LOSS AS A UNIVERSAL CONCEPT: A REVIEW OF THE LITERATURE TO IDENTIFY COMMON ASPECTS OF LOSS IN DIVERSE SITUATIONS

It has long been recognized that loss and its associated grief are important elements of many adverse life events that affect the entire global population: death, disability, traumatic events, abuse, terminal and chronic illness, aging, addiction, unemployment, relationship breakdown, war, migration, and educational failure. While there is significant empirical evidence of the potential deleterious effects of specific situations of loss across the global community, systematic discussion concerning the common elements of loss that are associated with adverse life situations in general has been limited. This review of the theoretical and empirical literature concerning various losses and the recommendations for care of those affected by such losses identifies common aspects of situations of loss and common recommendations in the careof those confronted by such losses. These common themes of loss are described by simple summary statements that can be communicated to a broad audience, hence enhancing community education and, potentially, community-wide mental health promotion.     

Youth Mental Illness and the Family: Parents’ Loss and Grief

Parents and family members whose adult child or relative has a mental illness endure significant losses, to which they respond with grief. Such grief may negatively affect family members’ physical and psychological health and also the relationship with their relative. Yet, research in this field is sparse. Very few studies have examined parents’ loss and grief in the context of the patient being a child or teen. It is not clear the extent to which parents’ loss and grief in response to their child or adolescent’s mental illness is similar or different to the accounts of older parents and family members caring for an adult relative with major psychopathology (e.g., Schizophrenia, Bipolar disorder). Parental loss and grief is not often addressed in child and adolescent mental health services’ provision of care; alarmingly, little is known about how best to support parents who access these services. The present study aimed to bridge this knowledge gap and identify the therapeutic needs of this younger parent population. Comprehensive interviews were conducted with 14 parents and one custodial grandparent of a youth aged 18 years or younger who was currently attending a child and adolescent mental health service. An inductive thematic analysis identified six themes; parents’ narrative of finding out, profound and pervasive loss, complex grief, waning support, the challenges of caregiving and a call for assistance. It can be inferred from these results that youth mental illness can constitute a source of loss and grief for parents. Participants’ loss and grief was largely consistent with the experience of families caring for an adult relative with major psychopathology. Opportunities for mental health practitioners to support families’ loss and grief were identified. Further studies are needed to enhance understanding of this complex and, to a large extent, ignored familial experience. Results do underscore the importance of clinicians acknowledging parents’ loss and grief and working directly with this experience over the course of youths’ treatment, perhaps in conjunction with family psychoeducation approaches.     

Promoting Meaning-Making to Help our Patients Grieve: An Exemplar for Genetic Counselors and Other Health Care Professionals

Genetic counselors and other health professionals frequently meet with patients who are grieving a loss. It is thus helpful for medical professionals to be familiar with approaches to bereavement counseling. Grief theory has evolved over the last few decades, from primarily stage theories of grief such as Kübler-Ross’s “five stages of grief” to frameworks that promote more complex and long-term ways to cope with a loss. Herein I present one recent grief theory – meaning-making - and describe how it can be applied to help parents of children with disabilities grieve the loss of the child that they expected. In particular, I describe a scenario that many genetic counselors face - meeting with the parents of a child with Down syndrome. I outline the research done on the reactions, grief and coping experienced by parents in this circumstance, and I present suggestions for encouraging healthy coping and adjustment for parents, based on the meaning-making perspective. The meaning-making theory can also be applied to many of the other losses faced by genetic counseling patients.     

Pastoral Theological Reflection on Grief: Contemporary Theory and the Practice of Ministry by Melissa Kelley

This article highlights four of Melissa Kelley’s contributions in her book Grief: Contemporary Theory and Practice. The author identifies these as: 1) Kelley’s capacity to distill and synthesize the most important areas of contemporary grief theory; 2) her work on attachment theory and its relationship to people’s ways of coping with grief; 3) the focus on the research of Bonanno et al. (Journal of Gerontology Series B: Psychological Sciences and Social Sciences 60:67–73, 2005) and showing us who is most vulnerable and in need of pastoral care during grief; 4) her emphasis on meaning making as the core of the grieving process. The article also lifts up questions concerning communal practices for grieving loss born of injustice and the need for prevention and fostering coping mechanisms so that the worst effects of grief might be mitigated.     

