation or situations

that demanded a change in their familiar patterns of functioning. The more change that was

required, the more hardship there was on families.

Demand Overload

Patterson and McCubbin (1983) hypothesized that cumulative family life changes

would be associated with a decline in family functioning. This was corroborated by Bass

and Bowman (1990) who reported that families with more caregiving strain for a terminally

ill member were also the families with greater bereavement strain. These families were also

more likely to utilize bereavement services and resources suggesting that the amount of

relief that was felt when the caregiving obligations were over was not offset by the strains

long-term caregiving imposed. McCubbin and Patterson (1983) further contributed to the

development of the family stress theory by developing an adaptation of Hill's (1949) family

crisis model to include the effects of stress when a family was already experiencing a pileup

of life events taxing the family system. Since developmental transitions are already









stressful points in the life cycle, additional demands made at those times could be expected

to create a high risk situation (Golan. 1978).

Reestablishing Balance

As the family struggles to regain equilibrium in response to a loss, adaptation is

necessitated, and a great deal of emotional energy is directed towards reestablishing balance

in the system. The system as a whole as well as individual members are all affected

(Rando, 1984).

The family's prior implicit functioning may be replaced by explicit rules as they

struggle to maintain control. If interactional patterns lose their implicit capacity and rely

totally on explicit constraints, the family becomes a source of tyranny for most of its

members, and family disorganization or dissolution becomes severe (Reiss, 1981).

Predicting the relationship between stress and family disorganization is an inexact

science. Although Rosen (1990a) suggested that families respond fairly characteristically

to crises, responding in the present much as they did in the past with an established

emotional style, other researchers find families to be less predictable. Sometimes a family

may be subjected to severe stress and show little disorganization; at other times in their

development, a similar stressful event may be overwhelming. Reiss (1981) highlighted

two factors to be of primary importance: the family's level of organization at the time of the

stressor event and the quality of its ties with its social environment. Lewis (1986), too,

highlighted the organizational structure of the family as a factor influencing how a family

responds to stress. He described one of the family system's essential tasks as distance

regulation, with most families living with some type of balance between separateness and

attachment. Well-functioning families tend to have organizational structures that allow for

both. This has a powerful influence on how the family responds to normative stress.

Lewis hypothesized that stress arises when individual family members' needs for

separateness and attachment occur at different times. The relationship of the family life









cycle to changes in family organizational structure is an important issue in understanding

family stress.

Walsh (1982) pointed out that a family's ability to cope depended on their ability to

manage a number of different dimensions of family life simultaneously: organization,

independence, self-esteem of members, cohesiveness, social support, controlling stress,

and the amount of change in the family. Coping involves achieving balance in the system,

allowing for facilitative organization while still promoting individual growth and

development. Studies have shown that a family's coping strategy is progressively

modified over time (McCubbin, Joy, Cauble, Comeau, Patterson, & Needle, 1980).

Paradoxically, stress can be the seed from which healthy reorganization is born.

Struggling to master a stressful situation may be the impetus a family needs for

developmental creativity (Eisenstadt, 1978; Osterweis et al., 1984; Walsh, 1982). "The

time of disorganization is a time for something new" (Reiss, 1981, p. 199). Ironically,

families who have been shown to have good problem-solving skills when facing a terminal

illness have experienced the loss of their loved one in a shorter period of time than those

who were disorganized and poor problem solvers (Reiss et al., 1986).

Impact of Death on the Family

A family's equilibrium is disturbed when a member is lost. Murray Bowen (1976)

has written a description of the family's reaction to death that has become a classic in the

family systems literature. The emotional reactiveness that is stirred up within families after

the death of a member has been termed by him the "emotional shock wave."

The "Emotional Shock Wave" is 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 ... of a significant family member. ... It
is not directly related to the usual grief or mourning reactions of people
close to the one who died. It operates on an underground network of
emotional dependence of family members on each other." (Bowen, 1976, p.
325)









Symptoms Produced

Rosen (1990a) has written that no family who has lived with a fatal illness can

remain unchanged from the ordeal. The same resources that enable families to cope and

endure (being close and supportive, having intimate knowledge of each other's strengths

and weaknesses) also enable them to hurt one another (Parkes & Weiss, 1983). Some

families may actually function better than before; others may experience a severe

deterioration of their normal functioning. Some achieve greater intimacy as a result of the

experience; others break under the strain. Some are able to redistribute the roles left vacant

by the deceased: others are permanently crippled by the vacated role.

Overfunctioning families may implicitly prohibit expression of grief which may lead

to children expressing their grief symptomatically through acting out behaviors outside the

home (Rosen, 1990a). Boundaries are violated and family systems can close up their

internal and external boundaries. Families may become disorganized; exhibit anxiety

through bickering, disagreements, interrupting, or substance abuse; be emotionally labile;

or turn inward, avoiding discussion of emotionally charged issues or threatening ideas and

idealizing the deceased. When the mourning process is suppressed, family and

interpersonal conflicts are often the result (Pincus. 1974). When the family system has

experienced more stress than it can deal with, it may experience ill health, extreme

interpersonal conflict, or become destructive (Olson, 1988).

Investigators using empirical methods have indicated that a significant number of

families who experienced the loss of a family member developed a crisis and/or symptoms

requiring mental health services within 9 months after the loss (Hadley et al., 1974). Barth

(1989) believes that the impact on children is more delayed, and that they are not seen in

therapeutic settings until 1-1/2 to 2 years after the death, when their behavior has escalated

calling attention to the family's suffering.









Depending upon the circumstances of the death, families may experience social

isolation and avoidance of discussion of the death by extended family and friends,

especially now with the prevalence of AIDS deaths (Rosen, 1989; Williams & Stafford,

1991). One of the significant characteristics Lindemann (1944) noted in his study was that

relationships with friends and family were conspicuously altered with individuals feeling

irritable, avoiding contact, and becoming progressively more socially isolated. As a result

of their pain, the surviving family members often feel an immense sense of loneliness and

isolation as communication among family members dwindles (Fleming & Adolph, 1986).

When discussion among nuclear family members becomes constricted, the family system is

at risk of becoming unable to help one another through the grieving process (Helmrath &

Steinitz, 1978). Families that encourage closeness and communication appeared to

experience fewer grief complications (Fleming & Adolph, 1986).

Role flexibility within the family system becomes an issue when a family member

dies (Lamberti & Detmer, 1993). One of the causes of the disequilibrium families face

when one of their members dies is that there is often a shift in power. responsibilities, and

roles necessitated as a result of the vacancy the deceased leaves (Rando, 1988). Vacated

roles may be instrumental ones such as economic support, maintenance of physical needs

and socialization of the children, or affective roles concerned with the giving and receiving

of love (Goldberg, 1973). Others are not as readily apparent but may leave quite a gaping

hole if the person served as the peacemaker, the troublemaker, the scapegoat, or the

worrier. Roles must be renegotiated in order for families to regain balance.

The reassigning of roles can be positive if families find new ways of functioning

that are better than before. People may discover abilities of which they were not aware or

finally be given recognition for their contributions to the family. The changing of roles can

have negative consequences if roles are not appropriately reassigned: expecting another

person to live in the deceased's image, robbing them of their own identity; overloading









some members of the family with more tasks than can be fulfilled; assigning a person tasks

that are developmentally inappropriate; or if there is disagreement about who should or is

entitled to fill a certain role.

Other roles that need to be renegotiated are the extrafamilial roles that involved the

deceased, organizations that the deceased participated in, or activities with the spouse,

child, or sibling (Goldberg, 1973). Lamberti and Detmer (1993) believed that less

functional families feel the need to maintain certain roles in the family, and a member will

appoint himself/herself to fill the role, or will be appointed by another to fill the role vacated

by the death. In more functional families, the loss of the role is recognized, but no one

person is expected to fill it. There is greater flexibility in the reorganization process.

Loss of a spouse. As noted earlier, Holmes and Rahe (1967) considered death of a

spouse to be the greatest stressor for an individual. In a study by Bass et al. (1990), two-

thirds of the bereaved spouses in their sample believed the death to be the most difficult

thing they had ever faced. Given normal life expectancy, it is not unusual to have bereaved

spouses who have been married 45 to 50 years. The severing of that bond is often

devastating, usually leaving the bereaved spouse alone and without the source of most of

their previous social interactions (Lund, Caserta, & Van Pelt, 1990). They are often

excluded from the sociability of couples from that point on and are thus deprived of the

normal avenues of social support that have been previously at their disposal. Women are

often the social links for couples, and Lund's study bore out the differences between men's

and women's social support networks following the death of their spouse. Whereas

support from family members remained stable over time, grievers over age 75 reported

consistently smaller networks with a noticeable decline at 6 months postdeath. Bereaved

spouses under age 75, however, had sharp differences in the support available to them

initially. Men had a much smaller network of support initially but increased their network









by 2 years postdeath to nearly double that of the women. Both networks of support were

largely same-sex.

A general deterioration of health (Bass et al., 1990) and an increase in mortality

among spouses of the deceased has been noted (Parkes, 1964, 1970b). A significant

increase in the morbidity of other family members 1 year postdeath was found in a

retrospective research study (Huygen et al., 1989). Stack (1982) also noted the tendency

of the bereaved to present to the doctor with physical symptoms of their grieving rather

than psychological symptoms and the importance of the physician differentiating grief from

depression. Medicating grievers can often retard and prolong the grieving process.

Bereaved spouses were also more likely to experience financial distress, miss work, or take

a job for the first time (Crosby & Jose, 1983; Parkes, 1970a). Most people whose spouse

dies are at a stage in their life when no other family members are living with them.

However, the ramifications in the rest of the family system can be seen in the following

section.

Loss of a parent. The most common loss in our society is that of the death of an

elderly parent (Bass et al., 1990). Many changes in family interaction patterns have been

noted clinically when an aged parent has died (Hargrave, 1992: Morgan, 1984). Increased

frequency of contact with other family members may result, especially adult children with

the widowed spouse, and can be expected to have an impact on the family as a system,

causing realignment of resources of time, space, and emotional involvement. Adult

children may find themselves combining living arrangements with a surviving parent who

is not able to live alone (Crosby & Jose, 1983).

Hargrave (1992) noted the conflict families often have over the estate of the

deceased and the deeper emotional conflicts that are usually behind that. There is also the

need to keep the family from disintegrating. Hargrave, as well as others (Osterweis et al.,

1984), noted the reorientation adult children face when they become the senior generation









after the death of both parents, being thrust developmentally into the next stage of life and

the midlife reevaluation that occurs as a result. Some studies have noted a relationship

between death of a parent and increases in suicide, attempted suicide, and clinical

depression (Birtchnell, 1975; Bunch & Barraclough, 1971). If the bereaved adult child has

not individuated or psychologically separated from the deceased parent, the grieving

process may be thwarted until that developmental task is achieved (Williamson, 1978).

