© 2019
MICHELLE J. BOWES
ALL RIGHTS RESERVED PSYCHOLOGICAL ADJUSTMENT, RELATIONSHIP SATISFACTION, AND
COMMUNICATION IN BEREAVED PARENTS
USING THE BOWEN FAMILY SYSTEMS THEORY
A Dissertation
Presented to
The Graduate Faculty of The University of Akron
In Partial Fulfillment
of the Requirements for the Degree
Doctor of Philosophy
Michelle J. Bowes
August, 2019
PSYCHOLOGICAL ADJUSTMENT, RELATIONSHIP SATISFACTION, AND
COMMUNICATION IN BEREAVED PARENTS
USING THE BOWEN FAMILY SYSTEMS THEORY
Michelle J. Bowes
Dissertation
Approved: Accepted:
______Advisor/Committee Chair Interim Director of the School of Counseling Karin Jordan, Ph.D. Varunee Faii Sangganjanavanich, Ph.D.
______Committee Member Acting Dean of the College of Health Heather A. Katafiasz, Ph.D. Professions Elizabeth A. Kennedy, Ph.D.
______Committee Member Executive Dean of the Graduate School Harvey L. Sterns, Ph.D. Chad Midha, Ph.D.
______Committee Member Date David H. Tefteller, Ph.D.
______Committee Member Wondimu M. Ahmed, Ph.D.
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ABSTRACT
This quantitative study investigated the role of communication on grief reaction, guilt, and relationship satisfaction in bereaved couples after the death of a child to gain a better understanding of the relationship between these variables. It also explored parental gender and time since death. Fifty-four couples were recruited through newsletters, support groups, and forums. Participants were directed to Qualtrics to fill out the following instruments: demographic questionnaire, the Attitudes towards Emotional
Expression Scale to measure communication, the Revised Grief Experience Inventory to measure grief reaction, the Guilt subscale of the Grief Experience Questionnaire to measure guilt, and the Marital Satisfaction Inventory-Revised to measure relationship satisfaction. Bowen family systems theory (BFST) was used as the guiding theoretical lens. There were three parametric measures used in this study: independent two-sample t-test, the Actor Partner Interdependence Model (APIM), and hierarchical regression. For the independent t-test, all the variables showed sufficient evidence at the 5% significance level of a significant difference in the average total scores. For communication males scored significantly higher than females and for grief reaction, guilt, and relationship satisfaction females scored significantly higher than males. The APIM found a statistically significant actor effect for a woman’s communication on her own grief reaction. For the hierarchical regression, the regression results indicated that this overall model did significantly predict female grief reaction. Time since death proved a
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significant predictor of female grief reaction. A discussion of the findings, limitations of the study, research and clinical implications, and direction for future research are addressed.
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ACKNOWLEDGEMENTS
I am indebted to many people for their guidance and support that has led to the completion of this dissertation. First and foremost, I would like to express my sincere appreciation to the bereaved parents who participated in this study by sharing their time and experiences. I wish to recognize the assistance given from many support group facilitators, both in person and online, along with several newsletters who continued to get the word out about this study and persisted to being committed to bringing it to the attention of their members, so they could decide if they wanted to participate. In particular, Compassionate Friend and The Mothers Enduring Neonatal Death (M.E.N.D) were invaluable. I am awestricken at the resilience of these parents and appreciate them for taking the emotional energy needed to provide information that will be helpful to other grieving parents. I want to extend a special thank you to all of the people who encouraged and supported me throughout this process. This dissertation would not have been possible without it. First, I would like to thank my family and friends who have been there through this long process. Secondly, I would like to thank my advisor and committee chair, Dr. Karin Jordan, and my former advisor the late Dr. Patricia Parr. I feel privileged to have worked with both of you. Finally, I would like to thank the following committee members for their guidance and input: Dr. Karin Jordan, Dr.
Heather Katafiasz, Dr. Rikki Patton, Dr. Cynthia Reynolds, Dr. Harvey Sterns, Dr David
Tefteller, and Dr. Wondimu Ahmed. In particular I want to thank Dr. Ahmed and Dr.
Patton for their statistical expertise, Dr. Tefteller for stepping in to replace a committee
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member when dysfunctional departmental politics came into play, also providing calmness and focus, Dr. Reynolds for her patience, Dr. Sterns for his content expertise, and Dr. Katafiasz for her theoretical expertise.
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DEDICATION
This dissertation is dedicated to my family and friends, especially my husband and best friend, Christopher. Christopher, you are one of the main reasons why I persisted throughout this process despite all of the obstacles. Your unconditional love and support have shaped my entire life. You challenge me to be a better person. I would not be me without you. I would like to acknowledge my mother Gloria, for being a role model and showing me what resilience looks like. I would like to recognize my mother- in-law, Carol, for her love, support, and assistance along with my step father-in-law,
Bernie. I would like to thank my friends who provided their own dissertation support group composed of Dr. Joanne Holbert, Dr. Dee Dee Hewit-Hewit, and Samantha Posey.
Thank you for keeping me sane, motivated, and grounded. Finally, I would like to thank
Dr. Karin Jordan and the late Dr. Patricia Parr. Your mentorship, encouragement, guidance, and professionalism made all the difference. What I learned throughout this process impacted much more than this dissertation.
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TABLE OF CONTENTS
LIST OF TABLES……………………………………………………………………...xvii
LIST OF FIGURES…………………………………………………………………...... xx
CHAPTER
I. INTRODUCTION ...... 1
THE PROBLEM ...... 2
GRIEF MODELS ...... 4
STRESS AND ILLNESS ...... 5
CRUCIAL FAMILY ADAPTATION CHALLENGES ...... 6
FRAMEWORK ...... 7
THEORETICAL FRAMEWORK ...... 7
STATEMENT OF THE PROBLEM ...... 9
GENERAL RESEARCH QUESTIONS AND HYPOTHESES ...... 9
PURPOSE OF THE STUDY ...... 12
PARENTAL ADAPTATION ...... 12
GRIEF REACTION ...... 12
GRIEF REACTION AND GENDER DIFFERENCES ...... 13
PARENTAL ADAPTATION ...... 14
GUILT AND GENDER DIFFERENCES ...... 14
COMMUNICATION ...... 14
RELATIONSHIP SATISFACTION ...... 15 viii
SOCIAL SUPPORT ...... 15
ASSUMPTIONS UNDERLYING THE STUDY ...... 16
DEFINITIONS OF IMPORTANT TERMS ...... 16
CHAPTER SUMMARY ...... 21
OVERVIEW OF THE REMAINDER OF THE PRESENT STUDY ...... 22
II. REVIEW OF THE LITERATURE ...... 23
KAMM’S (1999) STUDY: AN OVERVIEW ...... 24
DISSERTATION DIFFERENCES ...... 24
TRADITIONAL COUPLE OR FAMILY ...... 27
CONTEMPORARY COUPLES ...... 28
DEATH AND DYING THEORIES OVERVIEW ...... 29
TRADITIONAL MODELS ...... 30
GRIEF WORK ...... 30
PHASES OF GRIEF ...... 31
STAGES OF GRIEF ...... 31
TASKS OF GRIEF ...... 32
BIOGRAPHICAL MODEL...... 32
DUAL-PROCESS MODEL ...... 33
RANDO SIX “R” MODEL ...... 33
GRIEF TO PERSONAL GROWTH MODEL ...... 34
THE MULTIDIMENSIONAL MODEL ...... 34
FAMILY FOCUSED GRIEF THERAPY ...... 35
SUMMARY OF GRIEF THEORIES ...... 35
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SYSTEMIC APPROACH ...... 36
MURRY BOWEN: FOUNDER OF THE BOWEN FAMILY SYSTEM THEORY (BFST) ...... 37
THEORETICAL CONCEPTS OF BOWEN FAMILY SYSTEM THEORY (BFST) ...... 38
DIFFERENTIATION ...... 40
TRIANGLES ...... 42
NUCLEAR FAMILY EMOTIONAL PROCESS ...... 43
FAMILY PROJECTION PROCESS ...... 44
MULTIGENERATIONAL TRANSMISSION PROCESS ...... 44
SIBLING POSITION...... 45
EMOTIONAL CUTOFF ...... 46
EMOTIONAL PROCESSES IN SOCIETY ...... 47
DERIVATION OF GENERAL RESEARCH HYPOTHESES ...... 49
GRIEF-RELATED COMMUNICATION ...... 50
PARENTAL ADAPTATION GRIEF REACTION ...... 51
PARENTAL ADAPTATION GUILT ...... 52
RELATIONSHIP SATISFACTION ...... 53
FAMILY LIFE CYCLE (FLC) ...... 55
BEREAVEMENT AND DEATH ...... 57
IMPACT OF DEATH AND BEREAVEMENT SYMPTOMS ...... 59
KAMM (1999) LITERATURE REVIEW ...... 59
CURRENT LITERATURE REVIEW ...... 60
BEREAVEMENT AND DIVORCE ...... 63
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KAMM (1999) LITERATURE REVIEW ...... 64
CURRENT LITERATURE ...... 65
GRIEF REACTION AND GENDER DIFFERENCES ...... 66
KAMM (1999) LITERATURE REVIEW ...... 66
CURRENT LITERATURE ...... 67
COUPLES’ BEREAVEMENT BY TIME SINCE DEATH ...... 71
KAMM (1999) LITERATURE REVIEW ...... 71
CURRENT LITERATURE ...... 71
GUILT AND GENDER DIFFERENCES ...... 73
KAMM (1999) LITERATURE REVIEW ...... 73
CURRENT LITERATURE ...... 74
RELATIONSHIP SATISFACTION ...... 76
KAMM (1999) LITERATURE REVIEW ...... 77
CURRENT LITERATURE ...... 77
COMMUNICATION ...... 80
KAMM (1999) LITERATURE REVIEW ...... 80
CURRENT LITERATURE ...... 81
GENDER AND CULTURE ...... 84
KAMM (1999) LITERATURE REVIEW ...... 84
CURRENT LITERATURE ...... 85
SOCIAL SUPPORT ...... 86
KAMM (1999) LITERATURE REVIEW ...... 86
CURRENT LITERATURE ...... 87
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SUMMARY ...... 89
GENERAL RESEARCH QUESTIONS AND HYPOTHESES ...... 94
III. METHODOLGY ...... 98
RESTATEMENT OF THE PROBLEM ...... 98
RESEARCH DESIGN ...... 99
PARTICIPANTS AND DELIMITATIONS ...... 100
PROCEDURES ...... 100
GENERAL RESEARCH QUESTIONS AND HYPOTHESES ...... 102
INSTRUMENT MEASURES ...... 104
DEMOGRAPHIC QUESTIONNAIRE ...... 104
ATTITUDES ABOUT EMOTIONAL EXPRESSION SCALE (AEE): COMMUNICATION ...... 107
REVISED GRIEF EXPERIENCE INVENTORY (RGEI): GRIEF REACTION ...... 108
GRIEF EXPERIENCE QUESTIONNAIRE (GEQ): GUILT SUBSCALE: GUILT ...... 109
MARITAL SATISFACTION INVENTORY-REVISED (MSI-R): RELATIONSHIP SATISFACTION ...... 111
GLOBAL DISTRESS SCALE (GDS)...... 113
DATA ANALYSIS PLAN ...... 114
ACTOR PARTNER INTERDEPENDENCE MODEL (API) ...... 115
HIERARCHICAL REGRESSION ...... 116
CHAPTER SUMMARY ...... 117
IV. RESULTS ...... 119
RESTATEMENT OF THE PROBLEM ...... 119
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PARTICIPANT DEMOGRAPHICS ...... 120
PRE-ANALYSIS DATA SCREENING ...... 120
SAMPLE REPRESENTATIVENESS ...... 122
DESCRIPTIVE STATISTICS FOR VARIABLES ...... 122
BIVARIATE ANALYSIS ...... 128
RESEARCH QUESTION ONE ...... 129
COMMUNICATION ...... 129
GRIEF REACTION ...... 130
GUILT ...... 131
RELATIONSHIP SATISFACTION ...... 131
RESEARCH QUESTION TWO ...... 132
APIM DIAGRAM ...... 133
APIM: RESULTS FOR ACTOR, PARTNER ...... 134
APIM: RESULTS FOR COVARIANCE AND CORRELATIONS ...... 135
RESEARCH QUESTION THREE ...... 137
APIM DIAGRAM ...... 138
APIM: RESULTS FOR ACTOR, PARTNER ...... 139
APIM: RESULTS FOR COVARIANCE AND CORRELATIONS ...... 140
RESEARCH QUESTION FOUR ...... 142
APIM DIAGRAM ...... 143
APIM: RESULTS FOR ACTOR, PARTNER ...... 144
APIM: RESULTS FOR COVARIANCE AND CORRELATIONS ...... 145
SUMMARY ...... 149
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V. DISCUSSION ...... 154
STATEMENT OF THE PROBLEM ...... 154
RESEARCH QUESTIONS ...... 155
SUMMARY OF THE RESULTS ...... 157
GENERAL RESEARCH ONE ...... 157
INTERPRETATION OF STATISTICAL RESULTS FOR RESEARCH QUESTION ONE ...... 157
COMMUNICATION...... 157
GRIEF REACTION...... 157
GUILT...... 158
RELATIONSHIP SATISFACTION...... 158
GENERAL RESEARCH TWO ...... 158
INTERPRETATION OF STATISTICAL RESULTS FOR RESEARCH QUESTION TWO ...... 159
ACTOR EFFECTS...... 159
PARTNER EFFECTS...... 159
PREDICTOR VARIABLES...... 159
OUTCOME VARIABLES...... 159
GENERAL RESEARCH THREE ...... 160
INTERPRETATION OF STATISTICAL RESULTS FOR RESEARCH QUESTION THREE ...... 160
ACTOR EFFECTS...... 160
PARTNER EFFECTS...... 160
PREDICTOR VARIABLES...... 160
OUTCOME VARIABLES...... 160
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GENERAL RESEARCH FOUR ...... 161
INTERPRETATION OF STATISTICAL RESULTS FOR RESEARCH QUESTION FOUR ...... 161
ACTOR EFFECTS...... 161
PARTNER EFFECTS...... 161
PREDICTOR VARIABLES...... 161
OUTCOME VARIABLES...... 162
GENERAL RESEARCH FIVE (APIM) ...... 162
INTERPRETATION OF STATISTICAL RESULTS FOR RESEARCH QUESTION FIVE (APIM) ...... 162
INTERPRETATION OF STATISTICAL RESULTS FOR RESEARCH QUESTION FIVE (REGRESSION) ...... 162
COMPARISON TO KAMM’S RESULTS ...... 163
LINKING THEORY TO OUTCOMES ...... 164
GRIEF-RELATED COMMUNICATION ...... 164
GRIEF REACTION ...... 164
GUILT ...... 164
RELATIONSHIP SATISFACTION ...... 165
IMPLICATIONS FOR COUPLE AND FAMILY THERAPISTS ...... 165
LIMITATIONS OF THE STUDY ...... 167
RECOMMENDATIONS FOR FUTURE RESEARCH ...... 170
SUMMARY ...... 172
REFERENCES ...... 174
APPENDICES ...... 194
APPENDIX A. IRB APPROVAL LETTER ...... 195
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APPENDIX B. INFORMED CONSENT ...... 196
APPENDIX C. AUTHOR-DEVISED DEMOGRAPHIC QUESTIONAIRE ...... 199
APPENDIX D. THE ATTITUDES TOWARD EMOTIONAL EXPRESSION SCALE (AEE; JOSEPH, WILLIAMS, IRWING, & CAMMOCK, 1994) ...... 201
APPENDIX E. THE REVISED GRIEF EXPERIENCE INVENTORY (RGEI; LEV MUNRO, & MCCORKLE, 1993 ...... 202
APPENDIX F. GRIEF EXPERIENCE QUESTIONNAIRE (GEQ) (BARRETT & SCOTT, 1989): GUILT SUBSCAL ...... 203
APPENDIX G. THE MARITAL SATISFACTION INVENTORY- REVISED (MSI-R; SYNDER, 1997)219 ...... 204
APPENDIX H. DEMOGRAPHICS TABLES ...... 205
APPENDIX I. HISTOGRAMS, BOXPLOTS, Q-Q PLOTS ...... 214
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LISTS OF TABLES
Table Page
1. Demographic Characteristics (Most Salient) ...... 121
2. Descriptive Statistics for Variables ...... 123
3. Descriptive Statistics for Variables (skewness, kurtosis) ...... 123
4. Test of Normality ...... 125
5. Pearson’s (Correlations) ...... 128
6. Results of t-test and Descriptive Statistics for Communication by Sex ...... 130
7. Results of t-test and Descriptive Statistics for Grief Reaction by Sex ...... 130
8. Results of t-test and Descriptive Statistics for Guilt by Sex ...... 131
9. Results of t-test and Descriptive Statistics for Relationship Satisfaction by Sex…..…………………………………………………………………..132
10. Research Question Two: APIM Actor, partner effects ...... 135
11. Research Question Two: APIM Actor, Partner Effects (cont.)…………...... 135
12. Research Question Two: APIM Covariance ...... 135
13. Research Question Two: APIM Correlations ...... 136
14. Research Queston Three: APIM Actor, partner ...... 140
15. Research Queston Three: APIM Actor, partner (cont) ...... 141
16. Research Question Three: APIM Covariance……………………………….141
17. Research Question Three: APIM Correlations ...... 142
18. Research Queston Four: APIM Actor, partner ...... 145
19. Research Queston Four: APIM Actor, partner (cont)……………………….145
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20. Research Queston Four: APIM Covariance ...... 146
21. Research Question Four: APIM Correlations ...... 147
22. Hierarchical Regression: Males ...... 147
23. Hierarchical Regression: Females ...... 148
24. Race ...... 205
25. Age ...... 206
26. Location (by Couple) ...... 206
27. Employment Status ...... 207
28. Occupation ...... 207
29. Income ...... 208
30. Relationship Status...... 208
31. Infertility Treatment ...... 208
32. Number of Infertility Treatments ...... 209
33. Education Level ...... 209
34. Relationship Length ...... 210
35. Sex of the Deceased Child ...... 210
36. Religious Affiliation ...... 211
37. Same Religion ...... 211
38. Age of the Deceased Child ...... 211
39. Reason for Death ...... 212
40. Other Children ...... 212
41. Length of Time since Death ...... 212
42. Member of a Grief Support Group ...... 213
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43. Which Organization ...... 213
xix
LISTS OF FIGURES
Figure Page
1. Research Question Two: APIM Diagram ...... 133
2. Research Question Two: APIM Covariance and Correlations ...... 135
3. Research Question Three: APIM Diagram ...... 139
4. Research Question Three: APIM Covariance and Correlations ...... 140
5. Research Question Four: APIM Diagram ...... 144
6. Research Question Four: APIM Covariance and Correlations ...... 145
7. Communication Histograms ...... 214
8. Grief Reaction Histograms ...... 214
9. Guilt Histograms ...... 215
10. Relationship Satisfaction Histograms ...... 215
11. Time since Death (in Years) Histograms ...... 216
12. Commutation Boxplots ...... 217
13. Grief Reaction Boxplot ...... 217
14. Guilt Boxplot ...... 217
15. Relationship Satisfaction Boxplot ...... 218
16. Time since Death (in Years) Boxplot ...... 219
17. Communication Q-Q Plots ...... 219
18. Grief Reaction Q-Q Plots ...... 219
19. Guilt Q-Q Plots ...... 220 xx
20. Relationship Satisfaction Q-Q Plots ...... 221
21. Time since Death (in Years) Q-Q Plots……………………………………..221
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CHAPTER I
INTRODUCTION
Bowen (1976) described death as an ‘emotional shock wave’ that is experienced as the family goes from generation to generation. He stated that deaths previously experienced in a family (whether in the current family or in previous generations) directly and indirectly affected how the family copes and adapts in general (Bowen, 1976).
Regarding the death of a child within the family system, the child’s previously held roles and connections within the family (as a sibling and as a child) were missed by the others in the system (Kerr & Bowen, 1988). Conversely, everyone who then grieved was part of a family and of other relational systems that then influenced the unfolding grieving process (Bowen,1976). Gilbert (2006) reported:
Death is one of many events that can disturb a family. A family unit is in functional equilibrium when it is calm, and each member is functioning reasonable efficiency for that period. The equilibrium is disturbed by the loss of a member (p.80).
The purpose of this study was to gain a better understanding of the relationship between spousal communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It also examined whether parental gender and time since death have implications for those relationships. This was a replication study of Sherrie Kamm’s 1999 dissertation with moderate modifications.
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The Problem
Death is a normal part of the life cycle; it is ubiquitous. The experience of the death of others is universal to the human condition. The Merriam-Webster Dictionary
(2016) defines grief as “a deep sadness caused by someone’s death” (p. 530). However, grief can be a difficult construct to define especially when it occurs outside the normal life cycle or is ‘out of order’ in terms of chronological or social expectations (Walsh &
McGoldrick, 2004). For those born in the late twentieth century, the first death they are likely to experience is that of their parent(s), when they are middle-aged (Exley, 2004).
Other losses can be considered non-normative in this context. The impact of non- normative stressors, such as the death of a child, is crucially important in the mental health field. The impacts of bereavement for individuals often include physical, emotional, behavioral, and psychological reactions like sleep disturbance, self-destructive behavior, guilt, and the loss of social support (Barrett & Scott, 1989). This finding may also be true for couples. The way husbands and wives grieve and perceive their situation can result in misunderstandings. These misunderstandings can affect the couple’s marital relationship and thus decrease each other’s ability to be a primary source of support for the other after the death of a child (Lang, Goultet, & Amsel, 2004). Misunderstandings can also result because of culture and gender (Agar, 1994).
The dominant culture within the modern, post-industrial United States denies that death is inevitable and natural (Kramer, 1998). Western society has often been denoted as a death denying society (Kastenbaum, 1995; Kübler-Ross, 1969). Bowen (1978) reported that death is among the leading tabooed subject. One indication of this denial of death is the use of euphemisms (Riches, 1998). Instead of saying that an individual is
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dead, people more commonly say the deceased has ‘passed on’, ‘went home’, ‘went to meet his/her maker, or ‘went to the other side’ (Samuel, 2013). Thus, the preferred vocabulary in the United States for dying does not include the words ‘died’, ‘dead’, or
‘death’ (Samuel, 2013). Language may have an impact on grief (Neimeyer & Keesee,
1988). Rosen (1990) reported that the open communication system is one in which
“individuals are free to express their thoughts and emotions, whereas closed family systems discourage and invalidate members’ attempts to express unacceptable ideas or feelings” (p.22). Rosen (1990) also made it clear that the feelings to be expressed were not just those of grief, but included those such as “disappointment, helplessness, guilt, relief, and anger” (p. 91). Brown (1989) added that the ability to remain open to express one’s thoughts and feelings, and to remain nonreactive to the other’s anxiety, is related to the intensity and the duration of stress. She claims, “the longer and more intense the family stress is, the more difficult it is for the family relationships to remain open and the more likely it is that dysfunction will develop” (Brown, 1989, p.473). The experts agree that language and communication are critical to the grieving process (Bowen 1976;
Brown, 1989; Jordan, Kraus, & Ware,1993; Rosen, 1990).
