Citation
The differential impact of death on family stress levels as determined by stage of the family life cycle

Material Information

Title:
The differential impact of death on family stress levels as determined by stage of the family life cycle
Creator:
Harvey, Elizabeth Anne, 1947- ( Dissertant )
Sherrard, Peter A. D. ( Thesis advisor )
Miller, David M. ( Reviewer )
Amatea, Ellen ( Reviewer )
Gubrium, Jaber ( Reviewer )
Place of Publication:
Gainesville, Fla.
Publisher:
University of Florida
Publication Date:
Copyright Date:
1994
Language:
English
Physical Description:
xiii, 218 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Child psychology ( jstor )
Death ( jstor )
Families ( jstor )
Family members ( jstor )
Family relations ( jstor )
Grief ( jstor )
Life cycle ( jstor )
Parents ( jstor )
Psychological stress ( jstor )
Quadrants ( jstor )
Bereavement -- Psychological aspects ( lcsh )
Counselor Education thesis Ph.D
Death -- Psychological aspects ( lcsh )
Dissertations, Academic -- Counselor Education -- UF
Family ( lcsh )
Greater Orlando ( local )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Abstract:
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-tcentrifugal (CP-tCF), including middle years of childhood, settling down, and planning for retirement: centrifugal (Cf), encompassing adolescence, 40s reevaluation. and retirement: and centrifugal-teentripetal (CF-tCP), incorporating marriage/counship, middle adulthood, and late adulthood. Eighty-four Hospice families were assessed I 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 detelTIlined 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--7CF families, so did their stress; the reverse was true for CF farnilies--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.
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

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
020554380 ( AlephBibNum )
32522326 ( OCLC )
AKJ9954 ( NOTIS )

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Full Text










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)




Full Text

PAGE 1

THEDIFFERENTIAL IMPACTOFDEATH ON F AMll.. Y STRESS LEVELSASDETERMINEDBYSTAGEOFTHE F AMll.. Y LIFE CYCLEByELIZABETH ANNE HARVEY A DISSERTATION PRESENTEDTOTHEGRADUATE SCHOOL OFTHEUNIVERSITYOFFLORIDA IN PARTIAL FULFILLMENTOFTHE REQUIREMENTSFORTHEDEGREEOFDOCTOROF PHll..OSOPHY UNIVERSITYOFFLORIDA1994

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This dissertation is lovingly dedicated to membersofmy 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 permissiontoeat dessert fIrst and to my dad and brothers, whose losses far exceed my own Copyright 1994 by Elizabeth Anne Harvey

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ACKNOWLEDGMENTS I would liketoextend my deepest thanks to those family members, friends, and colleagues who have given me support and encouragement throughout the processofdesigning, 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 beginningofmy graduate program. He has served as advisor, teacher, supervisor, and chairofmy committee. His patience, encouragement. and feedback have been invaluable. And toDr.David Miller, whose door was always open and whose wordsofwisdom 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 sourceofencouragement throughout the doctoral program, pointing me towards valuable resources. offering insight and prompt feedback when needed. AndtoDr. JaberGubrium, a most congenial memberofmy committee, I am thankful for the voteofconfidence. Words cannot begintoexpress my gratitude to Anne Seraphine, astute statistician, without whom I cannot even imagine completing this project. Iamalso 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 helpfultome. To my weekly reunion group who has cheered and prayed me through many passages the last 3 years, my warmest thanks for keeping me accountableinall that I do. To the HospiceofNorth Central Florida, Iamso 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 collectingdata requiring their time and skills, which they so patiently and promptly provided, andtothe 84 families who agreed to participateiniii

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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 arn blessedtohave had the love and supportofmy 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 arn especially thankful to him for the many hours he spent at his computer providing all the graphics included in this dissertation.IV

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TABLE OF CONTENTSACKNOWLEDGMENTSiiiLIST OF TABLESviiiLISTOFFIGURES x KEY TO ABBREVIATIONS.. .. ............ ... .. .. ..xiABSTRACTxiiCHAPTERS INTRODUCTION 1 Scopeofthe Problem'"2 Theoretical Framework 3 Need for the Study 8 Purpose12VariablestobeMeasured13Research Questions14Definition ofTerrns15Organizationofthe Study182 REVIEW OF THE LITERATURE19Introduction19Sociocultural Influence 20 FrequencyofDeath 22 Ramifications for Family Therapy 23FromIndividualto FamilyImpacl...23 Individual Perspective 23 Family Perspective 25 Empirical Research 26Deathas aStressorEvent.30Individual Perspective 30 Family Perspective30The EffectofStress on the Family 32DemandsforChange32 Demand Overload 32 Reestablishing Balance 33v

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ImpactofDeath on the Family 34 Symptoms Produced 35 Adaptational Factors44Family Systems, Stress, and the Family Life Cycle 47FamilySystems47 Family Life Cycle 48 Family Stress 50 Family Stress and the Life Cycle51Family Life Spiral Model54Predictions 63 Other Variables Impacting Death that MaybeExpected to Vary by Life Cycle Phase 64 Social Support65Cohesion and Adaptability 69 Communication73Conclusion783MElliOOOLOGY80 StatementofPurpose 80Hypotheses81DelineationofRelevant Variables 82DependentVariable82 Independent Variables 82 Data Analysis84Descriptionofthe Population 84 Sampling Procedures , 86Subjects90DataCollection92 Instrumentation 93FamilyInventoryofLifeEventsandChanges(FILE)93 Stageofthe Family Life Cycle 96 Family Environment Scale (FES) 96 Family IndexofRegenerativity and Adaptation--General (FIRA-G) 98 Family Adaptability and Cohesion Evaluation Scale (FACES-D) 994DATA ANALYSISANDRESULTS102Analysis Procedures 102 Analysis Results'"" .... .. 105 HypothesesTesting.....................................................................124ChapterSummary128 5DISCUSSION129 Overviewofthe Study 129 Research Sample 130 RelationshipBetweenQuadrants in the Model andFamilyStress................. 133 Relationship Between Quadrants and Expressive Communication145Relationship Between Quadrants and Cohesion 147 Relationship Between Quadrants and Adaptability 149vi

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Relationship Between Quadrants and Social Support 153 SummaryofQuadrantEffects.........................................................153Relationship Between Communication and Stress 154 Relationship Between Cohesion and Stress 154 Relationship Between Adaptability and Stress155Relationship Between Family Subtypes and AmountofStress...................157 Relationship Between Social Support and Stress 164 SummaryofPredictor Variables for Stress165Relationship Between Cohesion and Communication166Relationship Between Adaptability andCommunication.........166Family Life Spiral Model. 167 Recommendations... .......... 170 Implications for Therapy 170 LimitationsoftheStudy.......... ..171Suggestions for FurtherStudy...............................................173 Chapter Summary 175 APPENDICES A LETTER TO FAMILIES176B FAMILY MEMBER SELECTION PROTOCOL 177 CSTAGEOFTHEFAMILYLIFECYCLE178D FAMILY INVENTORY OF LIFE EVENTS AND CHANGES (FILE) 182 E FAMILY ENVIRONMENT SCALE (FES)185F FAMILY INDEX OF REGENERATIVITYANDADAPTATION--GENERAL(FIRA-G)187 G FAMILY ADAPTABILITYANDCOHESION EVALUATION SCALES (FACES-II) 190 HDEMOGRAPHICQUESTIONNAIRE194LINEARSCORING AND INTERPRETATION FOR FACES-II196JLETTEROFINSTRUCTION TO FAMILIES PARTICIPATING BYMAIL.197KCOMPOSITION OF P ARTICIPANTFAMILIES199REFERENCES 202 BIOGRAPHICAL SKETCH 217 vii

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LIST OF TABLES Comparative Norms for Family Pile-up Over the Family Life Cycle 522TableofAnalyses853Comparative Breakdown by Ethnicity for Population Subsamples884 RepresentationofSample Across Family Life Cycle915Breakdown by County for Patient Census and Research Sample92 6Regression Model Testing Quadrant. Cohesion. Adaptability, Communication, Social Support, and Relative and Friend Support with Family Composite Score for Stress as Outcome Variable1067 Means, Discrepancies, and Standard Deviations for Instruments 1078Regression Model Testing Quadrant and Discrepancy Scores on Communication, Social Support, Relative and Friend Support, Cohesion, and Adaptability with Stress Discrepancy ScoresasOutcome Variable 1089Regression Model Testing Quadrant and Discrepancy Scores on Cohesion, Adaptability, Communication, Social Support, and Relative and Friend Support with Family CompositeScore for StressasOutcome Variable 11010Regression Coefficients and t-values for Interaction Model for Quadrant and Discrepancy Scores on Cohesion, Adaptability, Communication, Social Support, and RelativeandFriend Support with Family Composite Score for Stress as Outcome VariableIIIIJANOVA for Relationship Between Family Subtypes and Stress 11412ANOVAS for TypesofStressors by QuadrantliS13ANOV A for Individual Stress Scores by Individual's Stage in the Family Life Cycle 117 14 Individual Stress Scores by Individual Stageofthe Family Life Cycle 11815Regression Model Testing Quadrant, Cohesion. and Adaptability with Communication as Outcome Variable 120 viii

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16Regression Model Testing Quadrant and Discrepancy ScoresonCohesion and Adaptabilitywith Communication Discrepancy ScoresasOutcome Variable12217ANOVAS for Social Support. Relative and Friend Support, Cohesion, and AdaptabilitybyQuadrant12318ResultsofHypotheses Testing12519Top Stressors for Families 136 20 Top Ten Stressors by Quadrants13821Family SubtypesbyQuadrant15822Family TypesbyQuadrant.............................................................163ix

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LIST OF FIGURES Family Life Spiral ModeL... .. .. .. .. .6 2 Quadrantsofthe Family Life SpiralModeL9 3 CohesioninNormal Families Across the Life Cycle714 Operationalized Model875 Operationalized Model with Results of HypothesesTesting.......................104 6 Interaction Between Family Stress Scores and Communication Discrepancy Scores by Quadrant1137 Stress Mean Weighted Sums by Individual Stage on Family Life Spiral Model1198 Family StressbyQuadrant1349 Cohesion Mean Scores by Quadrant14810Cohesion Mean Discrepancy Scores by Quadrant. 15011Adaptability Mean ScoresbyQuadrant15112Adaptability Mean Discrepancy ScoresbyQuadrant15213Cohesion and Stress Mean Discrepancy ScoresbyQuadrant15614Family Subtypes for Total Sample 15915Stress Mean Scores for Family Subtypes 16016FamilySubtypes by Quadrant162x

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CFCPFACES-II FES FILE FIRA-GKEYTOABBREVlATIONSCentrifugal--outward focus and orientation Centripetal--inward focus and orientation Family Adaptability and Cohesion Evaluation Scales Family Environment Scale Family Inventory of Life Events and Changes Family IndexofRegenerativity and Adaptation--Generalxi

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AbstractofDissertation Presentedtothe Graduate Schoolofthe UniversityofFlorida in Partial Fulfillmentofthe Requirements for the DegreeofDoctorofPhilosophy THE DIFFERENTIAL IMPACT OF DEATH ON FAMILY STRESS LEVELSASDETERMINED BY STAGE OF THE FAMILY LIFE CYCLE By Elizabeth Anne HarveyApril,l994Chairperson: PeterA.D.Sherrard Major Depanment: Counselor Education The purposeofthis study wastodetermineifthere are points in the family life cycle when the deathofa member creates more stress than usual. The stagesofthe 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-tcentrifugal (CP-tCF), including middle yearsofchildhood, settling down, and planning for retirement: centrifugal(Cf),encompassing adolescence, 40s reevaluation. and retirement: and centrifugal-teentripetal(CF-tCP), incorporating marriage/counship, middle adulthood, and late adulthood. Eighty-four Hospice families were assessed I year after the deathoftheir loved onetodetermine the stress they had experiencedinthe past year. Levelsofcohesion, 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 levelsofcohesion and adaptability, with CP families the highest and CF families the lowest. Analyses byxii

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stageofthe family life cycle detelTIlined that the settling down stage evidenced significantly greater stress. Cohesion was a significant predictorofstress 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 ConnectedVery flexible families having the least stress. As levelsofcohesion and adaptability decreased, stress increased. Differences by quadrant were found for discrepancy scores on cohesion and adaptability, withCFfamilies more discrepant than CP families. A positive relationship was found between cohesion discrepancy scores and stress discrepancy scores. As communication discrepancy increased for CP--7CF families,sodid their stress; the reverse was true for CF farnilies--as communication discrepancy increased, stress levels decreased. Social support and adaptability were not foundtobe predictorsofstress. Increased adaptability predicted increased communication. Although stress measures by quadrant were not significant, there were differences on othermeasures that tended to confirm the theory behind the Family Life Spiral Model. Differences by stageofthe life cycle were found, and further studies are in order. xiii

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CHAPTER 1 INTRODUCTION The father came back from the funeral rites. His boyofseven stood at the window, with eyes wide open and a golden amulet hanging from his neck, fullofthoughts too difficult for his age. His father took himinhis arms and the boy asked him. "Where is mother?" "In heaven." answered his father, pointing to the sky. The boy raised his eyestothe sky and long gazed in silence. His bewildered mind sent abroad into the night the question, "Whereisheaven?" No answer came: and the stars seemed like the burning tearsofthat ignorant darkness. --Tagore, from The Fugitive "The fearofdeathisour deepest terror and the lossofa loved one our most profound sorrow" (Walsh&McGoldrick, 1991,p.xix).Ofall 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,ofcourse, have the necessary adaptational skills to weave the lossofa family member into the tapestryoftheir lives and have no needofintervention from mental health professionals. Others, however, do not adapt as well to the stressofloss for a varietyofreasons; often their loss exacerbates the multitudeofproblems they already face. This study addresses the impactofdeath on familiesintermsoftheir levelsofstress depending upon where they are in the family life cycle.

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2 Scope ofthe Problem A body of literature exists promoting theoretical premises about the impactofdeath 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 begantoseetheindividual's reaction to death within the contextoftheir family and acknow ledged the importanceofassessing both individual and family (Rando, 1984; Sanders, 1989). Giventhelackofsystemic assessment devices, however, families were initially assessed by measuring the individual family members' reactionstothe death (Bass, Noelker, Townsend,&Deirnling, 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 observationsoffamilies (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 impactofdeath on the familyasa unit (Bass&Bowman, 1990; Cohen, Dizenhuz,&Winget, 1977; Coleman, Kaplan,

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3&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 resultsofthe above research efforts studying the impactofdeath on families indicate that a family's inability to mourn its lossesisoften at the heartofclinical 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 behaviorofa child or adolescent. anxiety, phobiasorcompulsions, marital conflicts, depression, or the inabilityoffamily 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 interrelationshipsoffamily members can nowbeassessed with reasonable objectivity. This allows a more accurate depictionofthe family as a dynamic system, enabling the therapist to work more effectively with the family as a unit. Theoretical Framework At the heartoffamily systems assessment is the identificationofthe developmental stageofthe family in the family life cycle, originally seen as a linear model.Thefamily life cycle is composedofstages 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 stagesofthe life cycle offer the context for ongoing assessment and diagnosisoffamily problems . .. Symptoms and stressors, both present and past, are viewed in lightofthe family's developmental stage (Carter&McGoldrick, 1988; McCubbin&Thompson, 1991; Olson,

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41988; Olson, McCubbin, Barnes, Larsen, Muxen.&Wilson, 1983). Each stageofthe family life cycle has tasks and stressors that are specifictothat stage and nonnative at that point in time. Stressors that occur off-time. that is, at an unexpected point in the life cycle, or a pile-upofstressors within a short periodoftime 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)toinclude this pileupoflife events experienced by the family and have developed an instrument, the Family InventoryofLife 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 resultofthe pileupofstressors. A family's abilitytoadapt to a crisis and achieve a new levelofbalance depends on the reciprocityofthe family's functioning. When the demandsofthe family unit are not satisfactorily met by the family's capabilities, negative consequences will present through evidenceofdeterioration or breakdowninthe family unit, relationships within the family unit, and/or the psychological and physical healthoffamily members (McCubbin&Thompson, 1991). 7 Clinicians and researchers alike have theorized and documented that certain stagesofthe family life cycle are associated with higher levelsofstress than others under nonnative conditions (Carter&McGoldrick, 1988; Olson etaI.,1983). For example, families with young preschool children and school-age children experience a higher degreeofstress than "empty nest" families, but the most stressful stagesofthe family life cycle appeartobe adolescence and the launching stages (Olson et aI., 1983). Combrinck-Graharn (1983, 1985) has taken the linear family life cycle model and transfonned it into a continuous spiral to show the impactofthe interlockingofthe generations on developmental tasks. This spiral represents three generationsoffamily evolution with families oscillating between periods when they are centripetal (CP) or

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5centrifugal (CF) depending on the focal tasks requiredofthematthose stagesofthe family life cycle. Figure I illustrates the configurationofCombrinck-Graham's Family Life Spiral Model. Typically, an individual will experience three oscillations in a lifetime, spanning six developmental stagesofthe family life cycle: one's own childhood (CP) and adolescence (CF), the birth (CP) and adolescence (CF)ofone'schildren, and the birth (CP) and development (CF)ofone'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 memberstowork and rework issuesofintimacy in the CP stages and self-actualizationinthe CF stages. The CP stages are those with an inner orientation requiring intense bonding and cohesion (early childhood, child rearing, grandparenting). DuringCPperiods 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. TheCFstages 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 boundaryisloosened. 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 styleofthe family at particular stagesofthe family life cycle. Symptom formation. however, often occurs when the situation in the family is outofphase with the focal developmental tasksofthe family members, suchasthe deathofa child interrupting the child-rearing phaseofthe 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

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6CFCPPlanforRetirementRetirement40'sReevaluation ;; Grandparenthood(Childbearing Childbirth \'\. MiddleMarriageMiddleYearsSettlingAdulthoodCourtshipofChildhoodDown\ "",,,,,,,) LateAdulthoodFigureI.Family Life Spiral Model Source: A developmental model for family systems. Family Process, 24, 139-150.L.Comb rinck-Graham, 1985.

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7 Model in 1983, she hypothesized that because deathisexperienced as a departure, its occurrence may be more upsetting for a family that is not CF; the family might respondtoa member's death by tightening their external boundaries even more. She also speculated thatifthe predominanceofforceisCP at a timeinthe family life cycle when the family should be coming apart, the familyislikely to experience nonnormative stress. Additionally, she hypothesized that healthy families are those who are abletoadjust their structure to meet the ever-changing needsoftheir 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 increasesasthe levelofincapacitation or riskofdeath increases. Progressive diseases over time are more CP in termsoftheir effect on families than constant course illnesses. The additionofnew demands as an illness progresses keeps a family's energy focused inward; a constant course disease, on the other hand, allows a familytoenter or resume a more age-orstage-appropriate phaseofthe life cycle. Family members facing chronic illness and death must work togethertomanage the situation, frequencyofcontact among members is increased, time for activities and contacts outside the familyisminimized, and when death occurs, family members congregate to memorialize the lifeofthe deceased person. In contrasttoCombrinck-Graham's original hypothesis, Rolland hypothesized thatifthe death coincides with aCFperiod in the family, the impact wouldbemore severe at that time, affecting the developmental tasksofall the family members. Young adults may be forced to shelve their differentiation from the family in lieuofneedingtofill roles vacatedbythe deceased and, therefore. have their launching delayed. Midlife adults may be forcedtodelayorpass up new career opportunities.Ifdeath occurs at a CP period,although less severeinits impact according to Rolland, the effects may betoprolong temporarily this phase or cause families to become stuck at this pointofdevelopment.

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8Rosen (I990a, 1990b) noted that both CP andCFforces are at work at every stageofthe family life cycle, although one tendstodominate. 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. Comb rinck-Graham, Rolland, and Rosenallhypothesize that the CP forceofdeath 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 stagesofits life cycle. When the CP pull occursatCF stages.itmay interfere with the natural momentumofthe family's development and the achievementofnecessary individuation tasksofthose stages (Rosen, 1990a, 1990b). The Family Life Spiral Model has the potentialofbeing a helpful diagnostic tool if the theory behind its conception can be tested. Thereisclinical documentation that both CP and CF forces are normative over the courseofthe family life spiral, but there has been no empirical testingofthe modelintermsofhow death affects families at the various phases. which this study proposes to do. For purposesofthis study, the Family Life Spiral Model will be divided into four quadrants as delineatedinFigure2:the CP quadrant, encompassing birth. childbirth, and grandparent hood; the CP-tCF quadrant, encompassing childhood, settling down, and planning for retirement; theCFquadrant, encompassing adolescence, 40s reevaluation, and retirement; and the CF-tCP quadrant, encompassing marriage/courtship, middle adulthood. and late adulthood. Need for the Study The impactofloss at various stages in the family life cycle, and on the family as a functional unit, needstobe studied so that higher risk stages,ifany, can be identified. Then different interventions that were appropriatetoeach stageof family development could be developed and tested. Targeting bereavement services for families that are

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9 , , , , , , ,, '.Retirement40'sReevaluationLateAdulthood ,/,/,/,/,/,/" ICPI / /,/,//S " Grandparenthood , (Childbearing ' Childbirth /, / \t MiddleMarriage', / / MiddleYearsSettlingPlanforAdulthoodCourtship A ofChildhoodDownRetirement XA:olesc::J/,/, ,//// / /,Fi/iure 2.Quadrantsofthe Family Life Spiral Model

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10 predisposedtomore 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 resolutionofdifficulties (Bass&Bowman, 1990). Systemic impactofloss has been virtually unexplored with experimental research, and family therapy must move beyond clinical impressionsiftherapeutic potentialistobemaximized. 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 deathofa family member have both immediate impact and long-term ramifications in family development over the courseofthe 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 attendingtofamily 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 areaofdeath reactions in families are scarce. Thinking that notes the systemic effectsofevents that occur within familiesisrelatively recent and has not yet generated the varietyofassessment tools needed for family research. Although theory abounds about the ramificationsofdeath on the family unit, research beyond the formulation and testingofclinical hypotheses with individual families presenting for therapy has been virtually nonexistent. Possibly this areaofresearch has been thwarted by the plethoraofvariables that have been hypothesizedtoaffect the impactofdeath on families and the difficultyofcontrolling for them in order to isolate the effectsofone particular variable.

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IIRosen (personal communication, November, 1991) has suggested that a true experimental design testing the differencesinintervention strategies for CP orCFfamilies would be appropriate. However, the first stepisto test the predictive validityofthe theoretical model by seeingifthere are differences among family responses that reflect the stageofthe family life cycle in which the death occurs. This study takes this first step. Although a key issue relatedtothis theoretical model is the notion that death has a CP pull on families, that question was not addressed directlyinthis study; answering that question would require a longitudinal prospective study that would assess the family priortothe diagnosisofthe fatal illness, since chronic illnesses themselves are believed to have a CP pull.Inaddition, the family would needtobe observed over a periodoftime postdeath to measure the impactofdeath on their subsequent development. Obtaining such a sample is,ofcourse, logistically difficult and impractical. Another drawback to family assessment and family research is capturing the family's perception as opposedtoindividuals' perceptionsoftheir 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 pictureofthe family system outofthe areasofagreement or disagreement among them (Keeney, 1983). It is also important, both conceptually and methodologically,tofind ways to combine various family members' perspectives without losing too muchofthe individual perspective (Larsen&Olson, 1990). Mean scores are appropriate for some families but have the effectofmodifying 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 scoresorincongruency scores indicate the relative levelsofagreement among family members as to their perceptionsofthe dynamicsintheir family (Olson et al., 1983). Whereas mean scores conceal individual differences, discrepancy scores highlight the differences.In

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12some instances, discrepancy scores can be complementarytomean scores, providing a fuller pictureofthe 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 agreetoparticipate and only those who are old enoughornot too old, abletoread, and are not handicapped in some physical or emotional way will be represented when objective self-report assessments are the toolsofchoice (Larsen&Olson, 1990). The purposeofthis study was to test severalofthe predictions generated by the theory behind the Family Life Spiral Modelintermsofhow the crisis eventofdeath impacts families at different pointsinthe family life cycle. When there is a death in the family, is there a differential impact reflecting the phaseofthe life spiral? The importanceofthis study rests in its ability (a) to differentiate phases (i.e., quadrants)ofthe Family Life Spiral Model, (b) to determine if phaseofthe life spiral is indeed a significant variable influencing the perceived impactofdeath on family members, and (c) to discern which phaseofthe life spiral may be at higher risk for symptomatic reactions to the stressorofdeath. This author believes that there are now family assessment tools that allow the measurementofthe impactofdeath on families and the identificationofthe most significantofthe variables and that there are statistical programs now available thatcancontrol for variation influenced by other independent variables so that the variance attributable to stageofthe life spiral canbeisolated. The tools used to do the assessments in this study were self-report instrumentsofa retrospective nature. Although there are drawbacks to both retrospective and self-report assessments, such as the accuracyofan individual's memory and perception and the influenceofsocial desirability, the advantages outweigh the disadvantages in this study because it was the compositeofthe family members'

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13perceptionsofthe changes that had occurred in their family over the courseofa year that was considered essential. The population was drawn from family membersofpatients served by the HospiceofNorth Central Florida,anarea encompassingIIcounties. The variable, natureofdeath, was controlled for, inasmuch as admission to Hospice requires a diagnosisofa terminal illness and a prognosisof6 months or less to live; thus, death was expected and was not a sudden event that occured without warning. Because the ramifications for the family were likely to occur over a periodoftime after the death (Hadley et al., 1974), assessments were made at I year postdeath and were a compositeofthe family's reflectionsofevents that occurred in their family since the deathoftheir loved one. Variables to be MeasuredInadditiontostageofthe life spiral as the primary independent variable, several other variables that also influence the impactofdeath on families were measured. Differences were expected between phasesofthe family life spiral on these variables: the adaptability and cohesionofthe family, the family's degreeofexpressive communication. and the degreeofsocial support the family utilized when adaptingtothe stressorofdeath. Adaptability and cohesion were measured by the Family Adaptability and Cohesion Evaluation Scales (FACES-II); expressive communication was measured by the Family Environment Scale (FES), Expressiveness subscale; social support was measured by two subscales from the Family IndexofRegenerativity 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. Manyofthe items pertain to the objective assessmentofbehaviors 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 Fll..E, and a composite is made for allofthe family

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14members who are assessed. The differences in members' perceptionsoftheir 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' perceptionsofongoing stylesofinteraction within their families. They, too, were designed tobefilled out by each member and a composite made for all members. It is believed that this multiple perspective on the family, a formof"double description" (Bateson, 1979), produces a more accurate representationofthe familyasa system than one individual's perceptionoftheir family. Research Questions Little empirical research has been carried out on the impactofdeath on families, and none has been done with phaseofthe life spiral as the independent variable. Since the family life spiral is a primary lens through which families are assessed and theoreticians believe this tobe a significant variable determining how death impacts families, testing the significanceofthis appears to be an appropriate target for a research study. Because there are other variables believedtobeofimportance in assessing a family's vulnerability to adjusting to a loss and because those variables are expected to vary by phaseofthe life spiral, those variables were also measured. The goalofthis study was to expand the bodyofknowledge used to explain the impactofdeath on families and to determine which phasesofthe family life spiral may be at the greatest risk for experiencing undesirable outcomes.Tothis end, the following research questions were posed: I. Is there a difference in impact, both in degreeofstress and typeofstress, reported by family members at different phasesofthe family life spiral when there is a death in the family?2.How do the levelsofdisagreement among family members atCFphases compare with other phasesofthe family life spiral?

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153.Do family members at different life spiral phases differ in termsofreported levelsofexpressive communication, social support. family cohesion, and family adaptability? DefinitionofTerms For the purposeofthis study,key constructs and terms are defined as follows: Adaptability. Family adaptabilityisdefinedasthe extent to which the family system is flexible and able to change its power structure, role relationships, and relationship rules in responsetosituational and developmental stress (Olson et al., 1985). For the purposesofthis study, adaptability was determined by the adaptability score from FACES-II. Centrifugal. The term centrifugal, originating in the fieldofphysics, implies a moving away from the center. Applied to familiesina metaphorical sense,CFphasesofthe Family Life Spiral are those with an outer orientation and developmental tasks that emphasize personal identity and autonomy. Stagesofthe family life cycle when these tasks predominate are adolescence, midlife, and retirement. The external family boundaryisloosened, and distance between family members increases as family members begin to expect gratification from, and put their trustin,activities and relationships outside the family unit (Beavers, 1982). Centripetal. Also originating outofphysics, the term centripetal implies a moving towards the center. TheCPphases 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 trustingoffamily 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.

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16These forces then, CF and CP, are in oppositiontoeach other. an opposition that generates the oscillation characteristicofthe 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 connectedtotheir family and is defined as the emotional bonding that family members have toward one another. Cohesion incorporates conceptsofemotional bonding. boundaries. coalitions. time space. friends. decision making. interests. and recreation (Olson et aI., 1985). For the purposesofthis study, cohesion was determined by the cohesion score from FACES-II. Communication. In this study, communicationisdefined as the extent to which family members are encouragedtoact openly andtoexpress their feelings directly with one another. Communication was measured by the expressiveness subscale from FES for this study. Family. For purposesofthis study, a family is described as being a groupoftwo or more persons living together who are related by blood. marriage. or adoption (McCubbin&Thompson. 1991). Family life cycle. This is a term usedtodescribe the normal developmentoffamilies in the managementoftasks and events related to the entry and departureofindividuals from the household (Carter&McGoldrick. 1988). Child rearing is the element around which the family life cycle is organized. Various lineal modelsofthe family life cycle exist that organize the developmental schema into any numberofstages--5. 7,8.or 24 (Carter&McGoldrick, 1988; Duvall&Miller, 1985; Olson et aI., 1983). Traditionally, the lineal models have mapped the developmental progressionofa three-generational family

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17system that is understood as an ever-renewing system in which new generations are added and others die out; individual life cycles evolve within the contextofthe family life cycle. Family life cycle stage. Thisisthe stageinwhich each family perceives themselvestobe based on the chronological ageofchildren present in the home. For families whose children are all launched, stage is detennined by ageofoldest grandchildren,if5orunder; or on the developmental tasks the members are working onifall children have been launched and there arenograndchildren, or oldest grandchildren are over5.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 lifeofthe family continuing on as new generations are added.Itconsistsoffour phases that are simultaneously experienced from three different positions within the family life spiral (see Figure I). The model portrays the recursions inherent in the life cycleasone oscillates from CP phasestoCF phasesagain and again and again. Family Life Spiral phase. In this study, this term denotes thefour different phases (CP. CF, that families pass through over and over again throughout timeasgenerations 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 stagesofthe family life cycle simultaneously experienced by three generations within the family. When a family is at a CP phaseofthe family life spiral,itis assumed that they are operating in a CP style, with characteristics as defined previously, and the same is assumed for eachofthe other phases. Impact ofDeath. The impactofdeath in this study is defined in termsofthe changes in the lifeofthe family in the year postdeath. These changes encompass the stressesofintrafamily and marital relationships, pregnancy and childbearing, financial and

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18business strains, work-family transitions, illness and family caregiving strains, losses (other than the deathofthe Hospice patient), transitionsinand outofthe family, and family legal violations(McCubbin&Thompson, 1991). For the purposesofthis study, the impactofdeath was measured by FILE. Natureofdeath. Natureofdeath in this study is anticipated, as opposed to sudden and unexpected with no time to prepare. (Thisisdistinguished from timing in the life cycle, when unexpected would refer to ageofdeceasedattime of death.) For participantsinthis study, the deathoftheir family member had been anticipated and was not sudden and unexpected. Social Social support is defined hereasthe family's perceptionofthe degree to which they view relatives, friends, and the communityasa sourceofemotional and network supporttotheminthe managementoftheir stressors and strains (McCubbin&Thompson, 1991). For the purposesofthis study, social support was measuredbytwo subscales from FIRA-G, the Social Suppon subscale and the Relative and FriendSupponsubscale. ofthe Study Chapter 2ofthis studyisa reviewofthe related literature. Following Chapter 2 is a delineationofthe methodologyinChapter 3, containing a statementofthe purposeofthe study, hypotheses, delineationofrelevant variables, data analysis, descriptionofthe population, subjects, sampling procedures, data collection, and instrumentation. Chapter 4isa presentationofthe resultsofthe statistical analysesofthe data. Chapter 5 includes a discussionofthe results, implications for therapy, limitationsofthe study, and suggestions for further study.