Hargrave (1992) also described the guilt and remorse among family members who may feel

they have done too much or too little over the years to resolve conflicts that did not get

settled prior to the death of the family member.

Child's loss of a parent. Younger families that suffer the loss of a parent, leaving a

spouse as a single parent, often face financial hardships, childrearing and home-care

burdens, the need to redefine parental and familial roles, the surviving parent doing their

own grief work yet aiding the children in theirs, disciplinary problems, a tendency to

parentify older children, social isolation, and loss of the couple's friendship network

(Reilly, 1978). Children in these families who are at risk for suffering a pathological

bereavement reaction upon the loss of their parent may be predicted at risk by preexisting

family and environmental factors (Elizur & Kaffman, 1983), such as (a) those children

whose parents were divorced, separated, or experiencing marital discord; (b) those children

whose relationship with the surviving parent was disturbed; (c) those children whose

surviving parent exhibited emotional restraint; and (d) those children who had no substitute

parent figure.

Whether or not children are allowed to make their own decisions about participating

in death rituals also is a factor associated with a child's bereavement reaction. Weber and

Fourier (1985) found that families who were most cohesive tended not to allow their

children to make their own decisions about participating in death rituals; this tendency often

led these children to experience confusion and a greater need for support. Barth (1989)









believed that grieving children were more likely to display anxiety, shyness, or depression

rather than behavior problems in a school setting.

Although some children who lose a parent fare well and channel their grieving into

creative outlets, others often demonstrate nonresolution of their grieving resulting in

antisocial behavior (Eisenstadt, 1978). Early parental loss for children has been associated

with the development of depressive disorders and increased suicide risk (Osterweis et al.,

1984). The younger a child is, the more difficulty the child may have in adapting to the

loss. Developmentally children lack a cognitive framework that helps them to understand

the nature of death and dying. They are more dependent on the structure of family routines

and are less able to deal with the widespread disruption that follows the death of a parent

(Barth, 1989). Children learn how to grieve by modeling their parents. Parents who are

dealing with the loss may feel the need to be strong for their children in an effort to keep the

emotionality of the family in control. If the surviving parent is not openly expressing

emotion over the loss of their spouse, children in the family may conclude that showing

emotions is inappropriate, and the whole family may stifle their emotions in an effort to

protect one another (Moody & Moody, 1991).

The family with an adolescent or young adult in the launching stage often

experiences the onset of symptoms in family members when there is a loss at this time

(Haley, 1973). In a study by Raphael et al. (1990), adolescents who had lost a parent had

higher levels of health problems and more neuroses, were more introverted and impulsive,

and reported being more sexually active. The transgenerational impact of death has been

noted in psychiatrically hospitalized young adults whose symptom onset was found to be

associated with both concurrent grandparent loss and the patients being the same age as

their parents when a grandparent had died (Walsh, 1978).

Female adolescents were more likely to become involved in sexualized relationships

following parental loss in search of comfort and reassurance, whereas males were more









likely to engage in delinquent behavior, criminality, or drug abuse. These findings are

further validated by examining histories of male and female prisoners that reveal an excess

of parental death compared to a normal population (Osterweis et al., 1984).

Drug addiction in families has also been found to be significantly related to

premature loss and initial drug use (Coleman, 1980: Coleman et al.. 1986; Coleman &

Stanton, 1978; Stanton, 1978, 1980; Stanton, Todd, Heard, Kirschner, Kleiman, Mowatt,

Riley. Scott, & Van Deusen, 1978). Addict families have been found to experience a

higher proportion of traumatic, untimely, or unexpected losses of family members than

would be expected in the normal population. The addicts in these studies perceived their

families as discussing death and dying less frequently than normal families and also tended

to minimize death-related issues, although death issues were often a topic of discussion in

therapy sessions by the addict's initiative (Coleman et al., 1986; Stanton, 1978). These

researchers hypothesized that these losses had not been effectively resolved resulting in the

drug abuse.

Loss of a child. The loss of a child is an immense loss for parents, a time when

they feel they have literally lost part of themselves and certainly some of their hope for the

future (Schwab, 1992). The strain of such a death on a marital relationship sometimes

results in separation and divorce. In a study by Nixon and Pearn (1977), 7 of 29 marital

couples had separated following the drowning of their child. No separations occurred in

the 54 couples whose child had survived a near-drowning. Five of the couples who

experienced a loss were more resilient in response to the loss, indicating that the tragedy

had actually brought them closer. In another study of divorce among bereaved parents,

Klass (1986-1987) concluded that divorce occurred more often because of preexisting

problems in the marriage--there was simply no longer a reason to struggle with the marital

problems after the child had died.









Helmrath and Steinitz (1978) conducted a research study of the parents of newborn

infants who died shortly after birth and reported a sense of extreme isolation by the parents.

The extended family and the community's avoidance of discussion of the death seemingly

to protect the parents actually resulted in extreme distress for the bereaved parents. They

also reported a disturbance in communication between the parents as each grieved at a

different pace and often in different ways. This was corroborated in research carried out by

Schwab (1990) which found that there were significant differences between mothers and

fathers of deceased children in the use of certain coping strategies. Mothers were

significantly more likely to cry and write about their loss and grief as a means to seek

release from the tension; they were more likely to read about loss and bereavement, to

engage in helping others, and seeking support through an organized group. Themes that

most frequently emerged in later studies of the effects of a child's death on the marital

relationship included the husband's concern and frustration about their wife's grief, wives'

anger over husbands not sharing their grief, communication difficulties, loss of sexual

intimacy, and general irritability between spouses. Intense grief reactions were also

predictive of loss of intimacy in bereaved mothers and fathers in a study by Lang and

Gottlieb (1993).

Parents whose babies died of Sudden Infant Death syndrome were followed

longitudinally in a research study by Zebal and Woolsey (1984). Two months after the

death of their infant, when the reality had set in, external supports were waning. Woolsey

(1988) found similar results concerning social support for parents after SIDS deaths.

Benfield, Leib, and Vollman (1978) studied the effects of SIDS deaths on the marital bond

and reported that when communication between the couple was poor, critical emotional

issues were not discussed for an extended period of time. Zebal and Woolsey (1984)

attributed some of the difference in interactional patterns in the marriage to the differences

between the genders in their respective styles of grieving. Mandell, McClain, and Reece









(1988) found that fathers of SIDS infants increased their involvement with their work,

were stoic, and appeared to have a limited ability to talk about their feelings or ask for

support. In Mandell's (1980) study of SIDS parents. 6 of the 28 couples had divorced

after the death of their infant.

Families who lose a child member experience a disequilibrium which may weaken

the parents' ability to help their remaining children adjust. They may be unresponsive to

the children, unavailable, or detached. Normal exchanges about everyday matters become

unimportant, and the remaining children feel the ambivalence of the parents and can begin

to question their value to the family. Young siblings feel the withdrawal of the parent and,

consequently, the feeling of being loved. They may feel abandoned or punished and may

develop fears about themselves (Lewis, Lewis, & Schonfeld, 1991). Fulmer (1983)

described the role of the misbehaving child in response to the depressed and anxious

surviving parent. It is not unusual for the surviving children to feel guilty because of their

sibling's death and to begin to develop symptomatic self-punishing behavior as a result.

Parents can feel a real fear of becoming closer to their other children and then losing them

as well. They can also become overprotective, stifling the normal developmental process

(Arnold & Gemma, 1983; Cain et al., 1964: Payne, Goff, & Paulson, 1980). Siblings can

influence and help each other through the bereavement period and may compensate for

many of the difficulties parents experience during this time in consoling the other children

(Rubin, 1986).

Both positive and negative behaviors have been seen to increase after the death of a

child in a family (DeFrain, 1991). Some children become more attentive to their parents'

and siblings' needs and others become more frightened, angry, or withdrawn. A small

research study 1 year postdeath of families who had lost a child to cancer showed that of

the 26 surviving siblings, 15 developed behavior problems such as delinquency,

aggression, and poor relationships with parents (Tietz et al., 1977). Eight manifested









school achievement problems and six developed psychosomatic complaints. Mandell et al.

(1988) studied families of SIDS babies and noted behavioral changes in siblings in terms of

sleep patterns, social interactions, and parent-child interactions which were a reflection of

their own as well as their parents' adjustment.

The interaction of parents and children in each possible configuration can exacerbate

or mitigate each individual's response to the loss as well as that of the family as a whole.

The powerful impact of the loss upon family members strains their capacity to cope and

help each other after the loss occurs (Rubin, 1986). The fact that adults and children have

different capacities for grieving is another contributing factor. For very young children, the

parental response will influence their cognitive and emotional adjustment. Parents who can

model appropriate emotional responses for the children can enable this age group to adapt

more effectively. Older children rely less on the nuclear family and more on their peers,

but the effect of a death will restimulate the adolescent's attachment to their family and may

vary depending upon the attachment and ambivalence they feel. The period of greatest risk

and opportunity for the family is that of the first year following the death. Although most

of the problem behaviors are seen to subside eventually, some may require professional

help.

Adaptational Factors

That so much can go wrong, as evidenced in the review of the grief literature,

presents a challenge to a family's ability to survive. How well families adapt depends on a

number of variables, as indicated above. There is never a good time to experience the death

of a close family member, but there are times when the stress of such an event puts the

family at a higher risk for dysfunction than others (Walsh & McGoldrick, 1987). When

the death coincides with a time in the life cycle when the family is experiencing a number of

other concurrent stressors, they may have more difficulty coping and adapting. If there are

previous traumatic losses and unresolved mourning, the family will be more vulnerable in









the event of another death (Jordan, 1991-1992; Rosen, 1988-1989: Walsh, 1978). If the

deceased member dies at an unexpected time in the life cycle, such as childhood, young

adulthood, or during early parenthood, the death may be more difficult for the family to

deal with (Neugarten, 1976).

If the role of the deceased was not a significant one in the family, the family will be

more likely to adapt (Hare-Mustin, 1979; Herz Brown, 1988; Walsh & McGoldrick,

1991). The family's recovery will also be less problematic if the roles enacted by the

deceased can be reallocated to other family members without undue burden (Vess et al.,

1985-1986).