Brown (1989) supported the importance of modeling the use of direct language and of avoiding indirect terms or euphemizes. Rosen (1990) added, “The family’s shared acknowledgment of death begins with open communication in clear, noneuphemistic terms” (p. 89). Regarding this concept, Bowen (1976) wrote:
A tangential word may appear to soften the fact of death, but it invites the family to respond with tangential words, and the conversation soon reaches the point that one wonders if we are talking about death at all. The use of direct words helps to open a closed emotional system. (p. 329)
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The patterns established by such a shock wave often persist over generations (Bowen,
1978). Jordan, Kraus, and Ware (1993) discussed the mechanisms which suggest that families that are not grieving well, almost invariably manifest a communication shutdown. Culture also dictates how long grieving is acceptable (Rando, 1984).
American society considers it normal for those who have experienced loss to interact with the world in grief-stricken ways. However, in studying grief, Maciejewski (2007) reported that there was no consistency regarding how long an appropriate grieving period should last. During the grieving process, several things can happen. Research has shown that people isolate themselves during grief/loss, which may lead to depression and thoughts of suicide (Shear, 2015). An introduction to the different grief models will be discussed below.
Grief Models
Many specific theories and models have been developed to describe how bereaved individuals move through their grief. This paper will review the following models: (a) traditional, (b) grief work, (c) stages of grief, (d) phases of grief, (e) tasks of grief, (f) the biographical model, (g) the dual-process model, (h) Rando six “R” model, (i) the Grief to Personal Growth Model (j) The Multidimensional model, and (k) the Family
Focused Grief Therapy model. Traditional models have focused on symptom clusters
(Lindemann, 1944), while grief work focused on the bond between survivor and deceased
(Freud, 1957; Bowlby, 1961, 1970, 1980). Kübler-Ross (1969) determined a framework for the progression of emotional states called the stages of grief, while Parkes (1983) looked at the phases of grief. Worden (1991) observed the tasks of grief, while more recent models like the biographical model described where the grief stricken integrate the
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memory of the deceased in their ongoing lives (Walter, 1996). The dual-process model described grief as a process of oscillation between two contrasting modes of functioning
(Stroebe & Schut, 1999), while the Rando six “R” model includes 6 stages the bereaved go through. The Grief to Personal Growth Model delineates a pathway through grief
(Hogan, Greenfield, & Schmidt, 2001), while the Multidimensional model conceptualizes grief as a process of simultaneous change with seven dimensions (Payne, Horn & Relf,
1999). Finally, the Family Focused Grief Therapy model viewed grief from a family perspective (Chan, 2004). Next, stress and illness will be presented.
Stress and Illness
There have been instruments created to assess stress that can contribute to illness in individuals. The original scale of the Holmes and Rahe Stress Scale (Holmes & Rahe,
1967) is utilized by many counselors/therapists to measure stressful life events that can contribute to illness. To measure stress according to this scale, the number of "life change units" that apply to events in the past year of an individual's life are added and the final score provides a rough estimate of how stress affects health (Holmes & Rahe, 1967).
The number one stress event for an individual on this scale was “the death of a spouse” at
100, while the number five stress event was “the death of a close family member” at 63, and the seventeenth-ranked stress is “the death of a close friend” at 37 (Holmes & Rahe,
1967, p. 216). The death of a child and its impact on stress is not mentioned specifically.
This scale was finally updated in 1997 around the time of Kamm’s (1999) dissertation with the revised and expanded Recent Life Changes Questionnaire (RLCQ;
Miller & Rahe, 1997). The RLCQ added the death of a child, the death of a parent, and the death of a sibling to the list. Furthermore, the RLCQ finds gender differences
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between men and women regarding the death of a child (Miller & Rahe, 1997). “The death of a spouse” remains the number one stress event for men in the revised version.
However, for women the number one stress event is “the death of a child” followed by
“the death of a spouse” (Miller & Rahe, 1997, p. 282). Comparatively, “miscarriage” is the number 11 stress event for women and number 20th for men, with “pregnancy” being also identified as a stress event at number 11 for women and number 23 for men (RLCQ;
Miller & Rahe, 1997, p. 282). However, the total impact of grief, stress, and related isolation on the couple was not emphasized. The following section will review crucial family adaptation challenges.
Crucial Family Adaptation Challenges
Research suggests that there are crucial family adaptation challenges that, if not successfully resolved, leave family members vulnerable to dysfunction and heighten the risk of family conflict and dissolution (Walsh & McGoldrick, 2004). Research has shown that communication styles influence family functioning (Bowen, 1978; Gottman
& Krokoff, 1998; Johnson & Greenberg, 1994). By improving communication and support, relational functioning will improve and increase grief resolution. According to the literature on grief, support from family and friends has shown positive experiences that enhance grief resolution (Benkel, Wijk, & Moldander, 2009; Vachon & Stylianos,
1988). One of the most important variables thought to promote positive adjustment to the death of a loved one is communication (Kamm & Vadenberg, 2001). The literature reviewed suggests that during the grieving process, those with social support and open communication have less depression, less physiological illness, less anger, less problematic responses to loss, and better health (Benkel et al., 2009; Horsley & Patterson,
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2006; Rubin, 1999; Vachon & Stylianos, 1988). The framework for this study will be considered next.
Framework
The framework for this research study was the 1999 doctoral dissertation of
Sherrie Kamm. It investigated the relationship between couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. Parental adaptation was measured by the two concepts of grief reaction and guilt. These measures are two separate concepts and will not be combined. It also examined whether parental gender had implications for those relationships. The current research study was a modified replication of the Kamm
(1999) study and examined the same phenomenon when a couple’s child dies. The next section will discuss the theoretical framework as Kamm did not have a specific theory that guided her dissertation and this dissertation will use a specific theoretical lens.
Theoretical Framework
The examination of grieving in bereaved parents with high rates of emotional reactivity, required a theory that would have meaning for couples in dealing with their mental health needs. Such a theory that fits this benchmark is Murray Bowen’s Family
Systems Theory. Bowen’s model also considered the thoughts and feelings of each family member as well as the larger contextual network of family relationships that shaped the life of the family (Nichols, 2010). The importance to remember the application of systems thinking, when pondering these concepts, was the interaction of what is happening and how, when, and where it was happening. Bowen (1976) concluded that, we tend to react to situations better when we can become autonomous
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and independent, while remaining connected to the family mainstream. Bereaved parents expressed a need to grieve together to provide support and comfort to their partner, yet at the same time they need to grieve on their own as their bereavement is unique from that of their partners (Toller & Braithwaite, 2009). For a Bowenian, differentiation is the level at which one acknowledges his/her own feelings, emotions, and intellect (Nichols,
2010; Winek, 2010). The lower the level of differentiation, the more one reacts before one thinks, while the higher the level of differentiation, the more one thinks before one reacts (Nichols, 2010; Winek, 2010).
Bowenian Family Systems Theory (BFST) has played an instrumental role in the advance of the field of couple and family therapy (CFT). From a Bowenian viewpoint, it was believed that patterns of functioning from the thoughts, emotional, and feeling levels were passed down from previous generations and tended to become part of one’s current nuclear family or within other relationships (Nichols, 2010). The essence of BFST rests in the degree to which people can “distinguish between emotional process and intellectual process” (Papero, 1990, p. 35). The main concepts of BFST focused on the functional facts of the relationship system, which represented the capacity to think in systems concept and apply those concepts to every day experiences (Friedman, 1991).
According to Bowen, individuals or families with low differentiation levels would be more likely to respond poorly to stress (Bowen, 1976). These individuals are governed by their emotions, which made them emotionally reactive and
“underresponsible for themselves and/or overresponsible for others” (Titleman, 1998, p.
121). Bowen believed that psychological symptoms were more likely to occur when relationships and individuals were depicted by high levels of emotional reactivity (Kerr &
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Bowen, 1998). There is a lack of research, current and past, on the relationship between couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child from a Bowenian perspective. Following, the statement of the problem will be presented.
Statement of the Problem
This study was concerned with extending research on communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction in bereaved parents. To accomplish this goal, this research study utilized a valid and reliable quantitative measure of communication that specifically targets couple communication as well as appropriate quantitative measures of grief reactions, guilt, and relationship satisfaction. The next section will detail the research questions and hypotheses used for this dissertation.
General Research Questions and Hypotheses
This study attempted to answer the following questions:
1. Research Question One: This question will be assessed by an independent two
samples t-test. Is there a statistically significant gender difference in grief-related
communication, adaptation (grief reaction), adaptation (guilt), and relationship
satisfaction?
a. Hypothesis One: Communication, time, and the interaction of
communication by time were utilized as predictors in all analyses for
Kamm study. For gender, communication, and grief reaction Kamm
found the overall equation for men statistically significant, while for
women it was not significant. For guilt, the overall equation was
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significant (using the same predictors communication, time, and the
interaction of communication and time) for men and women. For
relationship satisfaction (again using the same predictors communication,
time, and the interaction of communication and time), Kamm found no
statistical difference for men, but found the overall equation significant for
women. Due to the differences in statistical approaches to the research
questions and the lack of research, Kamm’s findings and literature were
not able to be used for directionality.
2. Research Question Two: This question will be assessed by the Actor Partner
Interdependence Model (APIM). Is there a statistically significant relationship
between grief-related communication and grief reaction among couples?
a. Hypothesis Two: This researcher will use the best practices model for
dyads, the APIM. Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
3. Research Question Three: This question will be assessed by the APIM. Is there a
statistically significant relationship between grief-related communication and
guilt among couples?
a. Hypothesis Three: Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
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4. Research Question Four: This question will be assessed by the APIM. Is there a
statistically significant relationship between grief-related communication and
relationship satisfaction among couples?
a. Hypothesis Four: Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
5. Research Question Five: This question will be assessed by hierarchical regression.
Is there a statistically significant relationship between grief-related
communication, time since death, and grief reaction among couples?
a. Hypothesis Five: Due to a lack of research and an error in Kamm’s 1999
findings, wherein she inaccurately reported that a higher score on the
RGEI indicates a less severe grief reaction, her findings and literature
cannot be used to determine directionality of this hypothesis.
Purpose of the Study
The purpose of this research study was to replicate Kamm’s (1999) study and to investigate the relationship between couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child from a systemic perspective. Although Bowen has eight interlocking concepts, for the purpose of this study Bowen’s concepts of differentiation, emotional reactivity, and multiple generation transmission process are complementary and provided a broader perspective on grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction. The addition of using
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the Bowenian lens to view parental grief after the death of a child may offer a new direction for grief in the field of CFT. This information may be beneficial to therapists working with bereaved couples whose child has died. This current research study attempted to extend previous research on communication in bereaved parents and to exam the relationship between (1) couple’s grief-related communication, (2) adaptation of parents (measured by grief reaction and guilt), (3) relationship satisfaction of parents, and (4) gender implications for these relationships. To accomplish this goal, this study utilized a reliable and valid quantitative measure of communication specifically targeting couple’s grief-related communication after the death of a child, as well as appropriate quantitative measures of grief reactions, guilt, and relationship satisfaction.
There has not been an expansion of literature regarding relationship grief related communication about the death of a child, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction. There are no studies available using the
BFST for these constructs: grief related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction beyond Kamm’s 1999 dissertation. The next sections will provide an overview of the topics that can influence the grief process. These different topics were discussed by Kamm in her 1999 dissertation.
Parental Adaptation
Grief Reaction
Analysis (previous and current literature) of grief reaction has consistently shown that grief after the death of a child is unique, intense, and prolonged (Alam, Barrera,
D’Agostino, Nicholas, & Schneiderman, 2012; Dyregrov & Gjestad, 2011; Kamm &
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Vandenberg, 2001; Martin & Doka, 2000). The current literature was a departure from the older research when it came to how grief reaction can impact divorce, where older articles found that there was not enough data to accurately predict divorce. The devastation from the death of a child was still seen within the current literature as it impacted couple coping capabilities after the death (Arnold & Gemma, 2008; Bolton, Au,
Walld, Chateau, Martens, Leslie, Enns, & Sareen, 2013; Bolton, Au, Leslie, Martens,
Murray, Enns, Roos, Katz, Wilcox, Erlangsen, Chateau, Walld, Soiwak, Segui, Shear, &
Shareen, 2013; Eilegard & Kreicbergs, 2010; Lynstad, 2013; Rogers, 2005). Finally, regarding the time since death, the current literature found similar findings with grief decreasing over time (Stroebe, Finkenaure, Wijngaards-de Meij, Bout & Stroebe, 2013).
The next topics discussed by Kamm (1999) were grief reaction and gender differences.
Grief Reaction and Gender Differences
Current research studies have found findings similar to the older literature in that women had more intense and prolonged grief and are affected by grief more than men
(Alam et al., 2012; Bergstraesser, Inglin, Hournung, & Landolt, 2014; Jind, 2003;
Murphy, Shelvin, & Elkit, 2014; Stroebe et al., 2013; Wijngaards-de Meij, Stroebe,
Schut, Stroebe, van den Bout, van der Heijden, Dijkstra, 2005). Gender had a significant impact on grief reactions with women experiencing more depression (Murphy et al.,
2014), while men did not openly express their grief (Alam et al., 2012). The next topics discussed by Kamm (1999) were guilt and gender differences.
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Parental Adaptation
Guilt and Gender Differences
The current literature found similarities to past findings on guilt in bereaved parents in that guilt is common in bereaved parents although not all couples report having guilt (Barr, 2012, 2004; Ducan & Cacciatore, 2015; Jind, 2003). Bereaved mothers reported more guilt and shame than bereaved fathers; however, guilt and shame appear more problematic for men (Ducan & Cacciatore, 2015). One study looked at sexual intimacy after the death of a child and found that women reported linking guilt to the ability to have no pleasure (Dyregrov & Gjestad, 2011). Guilt hindered the healthy progression of mourning (Buckle & Fleming, 2011). In one study, the research found that shame and guilt forecast the level of bereavement intensity experienced by bereaved parents (Ducan & Cacciatore, 2015). The author also found that women’s bereavement is affected by their partner’s guilt, shame, and the quality of the marital relationship (Ducan
& Cacciatore, 2015). The next topic discussed by Kamm (1999) was communication.
Communication
Research focusing on effective communication when a couple is dealing with grief after the death of a child has been limited. It remains true that previous and current literature identify stress as originating from asynchronous grieving, (grieving occurring out of synch with the partners grieving), which can have detrimental consequences to the couple relationship (Bohannon,1990-91). Couples who were closed in their communication had a great deal of conflict and strain in their relationship (Toller &
Braithwaite, 2009). Couples with poor dyadic coping were prone to not speak openly with their partner (Bergstraesser et al., 2014). Communication played a vital role in the
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process of healing (Titus & de Sourza, 2011). It is believed that couple communication is one aspect that leads to relational satisfaction and couples with more positive bereavement communication demonstrated greater relationship satisfaction (Kamm, &
Vandenberg, 2001). The next topic discussed by Kamm (1999) was relationship satisfaction.
Relationship Satisfaction
According to the literature, events such as the death of a child that occur out of the customary sequence of development disturbs the normative progression and generates added stress (Lohan & Murphy, 2006). The past literature tended to focus on the negatives that occur after the death of a child and how it affected relationship (Dyregrov
& Matthissen, 1987; Gilbert, 1989; Schiff, 1977), while the current literature evaluated how the death could strengthen the relationship along with the negative (Rosenblatt,
2000). Couples who perceived their grieving as dissimilar had lower relationship satisfaction than bereaved parents who perceived their bereavement to be at similar level
(Buyukcan-Tetik, Finkenauer, Schut, Stroebe, & Stroebe, 2016). The next topic discussed by Kamm (1999) was social support.
Social Support
Research findings that related to levels of social support echoed work completed by earlier researchers, as the current literature was comparable to previous work.
Bereaved parents benefited from support (O’Connor & Barrera, 2014; Polantinsky &
Esprey, 2000) or feel ostracized by it (Hastings, 2000). Couples could particularly benefit if the support was from each other (Bergstraesser et al., 2014). Fathers reported
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benefits from talking to others, but not as often as mothers (Alam et al., 2012). The next section will discuss assumptions that underline this study.
Assumptions Underlying the Study
In this study, there were several assumptions:
1. A primary goal of this study was to add to the body of research by applying a
systemic lens that looks at the couple system and their values/beliefs after the
death of a child. This was done by using information from the demographic
questionnaire.
2. Self-report measures could be valuable because the interpretation was most
accurate through the eyes of the participant, however it may not be error free
as one member of the couple may have a different interpretation from the
other member.
3. Parents needed to be given the time to work through their grief issues due to
negative cultural norms as bereaved parents had a desire to share their grief,
but few ask for help or willingly listen (Arnold & Gemma, 2008).
The next session will define critical definitions of important terms needed to understand the jargon within this dissertation.
Definitions of Important Terms
The following sections briefly defined several important terms for the present study.
Adaptation: The bereavement experience or grief level experienced in reaction to loss.
Parental adaptation (grief reaction), parental adaptation (guilt) were two separate concepts.
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Bereavement: The recent loss of a significant person through death (Bolton et al., 2013).
Cleiren (1993) made an important distinction between bereavement and grief/mourning.
Reporting that bereavement refers to the loss per se or the objective situation, while the term grief/mourning refer to the processes that take place after the death.
Bereavement behavior: “The total response pattern, psychological and physiological, displayed by an individual following the loss of significant object, usually a loved one”
(Averill, 1968, p. 712).
Bereavement process: The behavioral, affective, and cognitive changes in the bereaved person after a death (Averill, 1968).
Bereaved: A person who has experienced a loss by death of another person (Cleiren,
1993).
Communication: The ability to solve problems and express affection/intimacy with a partner as measured by the Marital Satisfaction Inventory-Revised (MSI-R; Snyder,
1997). Communication was measured by the Attitudes Toward Emotional Expression
Scale (AEE; Joseph, Williams, Irwing, & Cammock, 1994).
Culture: Defined as a way of life (Martin & Doka, 2000).
Differentiation: A concept developed by Murray Bowen to describe the measure of an individual’s ability to separate intellectual, emotional system functioning, and the ability to maintain one’s autonomy while in an intimate relationship (Bowen, 1978).
Early fetal death: A fetal death that occurs at 20–27 weeks of gestation (Gregory,
MacDorman, & Martin, 2014).
Early fetal mortality rate: Number of fetal deaths at 20–27 weeks of gestation per 1,000 live births and fetal deaths at 20–27 weeks of gestation delivery (Gregory et al., 2014).
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Fetus: Defined from 8 weeks after conception until term while in the uterus (Barfield,
2016).
Fetal death: The intrauterine death of a fetus prior to delivery. Death before the complete expulsion or extraction from the mother of a product of human conception, irrespective of the duration of pregnancy, that is not an induced termination of pregnancy.
The death is indicated by the fact that, after such expulsion or extraction, the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps (Gregory et al., 2014). Fetal deaths are further subdivided as “early” (20–27 weeks' gestation) or “late” (≥28 weeks' gestation) (Gregory et al., 2014). For the purpose of this study, death prior to birth was classified as fetal death.
Fetal mortality: The intrauterine death of a fetus at any gestational age; however, it is generally divided into three periods (less than 20 completed weeks of gestation), intermediate (20-27 weeks of gestation), and late (28 weeks of gestation or more)
(Gregory et al., 2014).
Fetal mortality rate: Number of fetal deaths per 1,000 live births and fetal deaths. Rates based on data from the National Vital Statistics System (NVSS) are generally presented for fetal deaths of 20 weeks of gestation or more (Gregory et al., 2014).
Gender Differences: The term that is applied to the typical differences between men and women that is often specific to a particular culture (Nugent, 2017).
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Grief: A primarily emotional reaction to the loss of a loved one through death (Stroebe et al., 2001).
Grief Reaction: A complex of somatic and psychological symptoms associated with extreme sorrow or loss, specifically the death of a loved one. Somatic symptoms include a feeling of tightness in the throat and chest with choking and shortness of breath, abdominal distress, lack of muscular power, and extreme tiredness and lethargy.
Psychological reactions involve a generalized awareness of mental and anguish and discomfort accompanied by feelings of guilt, anger, hostility, extremes restlessness, inability to concentrate, and lack of capacity to initiate and maintain organized patterns of activates. Although both the somatic and psychological reaction have the potential for developing into pathetical conditions, appropriate adaptive behaviors and normal responses, such as sobbing or talking about the dead persons are methods of working through grief (Mosby, 2016). Adaptation was measured by the Revised Grief
Experience Inventory (RGEI) (Lev, Munro, & McCorkle, 1993) which measured levels of grief (continuous data) with higher scores indicating greater levels of grief; the categories were depression, existential tension, guilt, and physical distress. Because this study seeks to obtain a measure of overall grief reactions, only the total score was used.
Grieving: A response to loss and death that is organized by sequential steps, stages, or phases and bound by the dimension of time, requiring closure for resolution (Lindemann,
1944).
Guilt: The feelings of guilt and thoughts over one’s one acts of commission and/or omissions prior to the decedent’s death (Bailey, Dunham, & Kral, 2000). Guilt will be
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measured by the subscale of the Grief Experience Questionnaire (GEQ; Barrett & Scott,
1989). Parental adaptation (grief reaction) and parental adaptation (guilt) were two separate concepts.
Infant: Live born and younger than 365 days of age (Barfield, 2016).
Infant death: A live birth that results in death within the first year (<365 days) is defined as an infant death. Infant deaths are further subdivided as early neonatal (<7 days), late neonatal (7–27 days), neonatal (<28 days), or post neonatal (28–364 days) (Barfield,
2016).
Infant mortality rate: This entry gives the number of deaths of infants under one year old in each year per 1,000 live births in the same year. This rate is often used as an indicator of the level of health in a country (Barfield, 2016).
Intimate relationship: Are characterized by the greatest disclosure of information of self and other. This is particularly true with the disclosure of feeling (Levinger &
Senn,1967).
Live Birth: The complete expulsion or extraction from the mother of a product of human conception irrespective of the duration of pregnancy, which, after such expulsion or extraction, breathes or shows any other evidence of life (Barfield, 2016).
Mourning: Refers to the processes that take place after a death (Cleiren, 1993). For this dissertation mourning will be defined as the observable public expression dictated by one’s culture (Sanders, 1989).
Relationship satisfaction: Defined as an interpersonal evaluation of the positivity of feelings for one's partner and attraction to the relationship (Rusbult & Buunk, 1993).
This term was operationally defined by the individual’s score on the Marital Satisfaction
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Inventory-Revised (MSI-R; Synder, 1997).
Stillbirth: This term is also used to describe fetal deaths at 20 weeks' gestation or more.
Fetuses that die in utero before 20 weeks' gestation are categorized specifically as miscarriages) (i.e. at 20 weeks of gestation or more, or 28 weeks or more, for example)
(Gregory et al., 2014).
Social support: Understood to mean human interaction in which people give and receive emotional support, information, and concrete support with positive effects (Kahn, 1979).
The next section will provide a summary of chapter one.
Chapter Summary
Except for Kamm’s 1999 study, the effect of grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child had not yet been examined through a systemic lens.