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CHAPTER 2 REVIEW OF THE LITERATURE And ever has it been that love knows not its own depth until the hourofseparation. --Kahlil Gibran IntroductionTolive is to lose. One cansimply not escape loss (Viorst, 1986). Oneofthe most difficult events we confrontinthe life cycle is the lossofa loved one through death. When a close family member dies, the livesofthe individuals as well as the lifeofthe 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 fullnessofthe life cycle's evolutionllJY process from birth to death is oneofthe most painful adaptational tasksweface. Survivors' lives are irrevocably altered by their encounter with loss (Bowlby, 1980). Researchers have shown that oneofthe greatest stressors for individuals is the deathofa family member (Hare-Mustin, 1979; Holmes&Rahe, 1967). Although the finalityofdeath seems to bring the life cycletoa standstill, lifedoes continue after a loss. Just as birth connects one humantoanother 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 responsetodeath is greatly influenced by their life cycle development (Bowen, 1976; Herz, 1980; Herz-Brown, 1990; Rosen,19

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20I 990a, 1990b: Walsh&McGoldrick, 1987, 1991). Death impacts the family as a unit as well as eachofits members who have a different relationship with the deceased. "When links in the familial chain are broken by separationordeath, disturbing social and psychological disruptions are often created" (Raphael, 1984, in Sanders, 1989,p.147). And the impactofdeath continues to reverberate throughout the family system (Bowen, 1976), sometimes for generations as an unresolved legacy (Paul, 1967, 1974; Paul&Grosser, 1965). Sociocultural Influence Oneofthe reasons families in American culture have a difficult time adapting to the deathofa close family member is that they often have little prior experience with death, making adaptation difficult. Death in the horne used to be a natural occurrence. Postmortem preparation and funeral rituals took place in the horne, thus being integrated directly into family life. Families essentially had no choice but to face the painofthe endoftheir 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 hospitalsorinstitutions for careoflife-threatening conditions. This was reinforcedbythe institutionofMedicare and Medicaid in 1965, and the family was removed from direct hour-by-hour contact with the processofdying (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 learnhowto face death. Recent generationsofchildren have found themselves in middle age never having seen a corpseorattended a funeral, with no previous opportunity to incorporate a meaningful conceptofdeath into their conceptoflife (Pattison, 1977). In 1984, 90%ofthe deaths in the U.S. occurred in a hospitalorother health-care institution (Vital StatisticsoftheU.S.,1991). Two factors contributing to this high rate are the increased geographical mobility and distance between family members, as well as

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21 the involvementofmore and morewomenin the work force, making it difficult for family members to care for terminally ill and dying members. There are indicationsofa 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.By1988 the percentageofdeaths in the hospital had dropped to 75% (Vital Statisticsofthe U. S., 1991)andin 1992 the estimate was70%basedonlocal figures(A.S.Beckner,personalcommunication,October14, 1992). At the beginningofthe 19th century life expectancy was slightlyover34years; by the beginningofthe 20th century it had increased to47years; and now as the 20th century draws to a close, life expectancy is nearing 75 yearsofage (U.S. BureauoftheCensuscitedin Hargrave, 1992;Walsh& McGoldrick, 1987). Previously, childrencouldexpectto witness the deathofa parent before theygrewup and left home and certainly weremorelikelytowitness the deathofsiblings tochildhoodillnesses (Scott&Wishy, 1982,citedinWalsh&McGoldrick, 1987).Nowa person's first experience with deathofa close familymemberis often the lossofa parentwhenthe child is middle aged. Deathofa family member inourculture appears to cause greater psychological impact than in other cultures (Rando, 1984).Ourincreasingly smaller familiesandourincreased geographical separation from extended family tend to breed family systemswithoveridentification and overdependence. Emotional attachments to particular peoplebecomethenormandmakefor a higher vulnerability to stress.Thenuclear family'sbondfar outweighs thatofthe extended family network,andso dependency needs are relegated to a smaller circle (Sanders. 1989). The emotional investment becomes more focusedandintense, and there are fewer memberstoshare the loss.Ourculture places great emphasisonpreparing ourselves materially fordeath(Paul&Grosser, 1965).Thelife insurance industry, the social security system,programsforeconomicsecurityofsurvivors via trustsandwills, and prepaid burial plans are all

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22 evidenceofourwillingness to prepare ourselves financially for the eventualityofourowndeath. However,wetake very little care to prepare ourselves psychologically andmaynot even commemorateorritualize the deathofa loved one, perhaps to avoid the psychological painassumedto be associated (Imber-Black et al.. 1988),orpossiblybecauseofourdeceptiveemphasisonrationality (Paul & Grosser. 1965). FrequencyofDeath EstimatesofI-yearincidence ratesofbereavement range from5%to9%(Osterweisetal., 1984),amountingtoan estimated 13,000,000to20,000,000peoplewhoexperience the deathofan immediate family member annually (Vital Statisticsofthe U. S., 1991). It isestimatedthat 12,000,000 people lose a parenteveryyear;800,000lose a spouse; and400,000deaths are children under 25.Twoandahalfmillionofthosewholose a parent are childrenunderthe ageof18; 99%ofthosedeceasedparents are fathers (Barth, 1989; OsterweisetaI., 1984;Walsh& McGoldrick, 1987). In a key studyofnormal families across the life cycle (Olson et al., 1983), researchers found that 19%to23%ofthe 1000 couples interviewedhadlost a parentorclose relative in the preceding year. In viewofthis being a percentage basedonthe couple's response, it is in close proximity to the upperendofthe estimate by Osterweis et al. (1984). Although death is insomeways always expected, in that the only guarantee in lifeisthatwewill die, it does notoccurwith sufficient frequency tobeconsidered a normal everyday occurrence in the lifeofa family. Therefore, its occurrencedoesnot provide a situation wherein a familycancalionprevious adaptive skills tohelpthemthrough. Certainly the majorityofdeathsdonot result in a debilitating impactonfamilies.Somefamilies rise to the challengeofcoping with this experience, andsomefamily members actuallydobetter, appropriately growing and differentiating from the family as it used to be (Tietz et aI., 1977). A thirdofall major bereavements, however, result in problems for which professional helpmaybe required (Raphael. 1983; Sanders, 1989).

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23Ramifications for Family Therapy The familytherapy field has paid a lot of attention to certain issues affecting families: physical and sexual abuse, impactofdivorce, substance abuse, and eating disorders. However, there has been relatively little attention paid to the impactofdeath on families. Walsh and McGoldrick (199 I) initiated a landmark treatise on the impactofdeath on families as observedinthe clinical setting. Others have had input also in highlighting this asanareainneedofour 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 deathofthe family as they had experienced it (Greaves. 1983). Death modifies a family's structure and demands a reorganizationofthe family system that will guarantee its viabilityinthe future. The individual's reaction cannot be isolated from thatofthe family as a whole. For the individual the disruption in behavior and personality functioningissymptomatized through grief and mourning(Lindemann, 1944; Rubin. 1986). Each person's response, whether functionalornot, has consequences for eachofthe other family members. The impactofloss on the family, characterized through impact on their function and relationshipstoone another. can only be appropriately examinedinlightofthe entire interactional system (Rubin, 1986; Walsh&McGoldrick, 1991). From IndividualtoFamily Impact Individual Perspective Sigmund Freud's "Mourning and Melancholia" (1917) is the 20th century's first major treatise on the effectsofdeath on adult survivors and was wrinen from an individual psychodynamic perspective, focusing on the psychological processofdetaching from the lost object. Another psychiatrist. Erich Lindemann (1944), studied the impactofdeath on family members and relatives who survived the lossofa memberinthe 1942 Boston

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24 Cocoanut Grove nightclub fire. Although mostofhis observations hadtodo with individuals' reactions, oneofhis predictions about the type and severityofthe grief reaction was based on his observation that the overall makeupofthe family network was more predictiveofthe 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 disintegrationofthis social system and by a profound alterationofthe living and social conditions for the bereaved" (Lindemann, 1944,p.146). Freud's hypotheses about the importanceofthe mother-child relationship and consequent separation anxiety in human development became the central focusofBowlby'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 patternsofattachment behavior, eventually leading to chronic stress and severe depression. Distinguishing pathological grief from normal grief reactions became the focusofother 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 etaI.,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 typeofillness or death (Binger, Ablin, Feuerstein, Kushner, Zager,&Mikkelsen, 1969; Bolton, 1984; DeFrain, 1991; Williams&Stafford, 1991). These studies, some anecdotal and clinical observations and othersofan experimental design, focused on the individual. Later researchers focused on the dyad, for example, the effects on marital couplesofthe lossofa

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25child (Brubaker, 1985; Feeley&Gottlieb, 1988-89; Helmrath&Steinitz, 1978; Lauer, Mulhern, Wallskog,&Camitta, 1983: Rando, 1983; Schwab, 1992; Shanfield et al., 1984). Finally, Raphael (1983) and Parkes (1987-1988) both organized extensive reviewsofthe bereavement literature. Family Perspective Eventually, someofthese same psychodynamic researchers begantonote the influence on the familyofthe deathofa loved one. Paul and Grosser ( 1965), after acknowledging the dearthofliterature on the family's resolutionofgrief and the few studies based on empirical research, recorded clinical observationsofschizophrenic patients and their families, which suggested an association between the onsetofschizophrenia and the disruption to the family's equilibrium becauseofa previous death and described the subsequent difficultiesofsome families to adapttothe changing role demands on family members. In 1974, Paul, on the basisofclinical impressions, hypothesized that thereisa direct relationship between the maladaptive responsetothe deathofa loved person and the permanenceofsymbiotic relationships within the family. Suffering a significant loss many years previously with little empathy within the bereaved system seemedtoproduce family styles that were unresponsive to funher losses and disappointments.Thefamily may try to keep oneofitsmembers 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 Paultointervene with a corrective grief experiencehecalled "operational mourning"tofree 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 deathofa close family member. It was clear that a loss affects

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26all membersofthe 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.Ifthe family incorporates and embodies the cultural denialofdeath and fails to integrate it appropriately within the family or if the family deals with the death by avoiding discussionofit or mystifying it, psychopathology for the children will be much more likelytooccur. Parkes and Weiss (1983), through anecdotal accounts, began to observe that bereavement seldom affects only one survivor. The entire familyofthe deceased person could be traumatized sufficiently by the loss to create estrangement between family members. Defensive reactions impede attemptstoestablish 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 begantostress the importanceofgoing beyond a psychoanalytic viewpoint in order to recognize and treat the stress on theentire family system when deathofa close family member occurs (Hare-Mustin, 1979). Death was seen to be the precursorofunderlying problems, including an increase in family conflicts, school problems for children, role confusion, isolationofthe familyorindividuals, or overdependencyofone member upon another. Empirical Research A few researchers begantotry to capture a family's reaction to death by measuring the individual members within the family. Lewis etal.(1976) noted some dramatic differences in families they were studying with regardtothe interplay between physical illness and the family system. Families who discussed deathina personalized way in constructing a story endingtoa taped vignetteofa dying person had a significantly higher

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27numberofdaysinwhich no family member wasilLsuggesting that there was a relationship between a family's opennessindiscussing death, the amountofempathy they showed, and their own physical well being. Psychiatric help was needed for at least one family member in halfofthe 23 families participating in a studyoffamilies who had lost a child to leukemia (Binger et al., 1969) andin25%offamiliesofcystic fibrosis children who died (Kerner, Harvey, & Lewiston, 1979). There was a high incidence of emotional and health problems in parentsofthe cystic fibrosis children and an unexpectedly high incidenceofincomplete mourningasindicated by weekly visits to the grave 2 years postdeath or maintenanceofthe child's room as a shrine. Siblingsofcystic fibrosis patients (Kerner et al.•1979) had fewer adjustment problems than siblingsofleukemic patients (Binger et al., 1969), possibly duetothe lengthofthe illness and no hopeofcureincystic 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 ramificationsofthe death. In addition to clinical depression in a significant numberofthe parents and psychosomatic complaintsinboth children and adults in the families, they observed school achievement problems and behavior problemsinthe surviving siblings.Ina retrospective studyoffamilies who had experienced the deathofa child with cancer 7 to 9 years previously, manyofthe parents and siblings were still experiencing pained loss at the timeofthe study (McClowry, Davies, May, Kulenkamp, & Martinson, (987). The empty space created by the child's death was a characteristic noted by manyofthe participants, and different patternsofgrieving were noted with the family's response to that empty space. Norris and Murrell (1987) conducted a longitudinal study to determine differencesinhealth and stress levels for families who experienced lossofan immediate family member and those who experienced no losses. These researchers found no significant

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28 differenceinhealth effects, but they did note a sharp, significant increaseinpsychological distress, regardlessofprebereavement stress. There werenosignificant 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 deathofoneoftheir members (Huygenetal., 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 historyofnervous symptoms showed elevationofmorbidityinthe period before the loss; after the death, the difference gradually decreased, suggesting that bereavement may cause a shift in the system that changes the functionofthese behaviors. Raphaeletal.(1990) longitudinally studied the adjustmentofadolescents who had suffered parental loss and found higher levelsofgeneral health problems, more neuroses, introverted personalities, impulsive behavior, and more negative viewsoftheir school perfonnance. Interestingly, losses due to death were not significantly distinguished from losses by separation or divorce. A studyofthe effectsofall deaths in a family over four generationsofa 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 levelofsatisfaction with the family and. in tum, 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 levelofsymptoms, not her own, which speaks to the notionofreciprocityinmarital functioning. Women with high levelsoftraumatic loss seemed to become caretakersofmen with high levelsofpsychological symptomatology, allowing the wife to "overfunction" and the husbandto

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29 "underfunction." Traumatic losses may have served as growth catalysts for the women since muchofgrief work involves affiliative tasks, traditionally more characteristicofwomen's roles. Other intriguing findingsofthis study were that wives with greater stress and loss histories were in couples that had greater husband-wife discrepancies in their perceptionsofthe family. They were significantly different from nonclinical couplesinthat they had more difficulty in achieving shared consensus about the family and had lower levelsofactual and ideal cohesion and adaptability. Jordan noted that the damaged world viewofa 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 efforttoassess generational effects, Ponzetti (1992) compared the reactionsofparents and grandparentstothe deathofa child. Parents felt a significantly greater degreeofshock, 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 needtotalk 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 bereavementofparents and grandparents was different in that parents' reactions centered on their child, whereas the grandparents' concerns were for their children (the parentsofthe deceased child). This study emphasizes the importanceofassessing family members outside the nuclear family when a death occurs. Family members who had survived the murderofoneoftheir members were studied by Sprang et al. (1992-1993). Those who were found to grieve extensively were women, nonmarried. those with lower incomes, infrequent usersofsocial supports, and those more religiously inclined.

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30 TIle empirically based research studies on the impactofdeath on families cited above were largely carried out retrospectively through questionnaires or interview processes and the additive resultsofindividual assessment tools. Findings were primarily noted in the areasofmorbidity, psychological distress, behavioral disturbances, gender differences, social support, and generational differences. Death as a Stressor Event Individual Perspective Deathofa family member is a universal event that researchers agreeisoneofthe most difficult and stressful life cycle changes families face (Dohrenwend&Dohrenwend, 1974; Holmes&Rahe, 1967). The deathofone's spouse is listed as the single greatest stressor on Holmes and Rahe's Social Adjustment Rating Scale (Holmes&Rahe. 1967). Deathofa child also creates such significant stress for couples that marital discord erupts and may end in divorce, further disrupting these families (Kaplan et aI., 1976; Tietzetal., 1977). For a young childoradolescent the stress of losing a parent can produce high amountsofbehavior disturbance within 6 monthsofthe death (Kranzler et al., 1990) and can have lifelong impact on their development (Eisenstadt, 1978; Elizur&Kaffrnan, 1983; Johnson&Rosenblatt, 1981; Solomon&Hersch. 1979; Weber&Fournier, 1985). Lossofsiblings, grandparents, and other close relatives. too, can be quite stressful, depending on the natureofthe relationship (Binger etaI.,1969; Cain et al., 1964; Schumacher, 1984). Family Perspective As the American family has decreasedinsize 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 deathofoneofits members occurs (Rando, 1984). Death is a stressor event that produces a significant amountofchangeinthe patternsoffamily life, altering previous

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31subsystem dyads, alliances, and coalitions (Rando, 1984; Reiss, 1981). When a loved one dies, it is difficult,ifnot impossible, for the subsystems and boundariesofthe 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 deathofa child affects the family's subsystems just as profoundly. The sibling subsystem has lost a member. A parent may move in to the sibling systemtofill the void and "become" a child,ora child may move into the parental subsystemto"parent" the parent, which complicates the spousal subsystem. Extended family members may also be pulled in, all in an effort to reestablish equilibriuminthe family unit (Detmer&Lamberti. 1991). The immediate effectsofthe lossofa loved one are felt by those who are close to that person, but eventually the effectsofthe loss reverberate throughout the whole systemoffamily relationships transgenerationally, necessitating changes in interconnectedness and relationships (Detmer&Lamberti, 1991). The deathofa husband will affect his siblings (same generation) and his parents (older generation) and potentially grandparents and grandchildren (Detmer&Lamberti, 1991). The reactionsofthose close to the dead family member initiate a cycleofchangeinothers. Stressisgenerated not only in the immediate impact on those closetothe deceased but alsoasa resultofthe reactions that are produced in the restofthe family system (Gelcer, 1986). Valeriote and Fine (1987) differentiate between the primary effectsofa loss (the immediate impact on those who are close to the dead person) and the secondary effects which are the resultofchanges produced at the primary level. Bereavement will affect the family system in many ways. The deathofa member means the system is irrevocably changed. Interlocking roles, relationships, interactions, communications, and psychopathology and needs cannolonger 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 andeach component subsystem. The family viewofitself, the family myth, may be impossibletomaintain, andallthat it avoided may have to be confronted. The threat to the integrityofthe family

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32 unit may come not only through the change that lossofa family member brings, but also because that member may have occupied a key role in maintaining the system. or perhapsinregulating it in a crisis. Others may be unable to take over [the deceased's] roles and responsibilities. While the threattoits integrity may make family boundaries close over, individual members and the system itself may. in contradiction. desperately need the support and careofother systems. (Raphael, 1983,p.54) The vulnerabilityofthe family will be mediated by its abilitytoreceive support. requiring the family systemtobe opentoextended family and friends outside the immediate family (Detmer&Lamberti, 1991). The EffectofStress on the Family Demands for Change Theories about stress and families originatedinthe fieldofsociology. Hill (1949) was oneofthe first to examine why stressor events such as losses, illness, or separation produced such a varietyofdifferencesinfamilies' abilitiestoadapt. Families tendedtobe more stressed by situations for which they had littleorno prior preparation or situations that demanded a changeintheir familiar patternsoffunctioning. 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 terminallyillmember were also the families with greater bereavement strain. These families were also more likely to utilize bereavement services and resources suggesting that the amountofrelief that was felt when the care giving obligations were over was not offset by the strains long-term caregiving imposed. McCubbin and Patterson (1983) further contributed to the developmentofthe family stress theory by developing an adaptationofHill's (1949) family crisis model to include the effectsofstress when a family was already experiencing a pileupoflife events taxing the family system. Since developmental transitions are already

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33stressful points in the life cycle, additional demands made at those times could be expectedtocreate 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 dealofemotional energy is directed towards reestablishing balanceinthe system. The system as a whole as well as individual members are all affected (Rando, 1984). The family's prior implicit functioning maybereplaced 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 sourceoftyranny for mostofits members, and family disorganization or dissolution becomes severe (Reiss, 1981). Predicting the relationship between stress and family disorganizationisan inexact science. AJthough 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 subjectedtosevere stress and show little disorganization; at other times in their development, a similar stressful event may be overwhelming. Reiss (1981) highlighted two factors to beof primary importance: the family's leveloforganization at the timeofthe stressor event and the qualityofits ties with its social environment. Lewis (1986), too, higWighted the organizational structureofthe family as a factor influencing how a family responds to stress. He described oneofthe family system's essential tasks as distance regulation, with most families living with some typeofbalance 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 respondstonormative stress. Lewis hypothesized that stress arises when individual family members' needs for separateness and attachment occur at different times. The relationshipofthe family life

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34 cycle to changesinfamily organizational structureisan important issue in understanding family stress. Walsh (1982) pointed out that a family's ability to cope depended on their ability to manage a numberofdifferent dimensionsoffamily life simultaneously: organization, independence, self-esteemofmembers, cohesiveness, social support, controlling stress, and the amountofchangeinthe 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. Strugglingtomaster a stressful situation may be the impetus a family needs for developmental creativity (Eisenstadt, 1978; Osterweis et ai., 1984; Walsh, 1982). "The timeofdisorganization 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 lossoftheir loved oneina shorter periodoftime than those who were disorganized and poor problem solvers (Reiss et al., 1986). ImpactofDeath on the Family A family's equilibriumisdisturbed when a member is lost. Murray Bowen (1976) has written a descriptionofthe family's reactiontodeath that has become a classic in the family systems literature. The emotional reactiveness thatisstirred up withinfamilies after the deathofa member has been termed by him the "emotional shock wave." The "Emotional Shock Wave" is a networkofunderground"aftershocks"ofserious life events that can occur anywhere in the extended family system in the months or years following serious emotional eventsina family. It occurs most often after the death...ofa significant family member....It is not directly relatedtothe usual grieformourning reactionsofpeople close to the one who died. It operates on an underground networkofemotional dependenceoffamily members on each other." (Bowen, 1976,p.325)

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35 Symptoms Produced Rosen (1990a) has written thatnofamily 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 knowledgeofeach 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 deteriorationoftheir normal functioning. Some achieve greater intimacy as a resultofthe 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 mayimplicitly prohibit expressionofgrief which may leadtochildren 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 discussionofemotionally charged issuesorthreatening 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 experiencedmore stress than it can deal with. it may experienceillhealth, extreme interpersonal conflict, or become destructive (Olson, 1988). Investigators using empirical methods have indicated that a significant numberoffamilies who experienced the lossofa 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.

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36 Depending upon the circumstancesofthe death, families may experience social isolation and avoidanceofdiscussionofthe death by extended family and friends, especially now with the prevalenceofAIDS deaths (Rosen, 1989; Williams&Stafford, 1991). Oneofthe significant characteristicsLindemann (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 resultoftheir pain, the surviving family members often feel an immense senseofloneliness and isolationascommunication among family members dwindles (Fleming&Adolph, 1986). When discussion among nuclear family members becomes constricted. the family system is at riskofbecoming unable to help one another through the grieving process (Helmrath&Steinitz, 1978). Families that encourage closeness and communication appearedtoexperience fewer grief complications (Fleming&Adolph, 1986). Role flexibility within the family system becomes an issue when a family member dies (Lamberti&Detmer, 1993). Oneofthe causesofthe disequilibrium families face when oneoftheir members diesisthat thereisoften a shift in power. responsibilities, and roles necessitatedasa resultofthe vacancy the deceased leaves (Rando, 1988). Vacated roles maybeinstrumental ones such as economic support. maintenanceofphysical needs and socializationofthe children, or affective roles concerned with the giving and receivingoflove (Goldberg, 1973). Others are not as readily apparent but may leave quite a gaping holeifthe person servedasthe peacemaker, the troublemaker, the scapegoat, or the worrier. Roles must be renegotiated in order for familiestoregain balance. The reassigningofroles can be positiveiffamilies find new waysoffunctioning that are better than before. People may discover abilitiesofwhich they were not aware or finally be given recognition for their contributions to the family. The changingofroles can have negative consequencesifroles are not appropriately reassigned: expecting another person to live in the deceased's image, robbing themoftheir own identity; overloading

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37 some membersofthe family with more tasks than can be fulfilled; assigning a person tasks that are developmentally inappropriate; orifthere is disagreementaboUlwho should or is entitledtofill 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 needtomaintain certain rolesinthe family, and a member will appoint hirnselflherself to fill the role, or will be appointed by anothertofillthe role vacated by the death. In more functional families. the lossofthe roleisrecognized, but no one person is expected to fillit.Thereisgreater flexibility in the reorganization process. Lossofa spouse. As noted earlier, Holmes and Rahe (1967) considered deathofa spouse to be the greatest stressor for an individual. In a study by Bass et al. (1990), two thirdsofthe bereaved spousesintheir sample believed the deathtobethe most difficult thing they had ever faced. Given normal life expectancy, itisnot unusual to have bereaved spouses who have been married 45 to50years. The severingofthat bond is often devastating, usually leaving the bereaved spouse alone and without the sourceofmostoftheir previous social interactions (Lund, Caserta,&VanPelt, 1990). They are often excluded from the sociability of couples from that point on and are thus deprivedofthe normal avenuesofsocial support that have been previouslyattheir 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 deathoftheir spouse. Whereas support from family members remained stable over time, grievers over age75reported 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 networkofsupport initially but increased their network

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38by 2 years postdeathtonearly double thatofthe women. Both networksofsupport were largely same-sex. A general deteriorationofhealth (Bass etaI..1990) and an increase in mortality among spousesofthe deceased has been noted (Parkes, 1964, I 970b).A significant increase in the morbidityofother family members I year postdeath was found in a retrospective research study (Huygen et aI., 1989). Stack (1982) also noted the tendencyofthe bereaved to presenttothe doctor with physical symptomsoftheir grieving rather than psychological symptoms and the importanceofthe 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 stagein their life when no other family members are living with them. However, the ramifications in the restofthe family system can be seeninthe following section. Lossofa parent. The most common loss in our society is thatofthe deathofan elderly parent (Bass etaI.,1990). Many changes in family interaction patterns have been noted clinically when an aged parent has died (Hargrave, 1992: Morgan, 1984). Increased frequencyofcontact 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 realignmentofresourcesoftime, space, and emotionalinvolvement. Adult children may find themselves combining living arrangements with a surviving parentwho is not able to live alone (Crosby&Jose, 1983). Hargrave(1992) noted the conflict families often haveovertheestateofthe deceased and the deeper emotional conflicts that are usually behind that. There is also the needtokeep the family from disintegrating. Hargrave, as well as others (Osterweis etaI.,1984), noted the reorientation adult children face when they become the senior generation

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39 after the deathofboth parents, being thrust developmentally into the next stageoflife and the midlife reevaluation that occurs as a result. Some studies have noted a relationship between deathofa parent and increases in suicide, attempted suicide, and clinical depression (Binchnell, 1975; Bunch&Barraclough, 1971).Ifthe bereaved adult child has not individuated or psychologically separated from the deceased parent, the grieving process may be thwarted until that developmental taskisachieved (Williamson, 1978). Hargrave(1992) also described the guilt and remorse among family members who may feel they have done too muchortoo little over the yearstoresolve conflicts that did not get settled priortothe deathofthe family member. Child's lossofa parent. Younger families that suffer the lossofa 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 lossofthe couple's friendship network (Reilly, 1978). Children in these families who are at risk for suffering a pathological bereavement reaction upon the lossoftheir 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 hadnosubstitute parent figure. Whether or not children are allowed to make their own decisions about participating indeath rituals alsoisa factor associated with a child's bereavement reaction. Weber and Fournier (1985) found that families who were most cohesive tended not to allow their childrentomake their own decisions about participating in death rituals; this tendency often led these childrentoexperience confusion and a greater need for support. Barth (1989)

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40believed 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 nonresolutionoftheir grieving resultinginantisocial behavior (Eisenstadt, 1978). Early parental loss for children has been associated with the developmentofdepressive disorders and increased suicide risk (Osterweis et aI., 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 natureofdeath 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 deathofa parent (Barth, 1989). Children learn how to grieve by modeling their parents. Parents who are dealing with the loss may feel the needtobe strong for their children in an effort to keep the emotionalityofthe familyincontrol.Ifthe surviving parentisnot openly expressing emotion over the lossoftheir spouse, children in the family may conclude that showing emotions is inappropriate, and the whole family may stifle their emotionsinan efforttoprotect one another (Moody&Moody, 1991). The family with an adolescent or young adult in the launching stage often experiences the onsetofsymptomsinfamily 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 levelsofhealth problems and more neuroses, were more introverted and impulsive, and reported being more sexually active. The transgenerational impactofdeath 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

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41likely to engage in delinquent behavior, criminality, or drug abuse. These findings are further validated by examining historiesofmale and female prisoners that reveal an excessofparental death compared to a normal population (Osterweis et al., 1984). Drug addiction in families has also been foundtobe 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 proportionoftraumatic, untimely, or unexpected lossesoffamilymembers 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 atopiCofdiscussion 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. Lossofa child. The lossofa child isanimmense loss for parents, a time when theyfeelthey have literally lost partofthemselves and certainly someoftheir hope for the future (Schwab, 1992). The strainofsuch a death on a marital relationship sometimes resultsinseparation and divorce.Ina study by Nixon and Peam (1977), 7of29 marital couples had separated following the drowningoftheir child.Noseparations occurred in the 54 couples whose child had survived a near-drowning. Fiveofthe couples who experienced a loss were more resilientinresponsetothe loss, indicating that the tragedy had actually brought them closer.Inanother studyofdivorce among bereaved parents, Klass (1986-1987) concluded that divorce occurred more often becauseofpreexisting problemsinthe marriage--there was simplynolonger a reason to struggle with the marital problems after the child had died.