Numerous authors have noted that families who have clear direct styles of

communication deal better with the crisis of death than those where death is a toxic issue

that cannot be openly discussed (Walsh, 1982; Walsh & McGoldrick, 1991). When

feelings of sadness and loss as well as anger, guilt, and relief can all be openly shared, the

grieving process and the readjustment of the family will be more likely to proceed without

undue difficulty (Bowen, 1976; Lamberti & Detmer, 1993; Vollman et al., 1971). Open

communication also allows for a better fit in the reallocation of roles that is necessitated

after the loss of a family member (Vess et al., 1985-1986). When there are no conflicted or

estranged relationships at the time of death, families cope better (Bowen, 1976; Rosen,

1990b; Walsh & McGoldrick, 1991).

If the family has a wide source of social support and a large extended family close

by, there is a greater likelihood that they will successfully adapt to the loss of their loved

one (Walsh & McGoldrick, 1991). A cohesive but differentiated family will be more likely

to offer support and have tolerance and respect for individual differences in the grieving

process (Walsh & McGoldrick, 1991).

If the family has a history of being flexible in the face of crises and able to draw

from a wide range of healthy coping behaviors and resources, they will be less likely to









experience defeat when a family member dies. They will be more likely to accept the loss

and integrate it into their view of the evolution of life (Walsh & McGoldrick, 1991). The

more flexible they are, the more likely they will be able to handle the reorganization of the

family system that is necessitated because of the loss (Cohen et al., 1977).

Some researchers have found that when death is anticipated as a result of a chronic

illness, families cope significantly better than if the death is unexpected (Lindemann, 1944;

Neugarten, 1976; Parkes, 1975; Rolland, 1990; Sanders, 1989). However, other

researchers have shown that expected death did little to lessen the psychological distress

experienced after death (Norris & Murrell, 1987), and illness that required extensive

caregiving prior to the death has been shown to be linked with greater bereavement strain

(Bass & Bowman, 1990).

Length of time that the illness has been diagnosed is another factor of importance.

If the illness has been 3 months to a year in length, the family has sufficient time to

anticipate the death but not an excessive amount of time that depletes the family of its

caregiving and financial resources (Sanders, 1989; Walsh & McGoldrick, 1991). Grief

reactions have reportedly been more intense if the terminal illness has lasted for more than a

year (Payne et al., 1980).

The nature of the death is another factor. Suicides cause tremendous pain for the

surviving family members as do violent deaths where body deformity or dismemberment

have occurred (Vollman et al., 1971; Walsh & McGoldrick, 1991). Deaths with a social

stigma attached, such as AIDS, also impact the grieving process (Rosen, 1989; Williams &

Stafford, 1991).

Another critical factor in a family's ability to adapt to a loss is their belief system.

This may involve ethnic, religious, or philosophical ideas about death and the meaning

attached to it and will be very influential in how the family responds to a death of one of its

members (Herz Brown, 1988; Walsh & McGoldrick, 1991). Families who have









appropriate rituals and ceremonies to cope with the loss are better able to adjust than

families where there is no commemoration to aid the family in the expression of their grief

(Bolton & Camp, 1986-87; Imber-Black et al., 1988: Rosen, 1990b).

Walsh and McGoldrick (1987) identified some essential tasks families must

negotiate in order to adapt optimally to loss: (a) shared acknowledgement of the reality of

death, which is facilitated by open communication within the family; (b) shared experience

of the pain of grief, allowing all feelings about the loss--from sadness to anger--to be

expressed; (c) reorganization of the family system to compensate for the loss of the role and

relationships with the deceased; and (d) reinvestment in other relationships and life

pursuits, which often takes 1 to 2 years to accomplish.

Death does not have to be regarded as a tragedy but rather as a challenge and an

invitation for adaptive change (Greaves, 1983). It is dangerous to assume that all losses

produce debilitating responses or that a certain amount of grief work must be done before

one can move on with their life. Some people move from high distress to low; some

remain high; and others show no intense distress-all of these reactions are considered

normal adaptive processes (Wortman & Silver, 1989).

Family Systems. Stress, and the Life Cycle

Family Systems

The family system is defined as a group of individuals who are interrelated and

interconnected so that a change in one person affects the other family members both

individually and as a group, which, in turn, impacts the originator of the change. Feedback

loops denote that causality is not linear but circular: every action is also a reaction

(Guttman, 1991; Walsh, 1982). The family is greater than the sum of its parts and cannot

be captured by simply describing each individual within that family. Their differences are

equally as important as their similarities and serve to help maintain a stable state, referred to

as homeostasis (Guttman, 1991; Walsh, 1982). The patterns of their connections are









governed by the family's relationship rules which may be either implicit or explicit (Walsh,

1982) and are frequently passed on from one generation to the next (Bowen, 1976).

Crises in the family create stress and require the family to adapt in order to preserve

the family as a unit along with the well-being of each of its members (Walsh, 1982). In

systems thinking, an individual's problem is seen as an expression of an interactional

pattern in the family. The symptom may be functional in that it expresses the family

tension and stress even though the individual may be impaired in the process. Symptoms

are seen to occur most often at times of imbalance or disequilibrium in the system

(Steinglass, 1985). How the family responds to the individual in distress will be an

important factor in whether or not recovery takes place (Guttman, 1991: Walsh, 1982).

Death involves multiple losses for the family system. One death can mean the loss

of a child, a sibling, a parent, a spouse, or a grandparent, depending upon each

individual's connection with the deceased. Each of these unique relationships affects the

impact of loss on the whole family (Walsh & McGoldrick, 1987).

Family Life Cycle

The family developmental framework is another critical dimension that is added to

the interactionist perspective of the family system. The interrelatedness of family members

changes over the course of the family's life cycle, as roles and relationships between

parents and children evolve with the developmental changes of each of the family's

members (Walsh, 1982). The family life cycle is generally defined in developmental stages

and is characterized by the major events and developmental tasks the family is facing,

especially the addition and departure of family members (Carter & McGoldrick, 1988;

Duvall & Miller, 1985; Walsh, 1982). Generally, the major stages are courtship, marriage,

advent of young children, adolescence, children leaving home, readjustment of the couple,

retirement, growing old, and facing death.









Undergirding assessment is an understanding of what is considered "normative" for

families across the life cycle (Carter & McGoldrick, 1988). Normative refers to events and

transitions that most families can expect to occur at specified stages of the family life cycle

(Walsh, 1982). There are various schemas, but all are primarily geared around the

individual developmental stages of offspring (Carter & McGoldrick, 1988; Duvall &

Miller, 1985; Olson et al., 1983). More attention has been paid to the child-rearing phases

of the family than to the later stages of the family's life. The family life cycle perspective

views symptoms in relation to normal functioning over time, with the individual life cycle

taking place within the context of the family life cycle (Carter & McGoldrick. 1988).

The various stages of the family life cycle are based on the view that the
central underlying process to be negotiated is the expansion, contraction,
and realignment of the relationship system to support the entry, exit, and
development of family members in a functional way. (Carter &
McGoldrick, 1988, p. 13)
Developmental tasks for each stage vary from one theorist to another but are commonly

distinguished by the addition and deletion of members through birth, launching, marriage,

and death. A change for any member is a challenge for the entire family (Minuchin, 1985).

Family developmental tasks differ from individual developmental tasks in their relational

qualities. Ireys and Burr (1984) noted both individuating and integrating family tasks for

young adults.

As life cycle patterns in our time have made some significant changes with

increasing numbers of couples cohabitating, same sex marriages, lower birth rates, an

increase in divorces and remarriages, delayed marriages and childbirth, and increases in

numbers of single women giving birth without marrying, what is "normal" is becoming

more and more mythological (Carter & McGoldrick, 1988). Carter and McGoldrick (1988)

have developed additional phases of the family life cycle for divorced and remarried

families that are superimposed upon the normal family life cycle to indicate the

developmental tasks peculiar to these groups of people.









Family Stress

Family stress research had its beginnings with the work of Hill (1949) who studied

the stress of war separation and reunion on families. In an effort to understand why the

same stressor affected families differently, Hill (1958) developed a model of family crisis

called the ABCX model where A (the stressor event), interacting with B (the family's

crisis-meeting resources), interacting with C (the definition the family makes of the event),

produces X (the crisis). Attention to family stressors is directed at both normative and

nonnormative life events. A stressor is defined as "a situation for which the family has had

little or no prior preparation" and crisis as "any sharp or decisive change for which old

patterns are inadequate."

Advancing the ABCX model a step further, McCubbin and Patterson (1983)

developed the Double ABCX Model of Family Adjustment and Adaptation, incorporating

into it the concept of the "pile up" of family life changes. The FILE was developed in order

to measure the stress of a family. Life events which are experienced by the family as a

whole or by any one member are added together to determine the magnitude of life changes

facing the family as a whole. These researchers hypothesize that, as family life changes

accumulate, there is a decline in family functioning (McCubbin & Thompson, 1991).

Families who are already struggling with other life changes, such as a developmental

transition, may lack the resources to cope with any additional stressors (Golan, 1978). A

study by Bass and Bowman (1990) showed that the strain of caregiving was associated

with an increased use of bereavement services for families after the death of their loved

one, which also attests to the "pile up" of strains and stresses.

Most recently, McCubbin and Patterson have further adapted the Double ABCX

Model and now have introduced the Resiliency Model of Family Stress, Adjustment and

Adaptation, which includes family types and levels of vulnerability in addition to the

elements of the Double ABCX Model (McCubbin & Thompson, 1991).









Family Stress and the Life Cycle

David Olson and his associates have studied normal family development across the

life cycle (Olson et al., 1983, 1985). Families were studied on several dimensions: family

types, family stress, family resources, and marital and family satisfaction. By describing

the positive aspects of families that help them cope and deal with stress, the authors

established a backdrop against which to contrast families who are having problems coping

with specific issues. Their cross-sectional study examined characteristics of 1,140 intact

families from across 31 of the 50 United States. representing seven stages of the family life

cycle from young couples without children to retired couples. Specific stages of the family

life cycle were identified based on the age of the oldest child, the amount of transition or

change required in response to changing developmental needs of the family members, and

changes in family goal orientation and direction. Family norms were then developed by

stage of the family life cycle (Olson et al., 1983).

In assessing family stress, husbands and wives were asked to identify the stressors

and strains they had experienced during the past year. These stressors were recorded on

the FILE. The top stressors for each stage of the life cycle were calculated. The stress of

illnesses and losses of relatives, family members, and close friends appeared to be most

closely associated with the latter two stages, the empty-nest and retirement stages of the

family life cycle, as might be expected (Olson et al., 1983).

Olson et al. (1985) postulated that families under stress should be viewed along a

continuum ranging from extremely high stress to extremely low stress. Eighty-five percent

of the families in this study were clustered in the midrange of family stress.