Human lmmunodeficiency Virus Infection and the Gay Community: Counseling and Clinical Issues

The gay community has been and continues to be disproportionately affected by the acquired immune deficiency syndrome (AIDS) and the human immunodeficiency virus (HIV) infection. Need for risk-reduction education, mental health service provision, and assistance in grieving the ongoing loss of loved ones continues to exist among members of the gay community. Clinicians who work with gay clients should be aware of the critical issues confronting gay men who are at risk for infection, those who may already be infected with HIV, and their loved ones. This article highlights critical issues in introducing prevention in therapy and counseling, in supporting asymptomatic seropositive gay men and gay men with AIDS-related complex (ARC) and AIDS in their attempts to cope, and in assisting in the grieving process for those who have lost loved ones to AIDS-related illnesses.     

Mental ghosts and the process of grief

Abstract

Grieving the death of a loved one is an experience that many people will face at least once in their lifetime, but the lack of widely accepted guidelines as to what constitutes “normal” grieving results in mourning being a common experience with little universality. Memories may keep the deceased alive in the minds of the survivor and may even interfere with the formation of new relationships. This article considers the process of grieving the loss of a spouse and some of the individual factors, such as age, sex, and personal beliefs, that may account for variability in grief experiences. While several modeh detailing the grief process are discussed, the inappropriateness of establishing expectations for the nature and duration of grief is argued for.     

GRIEF: A NARRATIVE ACCOUNT

Grief is not a kind of feeling, or a kind of judgement, or a kind of perception, or any kind of mental state or event the identity of which can be adequately captured at a moment in time. Instead, grief is a kind of process; more specifically, it is a complex pattern of activity and passivity, inner and outer, which unfolds over time, and the unfolding pattern over time is explanatorily prior to what is the case at any particular time. The pattern of a particular grieving is best understood and explained through a narrative account, and not merely through a causal account, for narrative accounts in such cases have powerful explanatory, revelatory, and expressive powers which causal accounts lack. Although I will not argue for it here, I believe that this view of grief can be generalised to other kinds of emotion. If this is so, then many philosophical accounts of emotion are at fault in identifying emotion with a kind of mental state or event.     

A short-term grief and loss therapy group: Group members' experiences

Abstract

This article is an evaluative study of a short-term grief and loss therapy group conducted at a large Midwestern university's counseling center. The group was held for students who had experienced loss through death of a significant person. The author examines brief group psychotherapy, special considerations of the college student's grief experience, an adaptation of the brief group model for grieving students, and data gathered from the members of the therapy group. Students' scores on a grief instrument showed mixed results. Group members made journal entries at four times during the group experience. They reported that the group was a supportive and helpful experience; five of Yalom's (1995) eleven therapeutic factors could be discerned. Recommendations regarding the treatment of grieving students in a group setting are made.     

The Myth of Closure

Therapies for grief and loss have traditionally focused on the work of grieving. The goal was to reach an endpoint, now popularly called closure. There are, however, many people who, through no fault of their own, find a loss so unclear that there can be no end to grief. They have not failed in the work of grieving, but rather have suffered ambiguous loss, a type of loss that is inherently open ended. Instead of closure, the therapeutic goal is to help people find meaning despite the lack of definitive information and finality. Hope lies in increasing a family's tolerance for ambiguity, but first, professionals must increase their own comfort with unanswered questions. In this article, the authors, one a poet, the other a family therapist and theorist, offer a unique blending of theory, reflection, and poetry to experientially deepen the process of self‐reflection about a kind of loss that defies closure.     