An obstacle found in current grief literature was the disjointed nature of constructs that vary from type of loss experienced to type of discipline. Studies dealing with death tended to look at the functioning level of the bereaved that followed the loss, rather than the grief processes involved, especially as those processes focused on the lines of communication and marital satisfaction. The purpose of the present study was to enhance the understanding of the relationships between grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction in couples whose child died and was built on Kamm’s (1999) research. In addition, this research study included a comprehensive literature review, building on the literature review previously conducted by Kamm in her 1999 dissertation. The next section will provide an overview of the remainder of this study.
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Overview of the Remainder of the Present Study
Chapter II will include a review of the literature examining theoretical and empirical research relating to the consequences that the death of a child can have on bereaved parents’ individual and relational adjustment. Most importantly, the chapter will focus on the relationship between couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It will also examine whether parental gender has implications for those relationships. Chapter III will discuss the methodological framework of the present study (restatement of the program, independent variable, dependent variables, procedures, measures, and data analysis plan). Chapter IV will report the results of the statistical analyses used in this study to test the hypotheses stated in Chapter III, including descriptive and inferential statistics. Lastly, Chapter V will include a summary, conclusion, and discussion of the results reported in Chapter IV. Furthermore, the limitations and contributions of the present study will be discussed in addition to the implications for the counseling profession and recommendations for future research in this area.
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CHAPTER II
REVIEW OF THE LITERATURE
This chapter will provide a comprehensive literature review, focusing on the consequences that the death of a child can have on the parents’ individual and relationship adjustment. More specifically, the chapter will focus on the relationship between couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It will also examine whether parental gender has implications for those relationships. This literature review was built upon the work Kamm (1999) completed. This study was a replication of the Kamm (1999) study with moderate modifications. An overview of
Kamm’s study will be presented first, focusing on how attitudes towards communication and gender can discriminatorily influence relationship satisfaction and couples’ bereavement. Additional focus will evaluate how this replication study is different from the original Kamm (1999) study. After the review of the Kamm (1999) study, emphasis will be on the following: dissertation differences, traditional couple or family, contemporary couples, systemic approach, Bowen Family System theory (BFST), family life cycle, bereavement and death, impact of death and bereavement symptoms, bereavement and divorce, grief reactions and gender differences, couples’ bereavement by time since death, guilt and gender differences, relationship satisfaction, communication, gender and culture, and social support.
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Kamm’s (1999) Study: An Overview
Kamm (1999) conducted:
An empirical study investigating the relationship between couple’s grief- related communication about the death of a child and (1) adaptation of parents, and (2) relationship satisfaction of parents. This study also sought to examine whether gender has implications for these relationships” (p. 23)
Kamm did not utilize a specific theoretical lens in her 1999 dissertation, but instead used different broad guiding theoretical concepts. Kamm (1999) focused on theoretical literature, which suggested that communication is one of the most important variables influencing the adaptation of surviving family members following the death of a loved one. More specifically, communication improves post-death adjustment between grieving parents. Sharing of perceived meaning and allowing emotions to surface about the reality of the death via direct communication, along with provision of mutual support between partners, promoted healing in surviving parents. Theorists cited by Kamm
(1999) suggested that bereavement related communication is valuable for grieving parents. Beyond a general bereavement theory, Kamm (1999) focused her attention on the theories related to parental communication and gender differences. She found a lack of relevant scholarly research available to her during the time frame of her study. This study is a replication of the 1999 Kamm study with some modifications. The next section will describe the differences between Kamm’s 1999 dissertation and this dissertation.
Dissertation Differences
There were six differences between Kamm’s 1999 dissertation and this dissertation study. (1) Kamm (1999) looked at deaths between the ages of two through
19. Per the Centers for Disease Control and Prevention, Underlying Cause of Death
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(Martin, Hamilton, Osterman, Curtin, & Matthews, 2013), in 1999 there were 21,026 deaths for children from two through 18. For 2017, this figure was 15,588 for the same age group (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018). For this study, to ensure participant volume, this researcher examined fetal deaths (death prior to delivery, irrespective of the duration of the pregnancy), infant deaths (<1 to 364 days), deaths between the ages of 1 through 18, and deaths of adult children between the ages of 19 through 55.
(2) In Kamm’s 1999 study, her data reflected that time since death ranged from two months to over 27 years. Kamm (1999) did not articulate whether she had a cutoff regarding time since death. For this study, there was no cutoff regarding time since death to ensure a larger participant pool. Limitations that arise from this will be discussed in chapter 5.
(3) Kamm (1999) used repeated measures, which gave direct and interaction effects for paired data, however it is no longer best practices. Kenny and Cook (1999) reported multiple regression was a traditional method of analysis for dyads as the person is the unit of analysis. This researcher used the best practices model for dyads, which was actor partner Interdependence model (APIM). APIM was used to compare and identify different types of dyadic patterns that can depict the interpersonal influences of actors and partners. (Kenny & Ledermann, 2010). According to Kenny, Kashy and Cook
(2006), the capability of modeling and testing both the actor and partner effects brought the dyad into the mainstream study of relationships. Because of this model, suddenly one could conceptualize how relationship partners influence one another while simultaneously modeling the statistical interdependence that often exits between
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relationship partners (Kashy & Cook, 2006, p. viii). According to Kenny and Cook
(1999) “by studying only actor effects, researcher focus on the individual level of analysis; however, by including partner effects there is a possibility of identifying truly relational phenomena” (p. 435). More detail will be provided in chapter 3.
(4) In Kamm’s 1999 dissertation, participant parents were married and could participate individually if they were married, as it was not necessary for both to participate. Since this dissertation is written as partial fulfillment for a Couple and family
Therapy program, this researcher focused systemically, recruiting couple participants and did not allow individual participation. In keeping with common contemporary conceptualizations of couples in society, this study included married, as well as unmarried or cohabitating couple participants.
(5) The measurement for relationship satisfaction was changed from the Index of
Marital Satisfaction (IMS; Hudson, 1992) to the Marital Satisfaction Inventory-Revised
(MSI-R; Snyder, 1997). The IMS measures the extent to which one partner perceives problems in relationship but does not characterize the relationship as a unitary entity
(Hudson, 1997). It does not recognize the actor partner interplay nor is multidimensional, whereas the MSI-R is multidimensional. Supplementary information on the MSI-R will be provided in chapter 3.
(6) This researcher used the concepts from BFST (differentiation, emotional reactivity, and multiple generation transmission process) to conceptualize the constructs of grief related communication, adaptation (grief reaction and guilt), and relationship satisfaction. The next section will describe the concept of a traditional couple or family.
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Since Kamm (1999) used traditional married couples for her participants, the concept needs to be operationalized.
Kamm’s (1999) dissertation includes an error which potentially invalidates its findings. In her dissertation Kamm (1999) reported that a higher score on the Revised
Grief Experience Inventory (RGEI) (Lev, Munro, & McCorkle, 1993) indicated less grief. A review of the RGEI resulted in this researcher finding three different versions used in research, a 2004 thesis by Gilrain, a 2006 dissertation by Matthews, and a 2010 dissertation by Adwan. The RGEI for Gilrain was on a 6-pt Likert scale (1=slight agreement, 2=moderate agreement, 3=strong agreement, 4=strong disagreement,
5=moderate disagreement, and 6=slight disagreement), the RGEI for Matthews was on a
6-pt Likert scale (1= strong disagreement, 2= moderate disagreement, 3= slight disagreement, 4=slight agreement, 4=moderate agreement, 6=strong agreement), while the RGEI for Adwan was on a 5-pt Likert scale (1= Strongly Disagree, 2= Somewhat
Disagree, 3= Neither Disagree nor Agree, 4= Somewhat Agree, 5= Strongly Agree).
Adwan (2010) stated that the RGEI was modified to fit her purposes. Kamm (1999) does not list the RGEI in her Appendices. For the purposes of this dissertation, the RGEI of
Matthews was used as it is the only one that makes sense based on the questions. For example, I tend to be more irritable since the death of my loved one.
Traditional Couple or Family
Erera (2002) defined traditional couples as patriarchal organizations with a structure that consisted of a male father, a female mother, and their children. She reported that real families could not possibly meet the standards of the ideal traditional family portrayed in popular culture. The author focused on an economic perspective and
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believed that the diversity of families began with governmental tax reduction programs, which accelerated reductions in programs that aided families. The woman's traditional house-maker role was thus diminished as women were increasingly forced to work for necessities. Technological advances influenced cultural developments which spurred the women's liberation movement; these included birth control, abortion, and openness in sexual behavior. Additionally, more job opportunities were created for women and they became more independent. Erera (2002) stated that this new freedom caused a backlash, as she explains “diversity within the family was blamed for things like AIDS, child poverty, low education standards, substance abuse, high homicide rates, infertility and teen homicide rate” (p. 421). This dissertation departed from using traditional couples as participants and instead used contemporary couples, which are defined below.
Contemporary Couples
Glick (1989) reported that couple-hood was defined as the “legal, lifelong, sexually exclusive marriage, between one man and one woman” (p. 124). Garner (2016) in Black Law’s Dictionary, defined a family as
A group of individuals who share ties of blood, marriage, or adoption; a group residing together consisting of parents, children, and other relatives by blood or marriage; a group of individuals residing together who have consented to an arrangement like ties of blood or marriage” (p. 326)
The Merriam-Webster Dictionary (2016) defined a couple as “two persons married, engaged, or otherwise romantically paired; two persons paired together” (p. 286) and the definition for a family was a “group consisting of parents and children living together in a household” (p. 452). Morris (2016) defined a family as, “two or more people who share goals and values, have long-term commitments to one another and reside usually in the
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same dwelling” (p. 637). Bowen identified that the family operated as a
“multigenerational network of relationships” (Nichols, 2010, p. 127).
The literature pointed to several other definitions for contemporary couples.
Erera (2002) stated that contemporary couples are a structure that differs from that of a stereotypical traditional family. Cherlin (2009) suggested that a new style of marriage was emerging, one in which spouses were expected to cultivate a separate sense of self, openly communicate their needs, and take on more malleable roles rather than the rigid homemaker and breadwinner roles. Even though there were various definitions for families and couples as described above, for the purpose of this dissertation this researcher used Erera’s (2002) definition of a contemporary couple and Garner’s (2016) definition of family, which reflected current norms in the larger American culture which was used for this dissertation. This next section will give an overview of different death and dying theories.
Death and Dying Theories Overview
Whether utilizing the tasks of mourning or focusing on the reconstruction of one's meanings, grief can be understood as an opportunity for heightened self-perception
(Robak, 2002). The following models will be reviewed: (a) traditional, (b) grief work, (c) stages of grief, (d) phases of grief, (e) tasks of grief, (f) the biographical model, (g) the dual-process model, (h) the Rando six “R” model, (i) the Grief to Personal Growth
Model, and (j) the Multidimensional model. The only model that includes the family is the (k) Family Focused Grief Therapy model, which will also be included. A brief explanation of each models follows below.
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Traditional Models
Erich Lindemann, who coined the term ‘grief work’, was a psychiatrist who studied grief, doing research working with grieving survivors of the Coconut Grove tragedy (Satin, 1984). Lindemann (1944) was interested in understanding the symptomology of grief and focused on symptoms clusters. Through his research he established some common symptoms of grief which included the following: (1) somatic distress, (2) preoccupation with images of the deceased, (3) guilt, (4) hostile reactions, and (5) loss of pattern of conduct (Lindemann, 1944). He also noted a sixth, less common reaction, in which traits of the deceased person would appear in the bereaved person (Lindemann, 1944). Next, Sigmund Freud’s grief work will be outlined.
Grief work
Sigmund Freud was an Austrian neurologist and the founder of psychoanalysis.
For Freud (1957), grief work involved a process of breaking the ties that bound the survivor to the deceased. This psychic rearrangement involved three elements: (1) freeing the bereaved from bondage to the deceased, (2) readjustment to new life circumstances without the deceased, and (3) building of new relationships. The emphasis in Freud’s ideas on grief was about personal attachment (Freud, 1957). The theory stressed that grieving individuals are searching for an attachment that has been lost
(Freud, 1957). He described mourning as detachment from the loved one (Freud, 1957).
Freud began the foundation of the grief work model, then Bowlby expanded this concept.
Edward John Mostyn Bowlby, the founder of attachment theory, was a British psychologist, psychiatrist, and psychoanalyst believing that early childhood attachments played a critical role in later development and mental functioning (Stevenson-Hinde,
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2007). Bowlby (1980) recognized that a continued attachment to the deceased was the norm rather than the exception. Bowlby’s grief work included the following: numbing, yearning, disorganization, reorganization (Bowlby, 1961). Following will describe the
Phases of Grief.
Phases of Grief
John Bowlby and his colleague Colin Murray Parkes broke down Bowlby’s adaptive grief response into four phases of grief, with Bowlby starting with three and
Parkes adding a fourth (Maciejewski, Zhang, Block, & Prigerson, 2007). The phases included the following: (1) shock and numbness, (2) yearning and searching, (3) disorganization and despair, and (4) reorganization and recovery (Parkes, 1986). Bowlby and Parkes suggested that if we are restricted from going through the phases of grief, we will continue to be consumed by depression, anger, and that our outlook toward life will remain hopeless and negative (Maciejewski et al., 2007). Kübler-Ross was strongly influenced by Bowlby and Parkes, describing a 5-stage response of terminally ill patients to awareness of their impending death (Maciejewski et al., 2007).
Stages of Grief
Commonly known as the five stages of grief based on the 1969 work with Kübler-
Ross, a Swiss-American psychiatrist, developed from her interviews with terminally ill patients, which is arguable the best-known model to the general public. The five stages included the following: denial (“not me”), anger (“why me”), bargaining (exchange something for more time), depression (mourning the lost opportunity), and acceptance
(reconciliation “okay it is me”) (Kübler-Ross, 1969). There has been much criticism for this model since it was originally published, partially by the gerontology aging expert Dr.
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Robert Kastenbaum who found no evidence in his research that people move from Stage
1 to stage 5 (Corr, 2014). The next will be addressed William Worden’s Tasks of Grief.
Tasks of Grief
J. William Worden was a founding member of the Association of Death
Education and Counseling (ADEC), an innovator in the hospice movement in the US, and pioneered psychosocial oncology (Worden, 2005). Worden (2008) suggested that grieving should be considered an active process that involved engagement with four tasks: (1) the individual needed to accept the reality of the loss and that reunion was not possible, (2) the individual had to experience the pain of grief, (3) the individual needed to adjust to the environment where the deceased is missing. The consequences of the death may be enormous (emotionally and financially), and the bereaved may be forced to adopt a completely new lifestyle, and (4) the individual needed to relocate the deceased and invest in a new life (Worden, 20008). The following will discuss the biographical model.
Biographical Model
Tony Walter challenged contemporary grief models by analyzing his own experiences to suggest an alternative, more sociological model where the grief stricken integrated the memory of the deceased in their ongoing lives (Walter, 1996). The purpose of grief is not to move on without those who have died, but to find a safe place for them. Bereavement is part of the reflexive colloquy with others and self through which one makes sense of their existence. Walter (1996) stated “In other words, bereavement is part of the process of (auto) biography, and the biographical imperative the need to make sense of self and others in a continuing narrative is the motor that drives
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bereavement behavior” (p. 20). Religion can control what kinds of conversations about the dead are tolerable with gender being a further variable (Walter, 1996). The dual process model will be described next.
Dual-Process Model
This model was based on a paper by Margaret Stroebe and Henk Schut presented at the 1995 Meeting of the International Work Group on Death, Dying and Bereavement.
The Dual Process Model of Grief (Stroebe & Schut, 1999) was developed from a cognitive stress perspective and was the first to state that there were no defined stages of grief. The Dual Process Model described grief as a process of oscillation between two contrasting modes of functioning (Stroebe & Schut, 1999). In the ‘loss orientation’ the griever engaged in emotion-focused coping, exploring and expressing the range of emotional responses associated with the loss (Stroebe & Schut, 1999). At other times, in the ‘restoration orientation’, the griever engaged with problem-focused coping and is required to focus on the many external adjustments required by the loss, which included diversion from it and attention to ongoing life demands (Stroebe & Schut, 1999). The
Rando six “R” model will be outlined next.
Rando six “R” model
Therese A. Rando has written over 80 books pertaining to the clinical aspects of thanatology and is the director of the institute for the study and treatment of loss
(Pearlman, Wortman, Feuer, Farber, & Rando, 2014). This model had three phases: avoidance, confrontation, and accommodation (Rando, 1993). In avoidance the bereaved must recognize the loss by acknowledging and understanding the death. (Rando, 1993).
The confrontation phase involved reacting to the separation, recollecting and
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reexperiencing the deceased, and relinquishing the old attachment, while in the accommodation phase the griever needed to readjust and readjust to their new live without the deceased (Rando, 1993). The Grief to Personal Growth model will be explained next.
Grief to Personal Growth Model
Nancy Hogan and Lee Schmidt from the University of Miami sees grief as one approach to understanding how people grow as a result of loss (Hogan, & Schmidt,
2002). The model delineated a pathway through grief that indicated the bereft experience despair and detachment, followed by intrusive thoughts, and later avoidance of intense preoccupation with grief (Hogan, Greenfield, & Schmidt, 2001). Social support was shown to facilitate the bereft as they reconstruct their lives and found new meaning in life
(Hogan et al., 2001). A second path indicated that some bereaved individuals become mired in grief and need help to proceed toward personal growth (Hogan et al., 2001).
Next the multidimensional model is reviewed.
The Multidimensional model
The multidimensional model by Susan Le Poidevin’s refined the phases of grief while working at St. Christopher’s Hospice with Parkes (Parkes, 1996). Susan Le
Poidevin’s model conceptualized grief as a process of simultaneous change explained by seven dimensions in terms of (1) emotional, (2) social, (3) physical, (4) lifestyle, (5) practical, (6) spiritual, and (7) identity (Payne et al., 1999). By identifying the main areas of each dimension that are affected, individuals and those offering support could gain understanding of the grieving person’s circumstances and their grief reactions (Payne et al, 1999). The following questions are pondered for each dimension, was the griever at
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ease with showing emotions or did they believe in emotional control (emotional), what was the impact on physical health (physical), did the loss caused financial problems
(lifestyle), how were everyday practicalities managed (practical), what meaning had been ascribed to the loss (spiritual), and how had the loss affected self-esteem (identity) (Payne et al., 1999). Finally, the family focused grief therapy will be examined.
Family Focused Grief Therapy
The family focused grief therapy model was a preventive intervention designed for families at high risk of poor functioning during palliative care and bereavement
(Chan, 2004). Its intervention is aimed to enhance the functioning of the family through the exploration of the family's cohesiveness, communication of thoughts and feelings, and resolution of conflict (Chan, 2004). As the story of illness and related grief is shared, its impact on family functioning is observed. There are three sequential phrases: assessment involved identification of issues and negotiation of a therapeutic plan, intervention focused on agreed concerns, and termination incorporated consolidation and termination (Chan, 2004).
Summary of Grief Theories
All of the models presented suggested a process, phase, stage, or task which share a linear structure flowing to an endpoint. The final stage provides a detachment from the loss, a sense of closure or an ability to move on with a reference to a new life. So that life can be regrouped and meaningful again, most models implied that the bereft need to engage with their loss and work through it. All grief models are not good for all people, however, the ‘Kubler-Ross Model’ seems to be the grief model for the masses even though it has been criticized. Models tended to focus on individual with systemic models
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being few and far between. Since this dissertation was written as partial fulfillment for a
Couple and family Therapy program and must be viewed from a systemic approach, the next section describes why viewing grief from these interrelated parts is important.
Systemic Approach
A careful review of the literature from the time period of Kamm’s 1999 dissertation regarding parental bereavement, provides limited understanding of bereavement in relational terms as it applies to communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction. Kissane and Bloch
(1994) reported that empirical literature for systemic research on family bereavement was uncommon. It remained limited in scope and quantity during this period, while Stafford and Dainton (1995) stated that research reflected a need for a more systemic approach.
Along with limited research on parental bereavement, fathers were often overlooked, while the primary focus was on the mother (Rando, 1983; Stafford & Dainton 1995). A systemic approach, in this case intergenerational in nature, is critical to understanding bereavement processes which can be the impetus of an "emotional shock wave" (Kerr &
Bowen, 1988, p. 322). In 1978, Bowen described the emotional shock wave as a network of underground ‘after shocks’ 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 (p. 325).
Bowen family systems theory (BFST) is an intergenerational theory of human behavior that examines the family as an emotional unit and uses systems thinking to define the intricate interactions in the unit (Kerr & Bowen, 1988). According to Brown
(1999):
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A Bowen family system view of death considered the impact the death of an individual has for the family as a functional unit; a unit where each member’s coping and development is interdependent, hence any death will have immediate and long-term reverberations for every member and all other connected relationships. Grieving a death is much bigger than a response within an individual. (p. 158)
While Kamm’s (1999) approach was non-theoretical in nature, this writer has utilized a single theoretical lens, the BFST approach. The history of Dr. Murray Bowen’s founding of BFST itself will be examined in more detail below as it is important to understand how his history may provide insight into his theory.
Murry Bowen: Founder of the Bowen Family System Theory (BFST)
Dr. Murray Bowen, the founder of the Bowen approach, was born in rural
Tennessee on January 31, 1913 (Capuzzi & Gross, 2003). In 1949, he began a five-year research project studying relationships between schizophrenic patients and their mothers that emphasized emotional sensitivity (Nichols, 2010). He observed cycles of closeness and distance, which he referred to as the pursuer-distance dynamic (Gurman & Jacobson,
2002). Dr. Bowen broadened his focus in the 1950s to include a larger group of patients and their entire families (Nichols, 2010). Dr. Bowen’s emphasis was an intergenerational model of psychopathology based on the notion of a universal continuum (Winek, 2010).
The goal was not symptom-reduction, but improving the intergenerational transmission process (Winek, 2010). Nichols (2010) stated, “Bowen family systems therapy has by far the most comprehensive view of human behavior and human problems of any approach to family treatment” (p. 137). Friedman (1987) suggested that Bowen’s theory is not about family per se, but about life.
In 1959, Bowen began a thirty-one-year career at Georgetown University’s
Department of Psychology, where he refined his model of family therapy and trained
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numerous students, including Phil Geurin, Thomas Fogarty, Betty Carter, Monica
McGoldrick, and Michael Kerr, where he gained international recognition for his leadership in the field of family therapy. Bowen presented at the Family Research conference in 1967 illustrating his model with his own family of origin, which was unheard of at the time (Brown, 1999). He became a Clinical Professor, was Director of
Family Programs, and in 1975 founded the Georgetown Family Center. After contributing much to the discipline of couple and family therapy, he died of lung cancer in October 1990 (New York Times, 1990). The theoretical concepts of Bowen are discussed below.
Theoretical Concepts of Bowen Family System Theory (BFST)
BFST posits that conflicts and roles are transmitted from generation to generation and these transgenerational patterns influence such things as chronic anxiety levels, intellectual/emotional functioning, and mate choices (Kerr & Bowen, 1988). The family is the emotional unit of interlocking relationships that are understood from a historical perspective (Kerr & Bowen, 1988). The central premise is that unresolved emotional attachment to one’s family of origin must be resolved before one can differentiate a mature, healthy personality (Nichols, 2010). It specifically centers around two counterbalancing/competing life forces: togetherness (need for companionship) and individuality (need for independence) (Gurman & Jacobson, 2002; Nichols, 2010).