Major differences were found among the various family members and across the

stages of the life cycle (Table 1). Those differences can be accounted for by identifying the

differing developmental tasks and family structures of each stage and also by describing the

cohort differences between younger and older couples (Olson et al., 1985). Stages of the









life cycle that had the highest mean scores on the stress inventory were the launching,

adolescent, preschool, and school age stages, respectively. Olson and his associates

concluded that stage differences and individual differences should be taken into

consideration when carrying out any research project involving families.


Table 1

Comparative Norms for Family Pile-Up over the Family Life Cycle



Weighted Sum Family Life Spiral
Family Stage Mean Comparability


Couple 478 CF--CP

Preschool 530 CP

School Age 500 CP--CF

Adolescence 545 CF

Launching 635 CF--CP

Empty Nest 425 not comparable

Retirement 395 not comparable


Source: Family assessment inventories for research and practice, 2nd ed., by H. I.
McCubbin and A. I. Thompson (Eds.), 1991, p. 93.


Olson (1983) and McCubbin (1991) also noticed differences in families' responses

to stressors and strains at various points in the life cycle. Stressors, defined as specific

concrete events, were generally less stressful for families than on-going strains, those

conditions of an insidious and ongoing nature.

Transition periods in the life cycle have been known to be more difficult times for

families, occasions that involve both beginnings and endings, as in births, launching young









adults, retirement, and death. Haley (1973) noted that most periods of family stress occur

when someone is entering or leaving the family. All levels of the family system are in

greater flux at these times. Because there is a great deal of upheaval, rethinking, and

change, families' abilities to adapt are more heavily taxed, and they are, therefore, seen to

be more vulnerable to any additional stressor at those points (Rolland, 1990). McCubbin's

Double ABCX model is based on the belief that a family already struggling with one major

life transition is likely to have difficulty coping with concurrent stressors (McCubbin &

Patterson, 1983). Rapaport (1962) states that stressful transitions are turning points for

families, leading either to resolution and growth or to maladaptation. Symptomatic families

develop problems because they are not able to adjust to or negotiate the transition

(Hoffman, 1988: Stanton, 1978).

Haley (1973) noted that pathological behaviors tend to show up in the family life

cycle when one generation is prevented or held up in disengaging from another generation.

For example, serious illness and death are expected in late adulthood and are considered

normative developmental tasks for those stages of the life cycle. However, if those events

occur earlier in the life cycle, the event is considered "off-time," and the family lacks the

psychosocial preparation that comes later when their cohort is also experiencing similar

losses (Herz, 1980; Neugarten, 1976; Rolland, 1990). For example, if a young adult is in

the transitional stage of leaving home and a parent is diagnosed with terminal cancer, it may

alter the young person's ability to proceed on a normal developmental course, and it will

likely be necessary to alter, delay, or give up goals. The young adult will undoubtedly feel

torn between his/her own immediate pursuits and premature caretaking obligations (Walsh

& McGoldrick, 1987). The whole family is robbed of their expectation of a "normal" life

cycle, and the adaptations that will be required of them as a result are greater than had the

illness been diagnosed in late adulthood (Rolland, 1990). At transition stages, intense

grieving can occur over opportunities that have had to be relinquished, with loss of future









hopes and dreams. This can overwhelm and complicate the tasks of mourning the death of

one of their members, making adaptation difficult (Walsh & McGoldrick. 1987). The

ability of each family member to adapt, and the rate at which they do, will depend directly

on each individual's own developmental stage and their role in the family (Ireys & Burr,

1984; Walsh & McGoldrick, 1987).

Family Life Spiral Model

Early family life cycle theorists developed lineal models of the family life cycle

(Carter & McGoldrick, 1988; Duvall & Miller, 1985; Olson et al., 1983). However,

families do not ordinarily have a beginning and an end but rather continue on with births of

new members and deaths of others, adding generation upon generation. In accordance

with the repetitive recycling of the family life cycle stages and developmental tasks,

Combrinck-Graham (1983) devised the Family Life Spiral Model (Figure 1). Here the

cycles of the individuals in the family are related to each other across three generations

(Combrinck-Graham, 1985). The model represents the continuous spiral of family

evolution, portrayed in a three-generational span. The spiral is compact at the top to signify

periods of family closeness and spread out at the bottom to represent periods of family

distance. The compact periods reflect centripetal (CP) tendencies; the spread out periods

reflect centrifugal (CF) tendencies.

The integral concept in this model is that of the family's oscillation between CP

phases when it is most cohesive (birth, childbearing, and grandparenthood) and CF stages

when it is least cohesive (adolescence, the 40s reevaluation, and retirement). These terms

are borrowed from physics to describe the presence of opposite forces at work in

propelling developmental change in families; one force predominates at one stage of

development, while the other force predominates at the opposite stage. When a family is at

a CP phase in the life spiral, they are primarily looking for gratification from within the

family and the external boundary around the family restricts influence from the outside. At









CF phases, families are looking for gratification outside the family unit, and the family's

external boundary is relaxed in order to facilitate achievement of associated developmental

tasks (Beavers, 1982).

The use of the terms centrifugal and centripetal to describe family behavior is not

original with Combrinck-Graham's Family Life Spiral Model. Erikson (1963) used the

concepts in describing differences between two Indian tribes, the Sioux and the Yurok, in

the 1920s. Stierlin (1973) and associates (Stierlin, Levi, & Savard, 1972), in researching

adolescent runaways, discussed patterns of CF versus CP separation in adolescents and the

implication of these patterns for understanding runaway youth. The CP families were

described as having tight external boundaries, with families geared to meeting one

another's needs within the confines of the family. Excessive CP relationship styles often

are smothering to adolescents who are developmentally driven to differentiate from their

family members. An overinvolved parent and a "sick," detached, or destructive child are

often examples of these extreme CP styles. On the other hand, given a lack of clear

external boundaries and promoting a CF relationship style too soon leads to pushing the

adolescent out into the world prematurely. These patterns are more often evident in cases

of parental rejection and neglect (Stierlin et al., 1972). The forces of CP and CF are

generally functional for families but become dysfunctional when they are inappropriately

timed or excessively intense (Stierlin, 1972). When runaways fail, the assumption is that

the family uses CP and binding styles which block the adolescent's separation. When

runaways succeed, CF styles are assumed to be present in the families, and the use of

expelling dynamics pushes the adolescent out into premature autonomy (Stierlin, 1973).

The Timberlawn study of healthy families (Lewis et al., 1976) also used the CP/CF

concepts. The researchers initiated the development of a model of family patterns and

processes which correlates with the functioning capacities of offspring (Beavers, 1982;

Beavers & Hampson, 1990). In the Beavers Systems Model one continuum describes five









levels of family functioning: optimal, adequate, midrange, borderline, and severely

disturbed. The other continuum describes the family relationship style from CP to CF; the

extremes of CP and CF are associated with severely disturbed families, whereas the most

competent families avoid either extreme, tending to display a mix of CF and CP along the

developmental life cycle, more CP in the early years and more CF as the children approach

adolescence. Beavers' (1982) research indicated that there was a correlation between the

relationship style (CP or CF) and the kind of psychopathology found in the family. A

family whose predominant force is CP and who has not shifted its boundaries as children

approach adolescence is likely to experience dysfunction. Conversely, it is difficult to

effectively parent very young children with a CF relationship style because of the lack of

clear external boundaries and structure. At the extremes, CP families bind children and

make leaving difficult; CF families expel children before their individuation is complete.

Differences were also noted in the way CP and CF families handle ambivalent feelings

(Beavers, 1982). The CP families will try to repress or deny negative feelings and

emphasize the positive ones which serve as the glue for the CP style and are more

comfortable with negative or angry feelings which provide the force for outward

movement.

Upon examining the Family Life Spiral Model, it is noted that each spiral in the

model represents approximately 25 years, for example, from birth to childbearing is one

full cycle. At each new CP period, the generations change roles and status

(Combrinck-Graham, 1985). Moving back and forth between these two opposite styles

allows family members several opportunities to gain increasing mastery over the issues of

intimacy inherent in the CP stages and individuation in the CF stages (Combrinck-Graham,

1983). For an individual whose life spans three generations, there will be three periods of

CP family life and three of CF family life in which to master the challenges of intimacy and

individuation.









The transgenerational coming together and internal focus of the family at CP phases

is in evidence as family members organize around the event of a new birth in the family.

When a new generation has been added, the roles of the older generation are altered: The

childless couple are now parents: the couple's parents are now grandparents; sisters and

brothers are now aunts and uncles. All are in the process of learning new roles because of

the arrival of this new child. Bonding and attachment become the focus of relationships in

the family with the infant, emphasizing nurturing and caretaking (Combrinck-Graham,

1985, 1990). Family members, especially grandparents, come to see the new baby and

help out in the adjustment phase. Mother and father rework their schedules around the

baby's needs, and, for an extended period of time, life revolves around this new arrival.

The creation of a new "family" generates a tightening of the external boundaries of the

family unit and a relaxing of the interpersonal boundaries within the family to allow for

assimilation of this new arrival into the family system, to promote teamwork within the

family, and to provide the context most suitable for an infant's early development

(Combrinck-Graham, 1983).

Over the next 12 to 18 years the family changes to allow for the individuation of

this child by relaxing its external boundaries and shifting to a more CF relationship style.

The family develops patterns of relating that allow for differentiation and disengagement of

all the members (Combrinck-Graham, 1985). Outsiders are allowed into the family more

and more, and family members venturing out of the family gain a new perspective about

their own family. As children individuate, parents are freed to pursue their personal

development a little more, slowly modifying their family structure in response to greater

exposure to social forces. At the same time, grandparents, too, are redefining their

relationships with the larger society, with extracurricular activities occupying more of their

time (Combrinck-Graham, 1983).









As families enter into the CF stages of the family life cycle (adolescence, 40s

reevaluation, and retirement), the distance between family members is at its greatest; the

external boundary of the family is very diffuse; and family members are generally looking

for satisfaction outside the family unit. Family members are working on issues that

emphasize personal identity and autonomy, learning to differentiate and individuate from

the family system. Adolescence is the most CF period in the family life cycle, illustrated by

their normal interest in their peers and their adoption of role models other than their parents

(Combrinck-Graham, 1988). The stage of adolescence is noted for being one of the most

stressful phases of the family life cycle, with boundaries, functioning, and alliances being

very fluid and generating reverberations throughout generations of the family (Ravenscroft,

1974).

