Death in the Family by Michael Anderson
Of all life experiences, bereavement is considered to be the most traumatic for families and marital partners. Whenever or however it occurs, a death in the family can require significant emotional and social adjustment. This report discusses bereavement in families and marital relationships and the challenges it poses, both for counsellors, therapists and other health care professionals and for the families themselves.
As the anthropologists Huntington and Metcalf (1979) have shown, people in different cultures react to death in different ways. In our own culture, we have often been thought to lack the necessary mechanisms and structures for helping the bereaved to cope with their loss. Our reactions in the West have often been thought to 'deny' death; we are seen as maintaining a 'stiff upper lip' attitude about it. Indeed, some commentators have suggested that its absence from our consciousness renders it a virtually taboo subject. Yet death is a universal experience and happens in families every day. Research on communication in three-generational families, which we are currently conducting throughout the UK, is revealing that the death of a family member is frequently the one event which affects everyone else, young and old. The study, funded by the BT Forum, highlights the importance of talking about death. It appears, however, that, because of the affective bonds we as humans create between ourselves, contemplation of death can be for us abhorrent or even unthinkable.
Therapists and counsellors have come to recognise the importance of the process of bereavement within the family, and the need for people to be aware of the intensity of feeling and the difficulties of adjustment it evokes. Research has addressed these issues and attempted to respond by suggesting appropriate ways to help families and couples cope with the changes bereavement imposes.
These responses have been addressed to those who are bereaved themselves as well as to those charged with working with or caring for them (this may be a counsellor, a friend, or even another family member). Essentially, such research emphasises the need for bereaved persons to accept the death, and stresses the importance of sensitivity on the part of those caring for them.
Bereavement involves a deep sense of shock. Those who experience it are often unable to come to terms with their loss, and are unable to make the necessary adjustments to their lives. Emotional responses to death can be unpredictable. It is therefore necessary for those caring for the bereaved to be sensitive to the reactions of the bereaved person whatever these may be. Counsellors and academics agree that such sensitivity needs to be balanced by an encouraging of the bereaved to accept the reality of the loss of the loved one. In most cases this occurs naturally over time, but for some, coming to terms with bereavement represents a particularly difficult transition, the nature of which may vary according to the manner in which the death has occurred.
Death occurs in different ways and in a variety of circumstances. It can be sudden, violent, gradual, or even 'ambiguous' (Walsh and McGoldrick 1995, pp. 147-8). It is important for counsellors, therapists and other professionals to be aware of the reactions different kinds of death can evoke.
In the case of sudden death (through accident, murder, suicide, or even sudden illness) the remaining partner or family members will not have had time to anticipate or prepare for the impending bereavement. Naturally, this may result in severe shock and sudden depression or despair when remaining family members are forced to face the absence of a loved one immediately and without warning.
Along with the severe emotional trauma that sudden death can produce, there may also be practical issues that have to be addressed. For example, the deceased may have left unfinished business behind which the surviving family members may need to take charge of. These may be domestic concerns but could equally well be work-related or legal matters. It is important for counsellors and therapists to be aware of such concerns, and of the effects that addressing them can have on family relationships.
Death may be not only sudden but also violent. Murder, suicide, or a particularly horrific accident, for example, can even lead to life-threatening reactions on the part of other family members, as Figley (1989) has shown in researching those with relatives who have been killed in war. For the family of a murder victim, grief may be prolonged if family members believe that justice has not been served - that is, if the culprit has not been caught and justly prosecuted. Recent examples in the media have been the killing of Stephen Lawrence, and the O. J. Simpson case. Families often feel unable to grieve in such circumstances.
Gutstein (1995) has provided evidence that suicide is one of the most agonising kinds of death for surviving spouses or remaining members of a family to endure. Such a death can result in anger and guilt if family members blame themselves, or are blamed, for the death. The strain this can put on marital or other family relationships cannot be overemphasised. Moreover, the threat of social stigma may contribute to family shame. It is important that family members resist self-blame since this may seriously hinder their ability to adjust.
Death may also be gradual and prolonged, such as in the case of a long-term illness like cancer. Elisabeth Kubler-Ross (1969) has made a significant contribution in this area by making those who care for the dying, as well as professional counsellors and therapists, aware of different 'stages' in death and bereavement acceptance.
In cases such as people surviving in a comatose state, spouses and/or remaining family members can face excruciating dilemmas over whether, or how long, to maintain life-support systems. Issues of chronic pain, patient rights, medical ethics, religious beliefs and so on impinge inevitably on the minds of family members who may need to make difficult decisions. The case of Tony Bland, who lay in a persistent vegetative state after having been a victim of the Hillsborough disaster in 1989, exemplified this. The ethical dilemma of whether to turn off his life support system went to the Court of Appeal, raising the issue of whether such a comatose state should be accounted death. This particular case and others like it continue to be controversial.
But death may be 'ambiguous' in other ways. For example, the 'disappearance' of a soldier missing in action can create uncertainty among other family members. While hopes may be kept alive, they are undermined by a 'fear of the worst', a fear which may deepen as the duration of an absence increases. Such ambiguity can produce serious depressive illness in family members. McGoldrick and Walsh (1995, p.14) report the difficulty family members have in grieving over relatives who are only 'presumed dead'.