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42Helmrath and Steinitz (1978) conducted a research studyofthe parentsofnewborn infants who died shortly after birth and reported a senseofextreme isolation by the parents.Theextended family and the community's avoidanceofdiscussionofthe death seemingly to protect the parents actually resulted in extreme distress for the bereaved parents. They also reported a disturbanceincommunication between the parents as each grieved at a different pace and oftenindifferent ways. This was corroborated in research carried out by Schwab (1990) which found that there were significant differences between mothers and fathersofdeceased childreninthe useofcertain coping strategies. Mothers were significantly more likelytocry and write about their loss and grief as a means to seek release from the tension; they were more likelytoread about loss and bereavement, to engage in helping others, and seeking support through an organized group. Themes that most frequently emerged in later studiesofthe effectsofa child's death on the marital relationshipincluded the husband's concern and frustration about their wife's grief, wives' anger over husbands not sharing their grief, communication difficulties, lossofsexual intimacy, and general irritability between spouses. Intense grief reactions were also predictiveoflossofintimacy in bereaved mothers and fathers in a study by Lang and Gottlieb (1993). Parents whose babies diedofSudden Infant Death syndrome were followed longitudinally in a research study by Zebal and Woolsey (1984). Two months after the deathoftheir 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 effectsofSillSdeaths on the marital bond and reported that when communication between the couple was poor, critical emotional issues were not discussed foranextended periodoftime. Zebal and Woolsey (1984) attributed someofthe differenceininteractional patterns in the marriage to the differences between the genders in their respective stylesofgrieving. Mandell, McClain, and Reece

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43(1988) found that fathersofSillSinfants increased their involvement with their work, were stoic, and appeared to have a limited ability to talk about their feelings or ask for support.InMandell's (1980) studyofSIDS parents. 6ofthe28couples had divorced after the deathoftheir 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 ambivalenceofthe parents and can begintoquestion their value to the family. Young siblings feel the withdrawalofthe parent and, consequently, the feelingofbeing loved. They may feel abandonedorpunished and may develop fears about themselves (Lewis, Lewis,&Schonfeld, 1991). Fulmer (1983) described the roleofthe misbehaving child in responsetothe depressed and anxious surviving parent. It is not unusual for the surviving children to feel guilty becauseoftheir sibling's death and to begintodevelop symptomatic self-punishing behavior as a result. Parents can feel a real fearofbecoming 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 aI., 1964; Payne, Goff,&Paulson, 1980). Siblings can influence and help each other through the bereavement period and may compensate for manyofthe difficulties parents experience during this timeinconsoling the other children (Rubin, 1986). Both positive and negative behaviors have been seen to increase after the deathofa 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 I year postdeathoffamilies who had lost a childtocancer showed thatofthe 26 surviving siblings,15developed behavior problems such as delinquency, aggression, and poor relationships with parents (Tietz et aI., 1977). Eight manifested

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44school achievement problems and six developed psychosomatic complaints. Mandell et al. (1988) studied familiesofSillSbabies and noted behavioral changesinsiblings in termsofsleep patterns, social interactions, and parent-ehild interactions which were a reflectionoftheir own as wellastheir parents' adjustment. The interactionofparents and children in each possible configuration can exacerbate or mitigate each individual's response to the loss as well as thatofthe family as a whole. The powerful impactofthe 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 effectofa death will restimulate the adolescent's attachmenttotheir family and may vary depending upon the attachment and ambivalence they feel. The periodofgreatest risk and opportunity for the familyisthatofthe first year following the death. Although mostofthe problem behaviors are seentosubside eventually, some may require professional help. Adaptational Factors That so much can go wrong, as evidencedinthe reviewofthe grief literature, presents a challenge to a family's ability to survive. How well families adapt depends on a numberofvariables, as indicated above. Thereisnever a good time to experience the deathofa close family member, but there are times when the stressofsuch 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 familyisexperiencing a numberofother concurrent stressors, they may have more difficulty coping and adapting.Ifthere are previous traumatic losses and unresolved mourning, the family will be more vulnerable in

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45 the eventofanother death (Jordan, 1991-1992; Rosen, 1988-1989; Walsh, 1978).Ifthe 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).Ifthe roleofthe 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 problematicifthe 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 stylesofcommunication deal better with the crisisofdeath than those where death is a toxic issue that cannot be openly discussed (Walsh, 1982; Walsh&McGoldrick, 1991). When feelingsofsadness and loss as well as anger, guilt, and relief can all be openly shared, the grieving process and the readjustmentofthe family will be more likely to proceed without undue difficulty (Bowen, 1976; Lamberti&Detmer, 1993; Vollman et al., 1971). Open communicationalso allows for a better fitinthe reallocationofroles that is necessitated after the lossofa family member (Vess et al., 1985-1986). When there arenoconflicted or estranged relationships at the timeofdeath, families cope better (Bowen. 1976; Rosen,199Gb;Walsh&McGoldrick, 1991). If the family has a wide sourceofsocial support and a large extended family close by, there is a greater likelihood that they will successfully adapttothe lossoftheir loved one (Walsh&McGoldrick, 1991). A cohesive but differentiated family will be more likelytooffer support and have tolerance and respect for individual differencesinthe grieving process (Walsh&McGoldrick, 1991).Ifthe family has a historyofbeing flexible in the faceofcrises and able to draw from a wide rangeofhealthy coping behaviors and resources, they will be less likely to

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46experience defeat when a family member dies. They will be more likely to accept the loss and integrate it into their viewofthe evolutionoflife (Walsh&McGoldrick, 1991). The more flexible they are, the more likely they will be able to handle the reorganizationofthe family system that is necessitated becauseofthe loss (Cohen et aI., 1977). Some researchers have found that when deathisanticipated as a resultofa chronic illness, families cope significantly better thanifthe deathisunexpected (Lindemann, 1944; Neugarten, 1976; Parkes, 1975; Rolland, 1990; Sanders, 1989). However, other researchers have shown that expected death did littletolessen the psychological distress experienced after death (Norris&Murrell, 1987), and illness that required extensive caregiving priortothe death has been shown to be linked with greater bereavement strain (Bass&Bowman, 1990). Lengthoftime that the illness has been diagnosedisanother factorofimportance. If the illness has been 3 months to a year in length, the family has sufficient timetoanticipate the death but not an excessive amountoftime that depletes the familyofits caregiving and financial resources (Sanders, 1989; Walsh&McGoldrick, 1991). Grief reactions have reportedly been more intenseifthe tenninal illness has lasted for more than a year (Payne et aI., 1980). The natureofthe deathisanother factor. Suicides cause tremendous pain for the surviving family members as do violent deaths where body deformityordismemberment 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 abilitytoadapttoa loss is their belief system. This may involveethnic, religious, or philosophical ideas about death and the meaning attachedtoit and will be very influential in how the family responds to a deathofoneofits members (Herz Brown, 1988: Walsh&McGoldrick, 1991). Families who have

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47appropriate rituals and ceremonies to cope with the loss are better abletoadjust than families where thereisnocommemoration to aid the familyinthe expressionoftheir grief (Bolton&Camp, 1986-87; Imber-Black etaI.•1988; Rosen, I 990b). Walsh and McGoldrick (1987) identified some essential tasks families must negotiate in order to adapt optimallytoloss: (a) shared acknowledgementofthe realityofdeath. which is facilitated by open communication within the family; (b) shared experienceofthe painofgrief, allowing all feelings about the loss-from sadness to anger--to be expressed; (c) reorganizationofthe family system to compensate for the lossofthe role and relationships with the deceased; andCd)reinvestmentinother relationships and life pursuits. which often takes I to 2 yearstoaccomplish. Death does not havetobe regarded as a tragedy but ratherasa challenge and an invitation for adaptive change (Greaves, 1983). It is dangerous to assume that all losses produce debilitating responsesorthat a certain amountofgrief 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 shownointense distress--allofthese reactions are considered nonnal adaptive processes (Wortman&Silver, 1989). Family Systems, Stress, and the Life Cycle Family Systems The family system is definedasa groupofindividuals 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 tum, impacts the originatorofthe change. Feedback loops denote that causality is not linear but circular; every action is also a reaction (Guttman, 1991; Walsh, 1982). The familyisgreater than the sumofits parts and cannot be captured by simply describing each individual within that family. Their differences are equally as importantastheir similarities and servetohelp maintain a stable state, referred to as homeostasis (Guttman, 1991; Walsh, 1982). The patternsoftheir connections are

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48governed 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-beingofeachofits members (Walsh, 1982).Insystems thinking, an individual's problem is seen as an expressionofan interactional pattern in the family. The symptom maybefunctionalinthat 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 timesofimbalance 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 lossofa child. a sibling, a parent. a spouse, or a grandparent, depending upon each individual's connection with the deceased. Eachofthese unique relationships affects the impactofloss on the whole family (Walsh&McGoldrick, 1987). Family Life Cycle The family developmental frameworkisanother critical dimension that is added to the interactionist perspectiveofthe family system. The interrelatednessoffamily members changes over the courseofthe family's life cycle,asroles and relationships between parents and children evolve with the developmental changesofeachofthe family's members (Walsh, 1982). The family life cycleisgenerally defined in developmental stages and is characterized by the major events and developmental tasks the family is facing, especially the addition and departureoffamily members (Carter&McGoldrick. 1988; Duvall&Miller, 1985; Walsh. 1982). Generally, the major stages are courtship, marriage, adventofyoung children, adolescence, children leaving home, readjustmentofthe couple, retirement, growing old, and facing death.

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49 Undergirding assessmentisan understandingofwhatisconsidered "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 stagesofthe family life cycle (Walsh, 1982). There are various schemas, but all are primarily geared around the individual developmental stagesofoffspring (Carter&McGoldrick, 1988; Duvall&Miller, 1985; Olson et al., 1983). More attention has been paidtothe child-rearing phasesofthe family than to thelater stagesofthe family's life. The family life cycle perspective views symptoms in relationtonormal functioning over time, with the individual life cycle taking place within the contextofthe family life cycle (Carter&McGoldrick, 1988). The various stagesofthe family life cycle are based on the view that the central underlying process to be negotiated is the expansion, contraction, and realignmentofthe relationship system to support the entry, exit. and developmentoffamily membersina 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 deletionofmembers 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 tasksintheir relational qualities. Ireys and Burr (1984) noted both individuating and integrating family tasks for young adults. As life cycle patternsinour time have made some significant changes with increasing numbersofcouples cohabitating, same sex marriages, lower birth rates, an increase in divorces and remarriages, delayed marriages and childbirth. and increases in numbersofsingle women giving birth without marrying, whatis"normal" is becoming more and more mythological (Carter&McGoldrick, 1988). Carter and McGoldrick (1988) have developed additional phasesofthe 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 groupsofpeople.

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50Family Stress Family stress research had its beginnings with the workofHill (1949) who studied the stressofwar separation and reunion on families. In an efforttounderstand why the same stressor affected families differently, Hill (1958) developed a modeloffamily 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 makesofthe event), produces X (the crisis). Attentiontofamily stressors is directed at both nonnative and nonnonnative life events. A stressor is defined as "a situation for which the family has had littleorno prior preparation" and crisisas"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 ModelofFamily Adjustment and Adaptation, incorporating into it the conceptofthe "pile up"offamily life changes. The FILE was developed in ordertomeasure the stressofa family. Life events which are experienced by the family as a whole or byanyonemember are added together to detennine the magnitudeoflife changes facing the family as a whole. These researchers hypothesize that, as family life changes accumulate, thereisa decline in family functioning (McCubbin&Thompson.199I). 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 strainofcaregiving was associated with an increased useofbereavement services for families after the deathoftheir loved one, which also atteststothe "pile up"ofstrains and stresses. Most recently, McCubbin and Patterson have further adapted the Double ABCX Model and now have introduced the Resiliency ModelofFamily Stress, Adjustment and Adaptation, which includes family types and levelsofvulnerability in additiontothe elementsofthe Double ABCX Model (McCubbin&Thompson, 199 I).

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51Family Stress and the Life Cycle David Olson and his associates have studied nonnal family development across the life cycle (Olson etaI.,1983, 1985). Families were studied on several dimensions: family types, family stress, family resources, and marital and family satisfaction.Bydescribing the positive aspectsoffamilies 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 characteristicsof1,140 intact families from across31ofthe50United States. representing seven stagesofthe family life cycle from young couples without children to retired couples. Specific stagesofthe family life cycle were identified based on the ageofthe oldest child. the amountoftransitionorchange required in response to changing developmental needsofthe family members, and changesinfamily goal orientation and direction. Family norms were then developed by stageofthe family life cycle (Olson et aI., 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 mE. The top stressors for each stageofthe life cycle were calculated. The stressofillnesses and lossesofrelatives, family members, and close friends appeared to be most closely associated with the latter two stages, the empty-nest and retirement stagesofthe family life cycle, as might be expected (Olson etaI.,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 percentofthe familiesinthis study were clustered in the midrangeoffamily stress. Major differences were found among the various family members and across the stagesofthe life cycle (Table I). Those differences can be accounted for by identifying the differing developmental tasks and family structuresofeach stage and also by describing the cohort differences between younger and older couples (Olson et al., 1985). Stagesofthe

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52 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 I Comparative Norms for Family Pile-Up over the Family Life Cycle Weighted Sum Family Life Spiral Family Stage Mean Comparability Couple 478 Preschool 530 CP School Age 500 Adolescence 545 CF Launching 635 Empty Nest 425 not comparable Retirement 395 not comparable Source: Family assessment inventories for research and practice, 2nd ed., by H.I.McCubbin andA.I.Thompson (Eds.), 1991, p. 93. Olson (1983) and McCubbin (1991) also noticed differences in families' responsestostressors 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 conditionsofan 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

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53adults. retirement, and death. Haley (1973) noted that most periodsoffamily stress occur when someone is entering or leaving the family. All levelsofthe family system areingreater flux at these times. Because thereisa great dealofupheaval, 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 modelisbased 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 abletoadjust toornegotiate 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 stagesofthe life cycle. However,ifthose events occur earlier in the life cycle, the eventisconsidered"off-time," and the family lacks the psychosocial preparation that comes later when their cohortisalso experiencing similar losses (Herz, 1980; Neugarten, 1976; Rolland, 1990). For example,ifa young adult is in the transitional stageofleaving home and a parentisdiagnosed 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 tom between his/her own immediate pursuits and premature caretaking obligations (Walsh&McGoldrick, 1987). The whole familyisrobbedoftheir expectationofa "normal" life cycle, and the adaptations that will be requiredofthem as a result are greater than had the illness been diagnosedinlate adulthood (Rolland, 1990). At transition stages, intense grieving can occur over opportunities that have had to be relinquished, with lossoffuture

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54 hopes and dreams. This can overwhelm and complicate the tasksofmourning the deathofoneoftheir members, making adaptation difficult (Walsh&McGoldrick. 1987). The abilityofeach 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 modelsofthe family life cycle (Carter&McGoldrick, 1988; Duvall&Miller, 1985; Olson etaI.,1983). However, families do not ordinarily have a beginning and an end but rather continue on with birthsofnew members and deathsofothers, adding generation upon generation.Inaccordance with the repetitive recyclingofthe family life cycle stages and developmental tasks, Combrinck-Graham (1983) devised the Family Life Spiral Model(Figure I). Here the cyclesofthe individuals in the family are relatedtoeach other across three generations (Combrinck-Graham, 1985). The model represents the continuous spiraloffamily evolution, portrayed in a three-generational span. The spiral is compact at the top to signify periodsoffamily closeness and spread out at the bottom to represent periodsoffamily distance. The compact periods reflect centripetal (CP) tendencies; the spread out periods reflect centrifugal (CF) tendencies. The integral concept in this modelisthatofthe family's oscillation betweenCPphases when it is most cohesive (birth, childbearing, and grandparenthood) andCFstages when itisleast cohesive (adolescence, the 40s reevaluation, and retirement). These terms are borrowed from physics to describe the presenceofopposite forces at work in propelling developmental change in families; one force predominates at one stageofdevelopment, 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

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55CF phases, families are looking for gratification outside the family unit, and the family's external boundaryisrelaxed in ordertofacilitate achievementofassociated developmental tasks (Beavers, 1982). The useofthe 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 patternsofCFversus CP separation in adolescents and the implicationofthese 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 confinesofthe 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 examplesofthese extreme CP styles. On the other hand, given a lackofclear 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 casesofparental rejection and neglect (Stierlin etaI.,1972). The forcesofCP 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 usesCPand binding styles which block the adolescent's separation. When runaways succeed, CF styles are assumedtobe present in the families, and the useofexpelling dynamics pushes the adolescent out into premature autonomy (Stierlin, 1973). The Timberlawn studyofhealthy families (Lewis etaI.,1976) also used the CP/CF concepts. The researchers initiated the developmentofa modeloffamily patterns and processes which correlates with the functioning capacitiesofoffspring (Beavers, 1982; Beavers&Hampson, 1990). In the Beavers Systems Model one continuum describes five

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56levelsoffamily functioning: optimal, adequate. midrange, borderline. and severely disturbed. The other continuum describes the family relationship style from CP to CF; the extremesofCP and CF are associated with severely disturbed families, whereas the most competent families avoid either extreme, tending to display a mixofCF and CP along the developmental life cycle, more CPinthe early years and moreCFas the children approach adolescence. Beavers' (1982) research indicated that there was a correlation between the relationship style (CPorCF) and the kindofpsychopathology foundinthe family. A family whose predominant forceisCP and who has not shifted its boundaries as children approach adolescence is likely to experience dysfunction. Conversely,itis difficult to effectively parent very young children with a CF relationship style becauseofthe lackofclear external boundaries and structure. At the extremes, CP families bind children and make leaving difficult; CF families expel children before their individuationiscomplete. 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 angty feelings which provide the force for outward movement. Upon examining the Family Life Spiral Model, it is noted that each spiralinthe model represents approximately25years, for example, from birth to childbearingisone full cycle.Ateach newCPperiod, 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 issuesofintimacy inherent in theCPstages and individuation in theCFstages (Combrinck-Graham, 1983). For an individual whose life spans three generations, there will be three periodsofCP family life and threeofCFfamily lifeinwhichtomaster the challengesofintimacy and individuation.

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57 The transgenerational coming together and internal focusofthe family atCPphasesisinevidence as family members organize around the eventofa new birthinthe family. When a new generation has been added. the rolesofthe 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 areinthe processoflearning new roles becauseofthe arrivalofthis new child. Bonding and attachment become the focusofrelationships in the family with the infant. emphasizing nurturing and caretaking (Combrinck-Graham, 1985, 1990). Family members. especially grandparents, cometosee the new baby and help out in the adjustment phase. Mother and father rework their schedules around the baby's needs, and, foranextended periodoftime. life revolves around this new arrival. The creationofa new "family" generates a tighteningofthe external boundariesofthe family unit and a relaxingofthe interpersonal boundaries within the family to allow for assimilationofthis new arrival into the family system,topromote teamwork within the family, andtoprovide the context most suitable for an infant's early development (Combrinck-Graham, 1983). Over the nextl2to18years the family changestoallow for the individuationofthis child by relaxing its external boundaries and shifting to a more CF relationship style. The family develops patternsofrelating that allow for differentiation and disengagementofall the members (Combrinck-Graham, 1985). Outsiders are allowed into the family more and more, and family members venturing outofthe 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 responsetogreater exposure to social forces. At the same time, grandparents, too, are redefining their relationships with the larger society, with extracurricular activities occupying moreoftheir time (Combrinck-Graham, 1983).

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58Asfamilies enter into the CF stagesofthe family life cycle (adolescence, 40s reevaluation, and retirement), the distance between family members is at its greatest; the external boundaryofthe 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, leaming 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 adoptionofrole models other than their parents (Combrinck-Graham, 1988). The stageofadolescence is noted for being oneofthe most stressful phasesofthe family life cycle, with boundaries. functioning, and alliances being very fluid and generating reverberations throughout generationsofthe family (Ravenscroft, 1974). When all the children have reached this point and left home, thereisanother periodofreassessment with parents renegotiating their marriages, careers, and life directions, and grandparents shifting gears into retirement. When the launched children begintomarry and form their own family units, the familyisbeginning another shift towards a more CP system, negotiating peer-like relationships between newlyweds and parents and the reformingofstructures conducive for the CP periodofchildbearing. 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 patternsasthe "normal" three-generational family moves through the life cycle. When generations are separated by about 25 years, the CP and/orCFmovementofthe system appliestoall the generations simultaneously. However, complications appear when the CP family membersofthe 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 differentin

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59 age; the parent(s) has abandoned the child to be raised by grandparents; or the parents are a remarried family (Combrinck-Graham, 1983, 1985). A different kindofchallenge is presented in a family with many children, from young adults to newborns. These families must continue the processofallowing the differentiationofthe young adults while still providing clear structure and boundaries for the younger child(ren). Many times these families remain in prolonged CP states, and young adults achieve someoftheir CF differentiation by participating in the careofyounger children.Aneven greater complexityisadded by remarried families and blended families. One spouse may have children at a CF stage; the other spouse's children may be at a stage; and the newly blended family may choose to have a childoftheir 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 setofdevelopmental tasks imposed upon the normal family life cycle. Relationship between model and impactofdeath. Combrinck-Graham (1985) discussed the developmental misfit that can occur when a family system does not change to become moreCPor more CF as the stageofthe family life cycle requires. Numerous theorists have suggested that symptoms in a family are often signsofdevelopmental misfit (Carter&McGoldrick, 1988; Haley, 1980; Stierlin, 1972, 1973; Stierlin, Levi,&Savard, 1972).Ifa familyisat the stageofadolescence butispredominantly usingCPrelationship styles, one would expecttosee symptomatic behavior and thus a higher levelofstress in the family's interactions. Combrinck-Graham (1983) discussed the impactofdeath on families at bothCFandCPperiods in the life spiral. Although Combrinck-Graham originally hypothesized that death might have a more severe impact on families that were not at aCFperiod since

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60death was seen as a departure. she also noted that death has the effectofbringing family members together. especiallyifthereisa chronic illness preceding the death that necessitates family members servingascaregivers. Members come to participate in funeral and mourning rituals, and initial grieving is done in the companyofother family members. Rolland (I 987a, 1987b, 1988a) offered a conceptual framework for the interweavingofthe family life cycle and the conceptsofCF and CP with chronic and life-threatening illnesses.Hehypothesized that chronic illness exerts a CP pull on the family system.Inmuch the same way that birthofa new family member propels family members inward. so does chronic illness. The symptoms, lossoffunction, shifting roles. and the fearofdeath all cause the family to refocus inwardly (Rolland. 1987a).Ifthe illness coincides with a CF period for the family, for example. as young adults are launched, it may cause more problems because itiscontrary to the momentum set in motion by the normal progressionofthe developmental life cycle. Giving up the pursuitofa new life structure is more difficult once that process has been initiated thanifthe 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 severityofthe disease and the family's dynamics will influence whether their returntoa CP structure is temporary or a permanent involutional shift. For more fused families who face autonomy with a bitofcaution. the chronic illness may provide a good rationale for returning to,orstaying at, a CP period. This may merely prolong this period. or, at the worst, the family may become permanently stuck withnoone abletoleave home or move on with their developmental tasks (Detmer&Lamberti, 1991). The risk is that there maybea tendency for the CP pullofthe illness and the CP stageofthe family to amplify one another, creating overt family dysfunction. The tendencyofa diseasetointeract centripetally with a family grows stronger as the disease becomes more incapacitating or as the riskofdeath increases (Rolland, 1987a).

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61Progressive diseases are more CPintermsoftheir effect on families than are constant-course illnesses. With constant-course illnesses, a family may be permitted to enter or resume a moreCFphase once the family has adapted to their roles in regard to the illness. The terminal phaseofan illness forces most families back into a CP mode. Thus, they are outofphase with families in, or in transition toward, a moreCFperiod, and, therefore, this phase will be more disruptive in termsoffamily development. Coping with chronic illness and death are considered normative tasksinlate adulthood.Ifthey 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 typeofbalance between separateness and attachment. There are periods when individuals are more intensely connectedtoanother person(s) and periodsinwhich the individual is more detached from others. Affective arousal is more apt to be associated with periodsofattachment, and a more cognitive orientation prevails during periodsofseparation. 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 iffamily members have too much connectedness or too little connectedness, they may notbe abletorespond to developmental challenges with appropriate increases inCFor CP styles. Thus,ifdeath were a CP force, as Rolland hypothesized, it would be hardest forCFfamilies to respond appropriately. Taking an epigenetic approach which involves the idea that successful negotiationofdevelopmental transitions are dependent upon successful completionofearlier transitions, Lewis (1988) suggested that how a family respondstostructural changes demandedofthem depends on

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62the leveloffamily competence during the preceding stable period. He concluded that the relationship between family transitions to developmentofsymptomatic states may be different at different transition points. Rosen (1990a) has written that at every stageofthe family life cycle bothCFand CP forces are at work, although one tends to dominate. Regardlessofwhere 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 effectofclosing the family's external boundary so rigidly that they are prevented from receiving help from outside sources. TheCPeffectofthe crisis may make it difficult for the familytoproceed 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 violationoffamily boundaries as individualsinoverlapping life cycle stages each try to play significant roles. The problems that poses for a family are documented in a paper by Britton andZarski(1989) which points out theCPpullofa family member with AIDS on a family at aCFstagein the life cycle. Rosen (I990b) has observed that there are fundamental differences in the ways death will impact families at varying stagesofthe family life cycle. Becauseofthe differenceindevelopmental tasks at the various stagesofthe life cycle, some focused more on disengagement and leaving, others on consolidation and drawing together, the family's ability to adapt to the lossiscorrelated with their developmental stage. AtCFstages such as adolescence and young adulthood, the terminal illness and imminent death maybean impedimenttothe developmental taskofleaving home or may create such despair about the past that the family refuses to continue with life's tasks. A loss atCPstages, such as newly married couples, families with young children, or families who have launched their children, may create a developmental arrestinthe family process. The couple may tighten the external boundary on their family so much in an efforttoprotect their children that

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63developmentally the family is kept from moving towards a moreCFstyle as the childrengrowand mature.Whenfamilies are in the processofreorganizing after a loss, family boundaries may remain ambiguousorchange in responseto the stress the family has experienced. Boss (1980) proposed that the greater the boundary ambiguity after a stressor event, the higher the familyandindividual ambiguity. Failing to delineate the boundaries clearly serves tokeepthe family's stress at a high level, blockingthemfrom reorganizinganddevelopingnewstylesoffunctioning. Predictions WalshandMcGoldrick (199 I) have noted the lackofresearch on the differential impactofdeath at various stagesofthe family life cycle and for the family as a unit. "Even when the importanceofa particular death has been noted,ourtheory has lacked a framework for understanding the devastating impact certain lossescanhaveonfamily processes and hasmadelittle senseofthe ongoing problems that may follow from a family's inability tomournits losses" (Walsh & McGoldrick, 199I.p. xvi). Insufficient attention has been giventothe immediate and long-term effects on siblings, grandparents, and otherextendedfamily members when lossofan immediate familymemberoccurs (Walsh&McGoldrick,1987).Howa 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.Theprobabilityofa family experiencing the deathofoneofits members increases as the family moves farther along in the life cycle.AsOlsonetai. (1983) noted in their studyofnormal families across the life cycle, a family's stress level peaks at adolescenceandthe launchingofchildren and then declines significantly (Table I). Although Olson's stagesofthe family life cycledonot coincide perfectly with thoseofthe Family Life Spiral Model, the stress levelsoffamilies at those stages are congruent with the theoretical literature about family stressandthe family

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64life spiral stages.Itisimpossibletocompare the later stagesofOlson's family life cycle with the Family Life Spiral Model. He has reduced Combrinck-Graham's four stagesofgrandparenthood, planning for retirement, retirement, and late adulthood to two--empty nest and retirement. However,ifdeath occurs late in the life cycle, asinlate adulthood, even though it is moreofan 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, thatoflaunching. Perhaps the declining health and deathofoneoftheir older members is a factor contributing to the high stress associated with this stage. Whether or not deathisa universal stressor causing a similar amountofadded stress at each levelofthe life cycleisunknown. Given the magnifying effectsofthe pileupofstressors, 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,ifOlson's studyofnormal 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 attachmentinfamilies, andifthat occurs at a time when members are developmentally separated, there would be higher levelsofstress and symptomatology. However,ifdeath 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 Van' by Life Cycle Phase Several other variables that affect how a family might be impacted by the deathofoneofits members could be expected to vary throughout the courseofthe family life cycle as families oscillate back and forth between CF and CP phases. Those variables are social support, cohesion, adaptability, and communication.

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65Social Support Given what has been documented about the differencesinfamily relationship styles depending upon their CF or CP phase in the family life cycle, one might expect that there would be a greater utilizationofexternal supports by CF families since their orientationisoutward, implying a greater reliance on and trust in relationships and resources outside the familyinorder to meet developmental tasks. TheCPfamilies might be expectedtorely 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 thaninoutside 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 individualtobelieve they belong to a networkofcommunication involving mutual obligation and mutual understanding. McCubbin and Thompson (1991) added two other formsofsupport under social support: (a) appraisal support, whichisinformationinthe formoffeedback allowing the individual to assess how well they are doing with life's tasks, and(b)altruistic support, which is information receivedinthe formofgood will from others for having given somethingofoneself. Social support may include support from family membersorfrom friends, neighbors, work associates, socialorchurch groups,orhealth care providers. The social support families are abletomobilize 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

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66 extended family from whomtodraw suppon tendedtoget on with life after suffering a deathofoneoftheir members as opposedtomembers who each had their own separate circleoffriends from whom they derived mostoftheir suppon (Ellard. 1974). In some cases, families reponed that support from immediate family members was most beneficialtothem in coping with the death and that various institutional resources such as the church were not seen as hel pful (Weber&Fournier, 1985). Others reported that the bereaved families who heal satisfactorily report accesstoand useofan extended support network--family, friends, neighbors, religion. family cohesion, and involvement outside the family system(Valeriote&Fine, 1987).Ina research studyofparents who experienced the deathofan infant. bereavement was much more difficult becauseofthe lack of societal and family support (Helrnrath&Steinitz, 1978). There was a "conspiracyofsilence" by family and friends that produced immediate distress and feelingsofextreme isolation in the parents.Inanother studyoffamilies who had experienced the deathofa child duetocancer, those who were found tobecoping well had utilized a varietyofresources. 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 unabletoseek support from anyone (Davies. Spinella, Martinson, McClowry,&Kulenkamp, 1986). Older parents' reactionstothe deathoftheir 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 muchofthe support is left up to the remaining family members (Brubaker, 1985). Elizur and Kaffman (1983) conducted a longitudinal studyofchildren in Israel who lost their fathers and concluded that halfofthe children exhibited intense emotional disturbance. Their findings suggested that predeath family and environmental factors are significant determinantsofbereavement outcome. Children at low risk had mothers who

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67enlisted aid from the community whenever necessary: thus, external social support was seen as an important variable. In a research studyofbereaved widows, the typeofsupport needed and found to be utilized varied depending on the phaseofthe 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 seentoimpede 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 participationinsocial 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. Thisisunderstandable in termsofthe bereaved spouse feeling more compelledtoreorganize 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 networksofsupport than bereaved adult children. No differences between relative supportorpaidorprofessional helpers were noted, but there was a significant difference between useoffriends 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 studyofstress and illness, Cronkite and Moos (1984) found that the useofavoidance-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 I-year follow-up also demonstrated a strong negative correlation between the high stressllow symptomatology

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68 (better family support) group and the emotional and physical distressinboth men and women. Their conclusions were that the availabilityoffamily support servestoprotect individuals from negative psychological consequencesofstress, more so for women than men. Developing an expanded support network may be particularly beneficialtowomen facing bereavement (Holahan&Moos. 1986). Rando (1984) noted how critical social supportisfor people in bereavement, not that itisjustavailable but thatitisutilizedastime goes on. She indicates that itiscommon for grievers not to utilize support thatisoffered andtoisolate themselves despite the availabilityofsupport. Rosen (1990a) has noted instances where the absenceofsocial support in bereavement affects the family's ability to mourn its loss. Those instances are perinatal death. the lossofa newborn in the first few weeksoflife, and an AIDS-related death. In the latter instance, the social stigmaissuch 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 conspiracyofsilence between the family and their support network (Bolton. 1984; Brown, 1988; Imber-Black. 1991). The natureofterminal illness and deathissuch that it often isolates families from external support networks such as friends. work. and church. As the CP pullofthe illness and death increases, the family becomes more isolated and closed. Cohen et al. (1977) found that families who were abletocommunicatewith one another in a free flowofinformation were more likely to utilize internal support systems (primarily the family structure) than were their counterparts. Postdeath restabilization was positively correlated with the effective useofexternal support systems such as agencies, institutions, and individuals outside the nuclear family and also with the family's classification asCPo

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69Inanother study, it was found that parents and siblingsofchildren who died experienced less psychopathology postdeath when they cared for their children at home and had good family support (Mulhern, Lauer,&Hoffmann, 1983). There was a significant difference between the home care and nonhome care groupsintheir 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 researchofCohen etal.(1977) that indicated CP families actually made more effective useofexternal support systems thanCFfamilies. This is oneoftwo piecesofliteratureinthe social support field that incorporates the conceptsofCFand CP. Olson's studyofnormal families across the life cycle (Olson et aI., 1983)isanother and did show that there was a positive correlation between low stress families in the childbearing! childrearing stages (CP) and their useofsocial support. These findings are contrary, however, to the constructsofthe Family Life Spiral Model and the descriptionsofCPfamilies which suggest that their external boundaries are tight so astofilter that outside influence more selectively. Clearly, social and familial support are important factorsinhow a family copes with the stressofdeathofoneofits members at some stagesofthe family life cycle. Whether there are significant differences in a family's useofone or the otherofthose support systems, depending upon their stageofthe life cycle when dealing with the stressorofdeathofa 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 writingsofWalsh and McGoldrick (1991). How these variables might interface with the variationsoffamily relationship styles when they are atCForCPphasesofthe family life spiral is unknown.