When all the children have reached this point and left home, there is another period

of reassessment with parents renegotiating their marriages, careers, and life directions, and

grandparents shifting gears into retirement. When the launched children begin to marry and

form their own family units, the family is beginning another shift towards a more CP

system, negotiating peer-like relationships between newlyweds and parents and the

reforming of structures conducive for the CP period of childbearing. Older generations

may be brought closer to their children through infirmity or because they simply have more

time after retirement (Combrinck-Graham, 1983, 1985).

Exceptions to the model. The Family Life Spiral Model illustrates intergenerational

family relationship patterns as the "normal" three-generational family moves through the

life cycle. When generations are separated by about 25 years, the CP and/or CF movement

of the system applies to all the generations simultaneously. However, complications

appear when the CP family members of the newborn's family do not fit the normative

expectations. For example, the parents are single or not married; the parents are adolescent;

the parents are much older than usual for parenting; the parents are significantly different in









age; the parents) has abandoned the child to be raised by grandparents; or the parents are a

remarried family (Combrinck-Graham, 1983, 1985).

A different kind of challenge is presented in a family with many children, from

young adults to newborns. These families must continue the process of allowing the

differentiation of the young adults while still providing clear structure and boundaries for

the younger childrenn. Many times these families remain in prolonged CP states, and

young adults achieve some of their CF differentiation by participating in the care of

younger children.

An even greater complexity is added by remarried families and blended families.

One spouse may have children at a CF stage; the other spouse's children may be at a

CP-CF stage; and the newly blended family may choose to have a child of their own,

necessitating a CP relationship style (Combrinck-Graham, 1983, 1985). The stress on this

blended family would be expectedly high and the demands for flexibility enormous. As

Carter and McGoldrick have written (1988), these families have their own separate set of

developmental tasks imposed upon the normal family life cycle.

Relationship between model and impact of death. Combrinck-Graham (1985)

discussed the developmental misfit that can occur when a family system does not change to

become more CP or more CF as the stage of the family life cycle requires. Numerous

theorists have suggested that symptoms in a family are often signs of developmental misfit

(Carter & McGoldrick, 1988; Haley, 1980; Stierlin, 1972, 1973; Stierlin, Levi, & Savard,

1972). If a family is at the stage of adolescence but is predominantly using CP relationship

styles, one would expect to see symptomatic behavior and thus a higher level of stress in

the family's interactions.

Combrinck-Graham (1983) discussed the impact of death on families at both CF

and CP periods in the life spiral. Although Combrinck-Graham originally hypothesized

that death might have a more severe impact on families that were not at a CF period since









death was seen as a departure, she also noted that death has the effect of bringing family

members together, especially if there is a chronic illness preceding the death that

necessitates family members serving as caregivers. Members come to participate in funeral

and mourning rituals, and initial grieving is done in the company of other family members.

Rolland (1987a, 1987b, 1988a) offered a conceptual framework for the

interweaving of the family life cycle and the concepts of CF and CP with chronic and

life-threatening illnesses. He hypothesized that chronic illness exerts a CP pull on the

family system. In much the same way that birth of a new family member propels family

members inward, so does chronic illness. The symptoms, loss of function, shifting roles,

and the fear of death all cause the family to refocus inwardly (Rolland, 1987a). If the

illness coincides with a CF period for the family, for example, as young adults are

launched, it may cause more problems because it is contrary to the momentum set in motion

by the normal progression of the developmental life cycle. Giving up the pursuit of a new

life structure is more difficult once that process has been initiated than if the plans for such

have not been made or are only in the preliminary, less formulated stages (Rolland, 1987a).

Every family member's autonomy and individuation are affected. The severity of the

disease and the family's dynamics will influence whether their return to a CP structure is

temporary or a permanent involutional shift. For more fused families who face autonomy

with a bit of caution, the chronic illness may provide a good rationale for returning to, or

staying at, a CP period. This may merely prolong this period, or, at the worst, the family

may become permanently stuck with no one able to leave home or move on with their

developmental tasks (Detmer & Lamberti, 1991). The risk is that there may be a tendency

for the CP pull of the illness and the CP stage of the family to amplify one another, creating

overt family dysfunction.

The tendency of a disease to interact centripetally with a family grows stronger as

the disease becomes more incapacitating or as the risk of death increases (Rolland, 1987a).









Progressive diseases are more CP in terms of their effect on families than are

constant-course illnesses. With constant-course illnesses, a family may be permitted to

enter or resume a more CF phase once the family has adapted to their roles in regard to the

illness.

The terminal phase of an illness forces most families back into a CP mode. Thus,

they are out of phase with families in, or in transition toward, a more CF period, and,

therefore, this phase will be more disruptive in terms of family development. Coping with

chronic illness and death are considered normative tasks in late adulthood. If they occur

earlier, they will produce more stress in the individual and the family (Rolland, 1987a,

1987b).

Lewis (1986) noted that most individuals live with some type of balance between

separateness and attachment. There are periods when individuals are more intensely

connected to another persons) and periods in which the individual is more detached from

others. Affective arousal is more apt to be associated with periods of attachment, and a

more cognitive orientation prevails during periods of separation. Many people move back

and forth between separateness and attachment; others seem to remain relatively fixed with

either separateness or attachment dominant. Lewis sees well-functioning families as

allowing both. Stress, he says, arises when individual family members' needs for

separateness and attachment occur at different times.

Later, Lewis (1989) theorized that if family members have too much connectedness

or too little connectedness, they may not be able to respond to developmental challenges

with appropriate increases in CF or CP styles. Thus, if death were a CP force, as Rolland

hypothesized, it would be hardest for CF families to respond appropriately. Taking an

epigenetic approach which involves the idea that successful negotiation of developmental

transitions are dependent upon successful completion of earlier transitions, Lewis (1988)

suggested that how a family responds to structural changes demanded of them depends on









the level of family competence during the preceding stable period. He concluded that the

relationship between family transitions to development of symptomatic states may be

different at different transition points.

Rosen (1990a) has written that at every stage of the family life cycle both CF and

CP forces are at work, although one tends to dominate. Regardless of where the family is

in the life cycle, crises produce a powerful CP force. This may aid the family in managing

the crisis, but it may also have the effect of closing the family's external boundary so

rigidly that they are prevented from receiving help from outside sources. The CP effect of

the crisis may make it difficult for the family to proceed with future developmental tasks.

Centripetal families may find their development arrested or regressing symptomatically; CF

families may put their individuating tasks on hold and move in closer, causing violation of

family boundaries as individuals in overlapping life cycle stages each try to play significant

roles. The problems that poses for a family are documented in a paper by Britton and

Zarski (1989) which points out the CP pull of a family member with AIDS on a family at a

CF stage in the life cycle.

Rosen (1990b) has observed that there are fundamental differences in the ways

death will impact families at varying stages of the family life cycle. Because of the

difference in developmental tasks at the various stages of the life cycle, some focused more

on disengagement and leaving, others on consolidation and drawing together, the family's

ability to adapt to the loss is correlated with their developmental stage. At CF stages such

as adolescence and young adulthood, the terminal illness and imminent death may be an

impediment to the developmental task of leaving home or may create such despair about the

past that the family refuses to continue with life's tasks. A loss at CP stages, such as

newly married couples, families with young children, or families who have launched their

children, may create a developmental arrest in the family process. The couple may tighten

the external boundary on their family so much in an effort to protect their children that









developmentally the family is kept from moving towards a more CF style as the children

grow and mature.

When families are in the process of reorganizing after a loss, family boundaries

may remain ambiguous or change in response to the stress the family has experienced.

Boss (1980) proposed that the greater the boundary ambiguity after a stressor event, the

higher the family and individual ambiguity. Failing to delineate the boundaries clearly

serves to keep the family's stress at a high level, blocking them from reorganizing and

developing new styles of functioning.

Predictions

Walsh and McGoldrick (1991) have noted the lack of research on the differential

impact of death at various stages of the family life cycle and for the family as a unit. "Even

when the importance of a particular death has been noted, our theory has lacked a

framework for understanding the devastating impact certain losses can have on family

processes and has made little sense of the ongoing problems that may follow from a

family's inability to mourn its losses" (Walsh & McGoldrick, 1991, p. xvi). Insufficient

attention has been given to the immediate and long-term effects on siblings, grandparents,

and other extended family members when loss of an immediate family member occurs

(Walsh & McGoldrick, 1987).

How a family responds to stressful life events such as death appears to depend then

in part on the family's position in the family life cycle. The probability of a family

experiencing the death of one of its members increases as the family moves farther along in

the life cycle. As Olson et al. (1983) noted in their study of normal families across the life

cycle, a family's stress level peaks at adolescence and the launching of children and then

declines significantly (Table 1). Although Olson's stages of the family life cycle do not

coincide perfectly with those of the Family Life Spiral Model, the stress levels of families at

those stages are congruent with the theoretical literature about family stress and the family









life spiral stages. It is impossible to compare the later stages of Olson's family life cycle

with the Family Life Spiral Model. He has reduced Combrinck-Graham's four stages of

grandparenthood, planning for retirement, retirement, and late adulthood to two--empty

nest and retirement. However, if death occurs late in the life cycle, as in late adulthood,

even though it is more of an expected event and the family can be expected to cope more

successfully because it is "on time," it does coincide with the one point in the family life

cycle where family stress is the highest for the younger generations, that of launching.

Perhaps the declining health and death of one of their older members is a factor contributing

to the high stress associated with this stage.

Whether or not death is a universal stressor causing a similar amount of added

stress at each level of the life cycle is unknown. Given the magnifying effects of the pile

up of stressors, one might expect that a death at the launching stage and, therefore, in the

CF-*CP phase would produce far greater stress on the family system than a death at the

couple stage, if Olson's study of normal families gives us any clues. Lewis's (1986)

hypotheses about stress arising when individual family members' needs for separateness

and attachment occur simultaneously would correlate with the theory proposed here that

death creates a need for attachment in families, and if that occurs at a time when members

are developmentally separated, there would be higher levels of stress and symptomatology.

However, if death has a CP pull, as Rolland (1987a, 1987b, 1988a) suggested, then one

would expect that it may produce more stress on the family who is CF.

Other Variables Impacting Death that May be Expected
to Vary by Life Cycle Phase

Several other variables that affect how a family might be impacted by the death of

one of its members could be expected to vary throughout the course of the family life cycle

as families oscillate back and forth between CF and CP phases. Those variables are social

support, cohesion, adaptability, and communication.









Social Support

Given what has been documented about the differences in family relationship styles

depending upon their CF or CP phase in the family life cycle, one might expect that there

would be a greater utilization of external supports by CF families since their orientation is

outward, implying a greater reliance on and trust in relationships and resources outside the

family in order to meet developmental tasks. The CP families might be expected to rely

more on internal supports from the family itself given their inward orientation and tendency

to have tight external boundaries and more trust in family members than in outside

resources. No definitive answer is available from the literature, but some hypotheses may

be generated.