The Use of Rituals in Grieving for a Miscarriage or Stillbirth

Abstract

Preparation for their changing roles in family and society, as well as readying their intimate space for the arrival of an infant, totally engage expectant parents. Miscarriage or stillbirth may bring on a grief storm that strips away many tender roots and branches of new life in the community that the parents have been nurturing. Creation and participation in a grief ritual can bring the grieving parents to a healing resolution. This article describes the healing efficacy of ritual, its elements, and how a compassionate therapist can create one in collaboration with grieving clients.     

BEYOND THE BONDAGE OF BOUNDARIES

This narrative seeks to describe a route towards the roots of personal and cultural identity through shared journeys of loss and grief. It attempts to find lived spaces for spiritual growth and reconciliation through the complexity of shared experiences and through the search for ways of transcending the boundaries of cultural identity and culturally prescribed ways of grieving. The complex interplay of these juxtaposing themes and interconnecting tensions and paradoxes provides opportunities for new ways of being and the possibility of transcendence of barriers such as gender, ethnicity, culture, language difference, and social class. This is achieved in consideration of context and environment and through the metaphor of ''pushing out the boundaries of lived experience beyond common understanding.''     

Rethinking a Familiar Model: Psychotherapy and the Mental Health of Refugees

This paper examines with a somewhat critical eye the primary role that psychotherapy and other clinic-based services currently play in addressing the mental health needs of political refugees in the industrialized countries. Two factors are considered which suggest that refugee mental health needs might be better served by complementing clinic-based treatments with a variety of community-based interventions. The first factor concerns the pervasiveness of psychological distress within refugee communities, coupled with the reluctance of many refugees to utilize formal psychological and psychiatric services. This calls into question both the adequacy and appropriateness of clinical-based services as cornerstones of our response to the mental health needs of refugees. More precisely, it suggests the need to complement such services with a variety of culturally grounded, community-based strategies that do not require attendance in formal mental health settings. Second, recent findings have shown consistently that a considerable amount of the distress reported by refugees is related not to prior exposure to violent events, but to a constellation of exile-related stressors such as the loss of one's community and social network, the loss of important life projects, changes in socioeconomic status and related concerns about economic survival, the loss of meaningful structure and activity in daily life, and the loss of meaningful social roles. It is suggested that while psychotherapy can play an important adjunctive role in helping people confront these exile-related stressors, they may most effectively be addressed through targeted community-based interventions. Examples of such community-based approaches are briefly described, and suggestions are offered for community-level strategies that might be explored. The paper concludes by emphasizing the complementary nature of clinical and community-based programs, and by suggesting that psychotherapy might best be conceptualized as one component of a more comprehensive approach to addressing the mental health needs of refugee communities.     

Public and private responsibility for mental health services

Relative to public services, private sector corporate mental health care has significantly increased since the late 1960s. The many tensions encountered in assigning public and private responsibility for mental health service give rise to significant value-laden questions for psychologists. These questions go to the heart of community mental health, deinstitutionalization, mental health policy development and evaluation, and many other areas in which psychologists are playing major roles. The public-private issue should be understood historically, from the twin vantage points of developments in general medicine and in mental health. Among the many public interest and public policy matters psychologists and others concerned with mental health should address are the emergence of corporate chains; the nature, cost, and quality of private sector services; the compatibility of profit motivation and the motivation to provide care; and patient selection issues (e.g., cream-skimming). Public and private cooperation and planning are certainly in order if the public interest is to be served in addressing the nation's mental health problems.     

Fracturing drive or fracturing connections—relational considerations commentary on paper by Paul Williams

We tend to conceive of mourning primarily in intrapsychic terms. In this commentary I highlight how Harvey Peskin’s paper (this issue) helps us to appreciate that grief is not only the product of the individual mind but is also constituted relationally. Both what we experience in our grieving and how we express it is shaped by and through those around us whose grief we bear witness to, as we ourselves grieve and are witnessed by them.