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70Cohesionisdefined as the degreeofseparationorconnection between family members and primarily concerns the emotional bonding members have with one another (Olsonetal., 1985).Itmight be reasonable to expect that families would score higher on cohesion atCPphases than at CF phases, given the inward focus and orientationofCPphases. Adaptability is the extenttowhich the family system is flexible and abletochange its power structure, roles. and relationship rules in response to situational and developmental stress (Olson etal..1985).Therole realignments and reorganization that are necessitated after a loss are often immense. perhaps especially so the earlierinthe family's life cycle the death occurs. Familieswhofunctioned well after the lossofa child due to cancer were open, flexible. and adaptiveinresponse to the death (Davies et aI., 1986), as opposed to less functional families who were unableorunwilling to make changestotake them past their sadness. Olson (1988) noted the variation in family cohesion across the life cycleinhis studyofnormal families (Figure 3). Cohesion remained essentially the same from young couples without children through families with children ages 6to12.At that point, cohesion steadily declined. reaching its lowest point when families were at the launching stageandrising again until retirement when it leveled off. indicating it was a resource utilized more in the early and late stagesofthe family life cycle rather than at adolescence and launching.If this segmentofthe family life cycle is superimposed on the Family Life Spiral, one can begin to see the oscillations between levelsofcohesion throughout the life cycle, not just the one dip that is showninOlson's graph which would represent oneofthe three life cycle oscillationsinthe 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 levelsofcohesion are indeed

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7170 c: o.f/)OJJ: o U 68 66 64621234567Stages of Family Life Cycle Cohesion in Normal Families Across the Life Cycle Source: Families: What makes them work,D.H.Olson et aI., 1983,p.83. Note: I=Young Couples without Children 2=Childbearing Families and Families with Children in the Preschool Years 3=Farnilies with School Age Children 4=Farnilies with Adolescents in the Home 5=Launching Families 6=Empty Nest Families 7=Farnilies in Retirement

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72related to CF and CP relationship styles, then one may very well expect differencesincohesion in accordance with the oscillationsofthe Family Life Spiral. The differences in family adaptabilityparallelled 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)ofthe 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 adolescentoryoung adult in the launching phase. Relationships were found between past stressors, numberofdeaths, especially premature deaths, and the family's levelsofcohesion and adaptability. Families with higher levelsofpast stressors and numbersofdeath had significantly lower levelsofcohesion and adaptability. How muchofthe variance is duetothe stageofthe 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 adaptabilityaswell as cohesion. In Olson's Circumplex Modelofthe family system, families are categorized accordingtoboth their cohesion and adaptability scores. Depending upon their degreeofconnection and flexibility, they fall into16different subtypes, combining their scores on each continuum. The linear scoring for eachofthe scales with cutoff scores is in Appendix I. That there maybea relationship between these subtypes and the effectsofstress was shown in a later study by Olson and Stewart (1991). Their research results indicated that theseSUbtypesexplained someofthe differences in the family's response to stressful life events. "Flexibly connected" families were more vulnerable to the accumulationofstressful events; "structurally separated" families seemed to more affected by transitional changes. "Flexibly separated" and "structurally connected" families were affected by both

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73 stressful events and transitions. Thus, itissuggested that the effectonfamiliesoflife events and transitionsisinfluenced by cohesioninconjunction 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. lackofempathy, nonsupportive (negative)statements, poor problem-solving skills. and paradoxical and double-binding messages. In Olson's Circumplex Model, parents from balanced families tendedtohave more positive communication skills than extreme families which was corroboratedina research study by Rodick eta1.(1986). When a family member has died, the emotional intensity in the family system can be expected to rise significantly above normal. The abilityoffamily members to stay nonreactive while thoughts and feelings are exchanged between themisan 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 aretoremain nonreactive when the death occurs (Sanders, (989). The longer and more intense the stress, however, the more difficultitisfor the family relationshipstoremain open (Herz, 1980). Sanders (1989) writes that remaining openisperhaps oneofthe most important tasks families can learntodo in ordertoprevent misunderstandings arising at the timeofdeath. Families who have good open internal communication systems are more likely to discuss the death and plan for the reorganizationofthe family. How permissibleitis to express a full rangeoffeelings, from positivetonegative, 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, orjoywould be constricted and not as

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74apttoadjust effectively (Epstein, Bishop,&Levin, 1978). Black and Urbanowicz (1987) found thatinfamilies where oneofthe parents had died. avoidanceoftalking about the dead parent was associated with poorer outcome at I-year follow up. By 2 years there wasnosignificant difference. The openness that allows family memberstogrieve 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 capabilitiesoffamily members (Vess et aI.,J985-1986). Cohen etal.(1977) researched the postdeathadaptationoffamiliesofcancer patients in a longitudinal study. They found that,inadditiontothe 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 qualityoffamily relations postdeath. A significant finding is that the wife-mother was often found to have the roleoffamily communicator. and when she was the deceased, a family's readjustment was significantly jeopardized. pointing out that alternate channelsofcommunication need to be opened up priortothe deathofpatients who hold those rolesinfamilies. Becauseoftheir 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 contributestothat cutoff in communication. In a study by Davies et al. (1986), oneofthe characteristicsoffamilies who coped well with the lossofa child due to cancer was their openness. There was free discussion about the child's death and each

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75member'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 lotoftalk, it was diverted away from discussion about the deceased child. When a family member dies, the pain that the survivors experience can be difficulttoverbalize which mayleadto an increasing senseofloneliness 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 etaI.,1985-1986). On the other hand. they may know how but feel itisimportant to protect others by coping with their grief alone, which separates family members from one another and builds barriers to the grieving process (lreys&Burr, 1984). Families with closed communication styles may present a good fronttooutsiders yet not be open with one another; there is a "conspiracyofsilence" which becomes nonadaptive, preventing social support as well as intrafamilial support (Rosen, 1987; Sanders, 1989). Lewis etaI.(1976) carried out a research study on the openness with which families dealt with the themeofloss. They found a correlation between the families' verbal responses to a video simulationofa family death and their ability to discuss their reactions, and the amountofphysical illness the families recorded over the ensuing 6-month period. Families who were abletodiscuss death in a personal way, as opposedtoimpersonallyoravoiding the topic altogether, had a significantly greater numberofdays in which family members were all well. Another factor blocking communication after a deathinthe family is that family members each will grieve in their own way and at their own pace. Frustration builds as the awarenessofdifferences increases, making family members unabletobeofsupport to one another.Ina studybyFeeley and Gottlieb (1988-89), there was a correlation between parents' coping and communication following the deathoftheir infant. The mothers in

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76couples who had more discordant waysofcoping with the death perceived higher levelsofaversive 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 studyofparent couples who had experienced the deathoftheir infant and noted differences between fathers who were abletobedistracted from the grieving process while they were outofthe home at work for 8 totohours a day and the mothers who remained at home surrounded by their feelings and thoughtsofgrief with no one with whomtoshare them. Having anguish unloaded on them by their wives when they returned homefrom work became more and more problematic, creating more distance between the couples becauseoftheir inabilitytounderstand the differences in their feelings. When the linesofcommunication were opened between them, grief resolution begantooccur. Parents who were very closetotheir 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 timeofdeath (Shanfield et aI., 1984). Children from families where the communicationisopen between parent and child cope much better with death-related experiences and will be more likelytoreceive the necessary emotional support (Weber&Fournier, 1985).Ina studyofadolescent reactions to parental death, despite open discussionofparental 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 reluctancetodiscuss their feelings and a senseofneedingtoprotect the surviving parent. Instead, the adolescent talked with siblings and friends about their feelings. Mothersofchildren at low risk for poor adjustment to the deathoftheir fathers were foundtopromote open and clear communication and free expressionoffeelings (Elizur&Kaffman, 1983). Young adult

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77 drug addicts had experienced more deathsofimmediate family members than a normal sample and perceived their families as discussing death and dying less frequently (Coleman et aI., 1986). The authors surmised that the family environment that minimized the impactofdeath and avoided discussing death-related issues was relatedtothe subsequent substance abuseofthe young adult. Walsh and McGoldrick (1987, 1991) emphasized the importanceofclear information and open communication about the death as oneofthe essential tasks in the family's adaptationtoloss, especially in the activities denoting the death, such as the funeral and graveside services. When thereisan attempt to protect children or vulnerable members from those experiences, the grief processisapt to become blocked. The inability to accept the realityofdeath 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 familytoresolve the loss and "the unspeakableismore 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 importanceofthe opennessofthe family system in termsofits ability to permit communication on any subject without fearofbeing 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(I990a) has written that where families fallon the open and closed communication continuum is directly related to family boundaries in general. Those families with rigid external boundaries can be expectedtohave more closed communication styles; families that have open communication also have more open and fluid external

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78 boundaries. Thus, in termsofCP and CF,itmightbeexpected 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 aI., 1983)ofnormal families across the life cycle indicated that low stress was positively correlated with good communication at all stagesofthe family life cycle, except at empty nest and retirement, suggesting that those are resources that are underutilized at those stages. The associationsofthis variable then seemtobein contrast with previous predictions about which phasesofthe 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 assessmentoffamilies.Itis believed to be a significant detenninantofnormative stressorsasfamilies undertake the seriesofdevelopmental tasks that are necessary to negotiate the entry and exitoffamily members over the courseoftime. Previous researchers have delineated someofthe normative stressors that are associated with various stagesofthe normal family life cycle (Olson et aI., 1983). Family therapy theorists and researchers have postulated that timing in the life cycleisa key variableindetennining the impactofdeath 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). Lossofa loved one is one of the most stressful events families face. As familiesinrecent 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

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79 that are necessitated when oneoftheir members dies. Quite often one or moreofthe family members will present to mental health professionals for helpindealing with symptomatic behavior thatisassociated with a death in the family. As a profession, mental health practitioners must be awareofthe variables that impact how a familyisaffected by the loss andbeabletoassess what the family needs in ordertomove on in the developmental process.Iffamilies 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 abletodesign interventions more effectively which prevent further traumatothe family unit and promote appropriate healing forallinvolved. Numerous variables have been postulated in the literature: timing in the life cycle, roleofthe deceased in the family, opennessofcommunication in the family, useofappropriate ritualstocommemorate the loss, natureofrelationship with the deceased (conflicted, estranged, or harmonious), social support, flexibility in adapting to change, cohesivenessofthe family unit, whether death is expected or unexpected, lengthofillness, natureofthe death (murder, suicide, chronic illness, AIDS), religious beliefs, and ethnicity. Very few definitive studies exist, however, testing these hypotheses. This study measured the impactofthe deathofa family member on surviving members accordingtothe timingofthe death in the family's life cycle; selected other variables known to impact the family's experienceofa death that may differ by the family's place in the life cycle were also assessed.Ifsignificant differences between families at various stagesofthe family life cycle are identified, then appropriate interventions need to be designed for those target populations.

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CHAPTER 3 METI-lODOLOGY And you would accept the seasonsofyour hean. even as you have always accepted the seasons that pass over your fields. And you would watch with serenity through the wintersofyour grief.--Kahlil Gibran Statementof Pumose The purposeofthis study was to detennine whether there were differences in the levelsofstress reported by families at different phases in the family life spiral when they had experienced a death in their family. Four phases were identified: periodsofmore 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 phasesofthe family life cycle than at other phases due to the CP pullofdeath, whichiscontrary to the momentum and organizational patterns that are normal for families atCFphases. Numerous family resource variables are knowntoaffect the levelofstress experienced with the deathoffamily members; severalofthese variables were also measured in this study, specifically, a family's expressive communication, their useofsocial support, their cohesion, and their adaptability. 80

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81In 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 deathofa family member occurs, there isnosignificant difference in the amountofstress reported among families at CF, CF-tCP, CP,or CP-tCF phasesofthe family life spiral.H2:When deathofa family member occurs, there is no significant difference in the typeofstress reactions among families at CF, CF-tCP, CP,or CP-tCF phasesofthe family life spiral.H3:There is no significant difference in expressive communication among families at CF, CF-tCP, CP, or CP-tCF phasesofthe family life spiral. lit: There isnosignificant difference in social support among families at CF, CF-tCP, CP, or CP-tCF phasesofthe family life spiral. Hs: There is no significant difference among families at CF, CF-tCP, CP,or CP-tCF phasesofthe family life spiral on measuresoffamily cohesion.H6:Thereisno significant difference among families at CF, CF-tCP, CP, or CP-tCF phasesofthe family life spiral on measuresoffamily adaptability.H7:There is no relation between levelsoffamily stress and the family's cohesion and adaptability.Hg:There is no relation between levelsoffamily stress and measuresofsocial support.H9:There is no relation between levelsoffamily stress and measuresofcommunication.

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82HID:Thereisnorelation between a family's communication and their adaptability and cohesion. DelineationofRelevant Variables Dependent Variable The impactofdeath. the dependent variableinthis study, was defined in tennsofthe changes in the lifeofthe familyinthefITstyear postdeath. These changes encompass the extentofthe reported stressesofintrafamily and marital relationships, pregnancy and childbearing, financial and business strains. work-family transitions, illness and family caregiving strains, losses (in addition to the deathofthe Hospice patient), transitionsinand outofthe family, and family legal violations (McCubbin&Thompson. 1991). The FILE was used to assess these changes. Several independent variables were assessed: quadrantofthe family life spiral, social support, communication, cohesion, and adaptability. Independent Variables Stageofthe family life cycle. The ability of family members to adapttostressors and the rate at which they do was believedtobe related to the developmental stageofthe family and their locationinphase-space. Cenain periodsinthe 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).Inthis study, the stage of the family life cycle was assessed by determining the best fit with phases (i.e., quadrants)ofthe Family Life Spiral Model, using the methods developed by Olson etal.(1983)intheir studyofnonnal 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),

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83 especially the stress occasionedbythe deathofoneoftheir members. Communication has been noted to vary across the family life cycle as families' boundaries open and close to help facilitate the masteryofdevelopmental tasks at each stageofthe family life cycle (Rosen, 1987, 1990a). There are numerous facetsofcommunication that can be assessedclarityofcommunication, empathy, amountofself-disclosure,orexpressiveness--to name a few. The rypeofcommunication that was deemedofimportance for families coping with the deathofoneoftheir membersistheir levelofexpressive 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 subscaleofthe FES (Moos&Moos, 1986). Social support. Social support is defined as the family's perceptionofthe degree to which they view relatives, friends, and the community as a sourceofemotional support in the managementoftheir stressors and strains (McCubbin&Thompson, 1991). The importanceofsocial support has been shown to aid families who are coping with the deathofa family member, its utilization by families often varying with the stageofthe family life cycle (Bankoff, 1983; Brubaker, 1985: Cohen et al., 1977; Cronkite&Moos, 1984; Davies et al., 1986: Elizur&Kaffman, 1983: Ellard, 1974; Helrnrath&Steinitz, 1978; Holahan&Moos, 1985, 1986; Ireys&Burr, 1984; Mulhern et aI., 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 subscaleofFIRA-G. Cohesion and adaptability. Cohesion is defined as the degreeofseparationorconnection between family members and primarily concerns the emotional bonding members have with one another (Olson etaI.,1985). Adaptabilityisthe extenttowhich the family system is flexible and able to change its power structure, role relationships, and relationship rules in responsetosituational and developmental stress (Olson et al., 1985). The demands for cohesion and adaptability are high when dealing with the stressorofdeath

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84(Beavers. 1982; Beavers&Voeller, 1983; Davies et aI., 1986; McGoldrick&Walsh, 1983; Walsh&McGoldrick, 1991; Weber&Fournier, 1985) and have been shown to vary across the family's nonnal developmental life cycle (Olson, 1988; Olson et aI., 1983).Inthis study the variablesofcohesion and adaptability were measured by FACES-II (Olson et aI., 1985). Data Analysis Table 2 shows the analyses that were conducted. Multipleregression was used to evaluate the impactofdeath on families depending upon phaseof 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 someof the variation between phasesof the family life spiral. The impactofdeath on families was regressed on phaseofthe family life spiral (as represented in the four quadrantsofthe Family Life Spiral Model),aswell as on the other variablesofcommunication, social support, cohesion, and adaptability. Multiple regression was used in order to determine more accurately the significanceofthe phaseof the life spiral as a predictorofthe impactofdeath on the family, as well as the significanceofthe variablesofcommunication, social support, cohesion, and adaptability. ANOV As were usedtoanalyze the effectsofphaseofthe family life spiral on the variablesofsocial support, cohesion, and adaptability. These variables are operationalized as shown in Figure 4. Descriptionofthe Population The population was composedofthe familiesofpatients who were referred to the HospiceofNorth Central Florida by their physicians for comfort care during the last stagesoftheir terminal illness. The patient population was from an II-county areaofnorth central Florida, encompassing Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, and Union counties. The population in the stateof

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85Table 2 TableofAnalyses AnalysisHoIndependent Dependent Variables Variable RegressionHI.H7_9Quadrant Stress Interaction Cohesion Main Effects Adaptability Communication Social Support RegressionHI. H 7-9Quadrant Stress (D) Interaction Cohesion (D)a Main Effects Adaptability (D) Communication (D) Social Support (D) RegressionHI.H7-9Quadrant Stress Interaction Cohesion (D) Main Effects Adaptability (D) Communication (D) Social Support (D) ANOVAH7Cohesion! Adaptability Stress (Family Subtypes) RegressionH3,HIOQuadrant Communication Interaction Cohesion Main Effects Adaptability RegressionH3.HIOQuadrant Communication (D) Interaction Cohesion (D) Main Effects Adaptability (D) ANOVAHzQuadrantTypeofStress ANOVAH5Quadrant Cohesion Quadrant Cohesion (D) ANOVAH6Quadrant Adaptability Quadrant Adaptability (D) ANOVAH4Quadrant Social Support Quadrant Social Support (D)

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86 Table 2--eontinued Analysis ANaVA ANaVAa(D)denotes discrepancy scores. Independent Variables Quadrant Quadrant Individual Stages Dependent Variable RelativelFriend Support Relati velFriend Support (D) Stress Floridain1990 was 84% white, 14% African-American,1%Hispanic, and1%other (U.S. Bureauofthe Census, 1990). The populationoftheIIcounties serviced by HospiceofNorth Central Floridain1990 was 80% white, 18% black, and 2% other minorities (Florida Statistical Abstract, 1991). The HospiceofNorth Central Rorida patient census for 1992 was 83% white, 15% African-American, 1% other minorities, andI% not determined. Table 3 shows the percentages by categories for each population subsample. Women accounted for 51.6%ofFlorida's population in 1990 (U.S. Bureauofthe Census, 1990) and were 44%ofthe Hospice census for 1992. Fifty-nine percentofthe research sample were females,41% male. Sampling Procedures Each family who had been served by the HospiceofNorth Central Rorida was sent a letter approximatelyIImonths after the deathoftheir family member (AppendixA)explaining the purposeofthis research project and requesting their participation. Letters were sent out weekly beginning 5/6/93 through 8/20/93. A totalof373 letters were sent. Follow-up phone contact was made approximately 2 weeks after the mailingofthe letter. After 207 letters had been sent, 79%ofthe sample had been generated. It took

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Expressive Communication Adaptability Operationalized Model (numbers in parentheses denote hypotheses) 87

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88 Table 3 Comparative BreakdownbyEthnicity for Population Subsamples African Population Subsample White American Hispanic PopulationofFlorida, 1990 84% 14%1%Populationofservice area. 1990 80% 18% " HospiceofNorth Central Florida 1992 patient census 83% 15% " Research sample 90% 7% 2% "Not measured separately but included in "Other." Other1%2% 2%1%an additional 166 letters to add the final21%ofthe sample. Eighty-four families (23%) agreedtoparticipate.Ofthe 373 letters sent,21% were unable to be reached (either not at home, phone was disconnected, ornophone number was available), 23% declinedtoparticipate, and 33% were inappropriate (either single, notina usable family configuration, or as quadrants filled, unnecessary for the sample). Thus, the final return rate (returned! appropriate and reached) was 50%. In addition to assessing willingness to participate, the personal phone call was also used to determine whether a family configuration existed in each household that warranted further screening.Ifpermission was granted for participation. an assessment was made by phone as to which family members would be assessed (Appendix B). A minimumoftwo members from each family neededtobe available and agreeable to being assessed. No maximum was set. Eighty-eight percentofthe sample were two-member families; 10% were three-member families: one was a four-member family; and one had five members. A date was then set for the investigator to assess the participating family

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89 members. All assessments were completed within 2 weeksofthe I-year anniversaryofthe death. Stageofthe family life cycle (and the relevant quadrantofthe family life spiral) was also determined during the courseofthe phone call (AppendixC).Stage divisions were patterned after the Olson etaI.(1983) studyofnormal families across the family life cycle with categories added to coordinate with phasesofCombrinck-Graham's (1983, 1985) Family Life Spiral Model. The stageofthe family life cycle was determined by the ageofthe oldest child living at home. After all children had been launched from the home, stageofthe family life cycle was determined by ageofgrandchildren if present or.ifabsent, the developmental tasks the family was facing. Although most families have more than one child, the oldest child in the home is believedtoserve as the catalyst for introducing new demands on the family to change its previous patternsoffunctioning (Olson etaI.,1983). The personal phone call also allowed the researchertogive further explanation as to why the study was being conducted, the way the data wastobe collected, the typeofinstruments used, the approximate time commitment involved. and the necessary participationoftwo or more appropriate members from each family. Because the CP quadrantofthe model was especially difficult for which to find families, the methodological procedures were modified in order to obtainJ0ofthose families,Itwas determined that these assessments would be done by mail rather than in person, with the investigator being available by phone for questions and follow-up. Fiveofthose10families lived outofthe II-county area that HospiceofNorth Central Rorida serves, although the patient had lived within the service area. The remaining five families were willing and able to participateifby mail, but notinperson. The modified procedure entailed sending the packets by first-class mail to the families, with a letter (AppendixJ)detailing the specific instructions that would have normally been given in person. A stamped, self-addressed envelope was included. A

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90phone call was made by the investigator approximately I week after the packet had been mailed to insure arrival and also to seeifthere were any questions. Weekly phone calls were made to participants to check on the statusoftheir questionnaire packet untilJ0ofthe mailed packets had been returned. All packets were returned within 4 weeks.Twopackets were never returned. All 84ofthe families in the sample were sent a handwritten thank you note after the data were collected expressing the investigator's appreciation for their participation. Subjects The sample consistedof84 families. 80 from north central Florida. Threeofthe remaining four families were out-of-state family members, and one was in south Florida. They all were close to the deceased family member and present atornear the timeofdeath. A minimumof20families per quadrant on the Family Life Spiral Model constituted the sample. TheCPquadrant had20families; the CP-+CF quadrant had21families; theCFquadrant had 23 families; and the CF-+CP quadrant had 20 families. Seventy-fourofthe families had 2 people participating in the study; 8 had 3 members participate; I had 4 participants; and I had 5 members willing to participate.Ofthe sample, 48 (27%) were single, 102 (57%) married, I (.6%) separated, 10 (6%) divorced, andJ9(lJ%) widowed. Fifty-four percentofthe families sampled included only one generation in the sample; 46%ofthe sample assessed families with two generations living together and participating in the study. The primary caregiver was oneofthe family members assessed in 75 outofthe 84 families sampled. The configurationofthe families in the sample is shown in AppendixK.Sixteen had lost a spouse--14 had lost husbands and 2 had lost wives. Adult childrenwhohad lost a parent numbered 57--25 sons, 32 daughters. Adolescents who had lost a parent numbered 7--2 sons, 5 daughters. Four additional adult children lost a stepparent--2 stepsons, 2 stepdaughters. Three parents had lost children--2 mothers, 1 father; I

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91stepmother had lost a child. Eleven had lost a sibling--6 brothers. 5 sisters. Twenty-one had lost a grandparent; 4 had lost a greatgrandparent. One grandmother had lost a grandchild; I greatgrandmother had lost a greatgrandchild. One niece and I nephew were includedinthe sample. Fifty-two were in-laws. The percentageofdeceased patients by age at timeofdeath were as follows: I% were children, 6% were young adults (27-39),7%were in their 40s, 10% wereintheir 50s, 23% were in their 60s, 26% were in their 70s. and 27% were in their 80s. Frequency and percentofindividuals across the family's life cycle is showninTable 4. Breakdown by county is shown in Table5.Table 4 RepresentationofSample Across Family Life Cycle StageNPercent Adolescence2514% CourtshiplMarriage158% Childbearing 22 12% Settling Down 24 13% 40s Reevaluation 26 14% Middle Adulthood2112% Grandparenthood169% Planning for Retirement1810% Retirement 6 3% Late Adulthood 5 3% Greatgrandparenthood 21%

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92 Table 5 Breakdown by County for Patient Census and Research Sample County Hospice Patient Census 1991-1992 Research Sample Alachua BradfordJUnion ColumbiafSuwanneelHamilton DixieiGilchristlLevy Putnam ClayDuvalLakeVolusia Out-of-State 42% 7%13%12% 26%38% 8%12%8%26% 2%1%1%1%4% Data Collection Each family member participating in the study was given a separate packetofinstruments, coded in the upper right hand comer with numberoffamily and lettered for participant (e.g.,lOlAandlOISfor a two-member family andlOlA,lOIS,and IOIC for a three-member family, etc.). Each member filled out a demographic questionnaire, FILE. FES--Expressiveness Subscaie. FIRA-G--Social Support, and Relative and Friend Support Subscales, and FACES-II, for a totalof144 questions. These assessments took approximately 20 to 60 minutestocomplete. The interviewer was on hand to answer questions and process the assessment or available by phone for those participating by mail.

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93 Instrumentation In additiontoa demographic questionnaire (Appendix H) assessing age, sex, marital status, ethnicity, countyofresidence, ageofdeceased, relationship to deceased, and incomeofparticipant, there were four standardized instruments usedinthis study: (a) the Family InventoryofLife Events and Changes (FILE, Appendix D), (b) the Family Environment Scale (FES), Expressiveness Subscale (Appendix E), (c) the Family IndexofRegenerativity and Adaptation--General (FIRA-G), Social Support Subscale, and Relative andFriend Support Subscale (Appendix F), and (d) Family Adaptability and Cohesion Scales (FACES-II, Appendix G), A checklist for the stagesofthe family life cycle was filled out by the interviewer based on questioning family members as to their ages, agesoftheir children or grandchildren, and/or developmental tasks they were facing (AppendixC).Family InventoryofLife Events and Changes(ALE)Measurementofthe dependent variable, the impactofthe death. was measured by FILE, Form C (Appendix D). The FILE was used to assess the family's vulnerability as a resultofthe pile-upofstressors in the areasofintrafamily strains, marital strains, finance and business strains. work-family transitions and strains. illness, losses, transitions in and out, and legal violations. The theory behind Fll..E is that families who have experienced an unusual numberofstressors and strains have taxed their psychological and interpersonal resources. They are considered vulnerable to future stressors and strains, are prone to experience sudden tension and conflicts seemingly without provocation, and are less abletorecover from the impactofproblems or difficulties. Their problem-solving abilities may be hampered, leaving them with a feeling that there are many loose ends and unresolved conflicts. Eventually such excessive demands take their tollifthere are not sufficient resources to reduce the demands to a manageable level (McCubbin&Thompson, 1991).

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94The FILEisa7 I-item self-report insuument designed to record the life events and changes experienced by a family unit. Originally developedin1980, it was normed on980couples from a national sample. It is designed to be administered to one or more membersofa family unit. age12and above. Family members are asked to record whether certain life events and strains happened to any memberofthe family unit and to the family as a group during the past year. The items for FILE were created on the basisoffactor analysis and are grouped into nine scales. All events experienced by each memberofthe family are recorded. Internal consistencyofitems was evaluated. and the overall reliability (Cronbach's Alpha) for FILEis.81. Test-retest reliability ranges from .66to.84 for the individual scales andis.80 for the total scale. Validityofthe instrument was assessed by discriminant analyses between low-conflict families and high-conflict families who had children with cerebral palsy or myelomeningocele. High-conflict families experienced significantly higher numbersoflife changes. Construct validity has been assessed by comparing the FILE scales with a measureoffamily functioning, the Family Environment Scales (Moos, 1974). A pile-upoflife changes was found to be negatively correlated with desirable dimensionsofthe family environment. such as cohesion, independence, and organization, and positively correlated with undesirable characteristicsofthe family environment such as conflict (McCubbin&Thompson. 1991). Predictive validity studies were carried out on a groupofchildren with cystic fibrosis. A pile-upoffamily life changes was negatively correlated with the child's pulmonary functioning (McCubbin & Thompson, 1991). The FILE can be scored in numerous ways, depending upon the purposeofthe study. For this study, FILE was scored in two ways: I. The FILE was completed separately by each person. The family composite score was determined by examining the three completed insuuments simultaneously, one item at a time.Ifany member recorded yes on an item, the family score would be a yes and would

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95be given the appropriate standardized weight for that item. Weights based on the relative magnitude and intensityofthe event or strain are presentedinthe instrument. Given that family life events and strains are not all equal in demand, the weighting procedure appears to be a more accurate estimateofthe severityofthe stress facing families, rather than a sumofthe numberofstressors. These weights are summedtoobtain subscale scores and the total pile-up family-couple readjustment score. Higher scores signify higher perceived stress. This procedureisbased on the belief that each family member may actually observe and/or experience family life eventsorstrains differently. Each family member's observations and responses are treated as a valid recordoffamily stressors and strains (McCubbin&Thompson, 1991). The weighted sums also allow the comparisonofthis sampletoOlson's studyofnormal families and the stress levels recorded for normal families at each stageofthe family life cycle (Olson et aI., 1983) (see Table I). Discrepancy scores were not computed for weighted scores. 2. The second methodofscoringFll...Ewas the family discrepancy scores. The extentofdisagreement among family members with regardtotheir perceptionsoflife events and changesinthe family is an important factor to take into considerationinthe assessmentofthe impactofa stressor event such as death. Discrepancy scores allow the addressingofthe question."Do families at CF stages show more disagreement among family members than families at other stages?" In order to obtain the family discrepancy scores, the independent responsesofeach family member are scored separately and the numberofdiscrepancies between each pair recorded. Each discrepancy is given a scoreofone and summed for both the subscales and the total scale score.Inthis study mean discrepancy scores were computed for families as well as within-family standard deviations.

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96 Stageofthe Family Life Cycle Stageofthe family life cycle was assessed by the interviewer based on the categorical descriptionsinAppendixC.The family life cycle has been divided into a varietyofnumbersofstages, generally based on the events and developmental tasks the family is facing, primarily the entry and exitofvarious members from the system (Carter&McGoldrick, 1988; Combrinck-Graham, 1983, 1985; Duvall&Miller, 1985). The family life spiral follows a three-generational spiral continuum that portrays new generations being added as older generations die. However, in order to operationalize the family life cycle for research purposes, it was aligned with the family life spiral and divided into quadrants. The stagesofthe life cycle delineated here are those identified on the Family Life Spiral Model (see Figures 1 and 2) (Combrinck-Graham. 1983. 1985). The family life cycle stages are defined primarily by the ageofthe oldest child for families who still have children living at home. For those who have launched all their children, the stages are defined by the agesoftheir grandchildren or the developmental tasks the family without grandchildren is facing at the later stagesoflife. Each family member's placement on the Family Life Spiral Model was assessed by the interviewer to determine whichofthe four quadrants best fit each family's stageofdevelopment (AppendixC).Families were then categorized as CP, CF, or Families who did not clearly fit the model were not assessedinthis study. Family Environment Scale fEES) The independent variable, expressive communication, was measured by the Expressiveness Subscaleofthe EES (Moos&Moos, 1986). The Real Form (Form R), which measures people's perceptionsoftheir conjugal or nuclear family environments, was usedtoassess the extent to which family members are encouragedtoact openly and to express their feelings directly.