This theory can be used with individuals, couples, and families. However, typically it is the conjoint couple that would work on attaining insight and making the unconscious conscious (Nichols, 2010). The model focuses on strength and not pathology (Gurman & Knishern, 1991; Nichols, 2010). In this theory, there is a high
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premium placed on the balance between separateness and togetherness and it includes several assumptions (Kerr & Bowen 1988). First, the present is influenced by the past
(Kerr & Bowen 1988). Issues are ongoing and maintained by recurrent patterns (Piercy,
Sprenkle, Wetchler, & Associate, 1996). Second, change happens, and individuals can move along in the process of differentiation. Differentiation is internal and relational—it is isomorphic and recursive (Kerr & Bowen 1988). Third, anxiety inhibits change and needs to be reduced to facilitate change (Kerr & Bowen 1988). High intimacy and high autonomy are ideal (Kerr & Bowen 1988). Fourth, emotions are a physiological process, while feelings are the thoughts that name and mediate emotions, giving them meaning
(Kerr & Bowen 1988). Finally, symptoms are indicators of stress, chronic anxiety, and lower differentiation (Kerr & Bowen 1988). Anyone will become symptomatic with enough stress; however, more differentiated people can withstand more stress and, when they do become symptomatic, they recover more quickly (Piercy et al, 1996).
BFST is based upon eight interlocking concepts that describe separate facets of the total system (Kerr & Bowen, 1988). The eight concepts include the following: (1) differentiation, (2) triangles, (3) nuclear family emotional process, (4) family projection process, (5) multigenerational transmission process, (6) sibling position, (7) emotional cutoff, and (8) emotional processes in society (Kerr & Bowen, 1988). Six of these concepts address emotional processes occurring in nuclear and extended families
(differentiation of self, triangles, nuclear family emotional system, family projection process, multigenerational transmission process, sibling position), while the remaining two concepts address emotional processes across generations (in a family) and in society
(emotional cutoff, societal regression) (Gehart & Tuttle, 2003; Nichols 2010; Winek,
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2010). Bowen’s concept of differentiation was discussed below. This idea was a key concept along with emotional reactivity to conceptualize the constructs of grief related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction for this dissertation.
Differentiation
Differentiation is the cornerstone of the theory and the other concepts revolve around it (Papero, 1998). Papero (1998) stated that it is the degree of autonomy given the pressures of togetherness and the degree to which the individual has control over feeling states and behaviors. Differentiation may be seen, as the lifelong process to balance the internal and external processes of self-regulation (Gurman & Kniskern, 1991). Highly differentiated people react to the world rationally and are not ruled by their emotions, hence the term emotional reactivity (Kerr & Bowen, 1998). Differentiation is the ability to maintain self in the face of high anxiety (i.e. remain autonomous in a highly emotional situation) (Kerr & Bowen, 1998). Differentiation of self is the way humans handle the relationship between intellectual and emotional functioning (Kerr & Bowen, 1998). The ability to choose between intellectual functioning and emotional functioning gives one greater adaptation and resourcefulness when under stress (Bowen, 1978). Differentiation occurs on a continuum, with the low-end representing emotion and intellect so fused that one’s life is dictated by emotionality (Kerr & Bowen, 1998).
According to Friedman (1991), “differentiation is a lifelong process of striving to keep one’s being in balance through the reciprocal external and internal processes of self- definition and self-regulation” (p. 141). At the high end, individuals possess the ability to stay connected while being separate, along with the facility to stay rational in the face of
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strong emotion (Kerr & Bowen, 1998). Bowen defined anxiety as the organism's response to a real (acute anxiety) or perceived threat (chronic anxiety) and manifest itself by "emotional reactivity" (Kerr & Bowen, 1988, p. 113). A high premium is paid to facilitating change and decreasing emotional reactivity through a balance of intellectual and emotional functioning (Kerr & Bowen, 1998). Winek (2010) reports that “The more differentiated a self, the more a person can be an individual while in emotional contact with the group” (p. 83). Levels of differentiation are affected through generations, based on levels of differentiation of partners as they marry (Gurman & Jacobson, 2002;
Nichols, 2010).
Undifferentiated people have trouble managing anxiety and stress (Gurman &
Jacobson, 2002). Lack of differentiation increases chronic anxiety within the system and fusion between the spouses (Gurman & Jacobson, 2002). Emotional fusion is unstable and tends to produce the following: overt relationship conflict, reactive emotional distance, physical or emotional symptoms, and projection of problems on to children
(Gurman & Jacobson, 2002). This fusion between two people generates more chronic anxiety as one becomes more sensitive to what the other feels, thinks, or does (Bowen,
1978). The child who is the most emotionally attached to his/her parents is likely to be the object of parental projection and thus will have lower levels of differentiation
(Gurman & Jacobson, 2002; Nichols, 2010). Bowen believed that a minimum amount of fusion or distance is used to solve problems (Gurman & Jacobson, 2002). Bowen’s concept of triangles is discussed below.
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Triangles
A triangle is a network of relationships among three people (Kerr & Bowen,
1998). Two-person dyads are unstable since both persons must cooperate to make it work and as a result chronic anxiety is the driving force behind emotional triangles
(Gehart & Tuttle, 2003; Nichols, 2010). Triangles are linked closely with Bowen's concept of differentiation, in that the greater the degree of fusion in a relationship, the more heightened is the pull to preserve emotional stability by forming a triangle (Brown,
1999). Triangling is said to occur when the predictable anxiety in a dyad is relieved by involving a vulnerable third party who provides a detour for the chronic anxiety (Guerin,
Foggarty, Fay, & Kautto, 1996). An unstable two-person system will pull in a third person when there is stress or anxiety to gain stability (Gehart & Tuttle, 2003; Nichols,
2010). This temporarily reduces the anxiety; triangles can be temporary or fixed (Gehart
& Tuttle, 2003; Nichols, 2010). Triangulation freezes conflict in place and becomes a chronic diversion that undermines relationships (Gehart & Tuttle, 2003; Nichols, 2010).
There are four possible outcomes of triangulation: (1) stable twosome can be destabilized by the addition of third member (bringing conflict), (2) stable twosome can be destabilized by removal of third member (detriangulation), (3) unstable twosome can be stabilized by addition of third member (more harmonious), (4) and unstable twosome can be stabilized by removal of third member (conflict reduced) (Nichols, 2010).
When differentiation is low, or chronic anxiety is high, the triangling can become more intense (Kerr & Bowen, 1998). If the anxiety increases between the members of a triangle, yet another person is brought in, and so forth; thus, creating an interlocking pattern which may extend outside the family (courts, social service agencies). Most
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family problems are triangular (Nichols, 2010). For example, teaching a mother, better parenting techniques will not resolve the problem if she is over-involved with her son because of her husband’s emotional distance (Nichols, 2010). The lower the adaptive level of functioning or ability to cope with stress in a system, the more likely the people in the system will triangulate (Gurman & Jacobson, 2002; Nichols, 2010). The person with the least differentiation of self, who is the most vulnerable, will be the person most likely to get triangulated into some other dyad (Kerr & Bowen, 1988). Bowen’s concept of nuclear family emotional process is discussed below.
Nuclear Family Emotional Process
Nuclear family emotional process refers to the patterns of emotional functioning of a family (Kerr & Bowen, 1988). It is the most basic unit in society (Winek, 2010).
The emotional functioning of the family focuses on patterns that tend to play out in recurrent patterns (Kerr & Bowen, 1998). Nuclear family emotional system describes the range of relationship patterns in the system between parent and child (Kerr & Bowen,
1998). The pattern is likely to repeat the patterns of past generations, as well as to be repeated in future generations (Kerr & Bowen, 1998).
Undifferentiated family ego mass refers to the family as an emotional unity
(emotionally stuck together) or an interlocking relationship system (excess of emotional reactivity or fusion) (Gehart & Tuttle, 2003; Nichols 2010; Winek, 2010). When one is anxious, there is pressure for greater closeness or distance (Papero, 1998). The more intense the fusion, the more likely one will experience chronic anxiety and potential instability, hence the greater need to seek resolution through fighting, distancing, or banding together over concern for a child (Kerr & Bowen, 1988). Lack of differentiation
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in family constrains members’ ability to regulate emotionality and manage chronic anxiety (Kerr & Bowen, 1988). Bowen’s concept of family projection process is discussed below.
Family Projection Process
The family projection process describes the patterns through which parents project their problems or lack of differentiation to the children (Kerr & Bowen, 1988).
Parents tend to have relationships with their children that resemble those that their parents had with them (Kerr & Bowen, 1988). Emotional fusion between a couple leads to conflict, emotional distance, or reciprocal over-and-under functioning (Nichols, 2010).
Couples with unresolved family of origin issues create a family environment in which there is an intense focus on one or more children (Nichols, 2010). The ability to adapt is limited because of the intense focus of parental anxiety onto the child (Nichols, 2010). A child who is the object of projection becomes the child most attached to his/her parents and has the least differentiation of self (Gehart & Tuttle, 2003; Nichols, 2010; Winek,
2010). Bowen’s concept of multigenerational transmission is discussed below. This concept is a minor concept used to conceptualize the constructs of grief related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction for this dissertation.
Multigenerational Transmission Process
The multigenerational transmission process gives BFST its multigenerational emphasis and perspective (Gehart & Tuttle, 2003; Nichols, 2010; Winek, 2010). It describes the present context as derived from the past. The multiple generation transmission process describes the overall pattern of the family projection process as it
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involves certain children and avoids others (Kerr & Bowen, 1988). It looks at the family projection process across generations as it proceeds over multiple generations (Kerr &
Bowen, 1988). Familial emotional functioning patterns are repeated and maintained over generations (Gehart & Tuttle, 2003; Nichols 2010; Winek, 2010). Symptoms are a natural expression of chronic anxiety (Gehart & Tuttle, 2003; Nichols 2010; Winek,
2010). Symptoms are relieved by addressing the underlying chronic anxiety (Gehart &
Tuttle, 2003; Nichols 2010; Winek, 2010). The child who is most involved or fused moves toward lower levels of differentiation of self and the least involved child moves toward higher levels of differentiation (Gehart & Tuttle, 2003; Nichols 2010; Winek,
2010). Bowen’s concept of sibling position is discussed below.
Sibling Position
Sibling position provides important clues in predicting areas of family strength and weakness (Toman, 1961). Specific qualities/characteristics are attributed to a specific birth order or sibling position (Kerr, 1988). For example, firstborns identify with power and authority, which causes them to relate to siblings by dominating them (Gehart
& Tuttle, 2003; Nichols 2010; Winek, 2010). Firstborns may tend to be more self- confident than those born later (Gehart & Tuttle, 2003; Nichols 2010; Winek, 2010).
Later born children are more open to experience and may be rebellious (Gehart & Tuttle,
2003; Nichols 2010; Winek, 2010). They are more likely to identify with the oppressed and challenge the status quo (Gehart & Tuttle, 2003; Nichols 2010; Winek, 2010). These can become postures that people assume to manage undifferentiation in a relationship
(Kerr & Bowen, 1988). Children develop fixed personality characteristics depending on sibling position in the family (Toman, 1961). Sibling position determines the triangles
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one grows up in during childhood (Gehart & Tuttle, 2003; Nichols 2010; Winek, 2010).
Bowen’s concept of emotional cutoff is discussed below.
Emotional Cutoff
Emotional cutoff describes the most prominent mechanism involved in emotional processes between the generations (Kerr & Bowen, 1988). Individuals employ emotional cutoff or physical distance from the family of origin to insulate themselves from the effects of undifferentiation; however, it does not change one’s level of differentiation
(Kerr & Bowen, 1988; Papero, 1998). Kerr (1981) contends that emotional cutoff reflects a problem (underlying fusion), solves a problem (reducing anxiety), or creates a problem (isolating potential close contacts). The person cut off may look/feel independent from the family, but is not (Kerr & Bowen, 1988). People who cut off from their original families are more likely to repeat the same patterns in their own relationships (Kerr & Bowen, 1988). Bowen stressed the importance of resolving emotional attachments to their families of origin (Gehart & Tuttle, 2003; Nichols 2010;
Winek, 2010).
When individual choices are set aside in the service of achieving harmony with the system that can be described as emotional fusion (Kerr & Bowen, 1988). This is expressed as a sense of intense responsibility for another’s reaction or by emotional cutoff (Bowen, 1978). Fusion or lack of differentiation occurs when thoughts and feelings are not distinguished (Bowen, 1978). Bowen's research led him to suggest that varying degrees of fusion are discernible in all families (Kerr & Bowen, 1988). Fusion does not reflect the overall structure of family relationships; rather, it describes each person’s reactions within a relationship. A person in a fused relationship reacts to the
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perceived demands of another person immediately, without thinking over the choices or discussing them over with the other person (Brown, 1999). Hence, anxiously cutting off the relationship is as much a sign of fusion as intense submissiveness (Brown, 1999).
Emotional Processes in Society
Emotional processes in society include the pressure that society puts on togetherness and individuation (Kerr & Bowen, 1988; Papero, 1998). The larger society influences family dynamics (Kerr & Bowen, 1988). Social processes in families influence emotional processes in families (Kerr & Bowen, 1988). A family’s emotional processes are influenced by events and emotional processes that occur on the larger, societal level. Social forces (including sexism, racism, and poverty) fundamentally influence how families interact with each other (Gurman & Jacobson, 2002; Nichols,
2010). Criticisms surrounding multicultural issues have surfaced (Papero, 1998). The economic status of a family may influence the level of anxiety; however, the basic processes remain the same (Papero, 1998).
There is a belief that society responds emotionally during periods of stress and anxiety, offering short-term solutions rather than seeking more rational solutions that lead to greater individuation. As societies respond to chronic anxiety, they become more reactive and less differentiated (Gehart & Tuttle, 2003; Nichols 2010; Winek, 2010). The primary task of the individual is to have contact with the family, while remaining separate from it (Kerr & Bowen, 1988). The emotional process in society describes the extension of family emotional process into larger social systems. (Kerr & Bowen, 1988;
Nichols 2010). Bowen’s eight interlocking concepts are discussed above. For the purpose of this study, these concepts (differentiation, emotional reactivity, and
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multigenerational transmission process) were specifically used to conceptualize the constructs of grief related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction; however, the eight interlocking concepts of Bowen are included to give the reader a sense of how the concepts work together.
In summary, people vary in their receptiveness to making decisions as a group and groups differ in the amount of pressure they apply in pursuit of conformity. These variances reflect the level of differentiation between groups along with individual differences in how people think, feel, and act. The fundamental building block of larger emotional systems is the triangle, the three-person system. The four fundamental relationship patterns govern the nuclear family emotional system are marital conflict, one spouse dysfunction, child impairment, and distance or isolation. Parents convey their emotional problems to children through the family projection process. Variations in differentiation between parents and children are passed down through generations via the multigenerational transmission process. Bowen observed the influence of sibling position on behavior and development. Emotional cutoff occurs as an attempt at managing unresolved emotional issues between family members. Emotional processes in society govern behavior on a societal level.
This researcher is drawn to Bowen’s (1978) concept of an open communication style in which individuals are free to communicate thoughts and feelings reciprocally with another. Bowen (1976) highlighted the importance of family communication as a determinant within patterns of bereavement. Communication is either open or closed, and mourners withdraw into themselves if communication is closed (Bowen, 1976).
These closed patterns adversely impact the family, and as a result the grieved avoid their
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families (Bowen, 1976). Bowen (1976) thus recommended the bereaved should be explicit and direct in their use of language. The next section will explore the complementary concepts of BFST (differentiation, emotional reactivity, and multiple generation transmission process) in relation to the independent variable (grief related communication) and the dependent variables (grief related communication, grief reaction, guilt, and marital satisfaction). The next section will link Bowen’s BFST concepts to the four constructs within this dissertation: grief related communication, parental adaptation
(grief reaction), parental adaptation (guilt), and relationship satisfaction.
Derivation of General Research Hypotheses
The BFST concept of differentiation, emotional reactivity, and multiple generation transmission process is a useful framework to operationalize the variables of grief-related communication, parental adaptation (grief reaction), parental adaptation
(guilt), and relationship satisfaction within this dissertation. Kerr & Bowen (1988) hypothesized that family members often have difficulty separating their emotions and rational thoughts when a situation (like the death of a child) or relationship is high in emotional content. The multigenerational transmission process gives BFST its multigenerational emphasis and perspective as it describes the present context as derived from the past (Gehart & Tuttle, 2003; Nichols, 2010; Winek, 2010) and can provide a sub-context for bereaved parents whose child has died.
According to Friedman (1991), one’s inability to tolerate chronic anxiety is an important component related to problems and symptoms that develop in individuals and families. The antidote for these problems is the ability to become differentiated. Faced with a deeply anxiety-provoking situation like the death of a child, people can choose to
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moderate their emotional reactions based upon their level of differentiation (Bowen,
1978). The next section will discuss grief related communication as viewed through
Bowen’s concepts of differentiation and emotional reactivity.
Grief-Related Communication
The death of a close family member is often a life-wrenching event (Bowen,
1978). Brown (1989) wrote that many family emotional reactions and long-term adjustment difficulties arising from death originate in the lack of openness in the system.
Communication is either open or closed, and grievers draw into themselves if communication is closed (Bowen, 1976). Bowen (1978) defined a closed communication system as one in which the person is not “free to communicate a high percentage of inner thoughts, feelings, and fantasies to another who can reciprocate” (p. 322). These closed patterns negatively influence the family, and as a result, mourners avoid their families
(Bowen, 1976). Bowen (1976) recommended the bereaved should be direct and explicit in their use of language. Bowen (1978) believed that the closed communication system is amenable to change. It is important to understand the nature of a closed system.
In a closed system people cannot communicate their thoughts lest they upset the family or others (Bowen, 1979). Kerr and Bowen (1988) pointed out that anxiety and emotional reactivity are often used interchangeably in family systems theory. Emotional reactivity refers to acting automatically based on emotions and feelings rather than making choices through thoughtful reflection (Kerr & Bowen, 1988). Bowen (1978) went on to say, “I have chosen the concept of ‘open’ and ‘closed’ relationship systems as an effective way to describe death as a family phenomenon” (p. 322). By openness,
Bowen (1978) meant “the ability of each family member to stay nonreactive to the
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emotional intensity in the system and to communicate his or her feelings to the others without expecting the others to act on them” (p. 472).
Kerr & Bowen (1988) reported that “the lower the degree of differentiation, the greater the instability of the relationship balance and the less its capacity to adapt to change” (p. 71). A couple’s level of differentiation is related to their level of openness or closedness in communication and the ability to communicate impacts the level of differentiation (Bowen, 1978). Rosen (1990) and Shapiro (1994) asserted that Bowen’s concepts provide a useful tool for assessing and promoting family members’ ability to tolerate one another’s grief experiences and individual ways of expressing these. Bowen indicated that “under circumstances of sufficient stress and anxiety, any family may become less differentiated” and subsequently less able to tolerate expression of differing thoughts or emotions (Rosen, 1984-85, p. 174). The next section will discuss parental adaptation (grief reaction) as viewed through Bowen’s concepts of differentiation and emotional reactivity.
Parental Adaptation Grief Reaction
Bereavement due to the death of a child remains one of the most stressful events for parents (Amour, 2006; Arnold & Gemma, 2008; D'Epinay, Cavall & Spini, 2003;
Wing, Burg-Callaway, Clance, & Armistead, 2001). The impact of bereavement often includes physical, emotional, behavioral, and psychological reactions like sleep disturbance, a general grief reaction, self-destructive behavior, guilt, and the loss of social support (Abi-Hashem , 2017; Barr & Cacciatore, 2008; Barrett & Scott, 1989; Turton,
Evans, & Hughes, 2009). When thinking about the emotional system, Bowen (1978)
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adds the idea of individual variation in the ability to manage and retain adaptive flexibility, which is analogous to differentiation, a core concept of BFST.
Partners with lower levels of differentiation lack resilience, react more emotionally, and have less tolerance for stress (Roberto-Forman, 2008). Bowen (1978) reported that “the basic notion is that different organisms have differing ranges of tolerances to the demand to adapt. Once the tolerance level is surpassed, responses become increasingly rigid and intense” (p. 15). Since couples can engage asynchronous grieving, harmful and negative effects can result from unresolved bereavement
(Bohannon, 1990-91). There is an extreme imbalance between the “overfunctioning” spouse and the “underfunctioning” spouse (Bowen, 1978).
According to Bowen, individuals or families with low differentiation levels are more likely to respond poorly to stress. These individuals are governed by their emotions, which makes them emotionally reactive and “underresponsible for themselves and/or overresponsible for others” (Titelman, 1998, p. 121). Keeping in mind that the death of a child is outside the typical family life cycle and it disrupts the developmental normative procession and generates added stress (Lohan & Murphy, 2006). The next section will discuss parental adaptation (guilt) as viewed through Bowen’s concepts of differentiation and emotional reactivity.
Parental Adaptation Guilt
In our culture, even before the birth of their child, parents feel accountable for their children (Sanders, 1989). Guilt can hinder the healthy progression of mourning
(Buckle & Fleming, 2011) and forecast the level of bereavement intensity experienced by the parents (Ducan & Cacciatore, 2015). Sanders (1989) reported that facing grief and
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openly dealing with guilt can allow one to let go of negative reactions associated with grief. Bowen (1978) distinguished between feelings and emotions. Feelings such as guilt may be a surface awareness of emotions (Kerr & Bowen, 1988). Factors such as stressful life events (like the death of a child) and emotional support (from a partner) can play a part in the relationship between psychological symptoms and differentiation (Krycak,
Murdock, & Marszalek, 2012). According to Murdock and Gore (2004) low levels of differentiation are a strong predictor of psychological distress. Research has repeatedly shown that differentiation is positively correlated with well-being and negatively correlated with manifestations of psychological symptoms (Miller, Anderson, & Kaulana
2004). The next section will discuss relationship satisfaction as viewed through Bowen’s concepts of differentiation and emotional reactivity.
Relationship Satisfaction
It is important to understand the constructs that are happening in grief for the couple whose child has died. One of these constructs is relationship satisfaction. Bowen
(1978) hypothesized that dysfunction and stress are moderated by differentiation.
Toviessi (2003) found emotional reactivity to be the most significant predictor of stress and health. There is a link between differentiation and the ability to cope with stressful events (Murdock & Gore, 2004). Kerr and Bowen (1988) proposed that lower levels of differentiation are the cause of psychological and interpersonal difficulties. Thus, according to the BFST, low levels of differentiation, as indicated by emotional reactivity, would likely result in relationship difficulties (Kerr & Bowen, 1988). According to
Bowen (1978), one’s capacity to achieve support and intimacy in marriage is tied to one’s level of differentiation. Kerr and Bowen (1988) postulated that the amount of social
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support a person has from one’s partner is positively related to his or her level of differentiation. Broadly defined, social support is a system of people on whom an individual can rely for resources intended to improve/maintain one’s well-being
(Schumaker & Brownell, 1984). According to Skowron and Friedlander (1998), there are gender differences in the ways that differentiation difficulties are expressed, with women reporting stronger emotional reactivity and men reporting more problems with emotional cutoff. Skowron (2000) has shown that couples who report greater differentiation of self also report greater marital satisfaction. On the contrary, couples who are more emotionally reactive report more marital discord and distress (Skowron, 2000).