In the family stress literature, social support is an oft-cited resource for family

adaptation. Cobb (1976) defined social support as information exchanged at the

interpersonal level which provides (a) emotional support, leading the individual to believe

that they are cared for and loved; (b) esteem support, leading the individual to believe they

are esteemed and valued; and (c) network support, leading the individual to believe they

belong to a network of communication involving mutual obligation and mutual

understanding. McCubbin and Thompson (1991) added two other forms of support under

social support: (a) appraisal support, which is information in the form of feedback

allowing the individual to assess how well they are doing with life's tasks, and (b) altruistic

support, which is information received in the form of good will from others for having

given something of oneself. Social support may include support from family members or

from friends, neighbors, work associates, social or church groups, or health care

providers.

The social support families are able to mobilize when facing a chronic illness is

believed to be critical in how a family adapts (Ireys & Burr, 1984) and is assumed to be the

case when the chronic illness becomes terminal and death ensues. Those with a large









extended family from whom to draw support tended to get on with life after suffering a

death of one of their members as opposed to members who each had their own separate

circle of friends from whom they derived most of their support (Ellard, 1974). In some

cases, families reported that support from immediate family members was most beneficial

to them in coping with the death and that various institutional resources such as the church

were not seen as helpful (Weber & Foumier, 1985). Others reported that the bereaved

families who heal satisfactorily report access to and use of an extended support

network--family, friends, neighbors, religion, family cohesion, and involvement outside

the family system (Valeriote & Fine, 1987).

In a research study of parents who experienced the death of an infant, bereavement

was much more difficult because of the lack of societal and family support (Helmrath &

Steinitz, 1978). There was a "conspiracy of silence" by family and friends that produced

immediate distress and feelings of extreme isolation in the parents. In another study of

families who had experienced the death of a child due to cancer, those who were found to

be coping well had utilized a variety of resources, including friends, community agencies,

hospital and support teams, and each other. They felt free to ask for help or reject

unwanted offers. Families who were not coping as well were unable to seek support from

anyone (Davies, Spinetta, Martinson, McClowry, & Kulenkamp, 1986). Older parents'

reactions to the death of their adult child were hypothesized to be contingent largely upon

the formal and informal social support the elder parents could access. Supports outside the

family are generally quite minimal for the elderly, and so much of the support is left up to

the remaining family members (Brubaker, 1985).

Elizur and Kaffman (1983) conducted a longitudinal study of children in Israel who

lost their fathers and concluded that half of the children exhibited intense emotional

disturbance. Their findings suggested that predeath family and environmental factors are

significant determinants of bereavement outcome. Children at low risk had mothers who









enlisted aid from the community whenever necessary; thus, external social support was

seen as an important variable.

In a research study of bereaved widows, the type of support needed and found to

be utilized varied depending on the phase of the grief process. New widows needed the

nurturance and dependence that was best met by family members, but as they began to put

their lives back together, there was significantly more involvement with peers. A very

close-knit kin network was seen to impede that process, perhaps encouraging dependency

(Bankoff, 1983). The CP families would be more likely to be defined as a close-knit kin

network.

Bass et al. (1990) compared participation in social activities between bereaved

spouses and bereaved adult children and found the former group increased their

participation in outside activities such as going to dinner, shows, concerts, or the theater

more so than the latter group. This is understandable in terms of the bereaved spouse

feeling more compelled to reorganize social ties than an adult child whose associations and

daily routines are not generally contingent upon the parent's involvement. Bereaved

spouses had significantly larger networks of support than bereaved adult children. No

differences between relative support or paid or professional helpers were noted, but there

was a significant difference between use of friends and neighbors. This is corroborated by

Lund et al. (1990) who found familial support remaining steady for bereaved spouses but

dramatic increases in associations with peers.

In a longitudinal study of stress and illness, Cronkite and Moos (1984) found that

the use of avoidance-coping strategies among women was associated with higher stress and

lower family support. Similar findings by Holahan and Moos (1985, 1986) indicated that

women who were experiencing high stress but low symptomatology had better family

support than those with high stress and high symptomatology. A 1-year follow-up also

demonstrated a strong negative correlation between the high stress/low symptomatology









(better family support) group and the emotional and physical distress in both men and

women. Their conclusions were that the availability of family support serves to protect

individuals from negative psychological consequences of stress, more so for women than

men. Developing an expanded support network may be particularly beneficial to women

facing bereavement (Holahan & Moos, 1986).

Rando (1984) noted how critical social support is for people in bereavement, not

that it is just available but that it is utilized as time goes on. She indicates that it is common

for grievers not to utilize support that is offered and to isolate themselves despite the

availability of support.

Rosen (1990a) has noted instances where the absence of social support in

bereavement affects the family's ability to mourn its loss. Those instances are perinatal

death, the loss of a newborn in the first few weeks of life, and an AIDS-related death. In

the latter instance, the social stigma is such that AIDS survivors experience

"disenfranchised grief." They do not feel entitled to grieve publicly or ask for help in

working through that grief and, thus, are alienated from the support needed to resolve their

grief (Rosen, 1989; Williams & Stafford, 1991). Death by suicide also brings with it a

social stigma that can produce a conspiracy of silence between the family and their support

network (Bolton, 1984; Brown, 1988; Imber-Black. 1991).

The nature of terminal illness and death is such that it often isolates families from

external support networks such as friends, work, and church. As the CP pull of the illness

and death increases, the family becomes more isolated and closed. Cohen et al. (1977)

found that families who were able to communicate with one another in a free flow of

information were more likely to utilize internal support systems (primarily the family

structure) than were their counterparts. Postdeath restabilization was positively correlated

with the effective use of external support systems such as agencies, institutions, and

individuals outside the nuclear family and also with the family's classification as CP.









In another study, it was found that parents and siblings of children who died

experienced less psychopathology postdeath when they cared for their children at home and

had good family support (Mulhem, Lauer, & Hoffmann, 1983). There was a significant

difference between the home care and nonhome care groups in their preference for social

isolation, with the nonhome care group scoring higher in social isolation. This suggests

that families who utilized family support also utilized social support, which is in accordance

with the research of Cohen et al. (1977) that indicated CP families actually made more

effective use of external support systems than CF families. This is one of two pieces of

literature in the social support field that incorporates the concepts of CF and CP. Olson's

study of normal families across the life cycle (Olson et al., 1983) is another and did show

that there was a positive correlation between low stress families in the childbearing/

childrearing stages (CP) and their use of social support. These findings are contrary,

however, to the constructs of the Family Life Spiral Model and the descriptions of CP

families which suggest that their external boundaries are tight so as to filter that outside

influence more selectively.

Clearly, social and familial support are important factors in how a family copes with

the stress of death of one of its members at some stages of the family life cycle. Whether

there are significant differences in a family's use of one or the other of those support

systems, depending upon their stage of the life cycle when dealing with the stressor of

death of a family member, is unknown.

Cohesion and Adaptability

The relationship between family cohesion and adaptability and a family's ability to

cope with death has been described and documented in the writings of Walsh and

McGoldrick (1991). How these variables might interface with the variations of family

relationship styles when they are at CF or CP phases of the family life spiral is unknown.









Cohesion is defined as the degree of separation or connection between family

members and primarily concerns the emotional bonding members have with one another

(Olson et al., 1985). It might be reasonable to expect that families would score higher on

cohesion at CP phases than at CF phases, given the inward focus and orientation of CP

phases.

Adaptability is the extent to which the family system is flexible and able to change

its power structure, roles, and relationship rules in response to situational and

developmental stress (Olson et al., 1985). The role realignments and reorganization that

are necessitated after a loss are often immense, perhaps especially so the earlier in the

family's life cycle the death occurs. Families who functioned well after the loss of a child

due to cancer were open, flexible, and adaptive in response to the death (Davies et al.,

1986), as opposed to less functional families who were unable or unwilling to make

changes to take them past their sadness.

Olson (1988) noted the variation in family cohesion across the life cycle in his study

of normal families (Figure 3). Cohesion remained essentially the same from young couples

without children through families with children ages 6 to 12. At that point, cohesion

steadily declined, reaching its lowest point when families were at the launching stage and

rising again until retirement when it leveled off, indicating it was a resource utilized more in

the early and late stages of the family life cycle rather than at adolescence and launching.

If this segment of the family life cycle is superimposed on the Family Life Spiral,

one can begin to see the oscillations between levels of cohesion throughout the life cycle,

not just the one dip that is shown in Olson's graph which would represent one of the three

life cycle oscillations in the Family Life Spiral. Olson begins the life cycle with the newly

formed couple, eliminating birth, childhood, and adolescence, and flattens the life cycle

past launching which obscures any patterns that may exist. If levels of cohesion are indeed












70-


68-


S66
0
064


62-
I I I I I I I
1 2 3 4 5 6 7

Stages of Family Life Cycle




Figure 3. Cohesion in Normal Families Across the Life Cycle
Source: Families: What makes them work, D. H. Olson et al., 1983, p. 83.
Note: l=Young Couples without Children
2=Childbearing Families and Families with Children in the Preschool Years
3=Families with School Age Children
4=Families with Adolescents in the Home
5=Launching Families
6=Empty Nest Families
7=Families in Retirement









related to CF and CP relationship styles, then one may very well expect differences in

cohesion in accordance with the oscillations of the Family Life Spiral.

The differences in family adaptability parallelled the pattern seen with the cohesion

scale although the differences were not as pronounced (Olson, 1988). Scores on family

adaptability progressively decreased from the newly married couple through adolescence

and then increased again after the launching stage.

A pilot study (Jordan, 1991) of the relationship between cumulative loss from four

generations, current stress, and the family's current functioning provides findings that

correlate with Olson's (1988) study. Families studied were those with an adolescent or

young adult in the launching phase. Relationships were found between past stressors,

number of deaths, especially premature deaths, and the family's levels of cohesion and

adaptability. Families with higher levels of past stressors and numbers of death had

significantly lower levels of cohesion and adaptability. How much of the variance is due to

the stage of the family life cycle is unknown since the sample focused on the adolescent and

launching phases. The results do add support for the hypothesis that CP families would

score higher than CF families on adaptability as well as cohesion.