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97The Expressiveness Subscaleiscomposedofnine questions. answered True or False.tobe answered on an individual basis. To derive the individual's score, one point is given for False answers to questionsI,3, 6, and8;one point is given for True answers to questions 2,4,5,7,and 9. To derive a score for the whole family's viewofthe expressiveness environment. an average score can then be calculated for all the membersofeach family for each subscale. The degreeofdisagreement among family members with regardtotheir perceptionsofthe family environment varies among families. Since the degreeofdisagreement in families is an important characteristicofa family, the family discrepancy score was also used. It is, thus, possible to detenruneifhigh stress families show more disagreement than low stress families. Family discrepancy scores are computed by obtaining the absolute difference between each pairoffamily members for the total subscale score. For two member families thereisone possible pair with onescore representing the differences between the two members. For three-member families, there are three possible pairs with three scores representing the differences between each pair. The discrepancy score for a three-member familyisthe sumofthe score differences between each possible pair, with a rangeof0 (if all members wereinagreement on each question)to18(if two members were in disagreement with the third on each question, which is the worst-case scenario). The family discrepancy scoreisthe averageofthe discrepancy scores from each possible pair and expresses the extent to which these family members disagree about their family climate. Nonns for Form Rofthe FES were collected for 1,125 nonnal and 500 distressed familiesin198 I. The subsampleofnonnal families was from all areasofthe country, single-parent and muitigenerational families, families drawn from ethnic minority groups, and familiesofall age groups. Distressed families were from a local correctional facility, familiesofalcohol abusers, familiesofgeneral psychiatric patients, and families with a

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98 child in crisis. As expected, when compared with normal families, distressed families are lower on expressiveness. The items for the FES were constructed from information gathered in structured interviews with membersofdifferent typesoffamilies, normal and distressed. Psychometric criteria used to select items for the final formofthe FES were as follows: (a)Theoverall item split should be as close to 50-50 as possible to avoid items characteristic onlyofunusual families; (b) there wouldbean approximately equal numberofitems scored true and scored false ineachsub scale to control for acquiescence response set; (c) items within each subscale correlated more higWy within their own subscale than with any other subscale: (d) each sub scale would have low to moderate intercorrelations with other subscales: and (e)eachitem would discriminate among families (Moos&Moos. 1986). Internal consistency as measuredbyCronbach's Alpha was .69 for the expressiveness subscale; test-retest reliability from 2 months to12months ranged from .73 to .69. Form R thus appears to be stableovertime intervalsofas long as a year. Construct validity for the FES expressiveness subscale was found in its predictable relationshiptothe Spanier Dyadic Adjustment Scale. There was also a significant relationship between couples' perceptionsofhigh family cohesion. expressiveness, and lackofconflict and their reportsofemotional. social, and sexual intimacy. Professionally trained raters' ratings correlated significantly with families' reportsofcohesion. expressiveness. conflict, and religious emphasis (Moos&Moos, 1986). Family IndexofRegenerativity and Adaptation--General CfIRA-Gl The independent variable, social support, was measured by two subscales from FJRA-G, the Social Support subscaleandthe RelativeandFriend Support subscale, for a combined 25 questions. Eachofthese subscales was developed initially in 1982and

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99 nonned on samplesof2,400 nonnal families, 1,000 military families and 1,400 nonmilitary families. The Social Support subscale consistsof17items selected to record the degree to which families are integrated into the community, view the community as a sourceofsupport. and feel that the community can provide emotional, esteem, and network support. The psychometric propertiesofthe Social Support index include an internalconsistencyof.82 and a validity coefficient (correlation with the criterionoffamily well-being)of.40 (McCubbin&Thompson, 1991). The Relative and Friend Support subscale consistsofeight items selected to record the degree to which families call upon relatives and friends as oneoftheir strategies for managing stressors and strains. The psychometric propertiesofthis subscale include an internal consistencyof.82 and validity coefficient (correlation with FCOPES)of.99 (McCubbin&Thompson, (991). Scoringofthe Relative and Friend Support subscale involves the placementofthe score for eachofthe eight items on a Likert scale from I to 5 from strongly disagree to strongly agree, on the line to the leftofeach item. The individual's scores are then summed and added together with other membersofthe family to compute the family mean score. The Social Support subscale involves the same procedure as the Relative and Friend Support subscale. Family discrepancy scores were also computed for these subscales by the same means used for FILE and FES. Family Adaptability and Cohesion Evaluation Scales(fACES-illThe independent variablesofcohesion and adaptability were measured by FACESn.The scale is designed to measure family dynamics with a focus on system characteristicsofall the family members currently living at home. There is a versionofFACES-II for couples. The original version was developed by Olson, Russell, and Sprenkle in 1979 as an outgrowthoftheir Circumplex Model and modified in 1981. Using

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100factor analysis and alpha reliability analysis, the scalewas reduced from 90 items toSO.In1983theSO-itemscalewas administeredto2,400 individuals in Olson's studyofnormal families across the family life cycle (Olson et al., 1983), and with further factor analysis and alpha reliability analysis, the scale was reducedto30 items. Although FACES III developedin1985 is the most recent version, Olson advises that FACES-II is more advantageous for research purposes at the present time (D. Olson, personal communication, June 1991). Within the model, specific concepts that are used to diagnose and measure the cohesion dimension are emotional bonding, boundaries, coalitions, friends, decision making, interests, and recreation. Concepts usedtodiagnose and measure the adaptability dimension are family power (assertiveness, control. discipline), negotiation style, role relationships, and relationship rules. Bothofthese dimensions are lineal concepts, ranging from disengaged to very connected for cohesion. and rigid to very flexible for adaptability. Extreme families are more frequently found at the low endsofbothofthese continuums (disengaged and rigid) and balanced families at the high ends (very connected and very flexible). Cronbach Alpha figures for FACES-II are .87 for the cohesion dimension, .78 for the adaptability dimension, and .90 for the total scale. Test-retest reliability for the original SO-item versionofFACES-II over a4-to 5-week period was .84. Concurrent validity has been reported to be .93 for cohesion and .79 for adaptability with the Beavers Self-Report Family Inventory measureofglobal health (D. Olson, personal communication, June 1991). The FACES-II was administeredtoeach individualinthe family who was participatinginthe study. For couples without children, the Couples Form was used. Each respondent was asked to read the 30 statements and decide for each one how frequently the described behavior occurs in their family. The scale ranges from I (almost

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101never)to5 (almost always). Respondents indicated the appropriate number to the leftofthe item (see Appendix G).Inorder to score cohesion, the sumofthe scores for items 3, 9,15,25,and 29 are subtracted from 36. The sumofall other odd-numbered items plus item 30 is added to the first sum which gives the total score for cohesion.Thefinal rangeofan individual score on cohesion should be between 16-80. The same basic scoring procedure is used for scoring adaptability. The sumofitems 24 and 28 are subtracted from12.The sumofall other even numbered items except30is added to the first sum which gives the total for adaptability. The final scores for each individual on adaptability may range between 15-70. Total cohesion score:36(-)(+)(=)(sumof3,9, 15, 19, 25. 29) (sum all other odd numbers plus item 30) Total Cohesion Total adaptability score:12(-) (+)(=)(sum 24, 28) (sum all other even numbers except item 30) Total Adaptability The cutting points are noted on the Linear Scoring and Interpretation sheet in Appendix1.Couple and family mean scores are obtained by the following formulas (H=Husband, W=Wife, A=Adolescent): Couple Mean on Cohesion Couple Mean on Adaptability Family Mean on Cohesion Family Mean on Adaptability= =(HC+WC)/2(HA+WA)/2(HC + WC + AC) /3 (HA +WA+ AA) /3 Couple and family discrepancy scores (OS) are obtained by using the standard deviation.

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CHAPTER4DATAANALYSIS AND RESULTS When you look back at the anguish. suffering, and traumas in your life, you'll see that these are the periodsofbiggest growth. After a loss that brings you dreadfully painful months, you are a different man, a different woman.Manyyears later, you willbeable to look back and see the positive thingstogetherness in the family,faithorwhateverthatcameoutofthe pain. --Elisabeth Kiibler-Ross Analysis Procedures The analysisofdata for this study was accomplished by performing a multiple regression analysis using theSASGeneral Linear Model (GLM).Thegoalofthe regression analysiswasto determine the relationship between an outcome measure and relevant independent measures. This can be done globallybyexamining the entire model,oritcan be done for individual variables when the effects for allothervariables are held constant.Inthis study a seriesofregression models were developed to test 6oftheJ0 research hypotheses (see Table 2). A seriesofANOVAS were developed to test the remaining 4 hypotheses.Onesetofequations included quadrant, expressive communication, social support measures, cohesion, and adaptability as the independent variables, with amountortypeofstress as the outcome variable.Theothersetofequations evaluated quadrant as the input measure and communication, social support, cohesion, and adaptability as the output measures.Therelationship between cohesion and adaptability as 102

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103input variables and expressive communicationasthe outcome variable was also examined (see Table 2 and Figure 5).Inthe regression analyses, one equation tested for interactions between eachofthe other input variables. The absenceofinteraction indicates that the relationship between the dependentvariable and the independent variable does not change for different levelsofthe control variable. When plotted, the scores for eachofthe categorical variables are indicated by parallel lines when no interaction is present. If the equation which incorporated the interaction effects was foundtohavenosignificant improvement in modelfit,the main effects equation was utilized. The regression coefficients for that model were then tested for their levelsofattained significance. The regression coefficients provide information regarding the directionofthe relationship between each independent variable and dependent variable by examinationofthe signofthe coefficient. A positive coefficient indicates that an increaseinthe independent variable results in an increase in the dependent variable. A negative coefficient describes an inverse relationship: As the independent variable increases. the dependent variable decreases. The magnitudeofthe regression coefficient also indicates how much a change in the independent variable affects changeinthe dependent variable. For purposesofdetermining levelsofstatistical significance, the Type I error rateof.05 was established as the decision rule for all statistical tests. Source data were rounded to the nearest hundredth. Because 9ofthe 20 families sampled in the CP quadrant were assessed by mail, independent sample t-tests were first run to compare the meansofeach variable and scale in the assessment package for those assessments that were mailed and those that were obtained by home visit. No significant differences were found on 29ofthe 30 measures. The exception was for the discrepancy scores on the pregnancy and childbearing strains subscaleofthe FILE andisconsidered a Type I error that will not be discussed. No patternofresponse bias was found, and data were pooled for the analyses.

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Expressive Communication Social Support Adaptability104Type of Stress Amount of Stress .../// / / /// / OperationalizedModel with ResultsofHypotheses Testing (numbersinparentheses denote hypotheses; solid lines indicate significance at p<.05; broken lines indicate nonsignificance)

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105Analysis Results The first pairofequations evaluated HI,H7,Hg,andHg.Input variables were family life spiral quadrant and family mean scores on cohesion, adaptability, expressive communication, social support, and relative and friend support; the output variable was the family composite score for stress. The equation with interaction terms failed to achieve significance(Fm,60)=1.28, II =.22). However, the main effects equation was significant(F(g,7S)=2.36, II =.03) with this model accounting for 20%(R2=.201)ofthe variance in the leveloffamily stress (Table6).Cohesion was the only predictor variable that achieved significance, 12 =.04, and the regression coefftcient was negative, meaning that as cohesion increases I point, the family's stress levels can be expected to decrease 9.31 points on FILE, the measure for family stress. Quadrant(F=1.07, II =.37), adaptability (F=1.57, II =,21), communication (F=3.49, II =.07), social support (F=0.41, II =.52), and relative and friend support (F=1.30, II =.26) did not significantly predict degreesoffamily stress in this model. The means, discrepancies, and standard deviations for eachofthe variables are shown in Table7.The next seriesofequations tested the abilityofquadrant and the discrepancy scores on communication, social support. relative and friend support. cohesion, and adaptability to predict stress discrepancy scores (Table8).Both the interaction and main effects equations for this model testing HI, H7'Hg,andHgwere foundtohave significant F values,Fm,sg)=2.13, II =.01, andF(g,74)=2.76, II =.0099, respectively. However, the interaction model failed to achieve significance foranyoneofthe independent variables. Resultsofan overall test showed no significant difference between the two models(Fobs=1.41
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Table 6 Regression Model Testing Quadrant. Cohesion, Adaptability, Communication Social Support. and Relative and Friend Support with Family Composite Score for Stress as Qutcome Variable Input VariablesdfType IIISSF-value p-value Quadrant 3 160131.38 1.07 .37 Cohesion 223116.22 4.47 .04* Adaptability 78244.15 1.57 .21 Communication 173906,80 3.49 .07 Social Support 20487.83 0.41 .52 RelativelFriend 64735.13 1.30 .26 Error 75 3741278.45 Regression Standard Error Input Variables CoefficientofEstimate t-value p Intercept 1095,61 412.452,66.01 CP Quadrant 52,22 73.61 0.71 .48 CP-tCF Quadrant 103.95 71.81 1.45 .15 CFQuadrant -10.35 71.82 -0,14 .89 CF-tCP Quadrant0.00Cohesion -9.31 4.40 -2, II .04* Adaptability -7.68 6.13 -1.25 .21 Communication 39,07 20,93 1.87 .07 Social Support3.795.91 0.64 .52 RelativelFriend -6,61 5.81 -1.14 .26 *p<.05,106

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107Table 7 Means, Discrepancies. and Standard Deviations for Instruments InstrumentCP CP--7CF CF CF--7CP (n=20) (n=21) (n=23) (n=20) FILE (Stress) Weighted Sums Mean 425.5 464.7 444.5 389.0 Standard Deviation (226.8) (284.2) (203.2) (242.7) Discrepancy 6.02 8.45 9.18 6.71 Standard Deviation (5.48) (6.38) (5.25) (5.42) FACES-II (Cohesion) Family Mean 67.0 66.9 59.9 64.3 Standard Deviation (8.3) (8.4) (9.0) (10.2) Discrepancy 6.4 4.4 8.63.1Standard Deviation (7.0) (4.7) (5.0) (3.1) FACES-II (Adaptability) Family Mean5\.75\.446.8 52.4 Standard Deviation (6.1 ) (6.0) (6.9) (8.9) Discrepancy 5.2 4.1 8.0 4.6 Standard Deviation (4.8) (3.2) (6.1 ) (3.4) FES (Expressive Communication) Family Mean 5.97 5.565.46 5.82 Standard Deviation (\.7)( 1.3) ( 1.7) ( 1.6) Discrepancy\.15 \.641.74 .97 Standard Deviation (1.0) (1.0) (1.1 ) (0.7) Social Support Index Family Mean 60.8 62.5 62.4 63.3 Standard Deviation (4.4) (4.4) (4.9) (4.0) Discrepancy 4.2 4.4 3.1 4.1 Standard Deviation (3.2) (4.7) ( 1.9) (2.7) RelativelFriend Support Family Mean 25.0 26.0 26.3 26.2 Standard Deviation (3.7) (4.6)(4.3)(6.0) Discrepancy 4.53.9 3.63.5 Standard Deviation (4.4) (4.6) (2.7) (4.8)

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108Table 8 Regression Model Testing Quadrant and Discrepancy Scores on Communication Social Support. Relative and Friend Support. Cohesion. and Adaptability with Stress Discrepancy ScoresasOutcome Variable Input VariablesdfType III SS F-value p Quadrant 3 140.30 1.69 .18 Communication(D)a6.52 0.24 .63 Social Support (D)0.340.01 .91 RelativelFriend (D) 75.96 2.75.10Cohesion (D) 114.15 4.13 .05* Adaptability (D) 31.42 1.14 .29 Error 74 2045.02 Regression Standard Error Input Variables CoefficientofEstimate t-value p Intercept 4.53 1.55 2.92 .004 CPQuadrant -1.99 1.72 -1.16 .25 CP-7CF Quadrant 1.87 1.74 1.07 .29 CFQuadrant 0.41 1.79 0.23 .82 CF-?CP Quadrant 0.00 Communication (D)a -0.340.70-0.49 .63 Social Support (D) -0.020.19-0.11 .91 RelativelFriend (D) 0.25 0.15 1.66 .10 Cohesion (D) 0.31 0.15 2.03 .05* Adaptability (D) 0.170.161.07 .29 *p<.05.a(D)denotes discrepancy scores.

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l09 scores (F= 4.13.P. =.05). The regression coefficient was positive, indicating that as discrepancy scores on cohesion increased, there was an increase in the discrepancy scores on the stress measure. Neither quadrant (F=1.69, P. =.18) nor the discrepancy scores on communication (F=0.24, P. =.63), social support (F=0.01, p. =.91), relative and friend support (F=2.75, p. =.10), and adaptability (F=1.14, P. =.29) were significant predictorsofthe discrepancy scores for stress. An equation testing the predictive ability of quadrant and the discrepancy scores on cohesion, adaptability, communication, and social support for family composite stress levels was foundtobe significant (Table9).The interaction model achieved significance (Fm.59)=1.99, P. =.02) and accounted for 44%ofthe variance in the stress levels(R2=.437). The discrepancy score on cohesion was once again found to be a predictorofthe family stress levels (F=5.16, p. =.03). The regression coefficient was positive,indicating thatasdiscrepancy scores on cohesion increased, there was an increase on the stress measure. Interaction between quadrant and the discrepancy scores on communication was significant (F = 3.18, 12 = .03). When the regression coefficients were tested for significance, there was a significant differenceinthe relationship between the communication discrepancy scores and family composite stress levels for the CP-tCF and CF quadrants (Table 10). Figure 6 shows that as communication discrepancy scores go up for CP-tCF, thereisa corresponding increase in the family composite stress levels. However, for CF families, the reverse is true. As communication discrepancy scores go up, the family's stress goes down. After combining family scores on cohesion and adaptability according to Olson's Circumplex Modeltodetermine family subtypes (see Linear Scoring and Interpretation, AppendixI),an analysis was runofthe five most frequent family subtypesinthis study to determineifthere were any significant differences between subtypes and the amountofstress reponed. The five family subtypes that were includedinthe ANOVA were Very

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110 Table 9 Regression Model Testing Quadrant and Discrepancy Scores on Cohesion, Adaptability, Communication, Social Support, and Relative and Friend Support with Family Composite Score for StressasQutcome Variable Input VariablesdfType IIISSF-value p Quadrant 3 43096.02 0.33.80Cohesion (D)a 225034.95 5.16 .03* Adaptability(D)13073.61 0.30 .59 Communication (D) 1935.32 0.04 ,83 Social Support (D) 61516.831.41.24RelativelFriend (D) 150522.0 I 3.45 .07 Cohesion (D) by Quadrant 3 38723.48 0.30 .83 Adaptability (D) by Quadrant 3 139743,37 1.07 .37 Communication (D) by Quadrant 3 415360.94 3.18 .03* Social Support (D) by Quadrant 3 109901.52 0.84 .48 RelativelFriend (D) by Quadrant 3 310655.05 2.38 .08 Error 59 2572155.94 *p<.05. a(D) denotes discrepancy scores.

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111Table10Regression Coefficients andt-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 StressasOutcome Variable Regression Standard Error Input Variables CoefficientofEstimate t-va1ue p Intercept 215.33 116.94 1.84 .07 CP Quadrant 21.95 151.890.14.89 CP--tCF Quadrant -14.74 164.56 -0.09 .93 CF Quadrant 144.30 175.250.82Al CF--tCP Quadrant0.00Cohesion(D)a29.75 19.03 1.56 .12 Adaptability (D) 23.15 20.77 1.11 .27 Communication (D) -67.10 87.23 -0.77 .44 Social Support (D) 7.76 21.92 0,35,72RelativelFriend (D)2,7012.26 0.22 .83 Cohesion (D) by CP Quadrant -16.40 22.20 -0.74046 CP--tCF Quadrant -20.69 22.61 -0.92 .36 CF Quadrant -18.21 22.51 -0.81 .42 CF--tCP Quadrant0.00Adaptability (D) by CPQuadrant -7.60 24.88 -0.31.76 CP--tCF Quadrant -35.57 30.96-l.l5.26 CFQuadrant -30.11 23.07 -1.31.20 CF--tCP Quadrant0.00

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112Table IO--continued Regression Standard Error Input Variables CoefficientofEstimate t-value p Communication(D)byCP Quadrant 85.80 106.92 0.80 .43 CP-?CF Quadrant 201.86 109.86 1.84 .07 CF Quadrant -47.92 101.02 -0.47 .64 CF-?CP Quadrant 0.00 Social Support (D) by CP Quadrant 6.29 27.68 0.23 .82 CP-?CF Quadrant -15.23 24.80 -0.61 .54 CFQuadrant 27.42 36.32 0.75 .45 CF-?CP Quadrant 0.00 RelativelFriend (D)byCP Quadrant -15.57 18.05 -0.86 .39 CP-?CF Quadrant 24.15 18.92 1.28 .21 CF Quadrant 34.18 21.17 1.61 .11 CF-?CP Quadrant 0.00 *p<.05.a(D)denotes discrepancy scores.

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1131.21.41.6 O-+-----,--------r----,----:--,-----,-------, o0.20.40.60.81500E co u.100 (/) 400 Q)'o oen(/) (/) 300 -enQ):t:(/) oa.E200o U>-Communication Discrepancy ScoresFigure6.Interaction Between Family Stress Scores and Communication Discrepancy Scores by Quadrant

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114 ConnectedVery Flexible (n=20), Very Connected-Flexible(n=7), Connected-Flexible(n=21), Separated-Flexible (n=10), and Separated-Structured (n = 8). Significance was achieved(F(4.61)=3.79, 12 =.008), and these combinationsofcohesion and adaptability into subtypes jointly accounted for 20%ofthe variance(R2=.1989)inthe amountofstress reported by subtypes (TableII).Tukey's pairwise comparisons determined that there was a significant difference between the stress levels reported by Very ConnectedVery Flexible families (mean=285) and Separated-Flexible families (mean=569), as wellaswith Connected-Flexible families (mean=496) with Very Connected-Very Flexible families significantly lower in stress. The mean for Separated-Structured families was 506, but the small sizeofthe cell(n=8)created a sample size effect due to the unstable mean. TableIIANOV A for Relationship Between Family Subtypes and Stress Input VariabledfType III SS F-value p-value Family Subtype 4 778469.53 3.79 .008* Error613134492.63 *p<.05.H2was tested by running a seriesofANOVASfor eachofthe subscalesofthe Fll..E todetermineifthere was any significant difference among quadrants on the typesofstressors families experienced. Significance was achieved on only oneofthe nine subscales, pregnancy and childbearing strains,F(3,80)= 5.60,12 =.002 (Table 12). Quadrant accounted for 17%ofthe variance on this subscale(R2=.173). Tukey's posthoc pairwise comparison tests were run to determine which quadrants were

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115Table12ANOVASfor TypesofStressors by Quadrant Input VariabledfType III SS F-value p-value Intra-Family Strains Quadrant 3 5.68 .36 .78 Error 80 417.54 Marital Strains Quadrant 3.14.49.69Error 80 7.74 Pregnancy and Childbearing Quadrant 3 2.56 5.60 .002* Error 80 12.19 Finance and Business Quadrant 3.50.07.97Error 80 186.19 Work-Family Transitions Quadrant 3 3.86 .51 .67 Error 80 200.40 Illness and Family Care Quadrant 3 7.09 1.85.14Error 80 102.08 Losses Quadrant 3 1.10 .78 .51 Error 80 37.60 TransitionsInand Out Quadrant 3 4.21 2.70 .05 Error 80 41.53 Family Legal Violations Quadrant 3 .32 .49.69Error 80 17.61 *p<.05.

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116 significantly different. The CP quadrant and the CF quadrant differed significantly. 12 =.004.and the negative valueofthe estimate (-.35) indicated that the family mean for the CP quadrant(.44)was significantly higher on pregnancy and childbearing strains than the CF quadrant (.08). Examinationofthe means for the other quadrants indicated similar differences between theCPquadrant and the other two quadrants (CP--?CF =.02, CF--?CP =0.00). When no differences among quadrants were found in family stress levels, anANOVAwas runtodetermine if there were any significant differences between the individual's stage within the family life cycle and the amountofstress reported by the individual on the FILE. Because there were toofewindividualsinthe retirement, late adulthood, and greatgrandparenthood stages, these three were collapsed together. This model was then found to be significant,F(S.I7Jl= 2.50, 12 =.01(Table 13). Stageofthe life cycle accounted for 10%ofthe variance in the amountofstress reported(R2=.1046). Analysisofthe regression coefficients for the individual stages found that threeofthe stages had significant t-values, Childbearing (\2 =.02), Settling Down (\2 =.002), and 40s Reevaluation (Il =.04). Tukey's pairwise comparisons determined significant differences between individuals at the "settling down" stageofthe life cycle and those individuals at the "planning for retirement" stage. The mean weighted sum score for individuals at the settling down stage was 580 compared with a scoreof311for those in the planning for retirement stage (Table 14). This differenceisalso theoretically significantinthat bothofthese individual stagesofthe family life cycle are within the same quadrant on the Family Life Spiral Model and yet differ significantly in the amountofstress they experienced postdeath (Figure 7). Four equations for the model testingH3andHIOwere run.Thefirst pairofequations testing for interaction and main effects (input variables quadrant, cohesion, and

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Table13ANOV A for Individual Stress Scores by Individual's Stageinthe Family Life Cycle Input VariabledfType III SS FPIndividual Stages 8 1442501.20 2.50 .01* Error17112346014.78 Regression Standard Error Input Variables CoefficientofEstimate t-value p Adolescence 137.96 83.06 1.66.10Marriage/Courtship 109.02 93.94 1.16 .25 Childbearing 207.56 85.40 2.43 .02* Settling Down 268.14 83.783.20.002* 40s Reevaluation 172.90 82.392.10.04* Middle Adulthood 121.79 86.31 1.41 .16 Grandparenthood4.0692.320.04.97 Planning for Retirement0.00Retirement, -5.06 97.80 -0.05.96Late Adulthood,&Greatgrandparenthood *p<.05. 117

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118Table14Individual Stress Scores by Stageofthe Family Life Cycle Individual StageNAdolescence25Marriage/Courtship15Childbearing 22 Settling Down 24 40s Reevaluation 26 Middle Adulthood21Grandparenthood16Plan for Retirement18Retirement,13Late Adulthood,&Greatgrandparenthood Weighted Sum449420 519 580 484 433 316311306 adaptability; outcome variable expressive communication) each achieved significance,FOI.72):::;4.91. Il:::; .0001, andF(5.78):::; 11.13,12:::; .0001, respectively. However, no significant interaction was found in the first equation. Resultsofan overall test showed no significant difference between the two models(Fobs:::;.24
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119Planfor Retirement (321) Retirement (378)40'sReevaluation(434)Lat.Adulthood(180) , ICPI ",",","..",","'X Grandparenthood " " , , (323) " ,, (480) " ,Chlldbirth-..(," Middle Marriage'".... Mlddl.YearsSettling Adulthood Courtship,,', ofChildhoodDown(405) (432) " , ) (571) ,,1'''"" \ '" Adolescence , (527) , Figure7.Stress Mean Weighted Sums by Individual Stage on Family Life Spiral Model (each member assigned the family's composite score)

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120 Table15Regression Model Testing Ouadrant. Cohesion, and Adaptability with CommunicationasOutcome Variable Input VariablesdfType III SS F-value p-value Quadrant 3 4.45 0,96 .42 Cohesion 3,93 2,54,IIAdaptability 18.48 11.95 .0009* Error 78 120,56 Regression Standard Error Input Variables CoefficientofEstimate t-value p Intercept -2,07 1.12 -1.85 ,07 CPQuadrant 0,12 .40 0,30,77 CP-tCF Quadrant -0,26.40-0.66 .51 CFQuadrant 0,39.400,98 .33 CF-tCP Quadrant 0.00 Cohesion 0.04 .02 1.59 .11 Adaptability 0.10 .03 3.46 .0009* *p<.05. The second pairofequations testingH3andHIOexamined the relationship between quadrant and the discrepancy scores for cohesion and adaptability with the discrepancy scores for communication. Although the model testing for interaction achieved significance,FOUl)=4.45, 12 =.0001, no interaction was foundtobe significant. Resultsofan overall test showed no significant difference between the two models(Fobs=1.18
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121testing for main effects was significant,F(5.77)=8.15. 12 = .000 I. and predicted 35%(R2= .346)ofthe varianceinthe discrepancy scores on expressive communication. When the regression coefficients for this model were tested for significance. the coefficients for cohesion discrepancy scores and adaptability discrepancy scores were both significant (cohesion discrepancy. 12 = .01; adaptability discrepancy. 12 = .02) (Table 16). The regression coefficients for both were positive and nearly identicalinvalue (0.059 and 0.062). Thus, it can be expected that for every one point increase in discrepancy scores for either cohesionoradaptability. discrepancy scores on expressive communication canbeexpected to increase .06ofa point. Quadrant failed to achieve significanceinthe model with a u-value of.0502. ANOV AS were run to testH4.Hs. andH6(Table 17).Nosignificance was foundinthe equations testing quadrants as predictorsofthe useofsocial supportorrelative and friend support. Quadrant as predictorofcohesion was found to be significant.F(3.so)= 3.06.12= .03. and accounted for 10%(R2= .1029)ofthe variance in cohesion. The regression coefficient had a significant negative value (-7.16. 12 =.0 I). Tukey's pairwise comparisons were run to detennine the natureofthe mean differences. TheCPfamilies were found to have more cohesion.CFfamilies less. The mean cohesion score for CP families was 67.0: the mean score for CF families was 59.9 (see Table 7). There was also a significant difference in quadrant predictionofdiscrepancy scores on cohesion.F(3.so)= 4.74.12 =.004. Fifteen percent (R2=.1510)ofthe variance in the discrepancy scores were accounted forbythe quadrant. Tukey's pairwise comparisons showed significant differences between theCFquadrant and both and quadrants but not betweenCFand CP quadrants. Mean discrepancy scores on cohesion for theCFquadrant were 8.6. for families 3.1 and for families 4.4. indicating that there were significantly greater discrepancy scores for theCFquadrant as

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122 Table16Regression Model Testing Quadrant and DiscrepancyScores on Cohesion and Adaptability with Communication DiscrepancyScores as Qutcome Variable Input VariablesdfType III SS F-value p-value Quadrant 3 6.15 2.72 .05 Cohesion (D)a 5.25 6.96 .01 * Adaptability (D)4.606.11 .02* Error7758.01 Regression Standard Error Input Variables CoefficientofEstimate t-value p Intercept0.50.22 2.30 .02 CP Quadrant -.05 .28 -0.17.86 Quadrant 0.65 .28 2.36 .02 CFQuadrant 0.23 .29 0.81 .42 Quadrant0.00Cohesion (D)0.06.02 2.64 .01 * Adaptability(D)0.06.03 2.47 .02* *p<.05. a(D) denotes discrepancyscores.compared to and quadrants. The mean discrepancy score for the CP quadrant was 6.4. Equations testingH6for both mean and discrepancy scores on the adaptability measure by quadrant were significant, F(3.80)=2.92, 12=.04. and F(3.79)=3.19, 12=.03. respectively (Table 17). Quadrant accounted for 10% (R2=.0988) and11% (R2=.1081)of

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123Table17ANOVAS for Social Support, Relative and Friend Support, Cohesion, and Adaptability by Quadrant Input VariabledfType III SS F-value p-value Social Support (mean) Quadrant 3 65.47 1.09,36Error 80 1599,37 Social Support (discrepancy) Quadrant 3 22.890.72.54Error 80 847.53 Relative and Friend Support (mean) Quadrant 3 23,150,35,79Error 80 1775,13 Relative and Friend Support (discrepancy) Quadrant 3 13,530,26.85 Error 80 1390.68 Cohesion (mean) Quadrant 3 739,32 3.06 .03* Error 80 6444.84 Cohesion (discrepancy) Quadrant 3 370,994,74.004* Error 80 2086,01 Adaptability (mean) Quadrant 3434,002,92 .04* Error 80 3960.25 Adaptability (discrepancy) Quadrant 3 204,57 3,19 .03* Error 79 1688.06 *p<,05,

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124 the variance in mean scores and discrepancy scoresonadaptability, respectively, in both models. Tukey's pairwise comparisons determined thatCPfamilies had significantly higher scoresonadaptability (51.7) thanCFfamilies (46.8).CPfamilies also had significantlylowerdiscrepancy scores for adaptability(5.2)thandidCFfamilies (8.0). The more adaptable families were, the less discrepant were their perspectives about their adaptability. Hypotheses Testing Ten hypotheses were evaluated to test the theoretical assumptions in this study. A seriesofmultiple regression equations and ANOV AS generated p values that led to decisions to either rejectorfail to reject the null hypotheses (Table 18).HIstates there is no significant difference in the amountofstress reported among families ineachquadrantofthe family life spiral model. Based on the resultsofa seriesofmultiple regression equations, no direct significant differences on the outcome variable Fll..E were determined (Tables 6 and 8). Therefore, no statistical evidence existed to reject nullHj_H2states that there is no significant difference in typesofstress reactions among families in each quadrantofthe model. A seriesofANOVAS testing each subscaleofthe Fll..E by quadrant demonstrated a statistically significant association(Ft3.80)=5.60, p =.002) between scores on the Pregnancy and Childbearing Strains subscale and quadrantsofthe model (Table 12). A posthoc pairwise comparison determined the significant difference was between families atCPandCFquadrants (p =.004), with the negative valueofthe estimate indicating thatCPfamilies experienced significantly more pregnancy and childbearing strain thanCFfamilies. These data supported the rejectionofnullH2.H3states that there is no significant difference in expressive communication among families in each quadrantofthe Family Life Spiral Model. In two separate models testing

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Table18ResultsofHypotheses Testin& Hypotheses HI: When deathofa family member occurs, thereisno significant differenceinthe amountofstress reported among families atCF. CP,or phasesofthe family life spiral.H2:When deathofa family member occurs, thereisnosignificant differenceinthe typeofstress reactions among families atCF, CP,or phasesofthe family life spiral.H3:Thereisno significant differenceinexpressive communication among familiesatCF, CP,or phasesofthe family life spiral.H4:Thereisno significant differenceinsocial support among families atCF, CP,or phasesofthe family life spiral.H5:Thereisno significant difference among families atCF, CP,or phasesofthe family life spiral on measuresoffamily cohesion.H6:Thereisno significant difference among families atCF, CP,or phasesofthe family life spiral on measuresoffamily adaptability.H7:Thereisnorelation between levelsoffamily stress and the family's cohesion and adaptability.Hg:Thereisnorelation between levelsoffamily stress and measuresofsocial support.H9:Thereisnorelation between levelsoffamily stress and measuresofcommunication.HID:Thereisno relation between a family's communication and their adaptability and cohesion. DecisionFailto Reject RejectFailto RejectFailtoReject Reject Reject RejectFailto Reject Reject Reject125

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126the relationship between communication and quadrants, no significant differences were found (Tables15and16).Therefore, nullH3was notrejected. I1l states that there is no significant differenceinsocial support among families in each quadrantofthe model. Two subscales for social support were tested, the Social Support Index subscale and the Relative and Friend Support subscale. Neither one was found to be significantly associated with any particular quadrant (Table 17). There was, therefore, no evidence to reject nulll1l. Hsstates thereisno significant difference between measuresoffamily cohesion and quadrant on the Family Life Spiral Model. Equations testing the differences for mean as well as discrepancy scores on cohesion by quadrant both yielded significant results (Table 17). Quadrant was found to be a predictorofcohesion(F(3.80)=3.06, Il =.03), and posthoc comparisons indicated that CP families were found to have more cohesion,CFfamilies less. Discrepancy scores on cohesion were also associated by quadrant(F(3.80)=4.74, Il =.004),and Tukey's posthoc pairwise comparisons showed significant differences in the discrepancies betweenCFfamilies and CF-7CP and CP-7CF, withCFfamilies having significantly greater discrepancies within families. Data from these tests supported the rejectionofnull Hs.H6states that there is no significant difference among quadrants on measuresofadaptability. Significant differences were found among quadrants on both adaptability mean scores (F=2.92, Il =.04) and adaptability discrepancy scores (F=3.19, Il =.03) (Table 17). Tukey's pairwise comparisons indicated thatCPfamilies had higher scores on adaptability (51.7);CFfamilies had lower scores(46.8).TheCPfamilies also had significantly lower discrepancy scores for adaptability(5.2)than did theCFfamilies(8.0).The more adaptable families were, the less discrepant were their individual perspectives about their adaptability. Data from these tests supported the rejectionofnullH6.