Reactions to death and processes of bereavement within the family vary according to the particular relationship that is involved. For example, the loss of a wife or husband, while perhaps no less traumatic than the loss of a child, will probably result in a different process of emotional and social adjustment. Equally, the loss of a sibling may be registered quite differently from the loss of a grandparent. Although bereavement is felt uniquely by each person in the family, the particular relationship the individual had with the deceased person inevitably colours the experience of bereavement.
The death of a grandparent is likely to be one of the first experiences, or even the first experience, a child has of a death in the family. However, reactions will differ according to the age of the child or adult offspring and the emotional closeness of the relationship. As in other such cases, the parents may well have to explain to the child why the grandmother or grandfather has died.
Although they may not live in the same household, grandparents are commonly thought to dote on their grandchildren and 'spoil' them with favours and surprises, and not uncommonly to take their side in disputes with parents. This can lead to deep, trusting relationships that are suddenly ended by death. The loss of this relationship can deprive a child of an important dimension of his or her life. Relationships between the young and old are often assumed to be problematic simply because of age and generational outlooks. While these factors should not be underestimated, it is wrong to assume that grandparents and grandchildren have little to offer each other, as our own research is making clear.
The mourning of a grandparent's death can be complicated by the relationship that existed between the grandparent and his or her adult children. Parents may not get on very well with their children's grandparents, which may result in coalitions forming between grandparents and grandchildren with the parent being excluded - a phenomenon close to that described by Bowen (1966) as 'triangulation'. The death of the grandparent can lead to guilt or awkwardness on the part of parent or grandchild, which again can only be addressed and resolved with honesty and sensitivity.
It has been argued that the effect on a young child (or even an adult offspring) of the loss of a parent can be seriously underestimated by other members of the family such as the remaining parent or siblings. Although the child's reactions may depend on its age and family circumstances as well as on the quality of the relationship between the child and the parent who has died, if the child is young the trauma of loss may be compounded by anxieties about the emotional neediness of the remaining parent. Also, even adults who lose their parents can suffer greatly, not least in their marriage relationships, as one such person who sought outside help indicated:
My personal problem with my husband coincided with the death of my mother - so when I went to relationship counselling I was in grief as well as unhappy at home ... I thought about some of the things the counsellor had said to me and decided to try and work at my marriage … we have managed to at least make another go at it.
The death of a parent may also ignite or resurrect latent sibling rivalries where different post-death roles (whether domestic or business-related) are unquestioningly allocated to respective male/female offspring. For example, it may be presumed that girls or women will become the caregivers of dying or needy surviving parents.
For a young child who loses a sibling, the absence can prove a very confusing one. An inability to comprehend the fact of death may leave the surviving sibling expecting the imminent return of their brother or sister. The prolonged terminal illness of a sibling may mean diminished parental attention being paid to the needs of the surviving child. Alternatively, the death of a sibling may result in an overabundance of affection being concentrated on the surviving child, as the attention previously given to two now becomes directed towards one. Research by Legg and Sherick (1976) concerning parents who lose one of their children suggests that parents may endeavour to 'replace' a lost sibling by having another child. Legg and Sherick maintain that far from being a pathogenic reaction to death, this can facilitate positive adjustment for both the surviving sibling and parents.
Older siblings may or may not experience intense grief on a brother or sister's death, depending on their age and the closeness of the relationship at the time of death. Siblings who have 'fallen out' just prior to one of them dying may be disturbed by prolonged periods of guilt or frustration on account of their not having resolved their differences. On the other hand, death or impending death can unite siblings who may not have got on well together previously.
The death of a twin or triplet, whether an adult or a child, is also thought to have its own particular traumatic character. Since, so it is believed, twins and triplets share more than do siblings separated by age, they may genuinely feel they have lost not only a brother or sister but also a part of themselves. Research conducted by Cain, Fast and Erikson (1964) has shown that the death of a sibling can be mourned for many years afterwards, and can put long-term strain on different relationships within the family, resulting in dysfunctional relationships. Walsh and McGoldrick (1995) argue that this area has as yet not been sufficiently investigated.
There are, of course, many examples of adult bereavement affecting people's lives in different ways. For example, the death of kin or of a close friend can place great strain on a marriage. Grief causes people to react in different ways, and an inability or unwillingness to communicate feelings can stifle relationships or lead to one partner feeling excluded from the life of the other. Such situations may well contribute to marital and family breakdown (Walsh and McGoldrick 1995, p. 36).
The death of a spouse can be enormously traumatic since it may impose on the remaining partner the burden of raising any children alone. Alternatively, if the children are grown up and have left home, the death of a spouse can leave the surviving partner alone and isolated.
If the family contains young children, there may be important financial issues for the remaining spouse to consider, apart from the immediate emotional needs of the children. Some parents may need time alone to come to terms with the loss and, as Fulmer (1983) has pointed out, needy children may distract the bereaved parent from his or her own grief processes by asserting their own needs. Clearly, the children and the remaining parent need different kinds of support. It is important that the remaining parent's efforts to care for their children do not result in their neglecting their own needs. Those without children or whose grown-up children live far away may find themselves lonely and isolated, with the prospect of facing their grief without any support.