In Olson's Circumplex Model of the family system, families are categorized

according to both their cohesion and adaptability scores. Depending upon their degree of

connection and flexibility, they fall into 16 different subtypes, combining their scores on

each continuum. The linear scoring for each of the scales with cutoff scores is in Appendix

I. That there may be a relationship between these subtypes and the effects of stress was

shown in a later study by Olson and Stewart (1991). Their research results indicated that

these subtypes explained some of the differences in the family's response to stressful life

events. "Flexibly connected" families were more vulnerable to the accumulation of

stressful events; "structurally separated" families seemed to more affected by transitional

changes. "Flexibly separated" and "structurally connected" families were affected by both









stressful events and transitions. Thus, it is suggested that the effect on families of life

events and transitions is influenced by cohesion in conjunction with adaptability.

Communication

Olson (1989) defined positive communication skills as sending clear and congruent

messages, empathy, supportive statements, and effective problem-solving skills. Negative

communication skills include sending incongruent and disqualifying messages, lack of

empathy, nonsupportive (negative) statements, poor problem-solving skills, and

paradoxical and double-binding messages. In Olson's Circumplex Model, parents from

balanced families tended to have more positive communication skills than extreme families

which was corroborated in a research study by Rodick et al. (1986).

When a family member has died, the emotional intensity in the family system can be

expected to rise significantly above normal. The ability of family members to stay

nonreactive while thoughts and feelings are exchanged between them is an important factor

in the family's long-term adjustment to their loss (Brown, 1988; Rando, 1984; Rosen,

1987). The more families have been able to share their thoughts and feelings prior to the

death, the more likely they are to remain nonreactive when the death occurs (Sanders,

1989). The longer and more intense the stress, however, the more difficult it is for the

family relationships to remain open (Herz, 1980). Sanders (1989) writes that remaining

open is perhaps one of the most important tasks families can learn to do in order to prevent

misunderstandings arising at the time of death. Families who have good open internal

communication systems are more likely to discuss the death and plan for the reorganization

of the family.

How permissible it is to express a full range of feelings, from positive to negative,

from sadness to anger, or guilt and relief, plays a significant role in how well a family

readjusts (Lamberti & Detmer, 1993; Vollman et al., 1971). A family that responds with

love and compassion but never with anger, sadness, or joy would be constricted and not as









apt to adjust effectively (Epstein, Bishop, & Levin. 1978). Black and Urbanowicz (1987)

found that in families where one of the parents had died, avoidance of talking about the

dead parent was associated with poorer outcome at 1-year follow up. By 2 years there was

no significant difference.

The openness that allows family members to grieve together and review and mourn

the lost relationship facilitates mutual comfort and consolation from one another, often

pulling the family closer together than they were before (Sanders, 1989), and helping to

insure that the grieving will not become blocked or unresolved (Paul & Grosser, 1965;

Raphael, 1983). Open communication also is a factor in how well the family renegotiates

their roles in a manner that fits with the capabilities of family members (Vess et al.,

1985-1986).

Cohen et al. (1977) researched the postdeath adaptation of families of cancer

patients in a longitudinal study. They found that, in addition to the family's stage in the life

cycle, how well family members communicated with one another, sharing information and

decision-making, correlated with their postdeath adjustment. Families rated open in their

communication were more flexible about changing roles and had better quality of family

relations postdeath. A significant finding is that the wife-mother was often found to have

the role of family communicator, and when she was the deceased, a family's readjustment

was significantly jeopardized, pointing out that alternate channels of communication need to

be opened up prior to the death of patients who hold those roles in families.

Because of their inability to communicate openly, parents who have lost a child

often shut themselves off from one another (Schwab, 1992). Grief work is often highly

private and intense, and the desire to not stir up their spouse's emotions by talking about

the child who has died contributes to that cutoff in communication. In a study by Davies et

al. (1986), one of the characteristics of families who coped well with the loss of a child due

to cancer was their openness. There was free discussion about the child's death and each









member's response to that. Disagreement was allowed and served as an opportunity for

clarification. Closed families spoke for one another, and although there was a lot of talk, it

was diverted away from discussion about the deceased child.

When a family member dies, the pain that the survivors experience can be difficult

to verbalize which may lead to an increasing sense of loneliness and isolation as

communication dwindles (Fleming & Adolph, 1986). A closed communication structure

may produce members who do not know how to talk about their feelings, and they,

therefore, keep their grief to themselves, restricting the grieving process (Vess et al.,

1985-1986). On the other hand, they may know how but feel it is important to protect

others by coping with their grief alone, which separates family members from one another

and builds barriers to the grieving process (Ireys & Burr, 1984). Families with closed

communication styles may present a good front to outsiders yet not be open with one

another; there is a "conspiracy of silence" which becomes nonadaptive, preventing social

support as well as intrafamilial support (Rosen, 1987; Sanders, 1989).

Lewis et al. (1976) carried out a research study on the openness with which

families dealt with the theme of loss. They found a correlation between the families' verbal

responses to a video simulation of a family death and their ability to discuss their reactions,

and the amount of physical illness the families recorded over the ensuing 6-month period.

Families who were able to discuss death in a personal way, as opposed to impersonally or

avoiding the topic altogether, had a significantly greater number of days in which family

members were all well.

Another factor blocking communication after a death in the family is that family

members each will grieve in their own way and at their own pace. Frustration builds as the

awareness of differences increases, making family members unable to be of support to one

another. In a study by Feeley and Gottlieb (1988-89), there was a correlation between

parents' coping and communication following the death of their infant. The mothers in









couples who had more discordant ways of coping with the death perceived higher levels of

aversive communication (hostility and conflict) with their spouse. Mothers who had

difficulty discussing the event with their spouse reported more intense mourning. Women

who reported improved marital communication reported fewer bereavement symptoms.

Helmrath and Steinitz (1978) conducted a study of parent couples who had

experienced the death of their infant and noted differences between fathers who were able

to be distracted from the grieving process while they were out of the home at work for 8 to

10 hours a day and the mothers who remained at home surrounded by their feelings and

thoughts of grief with no one with whom to share them. Having anguish unloaded on

them by their wives when they returned home from work became more and more

problematic, creating more distance between the couples because of their inability to

understand the differences in their feelings. When the lines of communication were opened

between them, grief resolution began to occur.

Parents who were very close to their adult children and had good communication

with them during the illness preceding their child's death reported less guilt and unfinished

business with their child at the time of death (Shanfield et al., 1984). Children from

families where the communication is open between parent and child cope much better with

death-related experiences and will be more likely to receive the necessary emotional support

(Weber & Fournier, 1985). In a study of adolescent reactions to parental death, despite

open discussion of parental illness and impending death, communication patterns

reportedly changed between the surviving parent and the adolescent after the death

(Berman, Cragg, & Kuenzig, 1988). Conversation decreased due to reluctance to discuss

their feelings and a sense of needing to protect the surviving parent. Instead, the adolescent

talked with siblings and friends about their feelings. Mothers of children at low risk for

poor adjustment to the death of their fathers were found to promote open and clear

communication and free expression of feelings (Elizur & Kaffman, 1983). Young adult









drug addicts had experienced more deaths of immediate family members than a normal

sample and perceived their families as discussing death and dying less frequently (Coleman

et al., 1986). The authors surmised that the family environment that minimized the impact

of death and avoided discussing death-related issues was related to the subsequent

substance abuse of the young adult.

Walsh and McGoldrick (1987, 1991) emphasized the importance of clear

information and open communication about the death as one of the essential tasks in the

family's adaptation to loss, especially in the activities denoting the death, such as the

funeral and graveside services. When there is an attempt to protect children or vulnerable

members from those experiences, the grief process is apt to become blocked. The inability

to accept the reality of death may ensue and often is a contributing factor to cutoffs,

conflicts, and barriers being erected between family members. Secrets, myths, and taboos

surrounding the death make it difficult for the family to resolve the loss and "the

unspeakable is more likely to be expressed in dysfunctional symptoms or destructive

behavior" (Walsh & McGoldrick, 1991, p. 17). Walsh's research (1982) on

well-functioning families presented evidence that clear, direct communication facilitates the

family's adaptation and strengthens the family as an internal support network.

Rosen (1987, 1990a) also discussed the importance of the openness of the family

system in terms of its ability to permit communication on any subject without fear of being

censured or rejected. In an open family, members are free to express their thoughts and

emotions; closed families discourage and invalidate ideas or feelings that are deemed

unacceptable.

Rosen (1990a) has written that where families fall on the open and closed

communication continuum is directly related to family boundaries in general. Those

families with rigid external boundaries can be expected to have more closed communication

styles; families that have open communication also have more open and fluid external









boundaries. Thus, in terms of CP and CF, it might be expected that families who are CP

will have more closed communication styles, and CF families will have more open

communication styles. Olson's study (Olson et al., 1983) of normal families across the life

cycle indicated that low stress was positively correlated with good communication at all

stages of the family life cycle, except at empty nest and retirement, suggesting that those are

resources that are underutilized at those stages. The associations of this variable then seem

to be in contrast with previous predictions about which phases of the family life spiral, CP

or CF, are apt to have the greatest difficulty in adapting to a loss. If CF families are

suspected to have a more difficult time, but have more open communication styles which

are related to positive outcome, then their adaptation would clearly be positively affected by

that variable but negatively affected by cohesion and social support.

Conclusion

A family's position in the family developmental life cycle has long been a key factor

to consider in making an assessment of families. It is believed to be a significant

determinant of normative stressors as families undertake the series of developmental tasks

that are necessary to negotiate the entry and exit of family members over the course of time.

Previous researchers have delineated some of the normative stressors that are associated

with various stages of the normal family life cycle (Olson et al., 1983). Family therapy

theorists and researchers have postulated that timing in the life cycle is a key variable in

determining the impact of death on families but no definitive empirical research has been

done to test those theories (Brown, 1988; Combrinck-Graham, 1983, 1985; Herz, 1980;

Herz Brown, 1988; Rolland, 1987a, 1988b, 1990; Rosen, 1990a, 1990b; Walsh &

McGoldrick, 1991).

Loss of a loved one is one of the most stressful events families face. As families in

recent generations have had more limited exposure to the death and dying process, many

have not acquired the adaptive skills that help them effectively adjust to the many changes









that are necessitated when one of their members dies. Quite often one or more of the family

members will present to mental health professionals for help in dealing with symptomatic

behavior that is associated with a death in the family. As a profession, mental health

practitioners must be aware of the variables that impact how a family is affected by the loss

and be able to assess what the family needs in order to move on in the developmental

process. If families can be identified as being at higher risk for problematic coping with a

death, counselors and agencies working with patients and families facing death may be able

to design interventions more effectively which prevent further trauma to the family unit and

promote appropriate healing for all involved. Numerous variables have been postulated in

the literature: timing in the life cycle, role of the deceased in the family, openness of

communication in the family, use of appropriate rituals to commemorate the loss, nature of

relationship with the deceased (conflicted, estranged, or harmonious), social support,

flexibility in adapting to change, cohesiveness of the family unit, whether death is expected

or unexpected, length of illness, nature of the death (murder, suicide, chronic illness,

AIDS), religious beliefs, and ethnicity. Very few definitive studies exist, however, testing

these hypotheses.