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127H7states thereisno relation between levelsoffamily stress and the family's cohesion and adaptability.Inthe main effects model testing relationship between quadrants and mean scores on cohesion, adaptability, communication. and social support with family stress, a family's mean cohesion score was found to be a significant predictoroftheir levelofstress, F= 4.47,!l =.04 (Table 6). The regression coefficient for cohesion was negative (-9.31), meaning that as a family's cohesion increased. their stress decreased. In a parallel model testing the discrepancy scoresofthe above variables, cohesion discrepancy scores were also a significant predictorofdiscrepancy scores on stress (F=4.13, !l =.05). The regression coefficient was positive, meaning that as discrepancy scores on cohesion increased, the discrepancy scores on stress also increased. Adaptabilityinbothofthese models did not prove to be a significant predictorofa family's stress level. When cohesion and adaptability scores were combined together to determine family subtypes. the analysis showed significant differences between levelsoffamily stress and subtype (Table 11). Seventy-seven percentofthe familiesinthe study fell into five family subtypes. The remaining 23%ofthe families were deleted from this particular analysis. The model was significant (F = 3.79,!l = .008), and Tukey's pairwise comparisons determined that there were significant differences between the stress levels reported by Very Connected-Very Flexible families and both Separated-Flexible and Connected Flexible families. Data from these tests support the decisiontoreject this null hypothesis.Hgstates thereisno relation between levelsoffamily stress and measuresofsocial support. Two separate models incorporating two measuresofsocial support, the Social Support Index subscale and the Relative and Friend Support subscale, both failed to achieve significanceaspredictorsofa family's stress (Tables 6 and 8). There was, therefore, no evidence to rejectHg.H9states thereisno relation between levelsoffamily stress and measuresofcommunication. Communication as a predictoroffamily stress was tested in two different

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128 models and not found tobesignificant (Tables 6 and 8). However, in the model that tested the abilityofquadrants and discrepancy scores on expressive communication to predict a family's stress, a significant interaction was found (F=3.18, 12 =.03) between expressive communication discrepancy scores and quadrant in predicting the family's stress (Tables9and 10). Therefore, nullH9was rejected.HIOstates thereisno relation between a family's communication and their adaptability and cohesion.Inthe main effectsmodeLtesting mean scores for adaptability as predictorsofexpressive communication, adaptability was significant (12 =.0009), and the positive regression coefficient indicated that as adaptability increased. expressivecommunication canbeexpected to increase. Mean cohesion scores were not a significant predictorofcommunication (Table15).However, in the model testing discrepancy scores on cohesion and adaptability as predictorsofcommunication discrepancy scores. both cohesion and adaptability were significant (cohesion discrepancy, 12 =.01; adaptability discrepancy, 12 =.02) (Table 16). The positive valuesofthe regression coefficient for both indicate that as discrepancy scores increase for cohesion and adaptability, discrepancy scores on expressive communication increase. Data from these tests support the rejectionofnullHIO.Chapter Summary This chapter has presented discussionofthe procedures for the analysis and the resultsofthis research. The outcomeofthe findings was examinedinlightofthe decision rule to determine the acceptance or rejectionofthe null hypotheses. The statistical evidence derived from the analysis supported the rejectionofhypotheses 2, 5, 6,7,9, and 10.

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CHAPTERS DISCUSSIONItis the great mysteryofhuman life that old grief gradually passes into quiet, tender joys. The mild serenityofage takes the placeofthe riotous bloodofyouth. I bless the rising sun each day, and. as before, my heart sings to meet it. but now I love even more its setting, its long slanting rays and the soft, tender, gentle memories that come with them. the dear images from the wholeofmy long, happy life--and over all the Divine Truth, softening, reconciling, forgiving! --Fyodor Dostoevsky Overviewofthe Study The purposeofthis study wastodetermine if there are certain times in the family life cycle when experiencing the deathofa loved one creates more stress than usual. The theoretical model upon which the study was based was the Family Life Spiral Model which is a three-tiered model representing the evolutionofthe family life cycle across three generations simultaneously. The characteristicsofthe model that wereofspecial interestinthis study were the opposing centripetal (CP) and centrifugal (CF) forces. The dynamic in the model consistsofoscillations back and forth between CP andCFphases in the family life spiralasmembers face the challengeofmastering the developmental tasks that are relevant to each stageofthe family life cycle. That death has a CP pull on families gave risetothe questionofthe effectofthat CP pull depending upon where families wereinthe family life spiral--atCPphases, CF phases, or at the transitions betweenCPandCFphases, CP-4CF or CF-4CP. Because other variables were deemed to be significant predictorsofthe impactofdeath on the family and believed potentiallytovary depending upon the phaseofthe life spiral. they were also129

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130 included in the assessment. Those variables were expressive communication, social support, cohesion, and adaptability. By analyzing these variables through a multiple regression model, it was possible to hold oneormoreofthe independent variables constantinorder to determine the significanceofa single variable.Itwas also possible to determineiftwo variables interacted with one anotherinpredicting the varianceinthe dependent variable. Three questions wereofprimary interest. First, is there a difference in impact, both in degree and typeofstress, reported by family members at different phasesofthe family life spiral when there is a deathinthe family? Second, how do the levelsofdisagreement among family members vary among phases? And third, do family members at different life spiral phases differ in levelsofexpressive communication, social support, family cohesion, and family adaptability? Answers to these questions will be helpful for those professionals who work with families facing the lossofa loved one and who can identify families at high risk so that preventive measures might be taken. Research Sample Eighty-four families who had experienced the deathofa loved one who had been a patientofthe HospiceofNorth Central Florida participated in the study. All families in thell-countyservice area who were on the mailing list to receive Hospice bereavement literature were contacted by mail I month before the I-year anniversaryoftheir loved one's death informing them about the study and inviting their participation. Follow-up phone calls to eachofthose families approximately 2 weeks later assessed willingness to be included in the study as well as appropriatenessoffamily configuration for participation. Twenty-three percentofthe families contacted agreed to participate, 23% declined to participate, 33% were inappropriate (living alone, not in a usable family configuration, orasquadrants filled, unnecessary for the sample), and21%could not be reached (not at home, phone disconnected, and/or no phone number was available). The final return rate

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131(return/appropriate and reached) was 50%. There was a minimumof20 families per quadrantofthe Family Life Spiral Model, for a totalof84 families. Finding a sufficient numberofparticipant families in the CP quadrant wasdifficult. When the characteristicsofthe two stages composing this quadrant are examined. childbearing and grandparenthood, some theoretically relevant explanations for the difficulty can be suggested. First, couples at the childbearing stage are generallyintheir 20s or early 30s and the chances that they would experience the deathofa spouse or a child are statistically much smaller than at later ages. Furthermore. if they did experience the deathofa partner. only one spouse would remain, and the children would probablybetoo young(Le..12orunder) to be included as participants. Also, it is unlikely that a childbearing-stage couple would experience the deathofoneoftheir parents. given that their parents would only beintheir 40s and 50s, another age range where deathisless frequent. Second, the family life spiral theory proposes that CP families at the childbearing stage have tight external boundaries which limit outside influence upon the nurturanceoftheir young children. As anticipated, when the assessment process involved in this study was explainedasan in-home visit, the majorityofthe potential participants for this particular quadrant declinedtoparticipate. They were quite willingtoparticipatebymail, however. Finally, fewerofthe losses experienced by childbearing families wereofparents thaninother quadrants; rather, the deaths were more often thatofgrandparents and siblingsinthis quadrant thaninthe others. The other phaseoftheCPquadrant includedinthe study, grandparenthood, consistedofpeople whose children were all launched and their oldest grandchild was between the agesof0to5. Theoretically the grandparents would be approximately 50 years old. However, it was often found thatbythe time allofa couple's children were launched, their oldest grandchild was over the ageof5.Furthermore, it was not at all uncommon for single young adults to still be living at home in their early 20s. Nor was it

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132uncommontofind couples who were certainly readytohave grandchildren but whose children had decided not to have children or were delaying childbearing. Sevenofthe CP families were at grandparenthood stages; all except one experienced the deathofa parent. Differences in how emotionally close study participants were to the deceased were minimized in that75ofthe 84 families included the primary caregiver for the patient. Mostofthose caregivers were adult children caring for a dying parent. Only16ofthe 180 participants had lost their spouse. Fourteenofthose16were wives who had losthusbands and were now living with oneoftheir children; only two husbands who had lost wives were living with adult children. The imbalanceofspouses represented is likely due to the fact that widows and widowers living alone could not participate in the study becauseofthe definitionoffamily that was used. Thus, spouse caregivers were less likely to be includedinthe study unless they had combined residence with other family members. In this study there were more widows who were living with an adult child than widowers. The likely reason for the gender imbalance among spouses is that the life expectancy is greater for women than men, and, too, we might suspect that more widows gotolive with adult children than do widowers. One might expect that overall differences between generations as to their perspectives on the individual variablesinquestion mightbea factor in these results. However, the quadrants that had a significant percentage of the participants representing two different generations in the family, CF-tCP (50%) and CF (82.6%), were quite differentinthe amountofdiscrepancy between them. There were significant differences between quadrants on cohesion and adaptability discrepancy scores, with the highest discrepancy scores in theCFquadrant which are likely duetothe presenceofadolescentsinthat quadrant. The CF-tCP quadrant had the lowest discrepancy scoresoncohesion and nearly the lowest on adaptability. Differences between generationsofadults (largelyin

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133 CF--7CP quadrant) did not appear significant, but differences between adolescents and older generations were quite pronounced (CF quadrant). Relationship Between Quadrants in the Model and Family Stress Quadrant. or life spiral phase, was the independent variableofprimary interestinthis study. Means, discrepancy scores, standard deviations, and frequenciesofresponses for individual items in the assessment packet were all computed by quadrant. In a visual checkofthe quadrant means for family stress (Figure 8), the CP--7CF quadrant had the highest mean scores (464.7) and CF--7CP the lowest (389.0). The differences were not statistically significant, however,inthe regression model testing quadrant. communication, cohesion. adaptability, and social support with stress as the outcome variable (Tables 6 and 8). Therefore. the resultsofthis analysis did not support the rejectionofHI.However, later discussion will show the indirect effectsofthe quadrant's significance as a predictor for stress after controlling for cohesion (see Relationship Between Cohesion and Stress). That the greatest stress occurredinthe transitional phase (CP--7CF) where momentum is increasing towards aCFphase is intriguing. It would seem that more stressisplaced upon the family beingpulled away from theCPphase towards developmental tasks associated with CF phases than those families who are already CF when deathofa family member occurs. The pull back to CP developmental tasks appearstobe less stressful atCFthan at CP--7CF phases. Family members gradually begin moving towards differentiation from one anotherinthe CP--7CF phase. At the "settling down" stage, children enter school and are exposedtoother rules and waysofbeing. They become involved in outside activities which help them develop skills and abilities that set them apart from other family members. As parents' timeisfreedupsomewhat, they have more time for outside interests than at CP stages. At the "planning for retirement" stage, couples are reassessing their career goals

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134550 o Q) 0500(.)en E 450 "C Q) ...J:C) .-400Q) o o 350 ...en CPQuadrantFigure8.Family Stress by Quadrant (lines atop each bar represent Standard Error Bars)

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135and establishing financial security that allows themtoplan for separation from the work force. They are beginningtoredirect someoftheir energies towards other interests. This validates the literature cited earlier regarding the difficultyoftransition periodsinthe life cycle. When the systemisalreadyinflux at transition stages, the familyismore vulnerable to the effectsofadditional stressorsatthose times (Golan. 1978; Haley, 1973; Hoffman. 1988; Ireys&BUIT,1984; McCubbin&Patterson. 1983; Rapaport. 1962; Rolland, 1990; Stanton, 1978; Walsh&McGoldrick, 1987). The stressorofdeath seems to create more additional stress for families atthe CP-tCF transition thanatthe CF-tCP stage, presumably duetothe developmentally backward CP pullofdeath. That pull is contrarytothe momentuminforce at CP-tCF phases but notat CF--tCP phases.Anexaminationofthemost frequent strains and stressors reported by families overall and by quadrant (Tables19and 20) points out some interesting similarities and differences. Eachofthe quadrants checked the followingasoneoftheir top10stressors: "A parent/spouse died," "Deathofa husband's or wife's parentorclose relative," "Increase in the numberoftasks or chores which don't get done," and "A member purchased a carorother major item."Allthe quadrants except CP--tCF listed"Amember appears to have emotional problems." TheCFquadrant was the only quadrant nottolist "Increase in the numberofproblems or issues which don't get resolved"asoneoftheir top10stressors. The CP quadrant had more strains than stressors. Top stressors for this quadrant that were uniquetothese families were "Increased disagreement about a member's friends or activities" and "Parent/spouse became seriously illorinjured." "Decreaseinsatisfaction with job/career" was listed as a top stressor for this quadrantasitwasinthe CP--tCF quadrant. The CP-tCF quadrant had more stressors than strains when compared to the other quadrants and more work-related items than other quadrants. Thisisinaccordance with career development theories that indicate the "senling down" stageofthe life cycleasa time

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136 Table19Top Stressors for Families Item Weight Percent58.Deathofhusband'sorwife's parentorclose relative48 80%*56.A parent/spouse died98 75%* 16. Increase in the numberoftasks or chores which don't 35 62%* get done32.A member purchased a car or other major item1952%* 3. A member appears to have emotional problems 58 46%* 15. Increase in the numberofproblems or issues which1543%* don't get resolved50.Close relativeorfriendof tile family became seriously44 39%* ill6.Increase in arguments between parent(s) and child(ren) 45 37% 17. Increased conflict with in-laws or relatives 40 35% 35. Increased strain on family "money" for food, clothing,2135%* energy, home care45.Amemberwas promoted at workorgiven more 40 35%responsibilities59.Close friendofthe family died 47 35%*65.Amembermovedback homeora new personmoved 42 35%*into the household34. Increased strain on family "money" for medical/dental2333% expenses43.Decrease in satisfaction with job/career 45 32%*48.Parent/spouse became seriously illorinjured44 31%

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137Table 19--continued Item Weight Percent 14. Increased disagreement about a member's friends or 35 30% activities 38. A member changed to a new job/career4030%41.A member startedorreturned to work4129%26.TookOllta loallorrefinanced a loan to cover increased 29 27% expenses13.Increase in the amountof"outside activities" which the2526% child(renl are involvedill44. A member had increased difficulty with people at work 32 26% 39. Amemberlostorquit ajob55 24%5.Increase in conflict between husband and wife 53 24% 33. Increasing financial debts due to over-useofcredit3123% cards 54. Increased responsibility to provide direct care or 47 21% financial help to husband's and/or wife's parent(s)61.A member "broke up" a relationship with a close friend 35 21% 7. Increaseinconflict among children in the family 48 20% 2. Increaseofwife/mother's time away from family5120% *On listoftop10stressors by at least two quadrants Note: Stressors areillitalics; strains are in regular type.

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138 Table 20 Top Ten Stressors by Quadrants NumberofItem Weight PercentCPQuadrant58.Deathofhusband'sorwife's parentorclose relative482356.A parent/spouse died981916. Increaseinthe numberoftasks or chores which don't 3514get done32.A member purchased a carorother major item191317. Increased conflict with in-lawsorrelatives40113.A member appearstohave emotional problems 581015. Increaseinthe numberofproblems or issues which 4510don't get resolved 14. Increased disagreement about a member's friends or 35 8 activities43.Decrease in satisfaction with job/career 45 848.Parent/spouse became seriously ill orinjured448

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139 Table 20--continued NumberofItem Weight Percent Quadrant56.A parent/spouse died 982158.Deathofhusbandlsorwife'S parelltorclose relative 481916. Increase in the numberoftasksorchores which don't 3515get done50.Close relativeorfriendofthe family became seriously 4414ill 15. Increase in the numberofproblems or issues which 4512don't get resolved32.A member purchased a car or other major item191243. Decrease in satisfaction with job/career 451244. A member had increased difficulty with people at work 321245.A member was promotedatworkorgiven more 4011responsibilities59.Close friendofthe family died 471165.Amembermoved back homeora new personmoved4211into the household

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140 Table 20--continued NumberofItem Weight Percent CFOuadrant58.Deathofhusband'sorwife's parentorclose relative48 2356.A parent/spouse died982116. Increase in the numberoftasks or chores which don't 3519get done 13. Increase in the amountof"outside activities" which the 2515child(ren) are involved in 3. A member appears to have emotional problems5814 6. Increased disagreement about a member's friends or 4514activities32.A member purchased a carorother major item191335. Increased strain on family "money" for food, clothing,2113energy, home care50.Close relativeorfriendofthe family became seriously4413ill61.A member "broke up" a relationship with a close friend3513

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141Table 20--continued NumberofItem Weight Percent Quadrant58.Deathofhusband's or wife's parentorclose relative481532.A member purchased a car or other major item19143. A member appears to have emotional problems 581316. Increaseinthe numberoftasksorchores which don't 3513get done56.A parent/spouse died981334.Increased strain on family "money" for medicaUdental 23 12expenses 15. Increaseinthe numberofproblems or issues which 45 IIdon't get resolved38.A member changed to aflewjobicareer40II65.Amembermoved back homeoranewperson moved42IOinto the household35. Increased strain on family "money" for food, clothing,218 energy, home care59.Close friendofthe family died478 Note:Stressors areinitalics;strains are in regular type.

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142 for establishing oneselfina career. Major stressors in this quadrant included the serious illnessofa close relative or friendofthe family (which was reported more frequently than was the caseinCP or CF--7CP families). Eleven percentofthe families in this quadrant reported the decisionofa family member to return home or a new person moving into the household (which was similar to the percent reportedinthe CF--7CP quadrant) and the deathofa close family friend (which was not reported as a major stressor in the other quadrants). They were also the only quadrant that reported the deathofa close family friendasa top stressor. The CF quadrant, as might be expected with adolescents in the family, had stressors and strains uniquetoit."Increaseinthe amountof'outside activities' which the child(ren) are involved in," "Increased disagreement about a member's friendsoractivities," and "A member 'broke up' a relationship with a close friend" were 3ofthe top 10 stressors for this quadrant. The CF--7CP quadrant had stressors unique toit:"Increased strain on family 'money' for food, clothing, energy, home care" and"Amember changed to a new job/career. " These results are quite different than was expected based on those obtained by Olson (McCubbin&Thompson, 1991)inhis studyofnormal families across the life cycle (Table I). The higher scores in Olson's sample for nearly all the individual stagesofthe family life cycle except for the "settling down" stage are due to an older and lengthier versionofthe FILE (Form A) being used at the timeofthat study which is not comparabletoForm C usedinthis study. It is significant, however, that the means for eachofthe stagesinOlson's analysis are higher than the corresponding stagesinthis study, except for the familiesinthe "settling down" stage.Inthis study that stage had significantly higher scores on FILE than the other stages. It would appear that thisisa more stressful timetolose a loved one than any other stage.

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143When the quadrants were differentiated into the two or three individual stagesofthe family life cycle which constituted each life spiral phase, some very interesting differences are noted (seeFigure 7). Thescores for each stageofthe family life cycle are higher for each initial pass (beginning at adolescence) through each phase in the life spiral model, with each successive oscillation generating less stress than the previous one.Theonly exception in this studyisa very high score for a stage that was added to the model (but not illustrated) ("greatgrandparenthood") becauseofthe inclusion in the studyoftwo greatgrandmothers who were 88 and 93, respectively, and who were living in families that had experienced inordinate crisesinthe previous year. The meanofthe family's weighted sums in bothofthose families is exceptionally high and the low numberoffamiliesinthat stage (n=2) does not make this a reliable or stable celi. Clearly, individuals experienced less stress with each pass through the life spiral phases. Oneofthe points made about the oscillations between CP andCFphases is that the developmental tasks associated with each are quite different. From this model, it appears that when families are faced for the first timewith developmental tasksofnurturance and intimacy requiring cohesion and tight boundaries, more stress is generated than at the next stage requiring those same developmental tasks. The sameistrueoffamilies with adolescents confronted with the developmental tasksofautonomy and differentiation requiring a looseningofthose previously appropriate external boundaries. There is more stress the firsttime these tasks are faced than when the next successive revolution occurs. There is also the factor that the later in the life cycle that a death occurs (both for the individual experiencing the loss as well as the ageofthe deceased), the more likelyitis "on time" and, therefore, less stressful (Herz, 1980; Neugarten, 1976; Rolland, 1990; Walsh&McGoldrick, 1987). The above observations regarding reduced stress with each pass through the life spiral confirms the reasoning behind Olson's definitionofthe stageofthe family's life

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144 cycle as determined by the ageofthe oldest child. The most stressisgenerated the first time the family faces the developmental tasks required for the successful raising and launchingofthe child and lessens with each successive child (Olson etal..1989). Through examinationofthe differences between these individual stagesofthe family life cycleinan ANOV A, threeofthe stages had significant t-values, "childbearing" (I! =.02), "settling down" (I! =.002), and "40s reevaluation" stages (I! =.04). It should be noted here that the scores usedinthis analysis are each individual's total weighted sum score on the ALE. Because 46%ofthe assessed families crossed two generations (meaning that the assessment was not based on the inputoftwo people from the same generation but rather one from one generation and the other from another generationinthe same quadrant), "family" scores could not be usedtodetermine these differences. Tukey's pairwise comparisons determined a significant difference between the "settling down" stage and the "planning for retirement" stage. This differenceistheoretically significant in that bothofthese stages are within the same quadrantinthe model, yet they differ significantly in the amountofstress family members at each stage experienced after the deathofa loved one. Further examination revealed thatoftheIIfamilies at the "settling down" stage, all had experienced the early deathofa parent; the average numberofyears shortofthe parent's life expectancy was 7.64, with the mean ageofparental death at 67.36.Ofthe 6 families at the "planning for retirement" stage, 5 had lost parents and one a child. The mean ageofthe deceased parent at this stage was 77.4, 2.4 years greater than their life expectancy. The deceased child was 39 at timeofdeath, 36 years shortofthe life expectancy. Clearly, the lossofa parent at the "settling down" stage was more "off-time" than at the "planning for retirement" stage and may be a factor contributing to the high stress at this stageofthe family life cycle. Overall, however, premature death does not seemtocorrelate with the stress levels that are seen by quadrants. The greatest numberofpremature deaths occurredinthe

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145 quadrant, with the average ageattimeofdeath being 62, yet this quadrant had the lowest stress. In theCFquadrant, the mean age at timeofdeath was 65; for CP-.+CF families, 69 (the quadrant with the highest stress): and for theCPquadrant, the mean was 73. Statistical analysisofthe mean discrepancy scores for stress by quadrants did not prove tobesignificant, although the mean discrepancies forCFfamilies (9.18) differed the most from CP families (6.02). Eighteenofthe23families in theCFquadrant included an adolescent. This is in keeping with Olson's research (1989) that found widely discrepant views between adolescents and their parents on the FILE. Olson theorized that the leveloffamily stress may be elevated due to these discrepant perspectives between adolescents and parents, and although elevated in this study, the discrepancy did not prove to be a significant predictorofthe family's stress.Isit possible that theCPpullofdeath on the family increased the cohesion. adaptability, and communication in this sample such that there were smaller discrepancies than would normally be present? Noneofthe discrepancy score measures independently predicted family stress levels. However, there was an interaction between quadrants and the discrepancy scores for communication in predicting family stress which will be discussed in the following section. Relationship Between Ouadrants and Expressive Communication In the regression model testing the abilityofquadrant location to predict expressive communication scores in the family, quadrant location was not found tobesignificant (Tables15and 16). Therefore,H3was not rejected. Mean scores for each quadrant were 5.97 (CP), 5.56 (CP-.+CF), 5.46 (CF), and 5.82 (CF-.+CP). Does experiencing a death alter the communication stylesofthese families in some fashion? Or does communication style alter the stress experienced, or the stress alter the communication style? Not having assessed the families prior to the death, those questions cannotbeanswered with conviction. However, it is possible that CP families were

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146 developmentally more in synchrony with the CP pullofdeath and that their communication was more expressive. The recent births may have served as a reminderofthe cycleoflife and death and may thereby have normalized death, taking discussion about it outofthe realmofthe taboo. Deathina home setting is an intimate time for families, a timeofphysical and emotional closeness. Families attunedtothe intimacies associated with childbirth may feel moreofan ability to be open about death than other families. By contrast, families at other phases were removed from tasks requiring intimacy and nurturance. Because their members focus on developmental tasks associated with autonomy and differentiation, they may find the prospectofengaging in intimate conversation about death and dying incongruous. Developmentally, it is certainly characteristicofadolescents to be uncommunicative with family members about taboo subjects such as sex and death (Berman et al., 1988: Coleman et al., 1986; Elizur&Kaffman, 1983). Furthermore. adults at the "40s reevaluation" stage in midlife are often pained with facing their own mortality; when confronted with the deathofthe last surviving parent. they are thrust into the "next" generation to die. Talking about death and dying under such conditions suddenly becomes less abstract and more concrete, taking on many very personal implications. Quadrant was not a significant predictorofthe discrepancy in expressive communication scores for families in the regression model testing quadrant and discrepancy scores for cohesion and adaptability as predictor variables. Given that the l2-value was .0502, itispossible that had there been more power in the study (increased sample size or perhaps decreased variabilityinthe population by controlling for initial variance through a covariate measure such as stress before death) statistical significance would have been achieved.Inthe interaction model testing the capabilitiesofquadrant and the discrepancy scores on all the independent measures to predict family stress. a significant interaction

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147between quadrant and the discrepancyinexpressive communication scores was found (F=3.I 8.12 =.03) (see Figure 6). When the regression coefficients were tested, a significant difference was found between the CP4CF and CF quadrants. When quadrant was controlled, there was a significant difference between discrepancy scores on communication and family stress levels. As communication discrepancy scores increased for CP4CF families.there was a corresponding increaseinthe stress scores. However. forCFfamilies.ascommunication discrepancy scores increased. the stress levels decreased. These results canbeexplained by the natureofthe differences between familiesatthese two stages. For the most part CP4CF families are still boundtoone another and are less likely to have outside sourcesofsupport. so when their communication patterns are perceived discrepantly. those differences contribute to increased stress. On the other hand.CFfamilies have more discrepant scores but are disengaged from one another and rely more on outside sourcesofsupport. Their expectationsofone another are lower; therefore, their stressislower. Examinationofthe means indicates that the CF4CP quadrant had both the lowest stress (389.0) and the lowest discrepancy on communication (.97). The CP4CF quadrant had the highest stress (464.7) and the second highest communication discrepancy scores (1.64). Relationship Between Ouadrants and Cohesion Cohesion was foundtovary significantly by quadrant (Table17).CP families were found to have more cohesion andCFfamilies less. The mean score forCPfamilies on the cohesion scale was 67.0 and forCFfamilies the mean was 59.9 (Figure 9). This confirmed the findingsofOlson et al. (1985) that showed cohesiontodrop significantly as adolescents begintoseparate from the family (see Figure 3) but differed from his results that showed married couples without children had the highest levelsofcohesion. In this study those couples would beinthe CF4CP quadrant which had a mean cohesion scoreof

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7065 U) Q) o (.)enc: 60o.U) Q) J: o o 55CPCFQuadrant148 Fi&ure 9.Cohesion Mean ScoresbyQuadrant

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14964.3, about midrange. Jordan's findings (1991)oflow cohesion at adolescent stages were also corroborated. Discrepancy scores on cohesion were also foundtobe significantly different among quadrants. The means for each quadrant were 8.6 for CF families. 6.4 forCPfamilies, 4.4 for and 3.1 for (Figure 10). As the theory suggests,CFfamilies had greater discrepancies than did other families, largely due to the inclusionofadolescentsin17ofthe 23 familiesinthis quadrant. Adolescents view their familiesasmuch less close than do their parents (Olson et a!., 1989), which often seems to be a necessityinorder for themtodifferentiate appropriately from their families. However, this analysis indicated that CF quadrants differed significantly from and quadrants, but not so with CP quadrants. These findings are similar to thoseofOlson eta!.(1989) who found both the most cohesion and the most discrepancy on cohesion scores between couples (not families)inthe early stagesofmarriage and childbearing. Relationship Between Ouadrants and Adaptability Adaptability by quadrant was significant both for mean and discrepancy scores (Table17).A preplanned testofthe differences between CP andCFfamilies achieved significance with CP families being significantly higher on adaptability thanCFfamilies. Mean scores for all four quadrants were CP (51.7), (51.4), CF (46.8), and (52.4) (FigureII).That familiesinCF stages are less adaptable and flexible than other families was demonstratedinOlson's study (1988) and corroborated here.Infact, adaptability seems to hardly vary exceptinthe CF quadrant.Itdoes seemtopoint out that adaptabilityisnot a strong predictorofstress, however,inthat the quadrant with the most stress, did not exhibit any less adaptability than theCPor quadrants. The CF families were significantly more discrepant on adaptability scores than any other quadrant with a meanof8.0. The other scoresbyquadrant were (4.6), CP (5.2), and (4.1) (Figure 12). This isinkeeping with Olson's (1988) findings that

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0CU 8 '0 0 en 0c: 6 co 0cu'-0 0 .C 4 c: 0.0CUJ:: 02 0 CP CP.CF CF CF.CP 150Quadrant Fjg;ure 10. Cohesion Mean Discrepancy Scores by Quadrant

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5452 en Q) 050(.)en.., ..-42CPQuadrantFigure11.Adaptability Mean Scores by QuadrantlSI

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CF CP.CF CP15210 tJ)Q)I08 (.)en>to(.)c:m 6 a.Q)I-(.)tJ) .-C >to 4 .... .--..cm....Q. 2 m"t:J
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153 families with adolescents will have significantly greater discrepancies than families at other stagesofthe family life cycle. Relationship Between Quadrants and Social Support The social support literature pertaining to families' adaptation to the stressofdeath in the family life cycle suggested that families who utilized family support also utilized social support (Cohen et aI., 1977; Qlson et al., 1983). Those studies were questioned initially because they were contrary to the theoretical model behind the Family Life Spiral Model which described CP families as having tight external boundaries in order to filter outside influence selectively. Although analysesofthe useofsocial supportinthis study did not find any significant differences in the useofsocial support by quadrants, the trends were certainly contrarytothe above-cited research studies. There was very little difference across quadrants in the useofsocial support, either through the Social Support Indexorthe Relative and Friend Support subscale, except that for bothofthose measures theCPfamilies scored the lowest (see Table 7). SummaI)' ofQuadrant Effects Significant differences by quadrants were found for measuresofcohesion and adaptability, both for the mean scores and the discrepancy scores. The CP families had the highest cohesion scores and were significantly different from CF families on adaptability. The CF-7CP families were the most adaptable. The CF families had the lowest scores on cohesion and adaptability and the highest discrepancy scores on both measures. Although there were no significant differences between measuresofstress, communication, and social support by quadrant, mean scores indicate that CP-7CF families had the highest stress, CF-7CP families the lowest. There was also a significant interaction between quadrant and discrepancy scores on communicationinpredicting family stress levels.