I elaborate further on Peskin’s view of the role of witnessing during grieving and mine another profound implication in his discourse by pointing to the bidirectional influence between mourning and relationality. Not only is mourning fostered through relational engagement, but our grieving together can provide the mortar for the building and sustaining of community.     

Community-Based Interventions: A Return to Community Mental Health Centers' Origins

Consultation services offered by community mental health centers (CMHC) have gone through several significant changes since the signing of the Community Mental Health Center Act of 1963 (The President's Commission on Mental Health, 1978). Initially, consultation and education services were an integral part of the CMHC mission. With the passage of additional legislation that promoted a shift in focus, consultation services declined. By 1981, with the passage of the Omnibus Budget Reconciliation Act (Cutler, 1992) national mental health policy was adrift. Consultation and education were no longer seen as central components of mental health services, which increasingly were tied to acute care hospitalization. With a renewed focus on consultation and education, a coherent mental health policy can be reintroduced at the community level.     

Researching Grief: Cultural,Relational, and Individual Possibilities

This review of the author’s writings on grief focuses on cross-cultural research, research with 19th-century diaries, and qualitative interview studies of couples and families. The cross-cultural studies show that there are strong cultural differences in how people grieve. The diary data show that some people cycle into and out of intense grieving, even for years after a death, and the cycling is governed partly by what they do to control emotions and what they encounter that reminds them of their loss. The interview studies make clear that grieving is, for many people, relational, so looking only at individual grieving we miss much of the relational dynamics that are central to the experience of grieving for many people.     

CYBER COMMUNITY IN THE VALLEY OF THE SHADOW OF DEATH

This article provides an examination of the communicative needs and practices of those who have survived the loss of a loved one to suicide. Based on a study of a face-to-face support group for parents of children lost to suicide, and over 10,000 e-mails from a number of online support groups for survivors of the loss of a loved one to suicide, this article discusses intense communicative relations, exclusion from the general society, self-accrediting of experts in grief, reconstruction of identity to include the loss, ownership of the suicide, and rebuilding community.     

A Community‐Responsive Adaptation to Reach and Engage Latino Families Affected by Maternal Depression

As family researchers and practitioners seek to improve the quality and accessibility of mental health services for immigrant families, they have turned to culturally adapted interventions. Although many advancements have been made in adapting interventions for such families, we have yet to understand how the adaptation can ensure that the intervention is reaching families identified to be in greatest need within a local system of care and community. We argue that reaching, engaging, and understanding the needs of families entails a collaborative approach with multiple community partners to ensure that adaptations to intervention content and delivery are responsive to the sociocultural trajectory of families within a community. We describe a cultural adaptation framework that is responsive to the unique opportunities and challenges of identifying and recruiting vulnerable families through community partnerships, and of addressing the needs of families by incorporating multiple community perspectives. Specifically, we apply these principles to the cultural adaptation of an intervention originally developed for low‐income African American and White families facing maternal depression. The new intervention, Fortalezas Familiares (Family Strengths), was targeted to Latino immigrant families whose mothers were in treatment for depression in mental health and primary care clinics. We conclude with key recommendations and directions for how family researchers and practitioners can design the cultural adaptation of interventions to be responsive to the practices, preferences, and needs of underserved communities, including families and service providers.     

The suicide survivor's grief and recovery

While official estimates report approximately 30,000 completed suicides each year, some researchers claim the numbers range much higher. Each suicide has severe and prolonged effects on the family members and friends left behind. Those left behind, the survivors of the suicide, tend to experience a very complicated form of bereavement. This is due to the combination of the sudden shock, the unanswered question of "why," and possibly the trauma of discovering or witnessing the suicide. Survivors' grief reactions can become even more exacerbated by inappropriate responses from the community to the suicide. A mental health professional can help the survivor through this difficult grieving process by direct and indirect means.