This study measured the impact of the death of a family member on surviving

members according to the timing of the death in the family's life cycle; selected other

variables known to impact the family's experience of a death that may differ by the family's

place in the life cycle were also assessed. If significant differences between families at

various stages of the family life cycle are identified, then appropriate interventions need to

be designed for those target populations.













CHAPTER 3
METHODOLOGY


And you would accept the seasons of your heart,
even as you have always accepted the seasons
that pass over your fields.
And you would watch with serenity
through the winters of your grief.
--Kahlil Gibran


Statement of Purpose

The purpose of this study was to determine whether there were differences in the

levels of stress reported by families at different phases in the family life spiral when they

had experienced a death in their family. Four phases were identified: periods of more

centrifugal (CF) orientation or more centripetal (CP) orientation, and the two transitional

phases between those phases. Specifically, predictions generated by the theory behind

Combrinck-Graham's Family Life Spiral Model were tested, namely, that death would

have a more stressful impact on families at CF phases of the family life cycle than at other

phases due to the CP pull of death, which is contrary to the momentum and organizational

patterns that are normal for families at CF phases.

Numerous family resource variables are known to affect the level of stress

experienced with the death of family members: several of these variables were also

measured in this study, specifically, a family's expressive communication, their use of

social support, their cohesion, and their adaptability.









In this chapter the research hypotheses, relevant variables, data analysis, the

population, subjects, and data collection are described. The instrumentation and

methodology are also discussed.

Hypotheses

The following null hypotheses were evaluated in this study:

HI: When death of a family member occurs, there is no significant difference in the

amount of stress reported among families at CF, CF--CP, CP, or CP--CF phases of the

family life spiral.

H2: When death of a family member occurs, there is no significant difference in the

type of stress reactions among families at CF, CF--CP, CP, or CP-rCF phases of the

family life spiral.

H3: There is no significant difference in expressive communication among families

at CF, CF-4CP, CP, or CP---CF phases of the family life spiral.

H4: There is no significant difference in social support among families at CF,

CF-*CP, CP, or CP--CF phases of the family life spiral.

Hs: There is no significant difference among families at CF, CF--CP, CP, or

CP-CF phases of the family life spiral on measures of family cohesion.

H6: There is no significant difference among families at CF, CF---CP, CP, or

CP-CF phases of the family life spiral on measures of family adaptability.

H7: There is no relation between levels of family stress and the family's cohesion

and adaptability.

Hg: There is no relation between levels of family stress and measures of social

support.

Hg: There is no relation between levels of family stress and measures of

communication.









HIO: There is no relation between a family's communication and their adaptability

and cohesion.

Delineation of Relevant Variables

Dependent Variable

The impact of death, the dependent variable in this study, was defined in terms of

the changes in the life of the family in the first year postdeath. These changes encompass

the extent of the reported stresses of intrafamily and marital relationships, pregnancy and

childbearing, financial and business strains, work-family transitions, illness and family

caregiving strains, losses (in addition to the death of the Hospice patient), transitions in and

out of the family, and family legal violations (McCubbin & Thompson. 1991). The FILE

was used to assess these changes.

Several independent variables were assessed: quadrant of the family life spiral,

social support, communication, cohesion, and adaptability.

Independent Variables

Stage of the family life cycle. The ability of family members to adapt to stressors

and the rate at which they do was believed to be related to the developmental stage of the

family and their location in phase-space. Certain periods in the life cycle are known to be

more stressful for families, particularly those that involve both beginnings and endings, as

in births, launching young adults, retirement, and death (Haley, 1973: Herz, 1980;

Hoffman, 1988; Ireys & Burr, 1984; McCubbin & Patterson, 1983; Neugarten, 1976;

Olson et al., 1983; Rolland, 1990; Stanton, 1978; Walsh & McGoldrick, 1987). In this

study, the stage of the family life cycle was assessed by determining the best fit with

phases (i.e., quadrants) of the Family Life Spiral Model, using the methods developed by

Olson et al. (1983) in their study of normal families across the life cycle.

Communication. How family members communicate with one another is a key

factor in how well they are able to cope with the stressors they face (Olson et al., 1983),









especially the stress occasioned by the death of one of their members. Communication has

been noted to vary across the family life cycle as families' boundaries open and close to

help facilitate the mastery of developmental tasks at each stage of the family life cycle

(Rosen, 1987, 1990a). There are numerous facets of communication that can be assessed--

clarity of communication, empathy, amount of self-disclosure, or expressiveness--to name

a few. The type of communication that was deemed of importance for families coping with

the death of one of their members is their level of expressive communication, their ability to

be open in expressing their feelings with one another (Brown, 1988; Rando, 1984; Rosen,

1987; Walsh & McGoldrick, 1987, 1991). In this study expressive communication was

measured by the Expressiveness subscale of the FES (Moos & Moos, 1986).

Social support. Social support is defined as the family's perception of the degree to

which they view relatives, friends, and the community as a source of emotional support in

the management of their stressors and strains (McCubbin & Thompson, 1991). The

importance of social support has been shown to aid families who are coping with the death

of a family member, its utilization by families often varying with the stage of the family life

cycle (Bankoff, 1983; Brubaker, 1985: Cohen et al., 1977; Cronkite & Moos, 1984;

Davies et al., 1986; Elizur & Kaffman, 1983; Ellard, 1974; Helmrath & Steinitz, 1978;

Holahan & Moos, 1985, 1986: Ireys & Burr, 1984; Mulhern et al., 1983; Valeriote &

Fine, 1987; Weber & Fournier, 1985). Social support was measured in this study by the

Social Support subscale and the Relative and Friend Support subscale of FIRA-G.

Cohesion and adaptability. Cohesion is defined as the degree of separation or

connection between family members and primarily concerns the emotional bonding

members have with one another (Olson et al., 1985). Adaptability is the extent to which

the family system is flexible and able to change its power structure, role relationships, and

relationship rules in response to situational and developmental stress (Olson et al., 1985).

The demands for cohesion and adaptability are high when dealing with the stressor of death









(Beavers, 1982; Beavers & Voeller, 1983; Davies et al., 1986; McGoldrick & Walsh,

1983; Walsh & McGoldrick, 1991; Weber & Foumier, 1985) and have been shown to vary

across the family's normal developmental life cycle (Olson, 1988: Olson et al., 1983). In

this study the variables of cohesion and adaptability were measured by FACES-II (Olson et

al., 1985).

Data Analysis

Table 2 shows the analyses that were conducted. Multiple regression was used to

evaluate the impact of death on families depending upon phase of the family life spiral.

Other predictor variables measured were social support, communication, cohesion, and

adaptability. These other variables that are known to affect the way a family copes with

death were hypothesized to account for some of the variation between phases of the family

life spiral. The impact of death on families was regressed on phase of the family life spiral

(as represented in the four quadrants of the Family Life Spiral Model), as well as on the

other variables of communication, social support, cohesion, and adaptability. Multiple

regression was used in order to determine more accurately the significance of the phase of

the life spiral as a predictor of the impact of death on the family, as well as the significance

of the variables of communication, social support, cohesion, and adaptability. ANOVAs

were used to analyze the effects of phase of the family life spiral on the variables of social

support, cohesion, and adaptability. These variables are operationalized as shown in

Figure 4.

Description of the Population

The population was composed of the families of patients who were referred to the

Hospice of North Central Florida by their physicians for comfort care during the last stages

of their terminal illness. The patient population was from an 1 -county area of north-

central Florida, encompassing Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton,

Lafayette, Levy, Putnam, Suwannee, and Union counties. The population in the state of









Table 2

Table of Analyses


Analysis Ho Independent Dependent
Variables Variable


Regression
Interaction
Main Effects



Regression
Interaction
Main Effects



Regression
Interaction
Main Effects



ANOVA


Regression
Interaction
Main Effects

Regression
Interaction
Main Effects

ANOVA

ANOVA



ANOVA



ANOVA


HI, H7-9 Quadrant
Cohesion
Adaptability
Communication
Social Support

HI, H7-9 Quadrant
Cohesion (D)a
Adaptability (D)
Communication (D)
Social Support (D)

H1, H7.9 Quadrant
Cohesion (D)
Adaptability (D)
Communication (D)
Social Support (D)

H7 Cohesion/Adaptability
(Family Subtypes)

H3, Hlo Quadrant
Cohesion
Adaptability

H3, HIo Quadrant
Cohesion (D)
Adaptability (D)

H2 Quadrant

H5 Quadrant

Quadrant

H6 Quadrant

Quadrant

H4 Quadrant

Quadrant


Stress





Stress (D)




Stress





Stress


Communication



Communication (D)



Type of Stress

Cohesion

Cohesion (D)

Adaptability

Adaptability (D)

Social Support

Social Support (D)









Table 2--continued


Analysis Ho Independent Dependent
Variables Variable


ANOVA H4 Quadrant Relative/Friend
Support

Quadrant Relative/Friend
Support (D)

ANOVA Individual Stages Stress

a(D) denotes discrepancy scores.



Florida in 1990 was 84% white, 14% African-American, 1% Hispanic, and 1% other

(U.S. Bureau of the Census, 1990). The population of the 11 counties serviced by

Hospice of North Central Florida in 1990 was 80% white, 18% black, and 2% other

minorities (Florida Statistical Abstract, 1991). The Hospice of North Central Florida

patient census for 1992 was 83% white, 15% African-American, 1% other minorities, and

1% not determined. Table 3 shows the percentages by categories for each population

subsample. Women accounted for 51.6% of Florida's population in 1990 (U.S. Bureau of

the Census, 1990) and were 44% of the Hospice census for 1992. Fifty-nine percent of

the research sample were females, 41% male.

Sampling Procedures

Each family who had been served by the Hospice of North Central Florida was

sent a letter approximately 11 months after the death of their family member (Appendix

A) explaining the purpose of this research project and requesting their participation.

Letters were sent out weekly beginning 5/6/93 through 8/20/93. A total of 373 letters were

sent. Follow-up phone contact was made approximately 2 weeks after the mailing of the

letter. After 207 letters had been sent, 79% of the sample had been generated. It took


















Type of
Stress


Figure 4. Operationalized Model (numbers in parentheses denote hypotheses)




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