According to Bowen (1978), the greater the disturbance, the greater the emotional reactivity.
In summary, because there is a link between differentiation and the ability to cope with stressful events like the death of a child, Bowen’s concepts of differentiation, emotional reactivity, and multigenerational emphasis are crucial constructs to be measured. Grief related communication is synonymous with closed or open communication systems, while grief reaction is synonymous with adaptive flexibility, which is analogous to differentiation and emotional reactivity. Thus, emotional reactivity can be seen via physical, emotional, behavioral, and psychological responses. Partners with lower levels of differentiation lack resilience and react more emotionally in the face of a stressful situation like the death of child. Guilt may be a surface awareness of emotions and can forecast the level of bereavement intensity. Because lower levels of differentiation are the cause of psychological and interpersonal difficulties along with
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emotional reactivity, the construct of relationship satisfaction is a critical variable to be measured. The significance of the family life cycle (FLC) will be chronicled below.
Family Life Cycle (FLC)
Glick (1989) defined the family as a group of two or more related persons maintaining a common household. We are born into a family, which then provides formative shaping experiences, our first relationships being built within the familial context. With the family being embedded within the larger sociopolitical culture, the individual life cycle takes structure as it moves and progresses within the matrix of the family life cycle (Carter & McGoldrick, 2005). This researcher was interested in investigating the impact of death and bereavement symptoms since she believes this impact is often minimized by American society, especially in cases of miscarriage. This author also conceives that working through bereavement can be complex, especially concerning deaths outside the typical family life cycle (Walsh & McGoldrick, 2004).
The death of a child is outside of the FLC and it is important to conceptualize the loss as such. A brief description of the FLC and its origin will follow.
The FLC is based upon the family development approach, which “enables us to anticipate stresses, which normally and ubiquitously accompany ‘growing up’ families and their members, at the beginning of the cycle and ‘breaking up’ toward the end of the life span” (Hill, 1986, p. 20). The FLC defines predictable stages in family development
(Congress, 2016). Erickson (1998) stated that the FLC “is based upon normative age role expectations for the nuclear family” (p. 343). Families experience a crisis when they pass from one life cycle stage to another (Carter & McGoldrick, 2004). If left unresolved, these crises can lead to family conflict and breakup (Congress, 2016). Rowntree (1906)
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developed a rudimentary stage formulation that was related to the ratio of earners in a small town in England to their dependents over the life span of their families (Rowntree,
1906).
The earliest academic analyses of the FLC appeared in a rural sociology text book and included seven demographic stages (Sorokin, Zimmerman, & Galpin, 1931). Hill
(1948) developed a four-stage model, later expanding it to eight stages. A nine-stage model was then proposed by Hill and Rodgers in 1964. Carter and McGoldrick (1989) discussed important gender and cultural differences in recognizing the changing nature of the life cycle, although they retained the normative nature of the FLC and its dependence on stages. According to Erickson (1989), “Families are becoming so diverse that the very limiting constraints of the FLC idea seem to be failing in their ability to conceptualize the postmodern family” (p. 344).
It is this writer’s view that the concept of FLC has become less relevant for contemporary couples amidst rapid social change. Glick (1989) reviewed the FLC in the context of rapid social change and found that in 1980, the number of unmarried opposite- sex American couples living together had grown by five times since 1960. Glick (1989) also found that the number of births for unmarried women rose steeply over that same period, and he believed that the family structure, while not collapsing, was changing rapidly. Carter and McGoldrick (2005) believed that it was important to stop comparing contemporary structures and life cycles to families of the past. Carter and McGoldrick
(2005) further said that therapists must recognize the extent of familial variations and changing norms that had become widespread.
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In summary, the intellectual and emotional phases one passes through from childhood to advanced years as a member of a family are called FLC. In each stage, one faces challenges in family life that allow one to gain or build new abilities. Gaining these skills helps every family to work through these changes. Not everyone passes through these stages smoothly. Understanding the milestones and skills of each phase allows one to successfully move from one developmental stage to the next. Bereavement that occurs outside the usual FLC stage is difficult and is a focus of this writer’s interest. A review of the developments related to the FLC was discussed along with its limitations for today’s contemporary couples. While changes in families have occurred, the FLC continues to be an important concept to frame bereavement. The next sections outlined the different headers that Kamm (1999) utilized to organize her dissertation. This researcher thought it was key to honor her vision when possible and deviate from it when necessary due to interest or a need for more information due to the short length of Kamm
(1999). The larger notion of bereavement and death is discussed first.
Bereavement and Death
The pioneers of family therapy recognized that cultural forces and current social values shape our thoughts about ourselves, our families, and the outside world (Nichols,
2010). This includes our thoughts about what is "normal" and "healthy" and our expectations about how the world works (Nichols, 2010). However, Bowen was the first to realize that the history of a family creates a template which shapes the values, thoughts, and experiences of each generation of that family, as well as how that generation passes down these things to the next generation (Nichols, 2010).
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Maslow (1943) reported that a human needs food, water, warmth, and rest to survive at his/her basic level. This researcher would add relationships to that list as it is rare for people to thrive without them, an acknowledgment that humans live their lives through relationships. The death of a child is an overwhelming and unfathomable death
(Arnold & Gemma, 2008). Bereavement is the primary emotional reaction to the death of a loved one (Stroebe et al., 2001). Whenever we face death (our own or that of a loved one), we experience bereavement (Martin & Doka, 2000). Cultural background and gender can affect how one understands and approaches the bereavement process
(Neimeyer, Harris, Winokuer, & Thornton, 2011). The death of a child signifies a life- altering event for parents and is an all-encompassing experience (Gilmer, Foster,
Vannatta, Barrera, Davies, Dietrich, & Gerhardt, 2012). Umphrey and Cacciatore (2011) found that friends and family may expect a prompt return to ‘‘normal’’ following the child’s death, indicating a mismatch between societal expectation of the grieving period and that needed by parents. Klass (1988) reports that parents compare the death to an amputation as part of them is gone; thus, a child’s death clearly threatens parental identity.
In summary, death is an inevitable influence in the cycle of life. Because a couple has gone through an excruciating experience together, their relationship itself is an important resource after the death of a child. Parents who outlive a child can feel unsure of their basic competence as a parent. Following are some specific articles (old and new), which examine the impact of death and the symptoms of parental bereavement.
Below was the first of nine headers discussed by Kamm (1999) along with literature from the era of Kamm (1999) and current literature.
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Impact of Death and Bereavement Symptoms
There is a uniqueness and intensity in parental bereavement with physical, emotional, behavioral, and psychological symptoms. This broad range of symptoms has been measured in a variety of ways. The following sections will first review Kamm’s
1999 dissertation literature and then provide a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature, she found the devastating impact of the death of a child, along with normative symptoms of bereavement. Prior research identified that parental bereavement was unique and experienced as a particularly intense type of bereavement that resulted in symptoms that lasted longer and presented a wider variety of symptoms than other bereavement (Clayton, 1984; Fish & Whitty, 1983; Klass
1986). Sanders (1980) found that bereavement among parents surviving the death of a child was more intense than the bereavement following the death of a parent or spouse.
For a period after the death of a child, there were both emotional and physical vulnerabilities in parents (Kocher, 1986). Anger was a shifting emotion in bereavement that alternated with periods of depression (Pine & Brauer, 1986). Depression, prolonged sadness, and despair can become severe, even to the extent that bereaved parents sometimes lost their desire to live (Barrett & Scott, 1989; Pine & Brauer, 1986; Rando,
1986a; Rosen, 1984-85; Rubin, 1993; Saiki, Martinson, & lnano, 1994; Sanders, 1989;
Wheeler & Pike, 1993; Zisook & Lyons, 1988). Parental bereavement was so profound that most parents needed professional assistance to recapture their normal functioning status (Schiff, 1977). Furthermore, unmarried mothers were noted to be particularly at risk since they were unlikely to follow-up with medical professionals (Clyman, Green,
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Rowe, Mikkelsen & Ataide, 1980). Mothers more often than fathers talked about their isolation and about being called upon to give support to others, while fathers discussed their guilt (Clyman et al, 1980). Bereavement symptoms may be normative but can be corrosive to a couple’s union. Following are articles for the current review of the literature on the impact of death and bereavement symptoms.
Current Literature Review
In the Twenty years following Kamm’s 1999 dissertation, the uniqueness, intensity, and prolonged length of grief reactions of parents following the death of a child has not changed (Alam et al., 2012; Dyregrov & Gjestad, 2011; Kamm & Vandenberg,
2001; Martin & Doka, 2000). Parental bereavement due to the death of a child remains one of the most stressful events that individuals can experience in their lifetime.
“Bereaved parents often experience a bereavement that is unexpectedly pervasive, intense, complex, and enduring” (Wing, Burg-Callaway, Clance, & Armistead, 2001, p.
60). The death of a child is the most long-lasting and difficult of all bereavements as it challenges one’s perception of the proper order of the universe (Arnold & Gemma, 2008;
Gorer, 1965). Losing a child can be the most painful and devastating experience of a lifetime (Amour, 2006; D'Epinay, Cavall, & Spini, 2003). In 2005, Arnold, Gemma, and
Cushman studied the ongoing nature of bereavement and found that those who felt their bereavement continue versus those whose bereavement ended (32 percent of the 31 that responded) had a baby that was younger than one year.
Murphy and colleagues (2014) looked at 455 (254 females, 191 males) bereaved parents who lost a child (perinatal versus postnatal) and a control group of 110 participants (64 females, 46 males) who gave birth to a healthy child, through the lens of
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post-traumatic stress disorder (PTSD). They wanted to investigate a wide range of psychological reactions to trauma and to examine gender differences between the control group of parents and the bereaved parents up to five years post death. Bereaved participants were all members of the Danish National Association of Infant Death while the control parents attended the neonatal or maternity ward of two large hospitals in
Denmark. The authors used the Trauma Symptom Checklist (TSC; Briere & Runty,
1989). The instrument is a 35-item scale (4-point Likert scale) which measures trauma- specific and psychological symptoms associated with the death of a child. The checklist measures seven variables: aggression, interpersonal sensitivity, somatization sleep disturbance, dissociation, anxiety, and depression. The predictor variables were gender, age, and two dummy coded variables representing time of death to represent a distinction between the comparison group and the bereaved group. A series of t-tests were also employed to measure the difference between the control group and the bereaved parents on the individual subscales of the TSC.
The authors found that the bereaved parents scored higher on all the TSC subscales. For the main analysis, a multivariate regression analysis was used with the following predicator variables: age, gender, and whether the death was perinatal or postnatal. Bereaved parents experiencing a death displayed more traumatic symptoms than the control group. Problems that may affect interpersonal relationships or interpersonal sensitivity such as isolation and loneliness were the largest contributing variables in bereaved parents whose child suffered perinatal death. The authors found high levels of trauma in bereaved parents versus normative controls 5-year post death.
Bolton et al., (2013) studied bereaved parents who lost an offspring in a motor
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vehicle collision (MVC) to learn whether there was an increase in diagnosed mental disorders or relationship breakup. Datasets used in this study originated from Population
Health Data Repository from the Manitoba Centre for Health Policy in the Faculty of
Medicine of the University of Manitoba. There were 1,458 bereaved parents (572 fathers, 770 mothers, 95 stepfathers, 21 stepmothers) and 1,458 nonbereaved (572 fathers, 770 mothers, 95 stepmothers, 21 stepmothers). The date of the MVC death was scrutinized and used as the index date that was used for parent matching purposes and for delineating the time periods for analysis of outcomes. The authors looked at two time periods (two years prior to offspring death and two years after the offspring death). A generalized estimation equation of regression models used either a negative binomial or a
Poisson distribution. The models examined mental disorder (depression, anxiety disorder, alcohol use disorder, drug use disorder, dementia, suicide attempt, any mental disorders); physical disorder (cardiovascular disease, cancer, chronic obstructive pulmonary disorder, hypertension, diabetes, any physical disorder); social factors (low income, single relationship status); outcomes or negative health (health service utilization: physician visit for mental illness, physician visit for physical illness, hospitalization for mental illness, hospitalization for physical illness), and outcomes to calculate the adjusted prevalence ratios for each outcome of interest. The authors conducted two sets of analyses.
The first set concentrated on the cohort of bereaved parents and compared the adjusted prevalence ratio for the outcomes of interest between those in the 2-year post- death period with those in the 2-year pre-death period. The second set of analyses compared the nonbereaved parents with the matched bereaved parents using timeframe
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(pre-death versus post-death) by parent group (nonbereaved versus bereaved) interaction terms. The authors found that following post-death the prevalence of depression rose
10.9 percent to 31.3 percent, anxiety disorders rose by 45 percent, physical disorders were observed (cancer and hypertension), parents were more likely to be single in the two years after death, and physician visits for mental health increased. It should be noted that this research was on offspring death and not fetal death.
Martin and Doka (2000) reviewed physical, affective, cognitive, and behavioral reactions to bereavement. Physical reactions included tiredness, exhaustion, muscular aches, headaches, nausea, and menstrual irregularity. Affective reactions included anger, sadness, guilt, jealousy, anxiety, and fear. Cognitive reactions included apathy, inability to concentrate, and obsessive thinking. The many behavioral experiences included crying, illness, outward expression of emotion, social withdrawal, accidents, searching behaviors, absentmindedness, and increase in the use of alcohol or other drugs.
In summary, the current studies reviewed above showed similar findings to those of previous literature for the impact of death and bereavement symptoms. The death of a child is the most difficult bereavement. There is an increase in aggression, interpersonal sensitivity, somatization, sleep disturbance, dissociation, and anxiety. The next section will explore bereavement and divorce even though this construct was not measured in
Kamm’s 1999 dissertation nor will it be measured in this dissertation; however, the review of the literature is relevant.
Bereavement and Divorce
Given the strain and pile-ups stressors that the tragedy of losing a child may produce, is it inevitable that these couples will divorce? If the death of a child affects a
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couple’s relationship so severely it ends in divorces or separation, this affects the family structure and it would be critical to the counseling profession. The following sections will first review Kamm’s 1999 dissertation literature and then a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature she found that although empirical studies providing accurate information about divorce rates among bereaved parents were lacking, research demonstrated that relationship tension and discord were common among grieving parents (Bohannon,1990-91; Fish, 1986; Kaplan, Grobstein, & Smith,
1976; Klass, 1986; Koocher & O'Malley, 1981; Lang & Gottlieb, 1993; Najman, Vance,
Boyle, Embleton, Foster, & Thearle, 1993; Rando, 1991). There is evidence to suggest that the way husbands and wives grieve and perceive death can result in misunderstandings (Lang, Goultet, & Amsel, 2004). These misunderstandings can affect the couple’s relationship and thus decrease the ability of each to be a primary source of support for the other (Lang, Goultet, & Amsel, 2004). Research by Videka-Sherman and
Lieberman (1985) found that nearly half of parents, following the death of a child, mentioned relationship problems. Klass (1986) reported that the divorce rate among bereaved parents was 50-70 percent. Lang and Gottlieb (1991) observed that bereaved couples experienced bereavement symptoms at different times which caused stress between them. Najman et al., (1993) reported that bereaved parents’ relationships were less than satisfactory after the death of a child. The next section will review the current literature on bereavement and divorce.
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Current Literature
Eilegard and Kreicbergs (2010) challenged the idea that bereavement is associated with an elevated risk of divorce and found that bereaved parents were found to be significantly more likely than controls to be married to, or living with, their child’s other parent. However, Lynstad (2013) found that bereaved parents had a higher rate of divorce than other parents. In this study, the author found that bereaved couples ran a
60% higher risk of divorce than non-bereaved couples. The bereaved parents in this study had various negative psychosocial outcomes and were impacted by this event for many years. Arnold and Gemma (2008) found that a wide range of marital changes occur in these couples including significant distancing and subsequent divorce. These changes are due to the complex, ongoing, and non-linear processes of bereavement. Rogers’ 2005 dissertation found that divorce rates were higher for women who had other children in the home as these women had lower social support. Furthermore, she found that parents who experienced the death of an infant divorced at a higher rate than a control group.
Bolton et al., (2013), whose article has been discussed earlier in this literature review, reported that bereaved parents were more likely to divorce or separate than were nonbereaved parents. More specifically, the authors found that parents were more likely to be single after the death of an offspring, than they were two years prior to the death of their offspring.
Bolton et al., (2013) looked at outcomes for three cohorts: (1) parents bereaved by the suicide of an offspring (2) nonbereaved parent controls, and (3) parents who had offspring die in a motor vehicle accident. The authors collected data at two time periods: two years prior to offspring death and two years after the offspring death. They included
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1,415 suicide bereaved parents, 1,415 nonbereaved, and 1,132 motor vehicle collision bereaved parents. Generalized estimating equation models were used to account for correlated observations. The authors reported a significant rate of marital breakup. The rate of single status increased by 18 percent after the death of an offspring. This study did not examine fetal death. Gender difference were not examined in this study.
In summary, the studies reviewed above found that bereaved couples were more likely to divorce than nonbereaved couples. The current literature is a departure from the older literature where articles found that there was not enough data to accurately predict divorce. The devastation of this death is still seen within the current literature. The next section will explore grief reactions and gender differences.
Grief reaction and Gender Differences
The death of a child is a devastating experience, exhausting parents’ adaptive capacities (Kamm, 1999). Kamm (1999) examined gender differences and grief reactions. The following sections will first review Kamm’s 1999 dissertation literature and then provide a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature, she found there were strong gender differences in terms of grieving (Dyregrov & Matthissen, 1987). Mothers struggled with more intense grief reactions, which lasted longer (Bohannon, 1990-91; Dyregrov &
Matthissen, 1987; Kissane & Bloch, 1994; Pine & Brauer, 1986; Rando, 1983). Lang and Gottileb (1993) determined that mothers expressed their bereavement while fathers exerted more control over their emotions by trying to manage their bereavement by being preoccupied with supporting their wives. Bohannon (1990-91) conveyed that a major
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source of stress came from asynchronous grieving, in which grieving occurred out of synch since partners expressed bereavement in different ways or coped differently with their pain. As stated by Rando (1983) harmful and negative effects resulted from unresolved bereavement. Predictable grief reactions had physical, emotional, behavioral, and psychological components that included extreme crying, wailing, hostility, and aggression (Barrett & Scott, 1989). Reactions to bereavement also included preoccupation with feelings of guilt, rage, despair, and emptiness (Barrett & Scott, 1989).
Couples often expected that the same death would give them the same grief reaction, which was not always the case (Gilbert, 1989). Cook (1983) found that men suppressed their feelings early after the death, controlled their emotions, and used denial more often than women, while women expressed feelings early after the death and reported anger over their husbands’ lack of bereavement response.
Current Literature
Men have less thoughts than women about whether the death was due to something they did or did not do (Jind, 2003). Mothers were found to have more intense grief reactions (Murphy et al., 2014) and to exhibit more intense bereavement symptoms
(Wijngaards-de Meij et al., 2005). One study showed that when the bereavement symptoms were more intense for mothers, fathers scored higher than mothers on marital satisfaction inventories (Vollbehr, 2011).
Murphy, Shelvin, and Elkit (2014), whose article has been discussed earlier in this literature review, revealed that gender had a significant impact on all the subscales on the
Trauma Symptom Checklist (TSC; Briere & Runty, 1989). Males expressed less depression than females. The finding that males expressed less of the difficult symptoms
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was found throughout all the subscales on the TSC (aggression, interpersonal sensitivity, somatization, sleep disturbance, dissociation, and anxiety).
Stroebe, Finkenaure, Wijngaards-de Meij, Bout, and Stroebe (2013) examined partner-oriented self-regulation (POSR). The Dutch authors defined POSR as partners trying to protect each other from pain by avoiding talking about the death and trying to remain strong in each other’s presence. There were a total of 219 parent/couples which were identified by using obituary notices. They employed data from three research occasions of a three-wave longitudinal study. The authors looked at (1) bereavement, (2)
POSR, and (3) concern for the partner. Bereavement was measured by the Inventory of
Complicated Bereavement (ICG; Prigerson, Mac, Jewskib, Reynolds, Bierhals,
Newsomc, Fasiczkaa, Franka, & Domana, 1997). POSR was measured by means of three items tapping components (“I stay strong for my partner, I try to spare my partner’s feelings, I hide my feelings for the sake of my partner” (Stroebe et al., p. 398) of POSR that bereaved persons often mentioned in therapeutic session or interviews. Concern for the partner was measured by three items derived from interviews and therapeutic sessions with bereaved parents and by consulting the Relationship-Focused Coping Scale (RCS;
Coyne & Smith, 1991). They reported that Cronbach’s alphas ranged from .75 to .78
(Coyne & Smith, 1991).
The study design included three levels of nesting (data from the three data collections was nested within individuals, and data from the two partners in a relationship was nested within the couple). They used a multilevel regression analysis. The authors adopted an analytical approach based on the actor-partner model. “The model assumed that each dyad member’s score on the outcome variable would not be affected by his or
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her own score on the predictor variable (i.e. an actor effect), but also by his or her partner’s score on that predictor variable (i.e. the partner effect)” (Stroebe et al., 2013, p.398). The authors found the following: women experienced more bereavement than men; individuals experienced more bereavement when their partner reported more POSR; individuals reported less bereavement when the partner expressed concern for them;
POSR by one’s partner also contributed to one’s own bereavement; and men showed similar levels of POSR as women. They also found that when participants expressed more concern for their partners, they experienced more bereavement themselves, in contrast, the partner experienced less bereavement.
In 2012, Alam and colleagues studied 20 bereaved families (18 mothers and 13 fathers), which included seven couples. The participants identified as follows: 74 percent were Caucasian, 20 percent Middle Eastern, six percent Asian with 90 percent being married. The authors used content analysis from semistructured interviews with open- ended questions. Interviews were conducted at 6 (time one), 12 (time two), and 18 (time three) months after the death of the child. The authors stated that fathers and mothers reported grieving intensely the weeks after the death of the child. However, intense and prolonged grief reactions were reported by mothers (number not disclosed), but less often by fathers (number not disclosed). Four of the mothers (22 percent) stated that they wanted to die. The author reported that many mothers (85 percent) in time 2 (at 12 months) said that they were more likely to grieve privately and were more tolerant of differential grieving between spouses. In time 2, some fathers (40 percent) became more expressive about their bereavement, although most fathers (number not disclosed) did not openly express their bereavement.