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154 Relationship Between Communication and Stress Three different regression models tested measuresofcommunicationaspredictorsofstress.Inthe fust two, communication did not predict stress, nor did discrepancy scores on communication predict discrepancy scores on stress. However,inthe third regression model, the interaction model showed a significant interaction between communication discrepancy scores and quadrantinpredicting family stress (Tables 9 and10).There was a strong positive relationship between communication discrepancy scores and stress levels between the CP-.CF and CF quadrants, as discussed previouslyinthe section "Relationship Between Quadrants and Expressive Communication." The lackofa stronger relationship between communication and stressiscontrary to the hypotheses generatedbythe theoretical literature. Itispossible that significance mightbeachieved had the bereaved sample been a non-Hospice sample,inthat oneofthe benefitsofHospice involvementishelping families to communicate with one another about all facetsofthe death and dying process. Relationship Between Cohesion and Stress Cohesion was a significant predictorofa family's stressinthis study--the lower the mean score, the higher the stress, and the greater the discrepancy score, the greater the discrepancyinstress. The lower cohesion families experienced, the higher their stress levels. TheCPfamilies had the most cohesion (67.0) with CP-.CF families nearly the same (66.9). TheCFfamilies scored 59.9 and CF-.CP families scored 64.3. Stress levels by quadrants are as follows: CP (425.5), CP-.CF (464.7),CF(444.5), and CF-.CP (389.0). Indirectly, then,itcanbededuced that quadrantisa significant predictoroffamily stress levels when cohesioniscontrolled. Although thereisnodirect effect on stress between quadrants, thereisanindirect effect through cohesion. It is, therefore, quite intriguing that the quadrant with the most stress, CP-.CF, had comparatively high cohesion. Despite their cohesion, the stress experienced after the

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155deathofa loved one was still greater than for any other quadrant. Perhaps the family cohesion necessitated by the deathofa loved one counteracted theCFthrust appropriate to the family phase, and, as a result, more stress was generated. This seems to be the most significant indicator that theCPpullofdeath creates more difficulties for families at this phase (i.e., experiencing theCFpull outward) than any other. This observation lends credence to the theory-based notion that the "settling down" stage within the CP-tCF quadrantispredictedtobe the most stressful timeinthe family life cycle to lose a loved one. Despite being cohesive, adaptable, and skillful in using social support and relative and friend support, the families in this quadrant reported high stress after the death. However, these families may also be the most resilient becauseofthe resources availabletooffset the stress. There was a significant relationship between the discrepancy scores for cohesion and stress measures. As discrepancy scores on cohesion increased, there was a corresponding increase in the stress discrepancy scores (Figure 13). The differences between cohesion and stress discrepancy scores for CP and CF quadrants were negligible but considerably greater for the transitional quadrants, CF-tCP and CP-tCF. When the families were in flux, so were their perspectives on different measures. What is more significant theoretically is that the discrepancy scores on cohesion were the only discrepancy scores that were statistically significant in predicting stress discrepancies. Relationship Between Adaptability and Stress Although there were significant differences in adaptability by quadrants, adaptability by itself was not a significant predictorofthe amountofstress families experienced. Examinationofthe descriptive statistics reveals thatCFfamilies had the lowest adaptability mean scores, the highest discrepancy scores for adaptability, and oneofthe highest stress scores. On the other hand, the quadrant with the most stress, CP-tCF, had high adaptability mean scores and low adaptability discrepancy scores, once again

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156 CohesionDStress6 4210 U) Q) 'o (.)en 8 >-(.)ccoCo Q) '(.)U) .CU) U) Q) 'en"Cccoc o.U) Q) .c o U CP CP.CF CF CF.CP Quadrant FiEure 13.Cohesion and Stress Mean Discrepancy Scores by Quadrant (scales are not equivalent for cohesion and stress)

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157 indicating that despite being adaptable in the faceofthe deathofa loved one, those factors did not alter the amountofstress that followed. Whether or not it was a factor in how they coped with the loss and the ensuing stress cannotbedetermined since measuresoffamily well-being were not included. Relationship Between Family Subtypes and AmountofStress Olson's research (1991) has shown that the interaction between a family's cohesion and adaptability accounts for someofthe differencesinthe family's response to stressful life events. Differing levelsofcohesion and adaptability combinetogroup families into16different subtypes (AppendixI).Combining the scales for cohesion and adaptabilityinthis study produced five subtypes that were the most frequent (Table 21). Connected-Flexible families accounted for 25%ofthe sample, 23.8% were Very Connected-Very Flexible. 11.9% were Separated-Flexible, 9.5% were Separated-Structured. 8.3% were Very Connected-Flexible and 21.5% fell into 8 other subtypes (Figure 14). Based on the subtypes. family types were determined, ranging from Balanced to Moderately Balanced, to Midrange.toExtreme.Inthis sample. 25%ofthe families were Balanced, 42% were Moderately Balanced. 27% were Midrange, and 6% were Extreme. Significant differences were found between the five family subtypes that were the most frequent in this study and the amountofstress reported by each. Levelsofstress between Very Connected-Very Flexible families were significantly different from both Separated-Flexible families as well as Connected-Flexible families. The mean for Separated-Structured (506) was considered unstable due to small cell size (n=8). The bar graph (Figure15)makes it more visually clear that there is a relationship between decreasing levelsofcohesion and adaptability and the increase in stress. Did the increased stress produce lower levelsofcohesion and adaptability.ordid lower levelsofthose two measures lead toincreasedstressors? Without a longitudinal study. itisimpossibleto

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158 Table21Family Subtypes by Quadrant Family Subtype CP CF PercentVery ConnectedIVery Flexible75 26 23.8 VeT)' Connected/Flexible23 8.3 Very Connected/Structured 000 1.2 Very ConnectedlRigid 00 000 ConnectedIVery Flexible 0 24.8CO/lnected/Flexible 48 6 325.0Connected/Structured4.8ConnectedlRigid 00 0 1.2 SeparatedlVery Flexible 0 0000Separated/Flexible3 33 11.9Separated/Structured2239.5SeparatedlRigid 00 202.4DisengagedIVery Flexible 0000 0 DisengagedlFlexible 0 0 0 1.2 Disengaged/Structured 002.4DisengagedlRigid 0023.6Family Subtypesinitalicsare the five most frequentinthis sample upon which analysis was based.

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ITotal SampleI8.3%Very Connected Flexible25%Connected Flexible11.9%Separated Flexible9.5%Separated StructuredFigure14.Family Subtypes for Total Sample 15923.8%Very Connected Very Flexible21.5%Other Types

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700 (/)600Q) o (.)en 500E en 400 "CQ)....."5,300 0Q)3:(/)200(/)Q).....en 100VCVFVCFCFSFSS160FamilySubtypesFigure15.Stress Mean Scores for Family Subtypes Note: VCVF=Very ConnectedIVery Flexible VCF=Very ConnectedlFlexible CF=ConnectedlFlexible SF=SeparatedlFlexible SS=SeparatedlStructured

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161detennine the answer. Lewis (1989) theorized that families who have too much connectedness may notbeabletorespondtodevelopmental challenges with appropriate increases in CF or CP styles, but that would certainly be refuted here with the Very Connected-Very Flexible families having the least amountofstress following a death. The cohesion-adaptability subtypes were charted according to quadrant (Figure 16). As families oscillate between CP andCFstages, some interesting changes in their cohesion and adaptability are apparent. The percentagesoffamilies that were Very Connected-Very Flexibleis35% at CP, decreasing to 24% at to 9% at CF, and then back up to 30% at stages. Taking the analysis one step further in accordance with Olson's Linear Scoring and Interpretation guidelines and his family typology model, 25%ofthe sample were Balanced families, 42% were Moderately Balanced, Midrange families constituted 27%, and 6% were Extreme. Marked differences between these family types by quadrant are also interesting in termsofthe stress measures (Table 22). The greatest numberofBalanced families are in the CP quadrant (40%) and the least (9%) are in theCFquadrant. Nearly two-thirds (62%)ofthe quadrant are Moderately Balanced, with fairly equal distributions (30-39%)inthe other three quadrants. Midrange families were fairly similar across quadrants. with the least in the quadrant. There were no Extreme familiesinthe quadrant norinthe CP quadrant. The quadrant with the greatest stress had the highest percentageoffamilies falling into the Balanced and Moderately Balanced categories (86%). The other three quadrants ranged from 48%to70% for those two categories. That the quadrant had the greatest stress but also the greatest numberofbalanced and moderately balanced families can be interpreted in two ways. One, it provides even more evidenceofthe stressfulnessoflosing a loved one at a time when families are pulled so stronglyintwo different directions, as they areinthe CP-7CF

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CF20%SF15%VCVF35%Other10%CF38%VCF14%SF5%Other 9% 162SF13%CF26%VCVF9%Other35%CF15%SF15%VCF5%SS5%Other30%Figure16.Family Subtypes by Quadrant VCVF=Very ConnectedIVery Flexible VCF= Very ConnectedlFlexible CF=Connected/Flexible SF=SeparatedlFlexible SS=SeparatediStructured

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163Table 22 Family Types bv Ouadrant Extreme Midrange Moderately Balanced BalancedCP0 30% 30% 40% 014%62% 24%CF13% 39% 39% 9% 10% 25% 35% 30% quadrant. particularly during the "settling down" stage. Despite the fact that these families were well-balanced. cohesive and adaptable, and relied on external familial and social support in a manner similar to families at other stages, losses at those stages are associated with more stress than any other. The other possible interpretationistosuggest that these data support the validityofOlson's theory about the curvilinear relationship between the cohesion and adaptability scales for problem families. Although the concepts appeartobelinear measures for normal families, thereisevidence (hat clinical families fallon both extremesofthe two dimensions (Olson, 1991).Isit possible that "nonnal" families become "clinical" families when thereisan inappropriate amountofconnectedness and flexibility for the developmental tasks appropriatetotheir stageofthe life cycle? Is it possible that "Balanced" families, with high cohesion and high adaptability, are really more similarto"Extreme" families? Perhaps high cohesion and flexibility produce more unhealthy than healthy consequences at particular phasesofthe life cycle/spiral so that the terms usedinthe original Circumplex Model are more descriptive--"enmeshed" and "chaotic." In summary, the fact that families

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164 had higher stress than others may be more adequately explained as due to too much connectedness and flexibility which generate family enmeshment and chaos. Relationship Between Social Support and Stress A most surprising outcomeofthis research study was the lackofrelationship between the useofsocial support and the amountofstress families experienced. Social support is repeatedly documentedasbeing a critical factor for bereaved families and individuals in adapting to their loss (Walsh&McGoldrick, 1991). However. in three separate regression models incorporating useofsocial support as predictorofstress levels, no significant results were found. Two measuresofsocial support were used. the Social Support Index. which assesses the reliance upon community (six questions), nuclear family (six questions), and friends (five questions), and the Relative and Friend Support Subscale (four questions each for relatives outside the nuclear family and friends). One interpretation is that social supportisimportant and was utilized equally at all stagesofthe life cycle, although there were no statistically significant differences. Had the study compared bereaved families served by Hospicetobereaved families who did not use those or other home care services. it is possible that differences in social support may have been noted? Hospiceisa sourceofcommunity support where family members are encouraged tobeinvolved in the patient's care as well. A comparisonofthe means and standard deviations between this research sample and the normative sample for the social support instrument. FIRA-G. corroborates this hypothesis. The mean in this research sample varied from 60.8 to 63.3 across quadrants, with a variationinstandard deviation between 4.0 and 4.9. For the normative sample the mean was considerably lower and the standard deviation higher (mean=45.3 to 47.9 across stagesofthe family life cycle; standard deviation=7.5to8.1) (McCubbin&Thompson. 1991). This indicates there was a range restriction in this sample,inthat all participants had high levelsofsocial support. Whether that is due to death generating more support than normal events would

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165for these families, or whether thatisduetoHospice involvement asanagentofsocial support, or whether this particular sample simply consistedofpeople who were more apttouse social supportisunknown. There werenomeaningful differencesinthe means and standard deviations for the Relative and Friend Support subscale between this research sample and the normative sample. The lackofsocial support's relevancetothe modelisperhaps offset by the significanceoffamily cohesion, as documented repeatedlyinthese research results, and the benefitsofeach family's connection to Hospice.Itis less likely that disengaged families would choose to,orbeable to, care for a terminally ill member at home. When family involvement is emphasized, cohesion within the nuclear family may be increased by reliance on internal sourcesofsupport, so that reliance on social support from external sources is reduced. These results run counter to thoseofCohen et al. (1977) who suggested that families who utilized family support also utilized social support. However, the findingsofWeber and Fournier (1985) that families found more benefit from the support offered by immediate family members than various other institutional resources were confirmed. SummaI)' ofPredictor Variables for Stress Although quadrantsofthe Family Life Spiral Model did not have a direct relationship with stress levels, there was found to be an indirect relationship when cohesion was controlled.Aninteraction between quadrants and communication was found for predicting stress, with stress increasing across quadrants as communication discrepancy scores increased. The families had the lowest stress and the lowest communication discrepancy scores, with both measures increasing for CP families,again for families, and then continuingtothe highest communication discrepancy scores for CF families but slightly slower stress levels.

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166 Cohesion was predictiveofa family's stress both for the mean scores as well as discrepancy scores. The lower cohesion. the higher the stress; the lower the cohesion discrepancy scores, the lower the stress. Resultsofanalyses including adaptability indicated that despite being flexible and adaptable after the deathofa loved one, there was no significant alterationinfamily stress levels. However, when the cohesion and adaptability scales were combined together, it became apparent that the less cohesive and adaptable families were, the more stress they incurred. Social support was not found to be a significant predictorofa family's stress postdeath. Relationship Between Cohesion and Communication Becauseofliterature that connected a family's communication processes with their cohesion (Fleming&Adolph, 1986), analyses were conducted to determine the relationship between those variables. Cohesion mean scores did not predict a family's expressive communication levels, but the cohesion discrepancy scores were predictiveofcommunication discrepancy scores.Iffamilies differed significantly on their views about cohesion, they could be expected to differ significantly about their communication patterns. Although the theories about the relationship between communication and cohesion were not corroborated here statistically (Fleming&Adolph, 1986; Ireys&Burr. 1984; Rosen, 1987; Sanders, 1989; Vess et aI., 1985-1986), the occurrenceofsituations where families become disengaged with subsequent closed communication certainly occurs, albeit not in significantly high numbers. Relationship Between Adaptability and Communication Adaptability was a significant predictorofa family's expressive communication. both for mean scores as well as discrepancy scores. The more adaptable families were, the higher were their expressive communication scores. Two quadrants with high adaptability also had high expressive communication scores. and the quadrant with the lowest adaptability had the lowest communication score. No doubt it took greater openness in

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167communicationinordertobe more flexible. These results confirm the theories and findingsofprevious writers that families who communicate clearly and openly readjust and reallocate roles better than families who do not communicate as well and who are inflexible (Bowen, 1976; CohenetaI., 1977; Vess et al.. 1985-1986; Vollman et al.. 1971; Walsh, 1982; Walsh&McGoldrick, 1991). As with cohesion discrepancy, adaptability discrepancy scores were also predictive of communication discrepancy scores. When families had discrepant viewsoftheir adaptability, they also had discrepant viewsoftheir communication. Family Life Spiral Model The theory behind the Family Life Spiral Model served as the basis for this research study. and specifically the centripetal and centrifugal forces at work within the model. No empirical research had been donetotest hypotheses about the effectsofdeath on families depending upon whether they were at CP. CP-tCF, CF, or CF-tCP phases in the model. The model was divided into quadrants in order to group all the families at CP stages together, all the CP-tCF stages together, and so on. The artificial boundaries devised in order to measure the differences between various phasesofthe family life spiral did not allow for the effectsofvariations in career development, marital development, statusofaging parents and grandparents. and the previous historyofthe family in progressing through the stagesofdevelopment. Becauseofparameter definitions for each stage of the life cycle, there was much less difficulty placing families in a particular quadrant than was anticipated. When children wereinthe home,orgrandchildren were under the ageof5, the categorization was simplified. Whether those delimiters accurately captured families operating predominantly under CP forces or CF forces is unknown. but the assumption was made that developmental tasks appropriate to the agesofthe chiId(ren) were being negotiated.

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168Ingrouping families at disparate life cycle stages together into a single quadrant or phaseofthe life spiral model,nosignificant difference among quadrants was found on the amountofstressorsocial support in this study. There was an interaction between communication discrepancy scores and quadrants for predicting family stress. however, and the typeofstress for one subscale did differ by quadrant. Cohesion and adaptability were both significantly different among quadrants as the literature suggested. Although the amountofstress was not significantly different among quadrants, an examinationofthe means for each quadrant in lightofthe theories put forth in the literature allowsustosee trends and tendencies that maybehelpful in designing future studies. No oneofthe theories proposed by these researchers was wholly confirmed. Combrinck Graham (1983) initially hypothesized that death would be less upsetting for families who were CF since death is a departure and that lossofa loved one at any other phaseofthe life spiral could cause the familytotighten their external boundaries even more. The data do not support that prediction. The quadrant with the greatest stress was CP-4CF, and that showing the second greatest stress was theCFquadrant. Rolland (1987a) had hypothesized that death atCFphases would be more stressful than at CP phases. which was true,but the greatest stress occurred not atCFbut at the transitional CP-4CF phase. He theorized that givingupthe pursuitofa new life structure is more difficult once that process has been initiated thanifthe plans for such have not been made or are only in the preliminary stages. That did not seemtobe the case here. Presumably, plans for new family and life structures were in the preliminary planning stages at the CP-4CF phase and implemented in theCFphase. The assumptions made in the literature about transition stages were not wholly supported (Golan, 1978; Haley, 1973; Hoffman, 1988; Ireys&Burr, 1984; McCubbin&Patterson, 1983: Rapaport, 1962; Rolland. 1990; Stanton, 1978; Walsh&McGoldrick, 1987), in that the phase with the greatest stress was the transitional CP-4CF phase, and the

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169phase with the least amountofstress was the other transitional phase, CF-tCP. The CP-tCF transitional phaseofthe family life spiral was a much more difficult time to experience the deathofa loved one than the CF-tCP phase. When differentiating between the stagesofthe family life cycle and phasesofthe family life spiral, analysis was very revealing and pointed out a drawback in generalizing about the effectsofCPand CF forces across generations, especially in termsofstress levels. The differences between stagesofthe family life cycle in the amountofstress experienced were statistically significant. The greatest difference between two stagesofthe family life cycle occurred within one quadrantofthe family life spiral, the "settling down" and "planning for retirement" stagesinthe CP-tCF quadrant. Combining the scoresofthose two stages together into a mean score for the quadrant reduces the stress actually reported by those in the "settling down" stage. The amountofstress was clearly higher for the first revolution through this phase than it was at the succeeding one, and it may be that the intensityofCP and CF forces lessens as families progress through the life cycle. Whether or not the other variablesofinterest (cohesion, adaptability, communication. and social support) would have achieved statistical significance by life cycle stages is unknown but clearlyisworth considering for future studies. For those variables that did achieve significance by quadrant, we can only suppose that at least one stage within that quadrant would be significantifthe same research design was conducted using the distinct stagesofthe family life cycle rather than synthetic quadrantsofthe family life spiral. Combining two or three disparate stages together into one quadrant and making broad statements about the mean for those stages combined as a quadrant has the same effect as describing a family only in termsofmean scores. This is the valueofdiscrepancy scores. Just as it is importanttonot lose sightofthe individual within the system, differences between individual stages within the overall family life cycle must also be

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170examined. Some generalizations about CP or CF forces within the model are obviously accurate, and others may be less so. Sometimes the means are the more useful descriptors, and other times discrepancy scores may give a more complete picture. Recommendations Implications for Therapy The resultsofthis study point out several factors to consider when working with families who are anticipating the deathofa loved one and also helping them through the bereavement process. Identifying high-risk families is important so that services may be targeted appropriately. Assessing where families are in the family life cycle is importantinviewofthe resultsofthis study. The "settling down" stageofthe family life cycle is one where a great dealofstress occurs after the deathofa loved one. Preventive interventions aimed at maintaining levelsofcohesion and flexibility relevanttodevelopmental stage prior to the death may offset someofthe pile-upofstressors afterwards. Educating families about the effectsofthe illness and death upon their individual and family development would servetonormalize their experience and enable them to prevent someofthe added stressors and strains that might be expected at their particular stageofthe life cycle. Encouraging family members to continue their age and stage-appropriate development while engaginginthe care givingoftheir loved one and while grieving their lossisvital to recovery. An appropriate goal would be to generate cohesion (CP) sufficient for mutual support throughout the grieving process without giving up outside interests and activities (CF). Other interventions may focus on helping familiestoreestablish more developmentally appropriate boundaries, encouraging appropriate restructuringofthe roles within the family in lightofdevelopmental levels and strengths, normalizing the grief process, and encouraging continued opencommunication and connectedness while still allowing for appropriate differentiation. The most frequent stressors for each individual

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171stageofthe life cycle could be developed (rather than by quadrantaswas done in this study) and used as a guide for work with families facing the deathofa loved one. Limitationsofthe Study Dividing both the life cycle and the life spiral into segments helps to organize the data and allows the examinationofdifferences between stages and phases, but concretizing the stages and phases has limitations in that there are many factors that determine a person's position in their own individual life cycle as well as within the family life cycle and family life spiral (Gunnan, 1983; Lewis, 1989). Variations on the normal family life cycle are becoming more prevalent and, therefore, make such clear divisions much cloudier (Carter&McGoldrick, 1988; Combrinck-Graham, 1983, 1985). Families do not always fall cleanly into one stage. Although a major defining characteristicofthis study is the determinationofthe stageofthe family life cyclebythe ageofthe oldest child in the family,that has not been empirically established, and it may very well be that the youngest child has more influence on the holding forcesofthe family(L.Combrinck-Graharn, personal communication, November 13, 1992). As always in measurement, the biasofthe useofself-report assessment tools by themselvesiscalled into question (Lewis, 1989; McCubbin&Thompson, 1991). Do the family's observationsoftheir own behavior provide an accurate pictureoftheir dynamics? Would an outsider makinganobservational assessment be any more accurate? Retrospective assessments, such as Fll..E, call for a reflection on events and changes over the past year. This reflection calls into question the accuracyofthe individual's memory, the influenceofsocial desirability, and the tendencyofindividuals to constantly rework and rewrite their memoriesofevents to come up with a picture they can accept (Lewis, 1989). However, such assessments do offer the potentialofcapturing family dynamics across time which perhaps an independent observer would not be as likely to see (McCubbin&Thompson, 1991).

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172There is always the questionofwhether or not the instruments are able to depict accurately all the ramificationsofthe stressor eventofdeath and how well they depict the enduring and temporal characteristicsofthe family. A qualitative study may have gotten at those other elements more accurately. The representativenessofthe sampleislimited by the volunteer natureofparticipation in the study and the willingnessoffamilies to be assessed (Sanders, 1989). Familiesinbereavement may not be eager to openupthe wounds that may have occurred at the timeofthe loss. Those who did not agree to participate in the study may be those whose stress levels have been extremeorthe family conflict so great as to fragment the family unit. Families who have low levelsofexpressive communication may have been unwilling to participate. Those who did agreetoparticipate may have had a desire to gloss over problems that existed in the family in ordertoprotect the family image ortodeny the effectsofthe death: others may have exaggerated their responses to dramatize the effectsofthe death. Generalizabilityofthe study may be enhanced in this research study by the nonclinical natureofthe sample. Families referred to Hospice are referred becauseofa diagnosisofterminal illness. not becauseofmental health problems, so are not necessarily presenting with issues that would prompt treatment in traditional clinical mental health settings. In other words.these families may more accurately represent the "normal" family than would a sample taken from inpatient or outpatient mental health settings. However, as mentioned earlier, experiencing the deathofa loved one can certainly cause or exacerbate many situations that would prompt "normal" familiestobecome "clinical" families. The assumption is made that those who use Hospice services are representativeofthe population at large; however, there has been no systematic collectionofdatatocorroborate that assumption. There are families who do declinetobe admittedtoHospice. They are often those who are independent, reserved, or those who simplydonot want outsiders,

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173those who are not readytoadmit or accept that their loved oneisdying, or those who already have some other typeofhome care agencyinplace. These results cannot be generalizedtoother typesofdeaths, such as perinatal deaths, sudden deaths, accidental deaths, suicides, or homicides. The natureofa Hospice death, that is, admission to a Hospice program in anticipationofdeath due to a teaninal illness, appearstobe significantly differentiated from unexpected deaths in some aspects.Ina study by Bass and Bowman ( 1990), greater bereavement strain was experienced by families who reported more negative caregiving consequences. A positive correlation existed between utilizationofcommunity resources after the death and care giving strain. A later study by Bass, Bowman, and Noelker (199 I) showed that the presenceofprofessional helpers during the caregiving phase had a significantly positive influence on surviving caregivers' perceptionsofthe family's adjustment. Sudden unexpected deaths where extensive caregiving had not preceded the death could be expected to experience different typesofreactions. Generalizabilityofthese results beyond nuclear families is also not appropriate. The natureoffamily stressisnot the same as the effects on an individual, and, therefore, the results must be qualified by discussing the resultsintermsofthe life spiral, rather than the individual's stageofdevelopment. One last limitation to this study is thatofthe potentially outdated norms for the instruments that were used. Allofthe instruments were developed and normedinthe early 1980s, anditwould seem to be appropriate for the developers to establish norms based on their various recommended scoring procedures so that clinical and research samples could more accuratelybecompared to normal samples. for Further Study A future study that may more accurately determine significant differences between high-risk stagesofthe family life cycle would be the assessmentofnuclear families with

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174children living at home where the death that occurred was the deathofoneofthe adults' parents. The Beavers Systems Model assessments could thenbeused which would determinethrough self-report as well as through observational measures whether families were relating in CForCP styles, their competence, health. conflict, cohesion, leadership, and expressiveness. The FILE could be used to assess stress. A longitudinalassessmentoffamilies that begins upon admissionofthe patient into the Hospice program and follows up at the I-year anniversaryofthe patient's death may help to determine the natureofthe changes and the stress these families experience as they approach the death and grieve the death. This would also increase the powerofthe studyascovariates could be introduced. A comparative study might be undertaken between non-Hospice and Hospice patients' families. again with only nuclear families with childrenathome as participants. and the deceased being the parentofoneofthe adults being assessed in the nuclear family. However. a longitudinal study containing a predeath assessment would be difficult to obtain in this typeofstudy for the non-Hospice patients' families.Ifthe non-Hospice sample only included deaths that were anticipated and not sudden unexpected occurrences. this would allow differences to be discovered between the two different typesofdeath experiences to seeifthe resultsofHospice-involvement offset anyofthe stressors experienced postdeath. Including a measureofthe family's perceptionofthe stressor event, as well as their well-being. would also take the study one step further by determiningiffamilies at certain life cycle stages have greater resilience which offsets the stress associated with the deathofa loved one. Inclusionofthe differences in effectsbetween stressors and strains on the family would also be important in lightofOlson et al. (1989) and McCubbin's work (1991) that indicate families at certain stagesofthe family life cycle may be more vulnerabletoongoing strains rather than specific stressor events.

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175Chapter Summary This chapter has provided a discussionofresults and recommendations derived from a studyofthe impactofdeath on families depending upon their stageinthe family life cycle and their locationinthe family life spiral. The variables that were statistically significant were discussed and trends were examined for strengtheningoffuture studies. The implicationsofthese resultsintermsoftherapeutic involvement with families were also discussed.