There are no 'quick fixes' for bereavement, and no set patterns either in preparing for or in coping with it. While research shows that support and understanding are necessary, individuals, both lay and professional, need to be aware that those grieving may employ different ways of coping; they should be permitted to express their grief in ways which they feel to be most comfortable, and conversely should not be forced to adopt ways of grieving with which they feel uncomfortable.
As Rando (1985) has pointed out, the death of a young child in the family is often thought to be particularly tragic, and is likely to result in the parents experiencing highly distressing and long-lasting grief. Rando's research highlighted the pressure that such a death can place upon marital relationships and reported divorce rates as high as 80 per cent among parents bereaved in this way
Even the death of an older child can have a long-lasting effect on the parents, who may see their child's death as a cruel injustice - as a life ended before it has really begun. Parents can seem inconsolable at the loss of their child, and those entrusted with supporting and helping them can feel helpless, without any words of comfort to offer. It has been argued, however, that care-givers often underestimate the importance of their presence, which may be valuable even if they feel they have 'nothing to say'. The mere presence of another person can be a comforting factor in the suffering of a parent, whereas words may represent a hindrance.
Most children's deaths are explicable in terms of either accident, illness or disease, and these are tragic enough. However, recent exploration of the phenomenon of 'cot death' (Luben 1989) has highlighted the bewilderment that unexplained death can add to the natural shock and pain involved in child death. 'Meaningless', 'a waste', 'pointless' are media descriptions that have accompanied such tragedies, an indication of the void left not only by the death itself but also by the lack of explanation for it, which can lead to guilt and blame.
For the parents of terminally ill children, the process of the child's dying can effectively merge with that of bereavement, particularly if the time-period between diagnosis and actual death is significant. Such experiences can often lead to unrealistic expectations of the child being cured or alternatively a state of affairs where a fear of the worst can be so overwhelming as to drastically diminish the parent's quality of life. Also, research by Bluebond-Langer (1978) suggests that parents should not assume that dying children are unaware of their condition, even if they have not been informed about it for fear it would upset them. Bluebond-Langer reported that children find out about their conditions by talking to other patients. Although they reacted with confusion and distress, they were rarely traumatised in any severe or long-term sense. Bluebond-Langer implies that inability on the part of adults to accept the impending loss of their child keeps them from discussing the child's condition with the child or with their other children.
Although little research exists on the subject of losing a grandchild, it is too easy to assume that grandparents do not suffer greatly, or indeed as much as other family members, over such a loss. It is of course understandable to think that grief may well be worse for the parents of a child, but it cannot be assumed that grandparents are not deeply affected.
Potential care-givers may well regard the parents and members of the immediate family as being the only ones affected by grief. But for grandparents who fulfil a virtually parental role for the child (e.g. where they enact care-giving roles for working parents, or where parents are unable or unwilling to take care of their own children), the loss of a grandchild may be no less traumatic than it is for the actual parents.
Because of generational differences in mourning expectations, a different kind of sensitivity may need to be shown in caring for bereaved grandparents. They may or may not respond to encouragement to talk about their feelings. Although such encouragement can be helpful for parents, it should not necessarily be assumed that an older generation would respond in the same way. Nevertheless, bereaved grandparents should at least be given the opportunity to discuss their feelings.
Research has shown that healthy personal and collective adjustment after loss in the family is dependent upon clear and appropriate communication among family members (Parkes 1996a, p. 175). Good communication can aid the bereavement process, whereas poor communication can result in maladaptive symptoms in the longer term.
Walsh and McGoldrick (1995) offer a framework for considering the influences of family members on one another as they react to their experience of loss. They argue that the family's ability to adapt to loss well is dependent on each individual accepting death for what it is. The framework they offer consists of two key family tasks that promote immediate and long-term adaptation. These are:
Most couples or families cope with the death of a family member without any serious long-term pathological effects. Some family members, however, may find this more difficult than others may. Much has been written about this, and about the various types of services that are available to help.
Whichever member of a family it is who dies, and regardless of the kind of death endured, the experience affects different people in different ways. Therapeutic services exist for all those who find bereavement particularly difficult and for whom existing rituals and social networks are insufficient.
Most, if not all, of us experience bereavement in some way at some point in our lives. Natural and inevitable though this may be, it remains among the most difficult and traumatic of challenges for all those in long-term relationships. Emotionally and socially, bereavement forces each of us to face up to profound individual and collective questions which we are not always equipped to answer, and which our culture, for the most part, struggles to address fully.
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Cruse - Bereavement Care. Cruse House, 126 Sheen Road, Richmond, Surrey TW9 1UR. Tel. 0181-332 7227 (fax 7638).
The Association of Bereavement Services, 356 Holloway Road, London N7 6PN. Tel. 0171-700 8134 (fax 8146).
Support after Murder and Manslaughter. Cranmer House, 39 Brixton Road, London SW9 6DZ. Tel. 0171-735 3838 (fax 3900).
Cot Death Help Line. 0171-235 1721.