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Bergstraesser and contemporaries (2014) found that dyadic coping plays a central role in bereavement work and described gender aspects of the grieving process with mothers being affected more overwhelmingly by their child’s death than fathers. Twenty four couples whose child was treated at a large tertiary treatment center in Switzerland were interviewed and given the following instruments: SP-12 Health Survey (Bullinger,
2000) with a Cronbach alpha of .89, the German version of the Center for
Epidemiological Studies Depression Scale (CESD; Radloff, 1977) with a Cronbach alpha of .89, the Texas Revised Bereavement Inventory (TRIG; Znoj, 2008) with a Cronbach alpha of .88, and the Dyadic Coping Inventory (DCI; Bodenmann, 2008) with a Cronbach alpha of .79. The authors used content analysis and a reconstructive-hermeneutical approach. Following descriptive statistics, one step of method triangulation included the comparison of extreme groups (poor and good conditions). The authors then compared the qualitative analysis of (1) poor relationships, (2) good relationships, and (3) poor and well-functioning partnerships. The authors found that fathers and mothers expressed the need for togetherness (spending time as a couple) equally. Nevertheless, the authors reported that husbands tended to behave as loners. The authors found fathers desired not to talk about feelings, whereas mothers were more disposed to share their thoughts and feelings.
In summary, the studies reviewed above found similar findings to the older literature in that women had more intense and prolonged bereavement. Partners tried to protect one another from pain by communicating less about the death. The next section will explore couples’ bereavement by time since the child’s death.
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Couples’ Bereavement by Time since Death
It is widely believed that time plays a crucial role in the grieving process (Kamm,
1999). Grief symptoms should decrease with time. It should be noted that this heading did not appear until the results section of Kamm’s 1999 dissertation. The following sections will first review Kamm’s 1999 dissertation literature and then a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature she found parental bereavement was uncertain and could be expected to show great variability. Rando (2000) found that time did not provide full relief from symptomatology nor a reduction of the impact of the experienced death. Cook (1983) discovered that the parents of children who died recently were not systematically different from those who lost their child several years ago. She also found that parents measured the first year following the death of their child to be the most overwhelming and intense (Cook, 1983).
Current Literature
It is commonly believed that the first year following the death of a child is the most difficult, along with the commonly expressed belief that time heals all wounds
(Carney, 2011). Parents who have experienced the death of a child often report a strong sense of bereavement for a very long time. This bereavement goes beyond other people’s expectations of the bereavement recovery. It was identified that bereaved parents can develop feelings of isolation and loneliness (Murphy et al., 2014). Jind (2003) also reported that men, less often than women, had thoughts about whether they did or did not cause the death of their child. Stroebe, Finkenaure and colleagues (2013), whose article
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has been discussed earlier in this literature review, found that bereavement decreased over time. They reported that concern was predictable over time, and more specifically that partners expressed less concern for each other as time passed.
Polantinsky and Esprey (2000) studied whether bereaved parents could perceive a silver-lining from the death of a child, particularly when it came to gender. The authors looked at sources of variation (the length of time, the age of the bereaved, and the marital status of the bereaved) in the scores of bereaved parents using the Post Traumatic Growth
Inventory (PTGI; Tedeschi & Calhoun, 1995). The PTGI is a 21-item scale which measures five factors (new possibilities, relating to others, personal strength, appreciation of life, and spiritual change). The sample for this study consisted of 18 bereaved fathers and 49 bereaved mothers from the Compassionate Friends in Johannesburg, South Africa.
All were Caucasian, 73 percent married, 13 percent divorced, four percent single, and ten percent widowed (none of the participants were married to each other). T-tests for independent groups were conducted and analysis of covariance was used to ensure that the nature of the death, gender, and marital status were not confounded by current age or the length of time since the death of the child, or both.
The results of the t-tests were not significant, which indicated that there was insufficient evidence of gender differences. The simultaneous regression revealed that the length of time since the death of their child was not confounded by either the gender, the nature of the death, and/or the marital status. The length of time since the death of the child was however significantly correlated with the Post Traumatic Growth Inventory
(PTGI) total score. The authors stated that the study found a possible, although not significant, relationship between the length of time since the death and the perception of
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growth as a couple, with more value the longer time elapsed. Overall, the authors reported that the results indicated that bereaved parents did perceive strengthening of the couple relationship from their endeavors to cope with the death of their child. This was one of the few articles on gender, which was why this writer chose to include it in the literature review. Although there is a danger in discussing non-significant statistics as if they were significant, this was one of the few articles on gender and this writer felt that the fact that finding of insufficient evidence for gender differences was important to note.
In summary, the studies reviewed above found similar findings with bereavement decreasing over time as well as concern for their partner decreasing over time. The results suggested that beyond gender, bereaved parents did perceive a strengthening of the couple relationship from their attempts to cope with the death of a child; however, in this study, the length of time was not confounded by gender. The next section will explore guilt and gender differences in bereavement of parents.
Guilt and Gender Differences
Guilt is a powerful emotion. It is no less corrosive after the death of a child. The following sections will first review Kamm’s 1999 dissertation literature and then present a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature, she found guilt was typical in bereavement and often hampered the healthy progression of mourning (Rando, 1986).
Dyregrov and Matthissen (1987) discovered strong gender differences in the parents’ grief reaction after the death of a child, with mothers suffering more intense and longer lasting reactions than fathers, while men could resolve guilt feelings sooner than women.
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Pine and Brauer (1986) established that anger was a mutable emotional response to bereavement and alternated with periods of depression. Anger against oneself was turned toward others in bereavement. They also reported that guilt may accompany anger.
Bohannon (1990-91) noted that guilt was decreased over time for husbands, but not for wives. Higher guilt scores for wives were significantly related to more negative feelings about their marriages. Clyman et al., (1980) found that mothers acquiescently spoke of feelings of guilt, believing that they were the source of their infant’s problems, while only one father expressed feelings of personal guilt.
Current Literature
Wijngaards-de Meij and colleagues (2005) reported that parents feel more guilt, anger, despair, unsafe/insecure, sadness, and other emotional and physical symptoms about the death of a child than any other death. Other research finds that a father may feel helpless and ridden with guilt after the death of a child while a couple may experience serious discord in their relationship along with some struggles in roles, identities, and balance within the couple/parent unit and in the family (Landau, 2013).
The outcomes were consistently reported in the literature about women reporting more guilt and shame than men (Barr, 2012; 2004; Jind, 2003).
According to Ducan and Cacciatore (2015), shame, self-blame and guilt are common in bereaved parents. The authors did the first systemic examination of the evidence of the pervasiveness of shame, self-blame, and guilt in parents who had lost a child. They did an assessment of peer-reviewed literature from January 1975 to
November 2013, using PsycINFO, MEDLINE, Embase, CINAHL, Pubmed, and Science
Direct searching with the following words: bereaved parents, child death, perinatal death,
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neonatal death, stillbirth, sudden infant death, shame, self-blame, attributions, self- conscious emotion, self-criticism, that used the following criteria male and/or female bereaved parents over the age of 18. The study, sought to understand shame, guilt, and self-blame in the experience of bereaved parents. The article was included if it clearly articulated the authors’ research design, methods, and outcome. The authors found eighteen studies that met the criteria mentioned above. They found sufficient evidence that shame, guilt, and self-blame were experienced in bereaved parents, however they also found evidence that many bereaved parents did not report shame, guilt, and self- blame. The authors reported that there was strong evidence that women experience more guilt, shame, and self-blame than men. Furthermore, they discovered that the women’s bereavement is affected by their partner’s guilt and shame as well as the quality of the marital relationship. This was not the case for men. “While bereaved mothers reported more guilt and shame than bereaved fathers, guilt and shame appear more problematic for men” (Duncan and Cacciatore, p. 33). In addition, they found that shame and guilt forecast the level of bereavement intensity experienced by the parents.
Dyregrov and Gjestad (2011) studied 285 participants (169 women, 116 men) representing 175 couples who had a child die and found there were clear gender differences in reactions and perceptions. Out of the 175 couples, ten were chosen to be interviewed via a phenomenological mode of analysis. Descriptive statistics (cross tabulation with chi-square, standard deviation, mean and frequency), reliability analysis
(Cronbach’s alpha), correlation, and sequential regression (or hierarchical were used.
Relationship quality was measured through the Dyadic Adjustment Scale (DAS; Spanier,
1976). This study specifically investigated couple intimacy following the death of a
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child. Most of the respondents were cohabitating or married (91 percent). All the participants were Norwegian, but no information was given regarding race. The authors reported that women wrote about not feeling that they deserved anything positive or good. While specific numbers were not reported, several mothers linked their consciences of guilt to feeling no pleasure. The authors reported that men understood sexual function was a way to reduce tension and through that they could disconnect from the death of their child. Mothers reported more often than men (number undisclosed) that depression/sadness was the main cause of lack of sexual pleasures followed by physical exhaustion. On the other hand, women more often than men (number undisclosed) stated that they were frustrated as their partner did not understand the need for closeness rather than sex.
In summary, the studies reviewed above found guilt was common in bereaved parents although not all couples reported having guilt. Women reported more guilt while men reported more shame. Several women reported linking guilt to their lack of ability to have pleasure. While it is important to look at the relationship between guilt and bereavement, it is also important to look at the correlation between relationship satisfaction and bereavement. The next section will review the existing literature on parental bereavement and relational satisfaction.
Relationship Satisfaction
It is believed that couple communication is one aspect that leads to relational satisfaction (Kamm, & Vandenberg, 2001). In what way do grief reactions affect a couple’s relationship? The way a couple grieves can affect their relationship. The
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following sections will first review Kamm’s 1999 dissertation literature and then a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature, she found that grief reactions were linked to a couple’s relationship. Couples may need counseling to assist with relationship conflicts after the death of child (Schiff, 1977). A study by Dyregrov and
Matthissen (1987) found that couples felt their child’s death left them more distant in their relationship, noting that twice as many fathers felt as though they had grown apart from their partner after the death of their child. According to Sanders (1980), when the family system is disrupted by death, family members tend to react in manners they believe to be least disruptive. Carroll and Shaefer (1993-94) found that the capability to converse after the death was crucial to the maintenance of the relationship. In fact, coping patterns were tied to the use of emotional support from their spouse and their availability to each other. Gilbert (1989) determined that successful resolution of bereavement depended on the quality of the relationship. In fact, if couples mourned together, bereavement resolution was found to occur favorably. Another study, conducted by Levinger and Senn (1967), discovered that partners who expressed more satisfaction were less likely to discuss negative feelings.
Current Literature
The current literature on relationship satisfaction and parental bereavement specifically focuses on the strain often experienced by couples and families as they pass through the different developmental/life cycle stages. According to the literature, events such as the death of a child that occur out of the expected sequence of normative
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development disrupts the procession and generates added stress (Lohan & Murphy,
2006). Research has shown for example, that the marital relationship has been found to be negatively influenced by stressful life events (Itzhar-Nabarro, 2004). Other research has shown that a marital relationship may be stressed or strengthened after the death of a child (Rosenblatt, 2000). In addition, research has shown that sexual satisfaction has been consistently associated with higher marital satisfaction (Christopher & Sprecher,
2000).
In 2016, Buyukcan-Tetik and colleagues studied bereavement similarity to investigate concurrent and longitudinal effects on relationship satisfaction when partners have less, equal, or more bereavement intensity and whether it varied across gender in a three waves longitudinal study (6, 13, and 20 months). There were 229 Dutch couples whose child’s age at the time of death ranged between stillborn and 30 months. Of these couples, 67.7 percent of the deceased children were boys. To measure perceived bereavement similarity, the authors used a two-item scale developed for this study with the first item asking the participants to rate how much they were focused on their bereavement compared to their partner using a 5-point Likert scale. The second item asked participants to compare the level of thought they gave to their sadness with the level of thought their partner gave to their sadness. To measure relationship satisfaction the authors used an eight-item Relational Interaction Satisfaction Scale (Buunk &
Nijskens, 1980). The authors controlled for the effect of participants’ own bereavement level by using the 19-item Inventory of Complicated Bereavement (Prigerson, Mac,
Jewskib, Reynolds, Bierhals, Newsomc, Fasiczkaa, Franka, Domana, 1997). The authors’ data was composed of three levels, with each lower level nested in a higher level
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(time, individual, and couples), so they conducted multilevel analysis to deal with interdependence in the datasets. The authors found that parents who perceived dissimilar levels of bereavement (more or less bereavement) had lower relationship satisfaction than bereaved parents who perceived their bereavement to be at similar level. The study showed that similar perceived bereavement at the first study wave (six months) was related to the highest level of relationship satisfaction. At the second wave (13 months), the authors found that perceived bereavement similarity was associated with higher levels of partner satisfaction and negative effects of perceived dissimilarity, which increased over time.
In 2001, Kamm and Vandenberg studied 36 couples (32 Caucasian, 2 Native
Americans, and 2 African Americans) using the Attitudes towards Emotional Expression
Scale (AEE; Joseph et al., 1994), the Revised Greif Experience Inventory (RGEI; Lev,
Munro, & McCorkle, 1993), and the Index of Marital Satisfaction (IMS; Hudson, 1992) to examine attitudes about bereavement communication as it related to grief reactions and marital satisfaction in bereaved parents. The authors found that couples with more positive bereavement communication demonstrated greater relationship satisfaction.
Relationship satisfaction was also greater for the communication across time interaction.
However, attitudes about bereavement communication were not associated with relationship satisfaction. Furthermore, the authors established that women who valued more open communication had higher relationship satisfaction in the earlier stages of bereavement.
In 2012, Alam and colleagues, whose article has been discussed earlier in this literature review, found that 40 percent of the parents in the study conveyed that there
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was an enhancement in their relationship due to being more accepting of their dissimilar coping styles since the death of their child. They had seventeen percent of couples participating in the study reported relationship strain since the death of their child.
Bergstraesser et al., (2014), whose article has also been discussed earlier in this literature review, found that nearly all parents used the metaphor that the illness and the death of the child bonded them together. Some couples (number undisclosed) cultivated heart to heart talks when they felt they were drifting apart, whereas other couples felt dyadic conflicts. They also found that better coping strategies were utilized by couples who reported a well-functioning couple relationship.
A summary of the reviewed literature notes that one study found that those with bereavement similarity had higher levels of couple’s satisfaction, as did those with more positive attitudes. In addition, research studies showed that some couples found enrichment in their relationship as they were more accepting of dissimilar grieving styles.
The next section will explore couple communication and bereavement.
Communication
In the CFT field, communication between partners in a couple system is critically important. Kamm (1999) explored the role that communication plays in the grieving process of the couple. The following sections will first review Kamm’s 1999 dissertation literature and then assess current reviews of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature, she found that communication is believed to be a basic requirement for the development and maintenance of interpersonal relationships (Levinger & Senn, 1967). Levinger and Senn (1967) found that people tend
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to communicate more about positive matters more than negative ones. They found that partners ranked communication of positive feelings as more important than communication of negative feelings. Communication of feelings, according to the literature, is a critical task for adjustment (Carroll & Shaefer, 1993-94). According to
Kocher (1986), people tend to distance themselves from the death of their child by avoiding direct discussion. Kissane and Bloch (1994) reported that poor communication inhibits emotional expression. Sharing of feelings between partners and reinforcing feelings of trust has been shown to be the most critical factor for the resolution of bereavement (Pine & Brauer, 1986). A study in 1986 by Pine and Brauer suggested that open communication is a must for both objective and subjective thoughts and feelings.
Cook (1983) found that discrepant parental coping (one parent expresses negative feelings, while the other does not) was found to result in restricted communication and different coping style. Gilbert (1989) established that the ability to participate in honest and open communication was critical for bereavement recovery. She discussed that exchanging information gave a couple an awareness of understanding and mutuality.
According to Lepore, Silver, Wortman, and Wayment (1996), communication about traumatic experiences facilitates adjustment, whereby those who confront their intrusive thoughts can integrate the traumatic experience into their consciousness. They found that talking about intrusive thoughts assisted in cognitive processing and adjustment.
Current Literature
According to the literature, communication plays a central role the process of healing (Bosticco & Thompson, 2005). Walsh and McGoldrick (2004) identified that honest and open communication among family members has great importance in the
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adaptation post death. It has been reported that husbands may avoid communication and become less expressive because they are afraid that they will say or do the wrong thing and remind their wives of the death, resulting in deeper mourning (Wing et al., 2001).
Furthermore, it is believed that individuals may limit communication to shelter themselves from judgement or further harm (Toller 2005).
Bergstraesser and colleagues (2014) whose article has been discussed earlier in this literature review, reported that couples with poor dyadic coping were prone to not speak openly with their partner. Essential prerequisites for efficacious dyadic coping were well cultivated communication style, respecting idiosyncrasies in the partners
(especially with grieving), and an awareness that conflicts could be handled.
Toller and Braithwaite (2009) looked at 37 (24 women, 13 men) bereaved
Caucasian parents to determine how the marital partners communicatively traversed the dialectical contradictions that they experienced (grieving their child’s death together as a couple and apart as individuals). The authors grounded their study within the interpretive model and used a semistructured interview. The authors found that bereaved parents expressed a need to grieve together to provide support and comfort to their partner yet at the same time they needed to grieve on their own as their bereavement was unique from that of their partners. The authors reported that participants experienced a need to be both open and closed when it came to communication with one another. The authors stated that early in the grieving process they expected subjects to grieve similarly to one another. Parents who were expressive and open expected their partners to be the same, while couples who were closed had a great deal of conflict and strain in their relationship.
The authors found that the need to be open yet closed influenced the couple’s ability to
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grieve together and apart. All participants indicated that they and their spouses needed to communicate to share emotion and vent. The authors found that couples managed their opened-closeness, which the authors defined as being interconnected with the tension of grieving together versus grieving apart, in three ways; (1) becoming accepting of each other’s communication style, (2) being open with others and closed with their spouses, and (3) being closed verbally, but open nonverbally.
Titus and de Sourza (2011) used narrative methodology to explore grieving experiences by parents (nine mothers and one father whose ethnicities were undisclosed) before and after the death of a child in two Midwest hospitals. Each participant was asked to write a life story with four prompts: (1) changes in family interaction before the death, (2) changes in family interaction after the death, (3) reactions of family, friends, and others before the death, and (4) reactions of family, friends, and others after the death. Four themes emerged in the study: (1) disheartening and heartening experiences with others, (2) a time for control and a time for chaos, (3) normalcy and disruption in family life, and (4) meaning and senselessness in death. The authors found that communication played a vital role in the process of healing and talking about the deceased child helped families rebuild and grow.
In summary, the research studies described above ultimately found less communication in couples with poor coping. Since communication is critical to healing, the research suggests that couples need to grieve separately and together as a couple for support and comfort. A spouse who was open expected their partner to grieve similarly.
The next section will explore parental bereavement, gender, and culture complexities of parental bereavement.
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Gender and Culture
Cultural differences are highly relevant in the grieving process (Bowlby &
Parkes,1970). Gender role socialization can impact how a couple grieves and is an important element when evaluating couple’s level of bereavement. Cultural expectations of men and women may be seen as different and this may have an impact on the grieving process both individually and as a couple. The inclusiveness of culture also makes it difficult to distinguish its contributions from those made by other important influences such as spirituality and gender (Neimeyer & Keesee, 1988), however beyond gender differences the relevant and important dynamics of culture and religion would make this dissertation too complex and will not be covered. The following sections will first review Kamm’s 1999 dissertation literature and then a current review of similar research.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature, she found that American culture does not contain a substantial support system (Furman, 1978). Sex-determined role expectations for men are reported to emphasize an appearance of competence, independence, and the need to remain under control and unemotional (Jacobs, Kasl,
Ostfeld, Berkman, & Charpenteir, 1986). Cook (1983), found that cultural prescriptions regarding emotional reactions and behavioral reactions lead to typical post death behaviors such as mothers reported the ability to discuss feelings with others, while fathers were less likely to report the same. A study by Gilbert (1989), found that couples argued over the interpretation of each other’s behaviors. Interestingly, the research clarified that if couples could show the flexibility to alter their roles so that when a spouse was incapacitated or unable to respond in their normal fashion, the other spouse
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could step in effectively. This sharing, or role trading, centered around routine tasks that were part of normal family routines such as child care and household tasks, or normal errands, which were part of their relationship prior to the child’s death.
Current Literature
Early, Wood, and Diekman (2000), reported that gender is the strongest category of personal characteristics, because it captures a person’s attention even when compared to occupation, age, and race. According to the literature, emotional expression is closely tied to gender roles (Neimeyer, Harris, Winokuer, & Thornton, 2011). According to De
Ridder (2000), men engage in less emotion-focused coping than women. Women value expression of and sharing of emotion along with social support, while men emphasize privacy, cognition, and themes of control (Stroebe et al., 2004). Because mental health services can be helpful to people in expressing their bereavement, it is believed that men benefit more than women (Prigerson, Bierhals, Kasl, Reynolds, Shear, Berry, Newsom, &
Jacobs, 1997). Martin and Doka (2000) reported that:
It is critical not to overstate the effect of gender role socialization on the grieving process, however, females generally have superior verbal abilities and identify and show greater concern for others’ feelings, while males de-emphasize emotionality, while controlling their own emotions. Gender role norms are but one way that a culture influences bereavement and the patterns by which bereavement is experienced and expressed. (p. 113)
The authors reported that cultural norms impact not only the expression of bereavement, but the experience of it. Men live their lives in the public sphere, while women live in a more private sphere. Women were more invested in family roles and lost more of their identity through the process/experience of bereavement than men. Bergstraesser et al.,
(2014) whose article has been discussed earlier in this literature review, found that
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mothers were prone to sharing feelings and emotions, while fathers saw a greater importance in learning how others solve problems.
In summary, the above described research studies found more emotionality in women than in men, who are typically prone to control their feelings. These gender roles impacted grieving, including how individuals asked for and received support. The difference frames that men solve problems while women share their feelings in bereavement. The next section will explore the correspondence between parental bereavement and social support.
Social Support
The death of a child can make the bereaved parents feel ostracized and isolated as death is a difficult topic for Americans. Kamm (1999) examined the role of social support for grieving parents and assessed how couple support impacts the grief process. The following sections will first review Kamm’s (1999) dissertation literature and then present a current review of similar research involving acknowledge of marital status and its implication for social support.
Kamm (1999) Literature Review
In Kamm’s (1999) review of the literature she found that fathers tend to isolate themselves socially and recruit fewer types of emotional support, whereas mothers got more social support from family than husbands did, as the fathers were less likely to reach out for support (Bohannon, 1990-91). Bereaved parents did however report that relatives increased their distress and identified their mates as their most helpful sources of support (Carroll & Shaefer,1993-94). Mothers found family and friends less supportive than their husbands; however, fathers found support from these social systems to be more
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helpful and positive than did mothers (Dyregrov & Matthissen, 1987). A positive relationship was identified between a grieving parent’s health and their perceived helpful social support (Stroebe and Stroebe, 1993). Those who experience problems in their relationship also suffer problems in their larger social functioning (Chenug &
Hudson,1982). Mothers were more likely to note family members as sources of support, while fathers were less likely to report the same level of support from family members
(Cook, 1983). Hence, emotional support is directed to mothers at the expense of fathers.
Furthermore, men suffer ill effects of poorly developed social support (Jacobs, Kasl,
Ostfeld, Berkman, & Charpenteir, 1986). Social constraints interfere with adjustments as they do not allow for traumatic experiences to be confronted (Lepore et al., 1996).
Barrett and Scott (1989) found that it was often reported that family and friends did not provide enough support to the bereaved after the death of their child. This lack of support took various forms including lack of understanding, lack of concern, social isolation, abandonment of friendship, avoidance, and/or an unwillingness to listen on the part of family and friends. Kissane (1994) discovered that in infant death there were key elements for positive outcomes, including support, not only from extended families, but from the larger society as well. Lang and Gottileb (1993) identified that a social constraint for those who have lost a child is a lack of access to people who are willing to express genuine sympathy, or even simple words of comfort.