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APPENDIX ALEITERTO FAMILIES Dear Hospice family member: In our continued efforttohelp family members adapt to the deathoftheir loved one, a research studyisbeing conductedonthe stress experienced by families in these situations. This knowledge will enable us to better help families cope. As a Bereavement Counselor with Hospice and a doctoral candidateinCounselor Education at the UniversityofHorida, I am inviting you to participateinthis study. Participation will require about 30to60 minutes to complete several questionnaires designedtomeasure sourcesofstress and supportinthe family. I will administer these questionnaires to you in person. The results will be strictly confidential and your identity will notbemade known to anyone or appearinany writing. The study requires at least two membersofeach family household participate. These family members must be relatedtothe deceased by blood, marriage, or adoption, and must be13yearsofageorolder. Single member households will unfortunately not be able to participate. I will call youinthe next several weekstodiscuss questions you have concerning this study and to determine your willingnesstoparticipate.Ifyou agree. I will then arrange a timetovisit with you and administer the questionnaires. Your participation in the studyisofcoursecompletely voluntaryand you may withdraw from the study at any time. Pleasebeassured that no other use, beyond this project, will be madeofthe information you provide. If you have any questions about this research study, you may contact me at Hospice at (904) 378-2121 between the hoursof8:00 a.m. and 5:00 p.m., Monday through Friday. Sincerely, Liz Harvey, M.Ed., Ed.S. Hospice Bereavement Counselor176

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APPENDIX BFAMILYMEMBERSELECTIONPROTOCOLInorder to participateinthe study, there must be at least two membersofa family aged13or older living together in one household. Single-member households will not be included.Inordertodetennine which family membersina household will be assessed, preference will be given to family membersinthe following order as they are related to the deceased member, one from each category, repeating the sequenceasnecessarytoobtain the family sizeoftwo or three: I) Primary caregiver2)Spouse3)Child--from oldest to youngest 4) Parent5)Sibling--from oldest to youngest For each member, the following questions will be asked: I) Are you related by blood, marriage, or adoptiontothe deceased? 2) Are you13yearsofageorolder? Answers must be yes to both(I)and (2) in ordertoparticipate in the study. A minimumoftwo individuals from each family must agree to participate to be considered a family unit. All selected members must live in the same household.177

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APPENDIX C STAGE OF THE F AMll.. Y LIFE CYCLE This chartisfor the selectionofthe stageofthe life cycle that best fits each participating memberofthe family. When families with children living at home are being assessed, Combrinck-Graham's Family Life Spiral Stages will be used based on the ageofthe oldest child in the home. When the individuaUcouple being assessed has no children living at home, ageofgrandchildren (if present) or developmental tasksofthe individuaUcouple will be used to determine stageofthe family life cycle. The interviewer will circle the stage for each individual. Categorical descriptions for eachofthese stages follow. Combrinck-Graham's Family Life Quadrant Spiral Stages Adolescence CF Marriage/Courtship CF--7CP ChildbearingCPSettling Down CP--7CF 40s ReevaluationCFMiddle Adulthood CF--7CP Grandparenthood CP Plan for Retirement CP--7CF RetirementCFLate Adulthood CF--7CP Late Late AdulthoodCP178

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179Family Life Spiral Stages Adolescence (CF) Individuals at this stage are seen as achieving a satisfying and socially accepted gender role and developing more mature relationships with age-mates. Getting an education and achieving emotional independence from parents are primary concerns. Marriage/Courtship Couples in this stage are concerned with formulating and negotiating individual and couple goals and mutually acceptable lifestyles. Needs and demandsofyoung children have not been encountered. Childbearing (CP) Familiesinthis stage are similar in that the children spend mostoftheir waking hours in the home and the familyisoriented toward their growth and nurturance. Parents are primary sourcesofinformation and control, and the family is seen as child centered. Children are between 0 and 5 yearsofage. Settling Down Families at this stage are focused on the education and socializationofchildren. The oldest child in a family at this stage is between 6 and12yearsofage. 40s Reevaluation (CF) Familiesinthis stage are concerned with preparing theirteenagers to be launched from the home. Considerable demands are placed on the family due to the challengesofdealing with adolescents in the home. Middle Adulthood During this stage, adolescents are beginning to leave home to establish identities and roles outside the family unit. Parental roles and rules are changing, and the family is occupied with successfully launching its children. Grandparenthood (CP) Families at this stage are defined by the absenceofchildreninthe home. Parents still hold some former roles, but the familyislargely oriented toward couple needs and establishing more differentiated relationships with children and grandchildren. Family Planning for Retirement Families at this stage are reassessing career goals and beginning to wind down. Establishing financial security and planning for redirectionofenergies are guiding forces. Family in Retirement (CF) Families in this stage have largely completed the raising and supervisingofchildren. They have completed major career contributions and are occupied with couple maintenance as well as relationships with extended family and friends. They are adjusting to lossofjoband potentially decreased income.

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180 Family in Late Adullhood (CF-tCP) Families in this stage are beginning a life review and integration process. They are keeping mentally alert and effective as longaspossible and are adapting their interests and activities to reservesofvitality and energyofthe aging body. They commonly are facing lossofspouse, siblings and other peers and are withdrawing from their social network. Family in LateLate Adulthood (CP) Families in this stage have lived past their life expectancy and may have great grandchildren. Their physical reserves are waning as they begin to face the inevitabilityoftheir own death.

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APPENDIXDFAMILY INVENTORY OFLIFEEVENTS AND CHANGES (FILE)

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.'FA-WILYlJTJ'f.SSCOPWOAHattU1.THPflOJlCT000.-"""" FILE FamllVrlealtn PrOOfam FOAM C-I liDr.., =_..11 IGIO=..., C , C;, HMcCuDOlnFlO -:::JC ___ ---.:.J Family Inventory of Life Events and ChangesHemillonI. McCubtlnunee R. Wilton PURPOSEOver IhlWhIe CYCle.allfam'lles exoe'tfmCe many changes as a resultofnormalgrOwthandOevelooment01 memDers8nd aue10external ClTcumSlances. The 10110wlng115101 famllvhie Changescan happenIn alamllvat an..,. lime.Becausetamtlvmemoe,sareconnected10each Diner In some w.w, B Ide Changetorany one memDer affects all the OUler penons In fam,lv10someaegree.FAMlly"meansagrouDofIWO or morepersons liVing lcgelherwnoarerelaledOV01000. marrlaQe or010001101'1.ThIS Incluoes personswhO ,....e WIU'YOU;JnalOwhomyou nave a long lermComml1menl.DIRECTIONS "DID 'THE CHANGE HAPPEN IN YOURFAMIl vr' Please reaa e;licn lamlty hIecn;linge ana cJecrcJewhether Ithllppenel310anymemoerofyour famllY----1ncluding you.• DURINGTHELASTYEAR l"'-"e lUII IfIt haopeneo anylimeduringthelast12 monlfUi and cneckI ; • INTUfA.Ir1Il'fSTMIHS IIncrUt. otnuso.ndtlullus11111'......'/' 00"f,om I.m..., '6 InC'Utiol"""'e/mOlnlflllllle''''''''1' 0 0 l'OrtI.m,,,,, "lA m.m!lotf lO11nrs 10 n,••tmollOIl.1 00 ;HCD1em,'8, A membll'oours to 0'011'loll Iln "conor C 0III 66 ,IIIconI."b.lwnnnUIOiNlD 0 ,nll""dt";Illcruu.1l119um.nllO'I'W'••nll.rtntISl 0 0 InO(l'llIIlUetl! .,, IncIUUlnconlhCl,IIIlln9cn,IO'enlll 00 In,I.IIIoI,/, '8I InCIUUll1l,"ICUltyInm.n.9,nll 0 0 Illn'g.c:IlIIGlltnl" , NlClUUlllld'II:11lrv,,"",'II'9"lI9StllCOI 00 '91 cndOlr,nI16 '(fl',. ., Inc ruuCla,nlCut!YII'I""IAI9""9 00 (ll'IOIl,nlVIS I" m,n1911'1!lIOaa1e1111 0 0 IIl!!"rsl ,. 5uotote 1, Please lurn over Bodcomplelet Subcote I1 0....,un12 Yu NaScore II. '-'''''!TAL.STM.IhlS o o o ooD.oo.DIDTHE CHAHGEHAPPEN IN YOUAFAMIlY7I 0 IIIllcrllnllOlu9rll"'.M.00\11'IIItmllttl I :::JlrrtnUOf.CIIW1l,U IJInCflU.In Ill'e"'aunlot'C(MII.s'" 0 wn,umlc:lIl101ltnl.fllnvo.....llon FAMILY LIFE CHANGES t1 Ir.CI ..s.aconlj.ct"""llllnI ....1Oflll.I'",U ILl '0 1!l IIlCIIIUIIIIn, numltll 01 "rOltllrl'll III ,n",1SI:J..tlltllllon't9ftrlSOfYtd45 I 12InC:'.UfaGlnlCullVInmluqtn91ll1lntlsiIQ.I,/,'I16.lncr"Ulnln,","""OtfDIIUnO'Cl'IOru!'=w/'llCllllcnl\lllllont III. 5"Olls.IDII.nlwllUII'"IIGorll .... orc:tII 07." SaOllltl'"lnlnu,n",".,," 680 20.Incr .... dGII'tlCUItYHIIUoMnvrnUIi"I 0 """1 •• 'orm,, or UI.r.lI11lOOU ..21. lftCltl1.etGlffttulrywltllluull 0 r.I'IllN\lIlr" tlll'W'un llutrtMO.Ila....d. '8IDIDTHE CHANGE i I O,tfonqlUII12 Mcnlnl' Yu NoIScareFAMilY LIFE CHANGES182

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183DID lHECHANGEHAPPEN IN FAMILy1 Y LIFE CHANGES ID"'lf'ItLUII , I Score FAMilYLIFECHANGESDIDTHE (HANGEHAPPEN IN lOURJA'-"lY'LU' I .11Menln)rnNoScar.III'UGNANeTAND CHlL08E,t,'"NG nllAINS:u =1VI IllNESSAN:!fAMilY -CAII(STUINSP"enllIOOllseOtt.menr,ouslv IIIOf ,nltllfO1..,01o o o ,.10 .., 52IncrultGCllrt,tully....l'l'I.n.q.h9cnrOr'llUII'i' III Ofll'UllltGmttnQtt...5\ Amemoerlac.meIIn",llc.'I"d,ubled or CI'lIO'IICIlIy,U(IOltff"\I'ItO,I",ncllllUlfl.1N/WIleumeUlIOUUV ,II 53 Memb'rOf ellnI,J'lI"t....411comm,n,a 10 I..Jin,n:lUIUI'CIIC,I\Ul:l'"9nom," I -I 0-1 :JI:;\:J i= :J., , ",,-IVflfll'ANCE AND BUSINESS STIIIAINS A trlcmOCI9,vt Il,nn 10 Cf ."calco, en,la :OlOClOIII'luno.ttl,n,nCtc'Ie,nrcCOytllf\CIUl,OUCtftSU!![n.nq,01\Cr:IIG,IIO"''f:cncm.c.tlOltllCfl ... UIIltIl......eftftUnl;r,I."",,,,111,1'....'"-IInCItinG'U(lMllb,llty 10 plDYldtd.uelUltI _ hn.nc.lln,latanulblnCI"nCSfcr",.I'llllIl"III'/ o o 40,..,..,::0 "" II = 04.i 1"jtlO'II'lIC,
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APPENDIX E FAMILY ENVIRONMENT SCALE (FES)

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FAMlL Y ENVIRONMENT SCALE EXPRESSIVENESS SUBSCALE DIRECTIONS: There are 9 statements below. They are statements about families. You are to decide whichofthese statements are trueofyour family and which are false.Ifyou think the statement isTrueofyour family or mostlyTrue.circle the T next to the statement.Ifyou think the statement is False or mostly Falseofyour family, circle the F next to the statement. You may feel that someofthe statements are true for some family members and false for others. Circle Tifthe statement is true for most members. Circle Fifthe statementisfalse for most members.Ifthe members are evenly divided. decide what is the stronger overall impression and answer accordingly. Remember. we would liketoknow what your family seems like to you. So do not try to figure out how other members see your family, but do giveusyour general impressionofyour family for each statement. TFl.Family members often keep their feelings to themselves. TF2.We say anything we want to around home. TF3.It's hard to "blow off steam" at home without upsetting somebody. TF4.We tell each other about our personal problems. TF5.If we feel like doing something on the spurofthe moment we often just pickupand go. T F6.Someone usually gets upsetifyou complain in our family. TF7.Money and paying billsisopenly talked about in our family. TF8.We are usually careful about what we say to each other. TF9.There are a lotofspontaneous discussionsinour family.185

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APPENDIX F FAMlL Y INDEXOFREGENERATIVITY AND ADAPTATION--GEl\'ERAL (FIRA-G)

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SOCIALSUPPORTINDEXSUBSCALEDIRECTIONS: Please decide how much you agree witheachofthe following statements about your community and family. Decide whether you:(I)STRONGLYDISAGREE: (2) DISAGREE: (3) areNEUTRAL;(4) AGREE:or(5)STRONGLYAGREEwith the statements listed below. Indicate to the leftofthe item thenumberthat best describes how you think. I--STRONGLYDISAGREE2--DISAGREE 3--NEUTRAL 4--AGREE 5--STRONGL YAGREEI.IfIhad an emergency, even people I do not know in this community would be willing to help.2.I feel good about myself when I sacrifice and give time and energy to membersofmy family. 3.Thethings I do fo: membersofmy family and they do for me make me feel partofthis very important group.4.People here know they can get help from the communityifthey are in trouble.5.I have friends who let me know they valuewhoIamand what I can do.6.People can depend on each other in this community.7.Membersofmy family seldom listen tomyproblemsorconcerns; I usually feel criticized. 8.Myfriends in this community are a partofmy everyday activities.9.There are times when family membersdothings that make other membersunhappy.LO.I need to be very careful how much I do for my friends because they take advantageofme.LL.Living in this community gives me a secure feeling.L2.Themembersofmy family make an effort to show their love and affection for me.L3.Thereis a feeling in this community that people should not get too friendly witheachother. 187

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18814. This is not a very good communitytobring children upin.15. I feel secure that I am as importanttomy friendsasthey are to me. 16. I have some very close friends outside the family who I know really care formeand love me. 17. Member(s)ofmy family do not seemtounderstand me; I feel taken for granted. RELATIVE AND FRIEND SUPPORT SUBSCALE DIRECTIONS: Decide for your family whether you:(I)STRONGLY DISAGREE; (2) DISAGREE: (3) are NEUTRAL; (4) AGREE: or (5) STRONGLY AGREE with the statements listed below. Indicatetothe leftofthe item the number that best describes how you think. I--STRONGLY DISAGREE 2--DISAGREE 3--NEUTRAL 4--AGREE 5--STRONGL Y AGREE We cope with family problems by:I.Sharing our difficulties with relatives 2. Seeking advice from relatives 3. Doing things with relatives (get togethers) 4. Seeking encouragement and support from friends 5. Seeking infonnation and advice from people faced with the same or similar problem 6. Sharing concerns with close friends 7. Sharing problems with neighbors 8. Asking relatives how they feel about the problems we face

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APPENDIX GFAMILYADAPTABILITYANDCOHESIONEVALUAnONSCALES(FACES-IT)

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FACES-II DIRECTIONS: Please decide how much eachofthese statements describe your family now. Decide whetheritis(I)ALMOST NEVER, (2) ONCE IN A WHILE, (3) SOMETIMES. (4) FREQUENT!.. Y,or (5) ALMOST AL WAYStrueofyour family. Indicatetothe left of the item the appropriate number. I--ALMOST NEVER2--0NCEIN A WHILE 3--S0METIMES 4--FREQUENT!.. Y 5--ALMOST AL WAYSI.Family members are supportiveofeach other duringdifficult times. 2.Inour family,itis easy for everyonetoexpress his/her opinion.3.Itiseasier to discuss problems with people outside the family than with other family members.4.Each family member has inputinmajor family decisions.5.Our family gathers together in the same room. 6. Children have a sayintheir discipline.7.Our family does things together. 8. Family members discuss problems and feel good about the solutions. 9. In our family, everyone goes his/her own way. 10. We shift household responsibilities from person to person. I I. Family members know each other's close friends. 12. It is hard to know what the rules are in our family. 13. Family members consult other family members on their decisions. 14. Family members say what they want. 15. We have difficulty thinkingofthings to doasa family. 16.Insolving problems, the children's suggestions are followed. 17. Family members feel very close to each other. 18. Disciplineisfairinour family. 190

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19119. Family members feel closer to people outside the family than to other family members.20.Our family tries new waysofdealing with problems. 21. Family members go along with what the family decidestodo. 22.Inour family everyone shares responsibilities. 23. Family members liketospend their free timewith each other. 24.Itisdifficulttoget a rule changedinour family. 25. Family members avoid each other at home. 26. When problems arise, we compromise. 27. We approveofeach other's friends. 28. Family members are afraid to say whatison their minds. 29. Family members pair up rather than do thingsasa total family. 30. Family members share interests and hobbies with each other.

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192FACES-II (COUPLES) DIRECTIONS: Please dccide how much eachofthese statements describe your marriagc now. Decide whether isit(1) ALMOST NEVER, (2) ONCE IN A WHILE. (3) SOMETli\1ES, (4) FREQUENTLY, or (5) ALMOST ALWAYS trueofyour marriage. Indicatetothe leftofthe item the appropriate number.I-ALMOSTNEVER2--0NCEIN A WHll..E 3-S0METIMES4--FREQUENTL Y 5--ALMOST ALWAYSI.We are supportiveofeach other during difficult times.2.Inour relationship,itis easy for bothofustoexpress our opinion.3.Itis casiertodiscuss problems with people outside the marriage than withmypartner.4.We each have input rcgarding major family decisions. 5. We spend time together when wearehome.6.We are flexible in how wc handle differences.7.We do things together. 8. We discuss problems and feel good about the solutions.9.Inour marriage,weeach go our own way. 10. We shift household responsibilities between us. 11. We know each other's close friends. 12.Itishard to know what the rules are in our relationship. 13. We consult each other on personal decisions. 14. We freely say what we want. 15. We have difficulty thinkingofthings to do together. 16. We have a good balance of leadership in our family. 17. We feel very close to each other. 18. We operate on the principleoffairnessinour marriage. 19. I feel closertopeople outside the marriage than to my partner.

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20.Wetry new waysofdealing with problems. 21. I go along with whatmypartner decidestodo. 22. In our marriage,weshare responsibilities. 23.Weliketospend our free time with each other. 24.Itisdifficulttoget a rule changedinour relationship. 25. We avoid each other at home. 26. When problems arise,wecompromise. 27.Weapproveofeach other's friends. 28. We are afraid to say whatisonour minds. 29.Wetendtodomore things separately. 30.Weshare interests and hobbies with each other.193

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APPENDIX H DEMOGRAPHIC QUESTIONNAIRE I. Age__3. Marital Status: Single__Married Separated__Divorced Widowed2.4.Sex Ethnicity: Caucasian African American__Hispanic__Asian American__Other__5. CountyofResidence _ 6. Ageofdeceased family memberattimeofdeath__7. The memberofmy family who died was my husband, wife, mother, father, son, daughter, brother, sister, etc. _ 8. Were you the primary caregi ver for the deceased? Yes No 9. Your approximate individual annual income: Under $5,000 $30,000-$39,999 $5,000-$9,999==$40,000-$49,999 510,000-$14,999 $50,000-$59,999 $15,000-$19,999--$60,000-$69,999 520,000-$30,000==$70,000+ 10. Please check thefollowing services for appropriatenesstoyour situation: Would Have Used If Available Individual Counseling Marital Counseling Family Counseling Pastoral Counseling Support Group194

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APPENDIX I LINEAR SCORING AND iNTERPRETATION FOR FACES-II

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FACESII:LinearScoring&InterpretationCohesion80874Very73Connected77170665Connected6456059455Separated54 3 5150235Disengaged34115Adaptability70865Very64Flexible755 54650Flexible49546 45443Structured4234039230Rigid29115196FamilyType8Balanced76Moderately Balanced54MldRange32Extreme1

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APPENDIXJLEITEROF INSTRUCTIONTOFAMll.JES PARTICLPATING BY MAILDearThank you bothsomuch for agreeing to panicipateinthis research study and for allowingmetodo it by mail with you. Just to make sure you are clear about how to fill out these questionnaires, let me give you the instructions that I usually give people when I am doing the assessmentsinperson. I. First sign the "Informed Consent" which simply gives me pennission to use the data which you will provide.2.When answering these questionnaires, I want you to think back over the last yearofyour life, since the dateofthe deathofyour loved one, and check which stressors you have experienced or sourcesofsupport you have used in that periodoftime.3.Most importantlyisthat the definitionof"family" throughoutallthe questionnaires is "those people who are living together with you in your household." This does not refer to other family members who live outside your home. Any questions about "family members" refers to those members living with you. 4. On page twoofthe first questionnaire FILE, in the right-hand column. there is a section "VII. LOSSES." [The following statement was modified for each letter depending upon the panicipants' relationships to the deceased patient. This example represents the patient's son and his wife.) Make sure you check the correct boxes there to represent the deathof[loved one). [Son's name] should check box #56 YES and [daughter-in-Iaw's name) should check box #58 YES. If there have been other deathsinyour family this past year, please note those also.5.Manyofthe stressors on the FILE questionnaire will not apply to your family. Just check those items NO.6.Donot worry about the "Score" column to the rightofthe"YeslNo"boxes on FILE. The person who does the tabulating will enter those scores. 7. FACES-II has questions on the back sideofthe page.8.When you are through, please put both setsofquestionnaires and both the informed consents in the return envelope and send them backtome. 197

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198Ifyou should have any questions about howtoanswer anyofthe questionnaires. you may reach me at the Hospice office (1-800-727-1889) during the day or at home in the evening (904-373-5572) which you may call collect. Sincerely, Liz Harvey, M.Ed..Ed.S.

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APPENDIX K COMPOSITION OF PARTICIPANT FAMILIESCP101son102daughter103104 son105brother 106 wife107son108granddaughter 109 daughter 110 granddaughterIIIdaughter112NOTRETURNED113daughter 114 daughterliSNOTRETURNED 116 brother117sister 118 son I19daughter 120 son121daughter122stepson 201 wife 202 daughter 203 son 204 daughter 205 father 206 daughter 207 daughter 208 son 209 son 210 son211son 212 husband daughter-in-law son-in-law daughter-in-law sister-in-law granddaughter daughter-in-law grandson in -law son-in-law grancson-in-Iaw mother-in-law son-in-law greatgranddaughter sister-in-law brother-in-law daughter-in-law son-in-law daughter-in-law son-in-law stepdaughter-in-Iaw stepson son-in-law daughter-in-law son-in-law stepmother son-in-law son-in-law daughter-in-law grandson daughter-in-law daughter-in-law daughter 199 granddaughter

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200 AR.QE 213 son daughter-in-law 214 wife son 215 son daughter-in-law 216 daughter son-in-law 217 son daughter 218 son daughter-in-law 219 daughter son-in-law 220 daughter son-in-law221son daughter-in-lawCF301wife daughter 302 son daughter-in-law grandson 303 son daughter-in-law 304 wife son daughter 305 sister brother-in-law nephew 306 wife daughter 307 daughter son-in-law grandson 308 wife grandson 309 daughter granddaughter 310 grandson great granddaughter311stepdaughter greatgranddaughter 312 stepdaughter greatgranddaughter 313 daughter granddaughter 314 son daughter-in-law granddaughter grandson grandson 315 daughter son-in-law 316 daughter granddaughter 317 daughter son-in-law 318 daughter grandson 319 wife son daughter 320 son daughter-in-law321mother sister brother 322 wife daughter 323 daughter grandson CF-7CP 401granddaughter grandson-in-Iaw 402 son son 403 daughter grandson 404 wife daughter daughter 405 wife son 406 mother sister 407 brother sister-in-law 408 son daughter-in-law 409 grandmother greatgrandmother 410 daughter son-in-law411daughter son-in-law 412 brother sister-in-law 413 daughter son-in-law 414 daughter son-in-law grandson grandson

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415 son 416 sister 417 wife 418 brother 419 wife 420 wife daughter-in-lawniecegrandson sister-in-law grandson daughter201

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REFERENCES Aleksandrowicz,D.R.(1978). Interminable mourning as a family process. Israel JournalofPsychiatry and Relationed Disciplines, lQ, 161-169. Anderson.S.A.(1986). Cohesion, adaptability, and communication: A testofan Olson Circumplex model hypothesis. Family Relations, 35, 289-293. Anthony,E.J. (1970). The impactofmental and physical illness on family life. American JournalofPsychiatry, ill, 138-146. Arnold.J.A..&Gemma.P.B.(1983). A child dies: A portraitoffamily grief. Rockville, MD: Aspen Systems. Bankoff. E.A.(1983). Social support and adaptationtowidowhood. JournalofMarriage and the Family, 45,827-839. Barth,J.C.(1989).Families cope with the deathofa parent: The family therapist's role. In L. Combrinck-Graham (Ed.), Children in family contexts: Perspectives on treatment (pp.299-321). New York: Guilford. Bass, D. M.,&Bowman,K.(1990). The transition from caregiving to bereavement: The relationshipofcare-related strain and adjustment to death. The Gerontologist,30,3542. Bass,D.M., Bowman. K.,&Noelker, L. S. (1991). The influenceofcaregiving and bereavement support on adjusting to an older relative's death. The Gerontologist, l1., 32-42. Bass, D. M., Noelker.L.S., Townsend,A.L.,&Deimling, G.T.(1990). Losing an aged relative: Perceptual differences between spouses and adult children. 21(1). 21-40. Bateson, G. (1979). Mind and nature: A necessary unity. New York: E.P.Dutton. Beavers,W.R.(1982). Healthy, midrange, and severely dysfunctional families.InF. Walsh (Ed.), Normal family processes (pp. 45-66). New York: Guilford. Beavers, W. R.,&Hampson.R.B. (1990). Successful families: Assessment and intervention. New York: Norton. Beavers, W. R ..&Voeller, M.N.(1983). Family models: Comparing and contrasting the Olson Circumplex Model with the Beavers System ModeL Family Process, 22, 85 98. 202

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203 Benfield. D. G., Leib, S.,&Vollman, J.H.(1978). Grief responsesofparentstoneonatal death and parent participationindeciding care. Pediatrics, 62, 171-177. Bennan. H., Cragg,C.E.,&Kuenzig,L.(1988). Having a parent dieofcancer: Adolescents'reactions. Oncolo&yNursin&Forum,U, 159-163. Binger,C.M., Ablin,A.R., Feuerstein,R.c..Kushner, J. H., Zoger, S..&Mikkelsen,C.(1969). Childhood leukemia: Emotional impact on patient and family. The New England JournalofMedicine, 2M!, 414-418. Birtchnell,J.(1975). Psychiatric breakdown following recent parent death. JournalofMedical Psychology, 48, 379-390. Black, D..&Urbanowicz,M.A.(1987). Family intervention with bereaved children. JournalofChild Psychology and Psychiatry. 28, 467-476. Bolton,c.,&Camp,D.J.(1986-87). Funeral rituals and the facilitationofgrief work. 343-352.Bolton,I.(1984). Families coping with suicide.InJ.G.Hansen&T.T. Frantz (Eds.), Death and inthe family (pp. 35-47). Rockville, MD: Aspen Systems. Boss,P.G.(1980). Nonnative family stress: Family boundary changes across the life span. Family Relations, 22. 445-450. Bowen,M.(1976). Family reaction to death.InP.J. Guerin (Ed.), Family therapy: Theory and practice (pp. 321-335). New York: Gardner. Bowlby,J.(1961). Processesofmourning. International JournalofPsychoanalysis, 12,317-340. Bowlby.J.(1980). Attachment and loss (Vol. 3). New York: Basic Books. Britton,P.J.,&Zarski. J.J.(1989). HIV Spectrum disorders and the family: Selected interventions based on stylisticdimensions. AIDS Care. 1(1), 85-92. Brown,F.H.(1988). The impactofdeath and serious illness on the family life cycle.InB.Carter&M. McGoldrick (Eds.), The chan&ing family life cycle: A framework for family therapy (2nded., pp. 457-482). New York: Gardner. Brubaker,E.(1985). Older parents' reactionstothe deathofadult children: Implications for practice. JournalofGerontological Social Work, 2, 35-48. Bunch, J.,&Barraclough,B.(1971). The influenceofparental death anniversaries upon suicide dates. British JournalofPsychiatry, ill. 621-626. BureauofEconomic and Business Research. (1991). Florida Statistical Abstract. 1991. Gainesville: University PressofFlorida. Butler,R.N.,&Lewis,M.I.(1983). Aging and mental health: Positive approaches. St. Louis:C.V.Mosby.

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204 Cain, A.c.,Fast.I., &Erickson, M. E. (1964). Children's disturbed reactions to the deathofa sibling. American Journalof Orthopsychiatry, 34, 741-752. Carter, B.,&McGoldrick, M. (Eds.). (1988). The changing family life cycle: A framework for famjly therapy (2nd ed). New York: Gardner. Cobb, S. (1976). Social support as a moderatoroflife stress. Psychosomatic Medicine, l8.,300-314. Cohen,M.M. (1982).Inthe presenceofyour absence: The treatmentofolder families with a cancer patient. Psychotherapy: Theory. Research and Practice, .12(4), 453-460. Cohen, P., Dizenhuz, I. M.,&Winget,C.(1977). Family adaptation to terminal illness and deathofa parent. Social Casework, 58, 223-228. Coleman,S.B. (1980). Incomplete mourning and addict/family transactions: A theory for understanding heroin abuse. In D. J. Lettieri,M.Sayers,&H. W. Pearson (Eds.), Theories on drug abuse: Selected contemporary perspectives (pp. 83-89) (Research Monograph Series 30; DHHS Publication No. ADM 80-967). Rockville. MD: National Institute on Drug Abuse. Coleman,S.B., Kaplan,J.D.,&Downing,R.W. (1986). Life cycle and loss--The spiritual vacuumofheroinaddiction. Family process, 25, 5-23. Coleman,S.B.,&Stanton. M. D. (1978). The roleofdeath in the addict family.Im!rnl!l ofMarriage and Family Counseling, :!. 79-91. Colman,C.(1986). International family therapy: A view from Kyoto, Japan. Family 651-664. Combrinck-Graham, L. (1983). The family life cycle and families with young children. InJ.C.Hansen&H. A. Liddle (Eds.), Clinical implicationsofthe family life cycle: Family therapy collections (Vol. 7, pp. 35-53). Rockville, MD: Aspen Systems. Combrinck-Graham. L. (1985). A developmental model for family systems. Family Process, 24, 139-150. Combrinck-Graham, L. (1988). Adolescent sexuality in the family life spiral. InC.J. Falicov (Ed.), Family transitions: Continuity and change over the life cycle (pp. 107 131). New York: Guilford. Combrinck-Graham, L. (1990). Developmentsinfamily systems theory and research. Journalofthe American AcademyofChild and Adolescent Psychiatry, 29(4), 501-512. Crenshaw,D.A.(1990). Bereavement: Counseling the grieving through the life cycle. New York: Continuum. Cronkite,R.C.,&Moos, R.H.(1984). The roleofpredisposing and moderating factors in the stress-illness relationship. JournalofHealth and Social Behavior, 25, 372-393.

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BIOGRAPHICAL SKETCH Elizabeth Anne Harvey was born September 12, 1947, in Topeka, Kansas, the youngestoffour siblings. She graduated from Kansas State UniversityinAugust, 1968, with a BachelorofArts degree in French and education. Having married John Harvey June I, 1968, she worked as a secretary and office manager for 6 years while John finished his veterinary degree at Kansas State University and DoctorofPhilosophy degree from the UniversityofCalifornia at Davis. A family was started with Ashley being bornatthe end of the Davis years and Thad arriving later after the family had moved to Gainesville, Florida. Elizabeth worked outofthe home typing theses and dissertations for the graduate school and was actively involved in volunteer work in the church. conununity, and public schools for the next12years. She returned to graduate school at the UniversityofFloridain1986 to pursue trainingincounseling. She received her MasterofEducation and Specialist in Education degreesinAugust, 1989, and began the doctoral program in September, 1989. Seedsofinspiration for this work were sown over a long periodoftime. The deathofher sister. Sharon, at the ageof28. in a plane crash was an overwhelming tragedy that initiated a search for understanding and meaningofthe fragilityoflife. From that point on, life perspectives and values were changed, and empathy for other's pain and suffering was gained. As Elizabeth approached midlife, her mother. age 67, was diagnosed with leukemia and died within 9 months. Eight months later her sister-in-law, Rothi, who had been like a 217

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218sister to her after Sharon's death, died at the ageof42ofbreast cancer after a lO-year struggle.Twomonths later Sharon's son, Rock, age17,was killed in an automobile accident, and 4 months later her grandfather died, the only one who livedtoa ripe old age, 96. Within 3 years the family experienced yet another tragic loss with the deathofElizabeth's nephew, Todd, age 23, in an automobile accident. With nearly 30%ofthe immediate family members having died, and most far shortoftheir life expectancy, the messages about the preciousnessoflife have profound meaning. Elizabeth has been acutely awareofthe impactofdeath upon families as she has observed the many ramifications within her own familyoforigin. As a resultofthese life experiences, itiswith deep respect for families facing the deathoftheir loved ones that Elizabeth began working with HospiceofNorth Central Florida in1991as a bereavement counselor where she continues at the present time.

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I certify that I have read this study and that in my opinion it conformstoacceptable standardsofscholarly presentation and is ully adequate, iJope and quality,asa di",,
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