Current Literature
Parents who have lost a child experience a bereavement response that is persistent, powerful, and enduring, as the death of a child can trigger transformations in several domains of the parents’ lives, including emotional, physical, financial, spiritual,
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and social domains (Rando, 2000). Hastings (2000) reported that bereaved parents often felt ostracized and stigmatized by their support networks. In a separate study, it was determined that fathers felt positive support if they received information on various means of coping and the dissimilarities in grieving between spouses (Aho, Tarkka,
Astedt-Kurki, & Kaunonen; 2007). In addition, research has reflected that parents who received social support were more likely to be married (Rogers, 2005).
In 2014, O’Connor and Barrera investigated the stability of and change in parental self-identify in study intervals of 6, 12, and 18 months after the death of a child to cancer.
They studied 26 bereaved parents (16 mothers, 10 fathers) via semi-structured interviews with open-ended questions with content analysis. Most bereaved parents were married
(90 percent) and Caucasian (74 percent). Interview results were classified as showing reintegration (positive reframing, awareness of personal growth and purpose, positive perception of social support) or disintegration (unable to positively frame, limited awareness of personal growth and purpose, negative perception of social support). The author found that positive views of support helped the reintegration of those parents to work towards an integrated self-identity, while disintegration parents had an absence of support. Of the 16 parents in the reintegration group, 14 fell into the same group at 12 months, while of 13 parents in the disintegration group, 11 continued disintegration at 12 months. Eighteen parents were re-interviewed at 18 months. The author found that the number of those originally classified as reintegration was higher than those identified as disintegration.
Bergstraesser et al. (2014), whose article has been discussed earlier in this literature review, found that several couples (number not disclosed) learned to accept
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dissimilarities, which the authors hypothesized may explain why mothers tended to seek social support. This may be reflected in instances of triangling. Shared support was lacking in couples with poor dyadic coping.
Polantinsky and Esprey (2000), whose article has been discussed earlier in this literature review, found that the mean Post Traumatic Growth Inventory (PTGI) total score and four of the five factor scores (excepting spiritual change) were lower for non- married respondents. They hypothesized that married respondents scored higher because they received social support from each other.
In 2012, Alam et al., whose article has been discussed earlier in this literature review, found that fathers (42 percent) reported that there were benefits to talking to others, but not as commonly as mothers’ report (56 percent).
In summary, the above research examined parents’ reports of positive views towards support that led to integration or personal growth, while reports of negative views led to disintegration or limited growth. In the couples’ in which coping was lacking, there were no shared support. In addition, mothers were more likely than fathers to report benefit from support.
Summary
The preceding discussion explored both previous literature and current literature focusing on the consequences that the death of a child can have on parents’ individual and relationship adjustment. More specifically, the relationships between relationship communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child were examined. The discussion also surveyed whether parental gender has implications for those adaptations.
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The Bowen Family Systems approach was presented as a framework from which to examine the relationship between couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. Bowen’s model focuses on strength and not on pathology. Bowen’s concept of an open communication style, in which individuals are free to communicate thoughts and feelings reciprocally with another fit, symbiotically with parental bereavement and the ability to move forward (Bowen, 1978). The family life cycle was considered by Bowen to explain the difficulty of this non-normative death (Walsh &
McGoldrick, 2004).
The studies reviewed detail the devastating impact of the death of a child, along with normative symptoms of bereavement. The uniqueness and intensity of parental bereavement with physical, emotional, behavioral, and psychological symptoms was stressed. It was found that bereaved parents can be vulnerable and in need of professional assistance especially with the most extreme symptomology. Furthermore, it was found that unmarried mothers were noted to be particularly at risk since they were unlikely to follow-up with medical professionals. Mothers more often than fathers talked about their isolation and sense of responsibility to provide to others. Fathers discussed their guilt. While bereavement symptoms may be normative, they can be corrosive to a couple’s union. For example, there is an increase in aggression, interpersonal sensitivity, somatization, sleep disturbance, dissociation, and anxiety. How the couple faced the death was critical and influenced the outcome especially when there were problems prior to the child’s death.
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Mothers had a more intense grief reaction than fathers that they expressed in intimate ways. Husbands worked to maintain more control over their reactions. More physical symptoms were indicators of intense bereavement in females. A distinct relationship between grief reaction and its influence on relationship satisfaction and communication was noted and found to be potentially differentiating between partners.
The impact of asynchronous grieving was highlighted, particularly in terms of communication and relationship satisfaction. The ability to provide mutual comfort and to support emotional expression between partners appear to be integral in successful negotiation of the grief reaction. Partners tried to protect one another from pain by communicating less about the death. The first year after a child’s death can be extremely difficult. The research also showed that while bereavement decreased it did not cease entirely. Additional findings signified that residual guilt may play a mediating role. The results suggested that beyond gender, bereaved parents did perceive benefits from their attempts to cope with the death of a child. Guilt may follow anger. Even though guilt was high for men, their grief reactions were lower than those of their wives as they resolved their feelings of guilt sooner. Guilt seemed to mediate levels of relationship satisfaction for wives, with feelings of guilt being associated with more negative feelings about their marriage. Women reported more guilt while men reported more shame.
Several women reported linking guilt to the ability to have no pleasure. Not only is it important to look at guilt and bereavement, it is also important to evaluate the correspondence between relationship satisfaction and bereavement.
The ability of partners to be available and to support one another was linked to coping patterns. The ability to be present and available to one another, even during times
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of difficulty, has proven critical in the coping process. It has also been shown that gender differences impact mutual abilities to grieve, to communicate, and find a way to move forward together. Since grief reactions were also linked to a couple’s relationship after the death of a child, the initial reaction has been shown to be a difficult and complex time for couples. Abilities to reframe and to focus on positive attitudes, and mutual communication and support appeared to be critical to positive relational outcomes.
Furthermore, satisfied partners seemed to be more attuned to each other’s needs, and to be more in sync, than less satisfied partners. In addition, there were gender differences regarding relationship satisfaction and the need to disclose personal information. More specifically, wives who focused on disclosure expressed more satisfaction in their partnerships than did husbands. Research studies showed that some couples found more enrichment in their relationships when they were more accepting of dissimilar grieving styles.
The studies reviewed also showed that open and honest communication is critical for successful adjustment for those who are grieving. Discrepant coping undermines and restricts communication. This is compounded when emotions are difficult to express, since partners feel ostracized. The ability to communicate is important and different forms of communication are helpful. The simple act of listening to a spouse in the expression of their emotions is helpful for individuals who find it difficult to express themselves. Wives reported significantly more distance in their spousal relationships than husbands in the aftermath of such a death.
The research studies reviewed also contested that there is less communication in couples with poor coping. Since communication is critical to healing, couples need to
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grieve separately and together as a couple for support and comfort. A spouse who was open expected their partner to grieve similarly. In addition, the research showed that women and men can have different roles that may impact how the bereavement processes unfold and are ultimately resolved. Even though these roles tend to be expressed in typical manner in post-death situations, some partners maintain role flexibility and allow each other to avoid strict role definitions. If couples can express flexibility in their culturally defined roles, it can prove to be beneficial.
Finally, the research reviewed also showed that there is more emotionality in women than in men who typically control their feelings. These gender roles impacted grieving, including how they asked for and received support. Men solve problems while women share their feelings. A significant social limitation for bereavement-stricken parents is their lack of access to those who are willing to listen and empathize. It can be exceedingly difficult for those in social contact with these bereavement-stricken parents to comfortably offer comfort and compassion. Fathers were reported to be less likely to reach out for support and they tended to have poorly developed support systems compared to mothers. Mothers were connected, with family for support, even though relatives can often make grieving more difficult for them. Social support can have a positive effect on the health of those who are grieving. Social functioning can be challenging for those with relationship issues. Positive views of support led to integration or personal growth, while reports of negative views led to disintegration or limited growth. In the couples’ where coping was lacking, there was no shared support.
In addition, mothers were more likely than fathers to report benefit that came from support. This current research study attempted to extend previous research on
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communication in bereaved parents and to examine the relationship between (1) couple’s grief-related communication, (2) adaptation of parents (grief reaction and guilt), (3) relationship satisfaction of parents, and (4) gender implications for these relationships.
Following are the general research questions and hypotheses.
General Research Questions and Hypotheses
This study attempted to answer the following questions:
1. Research Question One: This question will be assessed by an independent two
samples t-test. Is there a statistically significant gender difference in grief-related
communication, adaptation (grief reaction), adaptation (guilt), and relationship
satisfaction?
b. Hypothesis One: Communication, time, and the interaction of
communication by time were utilized as predictors in all analyses for
Kamm study. For gender, communication, and grief reaction Kamm
found the overall equation for men statistically significant, while for
women it was not significant. For guilt, the overall equation was
significant (using the same predictors communication, time, and the
interaction of communication and time) for men and women. For
relationship satisfaction (again using the same predictors communication,
time, and the interaction of communication and time), Kamm found no
statistical difference for men, but found the overall equation significant for
women. Due to the differences in statistical approaches to the research
questions, Kamm’s findings were not able to be used for directionality.
2. Research Question Two: This question will be assessed by the Actor Partner
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Interdependence Model (APIM). Is there a statistically significant relationship
between grief-related communication and grief reaction among couples?
a. Hypothesis Two: This researcher will use the best practices model for
dyads, the APIM. Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
3. Research Question Three: This question will be assessed by the APIM. Is there a
statistically significant relationship between grief-related communication and
guilt among couples?
a. Hypothesis Three: Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
4. Research Question Four: This question will be assessed by the APIM. Is there a
statistically significant relationship between grief-related communication and
relationship satisfaction among couples?
a. Hypothesis Four: Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
5. Research Question Five: This question will be assessed by hierarchical regression.
Is there a statistically significant relationship between grief-related
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communication, time since death, and grief reaction among couples?
a. Hypothesis Five: Due to a lack of research and an error in Kamm’s 1999
findings, wherein she inaccurately reported that a higher score on the
RGEI indicates a less severe grief reaction, her findings and literature
cannot be used to determine directionality of this hypothesis
Chapter II included a review of the literature examining theoretical and empirical research relating to the consequences that the death of a child can have on bereaved parents’ individual and relationship adjustment. It examined the concepts of Bowen and why this researcher is utilizing BFST with the constructs of grief related communication, adaptation (grief reaction), adaptation (guilt), and relationship satisfaction. The next section will provide a restatement of the problem, the research questions and hypotheses, research design, participants and delimitations, procedures, instrumentation, a description of the study’s variables, the data analysis plan, and a review of the APIM along with a chapter summary.
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CHAPTER III
METHODOLGY
The purpose of this study was to gain a better understanding of the relationship between spousal communication, parental adaptation (grief reaction), parental adaptation
(guilt), and relationship satisfaction after the death of a child. It also examined whether parental gender and time since death have implications for those relationships. This chapter will outline the statistical findings of this study. This chapter will provide a restatement of the problem, research design, participants and delimitations, procedures, instrumentation, a description of the study’s variables, the data analysis plan, a review of the Actor Partner Interdependence Model (APIM), and a review of hierarchical regression. A chapter summary will also be presented.
Restatement of the Problem
Other than the Kamm’s 1999 dissertation, there have been a lack of studies with the constructs of grief related communication, adaptation (as measured by grief reaction and guilt), and relationship satisfaction. This study will be concerned with extending research on examining the relationship between spousal grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It is unclear how these constructs interact and shape the bereavement process for bereaved couples whose child has died. The current study will also examine whether parental gender has implications for those relationships.
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The Bowen Family System Theory (BFST) will be the theoretical framework for this study. The effect of grief on couple’s grief-related communication, parental adaptation
(grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child has not yet been examined through a systemic lens, particularly using BFST to guide the conceptualization. Using statistical best practices to update Kamm’s 1999 study along with a Bowenian lens will help provide a better understanding of how couples are impacted by the death of a child through a family systems lens. Following are the general research questions and hypotheses.
Research Design
This dissertation utilized a quantitative and cross-sectional research design. The variables for the study were grief related communication, parental adaptation (grief reaction), parental adaptation (guilt), relationship satisfaction, and gender. This study applied a Web-based survey. In a cross-sectional design, “one or more samples are drawn from the population at one time” (Shaughnessy, Zechmeister, & Zechmeister,
2012, p. 154). Using a cross-sectional design allowed this researcher to collect data on all variables at once and allowed multiple outcomes to be studied, which were ideally suited for the descriptive and predictive goals of survey research (Shaughnessy et al.,
2012). A power analysis determined that approximately 100 individuals or 50 dyads were needed to be able to determine if the variables were correlated (Ackerman,
Ledermann, & Kenny, 2015) with 25 dyads being the minimum (Kenny et al., 2006;
Miller & Johnson, 2014). This study was a modified replication study of Kamm’s 1999 dissertation utilizing updated statistical methods, modification to participants,
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populations, and measures. In her 1999 dissertation study, Kamm employed quantitative methods, which was the case in this study.
Participants and Delimitations
The sample population in the present study was limited to heterosexual couples who have experienced the death of their child as the research is interested in gender differences in the grief process. In addition, the present study was a replication of
Kamm’s 1999 dissertation where the couples were heterosexual. Same-sex couples were not turned away from participating; however, their data was not be used in this study.
Participants were delimited based on age, sex, race, or how the deceased child died.
Kamm (1999) looked at deaths between the ages of one though 19; however, she did not articulate why this age range was chosen. For this study, the death of the child was delimited to fetal deaths (death prior to delivery, irrespective of the duration of the pregnancy), infant deaths (<1 to 364 days), deaths between the ages of one through 18, and deaths of adult children age 19 through 55. The age of the death of the child was extended to allow for more participants. While contacting support groups to gauge interest in participation, it was repeatedly pointed out to this researcher by the support group facilitators that parents whose adult child had died suffer the same feelings of guilt, helplessness, hopelessness, depression and experience a lifelong change that is like those parents who have lost a younger child. It is unclear how the change in age will impact the findings.
Procedures
Participants were recruited from recipients of the Compassionate Friends’ newsletters and support groups; alivealone.org newsletter; the mothers’ enduring neonatal
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death (M.E.N.D.) newsletter; Parents of Murdered Children, Inc. (pomc.com) newsletter; and mothers in sympathy; and support (missfoundation.org) forums. The data was collected from January 06, 2018 to December 31, 2018. A total of 858 bereaved individuals whose child had died began the survey on the Qualtrics website; however,
546 were eliminated due to a large amount of missing data. This resulted in a total of 312 individuals, who completed the survey, which is a return rate of 36%. These participants had no missing data, therefore no replacement was needed. However, since this study was only concerned with paired couples, only the data from the 108 individuals i.e., 54 couples were used in this study. The sample of participants may not be representative of parents whose child has died, as those who participated were recruited through support groups for bereft individuals whose child had died and therefore have sought out some type of information and support.
The methodology of this dissertation was quantitative. First, approval was obtained from the Institutional Review Board at the University of Akron to conduct this study. Then the recruited participants were directed to Qualtrics to complete the online survey. The online survey included:(1) IRB approval letter (see Appendix A), (2) informed consent (see Appendix B), (3) a demographic survey (see Appendix C), (4) The
Attitudes towards Emotional Expression Scale (AEE; Joseph et al., 1994) (see Appendix
D), (5) Grief Experience Questionnaire (GEQ; Barrett & Scott, 1989) (see Appendix E),
(6) A Guilt subscale of the Revised Grief Experience Questionnaire (RGEI; Lev et al.,
1993) (see Appendix F), and (7) The Marital Satisfaction Inventory-Revised (MSI-R;
Snyder, 1997) (see Appendix G), (8) demographics tables (see Appendix H), (9).
Histograms, Boxplots, and O-Q plots (see Appendix I) Informed consent was inferred by
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each participant’s voluntary acceptance of the study protocol through completion of the online survey.
First, the data was screened for missing and incorrectly entered data, normality, and linearity. Descriptive statistics (specifically, frequencies) were examined for the demographics in the study.
General Research Questions and Hypotheses
This study attempted to answer the following questions:
1. Research Question One: This question will be assessed by an independent two
samples t-test. Is there a statistically significant gender difference in grief-related
communication, adaptation (grief reaction), adaptation (guilt), and relationship
satisfaction?
a. Hypothesis One: Communication, time, and the interaction of
communication by time were utilized as predictors in all analyses for
Kamm study. For gender, communication, and grief reaction Kamm
found the overall equation for men statistically significant, while for
women it was not significant. For guilt, the overall equation was
significant (using the same predictors communication, time, and the
interaction of communication and time) for men and women. For
relationship satisfaction (again using the same predictors communication,
time, and the interaction of communication and time), Kamm found no
statistical difference for men, but found the overall equation significant for
women. Due to the differences in statistical approaches to the research
questions, Kamm’s findings were not able to be used for directionality.
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2. Research Question Two: This question will be assessed by the Actor Partner
Interdependence Model (APIM). Is there a statistically significant relationship
between grief-related communication and grief reaction among couples?
a. Hypothesis Two: This researcher will use the best practices model for
dyads, the Actor Partner Interdependence Model (APIM). Since the
current study is the first known study to analyze this research question
using both female and male data simultaneously via dyadic data analysis,
Kamm’s findings and prior literature cannot be used to determine
directionality of this hypothesis.
3. Research Question Three: This question will be assessed by the APIM. Is there a
statistically significant relationship between grief-related communication and
guilt among couples?
a. Hypothesis Three: Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
4. Research Question Four: This question will be assessed by the APIM. Is there a
statistically significant relationship between grief-related communication and
relationship satisfaction among couples?
a. Hypothesis Four: Since the current study is the first known study to
analyze this research question using both female and male data
simultaneously via dyadic data analysis, Kamm’s findings and prior
literature cannot be used to determine directionality of this hypothesis.
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5. Research Question Five: This question will be assessed by hierarchical regression.
Is there a statistically significant relationship between grief-related
communication, time since death, and grief reaction among couples?
a. Hypothesis Five: Due to a lack of research and an error in Kamm’s 1999
findings, wherein she inaccurately reported that a higher score on the
RGEI indicates a less severe grief reaction, her findings and literature
cannot be used to determine directionality of this hypothesis.
Instrument Measures
Kamm’s (1999) study used the following instruments: (1) a questionnaire regarding demographics, (2) The Attitudes towards Emotional Expression Scale (AEE;
Joseph et al., 1994), (3) The Revised Grief Experience Inventory (RGEI; Lev, Munro, &
McCorkle, 1993), (4) a Guilt subscale of the Grief Experience Questionnaire (RGEI; Lev,
Munro, & McCorkle, 1993), and (5) The Index of Marital Satisfaction (IMS; Hudson,
1992) to establish whether grief communication was an important predictor of post-death adjustment and marital satisfaction. For this study, the researcher did not use the IMS in favor of the Marital Satisfaction Inventory-Revised (MSI-R; Synder, 1997). The IMS measures the extent one partner perceives problems in the relationship but does not characterize the relationship as a unitary entity (Hudson, 1997). It does not recognize the actor partner interplay nor is it multidimensional, whereas the MSI-R is multidimensional. A brief description of each instrument follows below.
Demographic Questionnaire
Developed by the researcher, this instrument was used to gather demographic information such as gender, age, employment status, occupation, relationship status, level
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of education, ethnicity, religious affiliations, whether the partner’s share the same religion, income level, gender of the deceased child, the age category of the deceased child, length of time since child’s death, and cause of child’s death, and whether the couple is affiliated with a support group. The following categories were determined by using the Qualtrics survey software: Handbook for research professional (Qualtrics survey software: Handbook for research professionals, 2012) with exception of how the child died, which was taken from Kamm’s 1999 dissertation. Gender was assessed dichotomously (Male/Female/Other); age of the participant was assessed via the following categories: 18-24, 25-34, 35-44, 45-54, 55-64, 65 or older, or decline to answer. Employment status was assessed via the following categories: full-time, part- time, homemaker, unemployed, retired, student, other, or decline to answer. Occupation was assessed with the following categories: executive/advanced professional, business manager/lower professional/teacher, administrative personal/small business owner, skilled manual, semi-skilled/machine operator, unskilled, clerical/sales/technical, student, other, or decline to answer; relationship status was assessed dichotomously
(married/cohabitating). The length of the couple’s relationship was assessed with the following categories: less than one year, one year, two years, three years, four years, five years, six years, seven years, eight years, nine years, ten years, 15 years, 20 years, 25 years, 30 years, 35 years, 40 years, 45 years, 50 years, over 50 years, or decline to answer. Education was assessed via the following categories: less than a high school diploma, high school or equivalent (e.g. GED), some college, technical school, associate degree, bachelor’s degree, master’s degree, professional degree (e.g. MD, DDS, DVM), doctorate degree, or decline to answer. Ethnicity was assessed via the following
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categories: American Indian or Alaska Native, Asian-American, African-American
(Black), Hispanic and Latin-American, European-American (Caucasian), Native
American, or Native Hawaiian, Other Pacific Islander, Other, or decline to answer.
Religious affiliation was assessed with the following categories: Seventh-day Adventist,
Agnostic, Atheist, Buddhism, Christianity, Hinduism, Islam, Judaism, Mormonism,
Sikhism, Other, or decline to answer. Assessing whether the couple shares the same religion was assessed by asking whether the partner’s share same religious affiliation with the following categories: yes, no, or decline to answer. Income was assessed via the following categories: under $20,000, $20,000 – 39,999, $40,000 – 59,999, $60,000 –
79,999, $80,000 – 99, 999, $100,000 or more, or decline to answer. The age of the deceased child was assessed via the following categories: fetal death (death prior to delivery, irrespective of the duration of the pregnancy), infant death (<1 to 364 days), deaths between the ages of 1 through 18, or deaths of adult children age 1 through 55.
The length of time since the child’s death was assessed via the following categories: less than one year, one year, two years, three years, four years, five years, six years, seven years, eight years, nine years, ten years, 15 years, 20 years, 25 years, 30 years, 35 years,
40 years, 45 years, 50 years, over 50 years, or decline to answer. How the child died was assessed with the following categories: accident, homicide, suicide, illness (e.g. cancer), or medical (e.g. SIDS), other, unknown, or decline to answer. If the child was the result of infertility was assessed by the following categories: yes, no, or decline to answer.
How many fertility treatments was assessed by fill in or decline to answer; if the couples has other children was assessed dichotomously (yes/no/decline to answer), and if the couple is affiliated with a support group for bereaved parents was assessed
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dichotomously (yes/no/decline to answer). The next section will examine the Attitudes about Emotional Expression Scale (AEE) instrument.
Attitudes about Emotional Expression Scale (AEE): Communication
Thoughts and behaviors surrounding the expression of emotions, particularly those which are thought to restrict social support seeking during times of distress, was assessed by using the Attitudes towards Emotional Expression Scale (AEE; Joseph,
Williams, Irwing, & Cammock, 1994). Attitudes about emotional expression can range from good to bad (Olson & Zanna, 1993). The AEE is a 20-item scale with high internal reliability (Cronbach’s alpha = 0.90) and convergent validity (Joseph et al., 1994; Laghai
& Joseph, 2000). The AEE measures four factors: (1) the idea that the expression of emotions is a sign of weakness (weakness) and that others should not be saddled with one’s problem, (2) the tendency to keep emotions to oneself (bottled-up), (3) the belief that emotions should be kept under control (keep in control), and (4) the belief that other people will reject expressed emotions (social rejection) (Joseph et al., 1994).
Scores on the total scale have a possible range of 20 to 100, with higher scores indicating more negative attitudes toward emotional expression, i.e. more stoic behaviors, beliefs, and attitudes (Laghai & Joseph, 2000). Higher scores on the total 20-item attitudes towards emotional expression scale were also associated with lower scores on the seeking social support scale (Joseph, 1994). The authors of the AEE originally designed the measure to add specificity to the cognitive behavioral theory that individuals with dysfunctional assumptions are predisposed to mental illness when such assumptions are activated in the here and now by critical incidents (Beck & Beck, 2011). This instrument has been used in clinical (Meyer, Leung, Barry & De Feo, 2009) and non-
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clinical groups (Laghai & Joseph, 2000). The next section will examine the Revised
Grief Experience Inventory (RGEI) instrument.
Revised Grief Experience Inventory (RGEI): Grief Reaction
The Revised Grief Experience Inventory (RGEI; Lev, Munro, & McCorkle, 1993) was used to measure common grief-related experiences. The RGEI is a shortened and revised version of the GEI, originally developed by Sanders et al., 1979. The RGEI is a
22-item scale of grief symptomatology and intensity. It is a multidimensional measure of grief, which includes four domains: (1) physical distress, (2) depression, (3) existential concerns, and (4) tension and guilt (Lev et al., 1993). The Cronbach alpha coefficients for the four subscale scores were the following: depression, 0.80; physical distress, 0.83; existential concerns, 0.87; and tension and guilt, 0.72 (Nezu, Ronan, Meadows, &
McClure, 2000).
Since grief is a multidimensional process, a questionnaire that outlines the different aspects of grief in its subscales was important because it ensures one was measuring for more than just depression (Lev et al., 1993). The full RGEI scale has demonstrated good reliability (alphas between 0.88 and 0.93) (Lev et al., 1993; Meuser &
Marwit, 1999-2000). The RGEI subscales have reliability alphas of 0.87, 0.80, 0.72, and
0.83 respectively; an overall internal consistency alpha coefficient is 0.93 (Lev et al.,
1993); and validity about parental bereavement (Wickie & Marwit, 2001).
Each item is rated on a 6-point, Likert-style scale with five possible responses: strongly disagree (1) slight agreement, (2) moderate agreement, (3) strong agreement,
(4) strong disagreement, (5) moderate disagreement, and (6) slight disagreement (Lev et al., 1993). Overall higher scores indicate higher levels of grief. No cutoff scores were
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provided, but scores can be compared with norms (Nezu et al., 2000). The mean score on the RGEI is 75.5 (SD=25.7) with scores ranging from 22 to 132. The mean score for the subscales are as follows: depression, 23.0 (SD=7.0); physical distress, 22.5
(SD=9.3); existential concerns, 20.1 (SD=8.5); and tension and guilt, 10.0 (SD=4.6)
(Nezu et al., 2000). Because this study seeks to obtain a measure of overall grief reactions, only the total score was used. The RGEI was tested in its validation study on grieving family care givers who had experienced the loss of a loved one. Therefore, its contents could have been more geared toward what is expected of a family to experience
(Matthews & Marwit, 2004). The overall score has been shown to have adequate validity about parental bereavement (Matthews & Marwit, 2004). The next section will examine the guilt subscale of the Grief Experience Questionnaire (GEQ).
Grief Experience Questionnaire (GEQ): Guilt Subscale: Guilt
This researcher used the Guilt subscale of the Grief Experience Questionnaire
(GEQ; Barrett & Scott, 1989) to measure guilt and self-blame as these common elements of parental bereavement are not adequately examined in the RGEI. The GEQ is a 55- item self-administered questionnaire. The questions are designed to assess 11 components of grief: (1) somatic reactions (items 1-5), (2) general grief reactions (items
6-ten), (3) search for explanation (items 11-15), (4) loss of social support (items 16-20),
(5) stigma (items 21-25), (6) guilt (items 26-30), (7) responsibility (items 31-35), (8) shame (items 36-40), (9) rejection (items 41-45), (10) self-destructive behaviors (items
46-50), (11) unique reactions to suicide (items 51-55) (Barrett & Scott, 1989). According to Bailey, Dunham, & Kral (2000) there are eight subscales: (1) abandonment/rejection,
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(2) stigmatization, (3) search for explanation, (4) guilt, (5) somatic reaction, (6) responsibility, (7) self-destructive orientation, (8) shame/embarrassment.
The authors reported that the abandonment/rejection dimension centers predominantly around feelings of being deserted, rejected, or abandoned by the deceased, while the stigmatization dimension refers to the experience of a perceived loss of ties or social support and stigmatization following the death. The search for explanation dimension reflects a search for the underlying reasons for an understanding of why the death occurred. The guilt dimension taps the experience of feelings of guilt and thoughts over one’s acts of commission and/or omissions prior to the decedent’s death. The somatic reactions dimension echoes common somatic reactions after a bereavement and measures the bereaved person’s general perception of his or her physical condition during the bereavement experience. The responsibility dimension reflects beliefs of some bereaved persons that they may have has some sort of personal responsibility for the occurrence of the death, while the self-destructive orientation dimension taps behaviors or cognitions indicative of a self- destructive orientation during the period following the death. Finally, the shame/embarrassment dimension taps into the feelings of embarrassment and shame that may arise regarding the circumstances, nature, or cause of the death. These reactions are more likely in the case of suicide. The authors reported that any given scale is indicative of a greater likelihood that the specific grief reaction has been experienced.
Items are scored on a 5-point Likert scale (ranging from never to almost always) measuring frequency of experience with higher scores indicating more intense feelings of guilt (Barrett & Scott, 1989). The GEQ has been demonstrated to empirically
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differentiate between suicide and other forms of bereavement, including accidental deaths
(Bailey et al., 2000; Barrett and Scott, 1989). The authors found that this scale demonstrates reliability, a = 0.82 and high internal consistency as measured by
Cronbach’s alpha, a = 0.97. Furthermore, most subscales demonstrated moderate to high internal consistency (1) somatic reactions, a = 0.7910 (2) general grief reactions, a =
0.6849 (3) search for explanation, a = 0.6945 (4) loss of social support, a = 0.8621 (5) stigma, a = 0.8793 (6) guilt, a = 0.8935 (7) responsibility, a = 0.8803 (8) shame, a =
0.8299 (9) rejection, a = 0.8731 (10) self-destructive behaviors, a = 0.7614 and (11) unique reactions to suicide, a = 0.7779 (Barrett & Scott, 1989). Overall the GEQ appears to be a multidimensional measure of grief phenomenology (Bailey et al., 2000). It has also been reported that the factorial validity of GEQ has not yet been empirically confirmed (Bailey et al., 2000; Tomita & Kitamura, 2002). The authors intended to originally measure guilt in spousal bereavement, however, Tomita and Kitamura (2002) reported that these scales were all developed for measuring grief rather than guilt or shame specifically. The next section will examine the Marital Satisfaction Inventory-
Revised (MSI-R).
Marital Satisfaction Inventory-Revised (MSI-R): Relationship Satisfaction
This researcher used The Marital Satisfaction Inventory-Revised (MSI-R; Synder,
1997) to measure relationship satisfaction. The Marital Satisfaction Inventory-Revised
(MSI-R; Synder, 1997) is a complete restandarization and revision of the Marital
Satisfaction Inventory-Revised (MSI; Synder, 1981). The manual reports that the revision encompasses significant improvements to the instrument including a larger and more representative standardization sample, a smaller number of inventory items
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(Synder, 1997). The MSI-R detects the extent and nature of relationship distress along key dimensions via “True” or “False responses to each of the 150 MSI-R inventory items, the last 21 of which are applicable only to couples who have children. Individuals' responses are scored along the 13 profile scales using normalized T-scores based on gender-specific norms (Synder, 1981). Thus, for each scale the mean score for nondistressed couples from the community is 50, with a standard deviation of ten.
The MSI-R is a multidimensional inventory which takes about 20-25 minutes to complete and can identify relationship strengths and deficits that can interact with difficulties such as physical illness, substance use, sexual dysfunction, and depression.
There is considerable use of this instrument as a multivariate criterion of marital functioning research. The 13 scales have two validity scales (conventionalization and inconsistency), one Global Distress Scale (GDS) and ten additional scales Affective
Communication (AFC), Role Orientation (ROR), Problem-Solving Communication
(PSC), Aggression (AGG), Time Together (TTO), Dissatisfaction with Children (DSC),
Disagreement about Finances (FIN), Conflict over Child Rearing (CCR), and Sexual
Dissatisfaction (SEX) (Synder, 1981). Since the MSI-R has so many sub scales available to the user, a determination was made to use the main scale Global Affective Scale
(GDS) as this closely matched the relationship satisfaction variable.
A strong advantage of the MSI-R over other commonly-used measures of marital quality is that the MSI-R allows for much finer granularity than other instruments when interpreting results (Snyder, 1997). Ranges of distress on the MSI-R identify high, moderate, and low scores on each dimension. The user is not precluded from introjecting his or her own theoretical framework on test data (Snyder, 1997). Since this dissertation
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is conceptualized with the concepts from Bowen, the description from the manual were utilized, then linked to Bowen where indicated.
Global Distress Scale (GDS). The global distress scale, which is the only scale that this study will be using from the MSI-R, measures individuals’ overall dissatisfaction with their relationship (Snyder, 1997). As with other subscales on the MSI-R, a lower T- scores indicate lower distress, or higher satisfaction and higher T-scores indicate a higher level of distress or dissatisfaction (Snyder, 1997). GDS scores (below 50T) describe relationships that are satisfying, and their partners are viewed as friends (Synder, 1981).
Moderate GDS sores (50T-60T) reflect significant levels of relationship struggles
(Snyder, 1997). High GDS scores (60T) suggest widespread relationship difficulties
(Snyder, 1997).
The MSI-R instrument possess a high level of both internal consistency and temporal stability (Synder, 1997). Internal consistency for the MSI-R scales are derived from a combined sample of 100 individuals in couple therapy and 2,040 individuals from the community ranged from 0.70 to 0.93 (M = 0.82), while the discriminant validity ranged from 0.43 to .75 (p<.001) (Jamieson, 2007; Snyder & Aikman, 1999). Six-week temporal stability coefficients for a sample of 210 individuals from the general community range from 0.74 to 0.88 (M = 0.79; Snyder, 1997). An evaluation of 50 clinical couples and 77 community couples matched on demographic indices showed that each of the MSI-R scales discriminated between the community and clinic couples, with moderate to large effect sizes (Cohen’s d) ranging from 0.43 to 2.35 (M = 1.07; Snyder,
1997). Harper and Sandberg (2009) noted that when wives and husbands were more depressed, both problem solving processes and affective communication were impaired
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for the couple. Additionally, problem solving communication and affective communication were worse when both spouses were depressed, compared to when only one spouse was depressed (Harper & Sandberg’s, 2009). Moreover, when one or both partners were depressed, both wife and husband communication scores were worse than when neither husband nor wife was depressed (Harper & Sandberg, 2009). The next section will review the data analysis plan.
Data Analysis Plan
Studies in social science often emphasize the influence that individuals have on one another (Fitzpatrich, Gareau, Lafontaine, & Gaudareau, 2016). One essential feature of relational data is that measurement reflects not only the characteristic of the person who provides the score, but also the characteristic of one’s partner, for example, an interpersonal system (Kenny & Cook, 1999). This study worked with dyads. According to Kenny and colleagues (2006), dyads are “the fundamental unit of interpersonal interaction and interpersonal relation” (p. 1). This study implemented a quantitative versus qualitative research design as the study was predictive as opposed to interpretive.
Descriptive (demographic questions) and inferential statistics (research questions) were used in this research study. The data analysis plan employed descriptive statistics to describe the basic features of the data and summarize it, for example, to look at whom will be part of the sample, while inferential statistics were used to make inferences about the data (Mertler & Vannatta, 2010; Salkind, 2001). Specifically, this study used a bivariate analysis to look at correlations, path analysis (APIM) (research questions two through five) to determine relationships between variables, an independent two-sample t- test (research question one), and hierarchical regression (question five) to test the
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relationship between communication, time since death, and grief reaction. Hierarchical regression can be a useful means of statistical control, and for examining incremental validity (Fox, 1991). Hierarchical regression is an appropriate tool for analysis when variance on a criterion variable is being explained by predictor variables that are correlated with each other (Pedhazur, 1997). Since the researcher’s population was dyads, non-Interdependence, or the degree of similarity between the two members of the dyad, needed to be accounted for on variables as this information affects the choice of statistical analysis (Kenny et al., 2006).
According to Fitzpatrich and colleagues (2016), “important errors and misinterpretation can be made when inappropriate statistical methods and tools are implemented” (p. 74). Kamm (1999) used repeated measures, which give direct and interaction effects for paired data, however these methods are no longer best practices.
Kenny and Cook (1999) reported that multiple regression is the traditional method of analysis for dyads as the person is the unit of analysis. This researcher used the best practices model for dyads, which is the actor partner Interdependence model (APIM)
(Fitzpatrich et al., 2016; Kenny et al., 1999). Prior to APIM, researchers had insufficient statistical choices for handling interdependent data, such as data from dyads (Kenny et al., 2006).
Actor Partner Interdependence Model (APIM)
The APIM was used to compare and identify different types of dyadic patterns that can depict the interpersonal influences of actors and partners. (Kenny & Ledermann,
2010). APIM is a structural equation model (SEM), which runs a series of pooled regressions that reduce type 1, i.e., rejecting the null hypothesis that the predictor variable
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has no effect when it is true (Kenny et al., 2006). It is a model that simultaneously estimates the effect of a person’s own variable (actor effect) and the effect of the same variable but rather from the partner (partner effect) on an outcome variable (Kenny et al.,
2006). The actor and partner variables are the same variable from different persons, i.e. where an individual is treated as an actor and a partner (Kenny et al., 2006). APIM analyses was used due to the relative non-Interdependence observed in levels of anxiety, which comes with the stress of having a deceased child.
In the APIM model, there are two dyad members and two variables (Kenny et al.,
2006). X and Y. X has two X scores X1 X2 and Y has scores Y1 Y2. There is an assumption that X causes or is antecedent to Y (Kenny et al., 2006). A person’s own X affects his or her own Y, and the effects of X1 on Y1 and X2 on Y2 are called actor effects
(Kenny et al., 2006). A person’s X affects his or her partner’s Y and the effects of X1 and
Y2 and X2 on Y1 are called partner effects (Kenny et al., 2006). There are two correlations in the model (Kenny et al., 2006). The two X’s may be correlated as represented by the curved line on the left. The second is the residual non-
Interdependence in the outcome scores (Y’s) represented on the right (Kenny et al.,
2006). This represents the non-Interdependence not explained by the APIM (Kenny et al., 2006).
Hierarchical Regression
Beginning with a linear causal relationship in which the variable X
(communication) is presumed to cause the variable Y (grief reaction), a moderator variable M (time since death by gender) is a variable that alters the strength of the causal relationship (Frazier et al., 2004). Most moderator analysis measures the causal
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relationship between X and Y by using a regression coefficient (Frazier et al., 2004).
Moderators address ‘when’ or ‘for whom’ a predictor is more strongly related to an outcome, mediators establish ‘how’ or ‘why’ one variable predicts or causes an outcome variable (Frazier et al., 2004). More specifically, a mediator is described as a variable that clarifies the relationship between a predictor and an outcome (Baron & Kenny,
1986). In other words, a mediator is the mechanism through which a predictor influences an outcome variable (Baron & Kenny, 1986). As Kerlinger (1986) noted, while there is no “correct” method for choosing the order of variable entry, there is also “no substitute for depth of knowledge of the research problem . . . the research problem and the theory behind the problem should determine the order of entry of variables in multiple regression analysis” (p. 545). Due to the lack of research on these variables, Kamm’s
(1999) dissertation was used as a model to enter the three predictor variables into the regression model.
Chapter Summary
This study implemented a quantitative research design, as the study being replicated was quantitative. The purpose of this study was to gain a better understanding of the relationship between spousal communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It also examined whether parental gender and time since death have implications for those relationships. The Bowen Family System Theory (BFST) was the theoretical framework for this study. To measure grief related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction the Attitudes towards
Emotional Expression Scale (AEE; Joseph et al., 1994), Grief Experience Questionnaire
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(GEQ; Barrett & Scott, 1989), the Guilt subscale of the Revised Grief Experience
Questionnaire (RGEI; Lev et al., 1993), and The Marital Satisfaction Inventory-Revised
(MSI-R; Snyder, 1997) were completed by bereaved parents. Data collected was analyzed in SPSS using descriptive and inferential statistics. The best practice of using the APIM for dyads replaced the multiple regression statistic that Kamm (1999) used.
Results of these analyses are presented in the following chapter.
In summary, five types of statistical analyses were used for this study. First, descriptive statistics were reported for the means, standard deviations, frequencies, and percentages for demographic variables. Second, an Independent two-samples t-test was used to look at gender differences. Third, a bivariate analysis was used to look at correlations. Four, path analysis (APIM) was used to address non-Interdependence.
Five, hierarchical regression was used to test the relationship between communication, time since death, and grief reaction. This chapter provides an overview of the methodology, including a restatement of the problem, general research questions and hypotheses, research design, participants and delimitations, procedures, measures, data analysis plan, and chapter summary plan for this study.
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CHAPTER IV
RESULTS
Chapter IV presents the statistical findings of the present study. The purpose of this study was to gain a better understanding of the relationship between grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It also examined whether parental gender and time since death have implications for those relationships. The Bowen
Family System Theory (BFST) was the guiding theoretical framework for this study.
This chapter will provide a restatement of the problem, participant demographics, sample, pre-analysis data screening, descriptive statistics for the variables, inferential statistics, and a summary.
Restatement of the Problem
Other than Kamm’s 1999 dissertation, there has been a lack of studies with the constructs of grief related communication, adaptation (as measured by grief reaction and guilt), and relationship satisfaction among bereaved couples. This study was concerned with extending research on examining the relationship between spousal grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It is unclear how these constructs interact and shape the bereavement process for grieving couples whose child has died.
The current study also examined whether parental gender has implications for those
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relationships. The Bowen Family System Theory (BFST) was the theoretical framework for this study. The effect of grief on a couple’s grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child has not yet been examined systemically, particularly using BFST to guide the conceptualization. It was necessary to update Kamm’s 1999 study utilizing most current statistical best practices. These methods, along with a Bowenian perspective, helped to provide a better understanding of how couples are impacted by the death of a child.
Pre-Analysis Data Screening
Pre-analysis data screening was conducted for accuracy of the data collected in order to determine if any missing data or outliers were present to help ensure valid results of the descriptive statistics and inferential statistical analyses (Mertler & Vannatta, 2010).
A total of 858 bereaved individuals whose child had died began the survey on the
Qualtrics website; however, 546 were eliminated due to a large amount of missing data.
This resulted in a total of 312 individuals, who completed the survey, which is a return rate of 36%. These participants had no missing data therefore no replacement was needed. However, since this study was only concerned with paired couples, only the data from the 108 individuals i.e., 54 couples were used in this study.
Participant Demographics
The demographic questionnaire addressed these twenty data points: (1) race, (2) residential location, (3) age, (4) employment status, (5) occupation, (6) income, (7) relationship status, (8) length of relationship, (9) if the deceased child resulted from infertility treatments, and if applicable, (10) the number of treatments. (11) education
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level, (12) religious affiliation of partners, (13) whether the couple shared the same religion, (14) age of the deceased child, (15) sex of the deceased child, (16) how long the child had been deceased, (17) what the child died from, (18) if individual had other children, (19) if the individual was a member of a support group, and if applicable (20) which group they were affiliated with. Frequencies and percentages of the most salient information are presented in the table below. The entire table for each demographic category can be found in Appendix H tables.
Table 1–Demographic Characteristics (Most Salient)
Female Male Variable N (54) % N (54) % Race: European-American/Caucasian/White 44 81% 43 80% Employment Status: Full-time 30 56% 33 61% Income: $100,000 or more 28 52% 30 56% Relationship Status: Married 53 98% 53 98% Education Level: Bachelor’s degree 15 28% 14 26% Relationship Length: 15 years 8 15% 10 19% Sex of Deceased Child: Male 36 67% 36 67% Religious Affiliation: Christianity 40 74% 35 65% Share Same Religion: Yes 41 76% 43 80% Age of Deceased Child: Adult child (19 through 55) 22 41% 22 41% Reason for Death: Medical (e.g. SIDS) 17 31% 17 31% Other Children: Yes 50 93% 53 98% Time since Death: 2 years 9 16% 10 18% Member of a Support Group: Yes 42 78% 31 57%
Most of the sample (N = 108) identified as European-American/Caucasian/White
(81% female, 80% male) and Christian (74% female, 65% male) with 76% of women reporting they shared the same religion as their partner and 80% of men stating they shared the same religion. Twenty six percent of females chose the age range of 35-44,
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while the highest percentage of males (26%) selected 55-64. The majority of couples were married (98%), working full-time (56% female, 61% male), earned an income of
$100,000 or more, had an education level of bachelor’s, and chose 15 years for the length of their relationship (15% female, 19% male). A majority of the deceased children were male (67%), an adult child (41%), and died due to a medical reason (31%). The highest percentage for time since death was 2 years (16% female, 18% male), most had other children (93% female, 98% male), and were members of a support group (78% females,
57% males).
Sample Representativeness
In the present study a sample of 108 individuals (54 couples) answered the surveys and met all the criteria. Among the 108 individuals (54 couples), there were no missing data. Couples from many different locations across the United States and one couple from Australia participated and the resulting data set, met the minimum requirements for statistical analysis. The sample a majority of married couples,
Caucasian, and Christian couples who were not presumed to be representative of the larger national population.
Descriptive Statistics for Variables
Descriptive statistics for all four variables (communication, grief reaction, guilt, and relationship satisfaction) in the data sample were analyzed. Descriptive statistics for the variables including means, standard deviations, minimums, maximums, and the number of participants are presented next.
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Table 2–Descriptive Statistics for Variables
Gender N Min Max Mean SD Communication (AEE) F 54 25 81 48.28 11.972 M 54 13 88 54.31 11.510
Grief Reaction (RGEI) F 54 26 119 79.06 24.842 M 54 26 127 63.63 24.518
Guilt F 54 6 25 14.22 4.951 M 54 5 21 11.98 4.263
Relationship Satisfaction (GDS) F 54 4 15 55.70 2.758 M 54 2 14 57.51 3.219
Time since Death in Years F 54 0 30 5.93 5.959 M 54 0 30 5.98 5.967 Note. F=Female, M=Male, SD=Standard Deviation, Min=Minimum, Max=Maximum
The descriptive statistics for skewness and kurtosis are presented next.
Table 3–Descriptive Statistics for Variables (skewness, kurtosis)
Variable Gender N Skewness Kurtosis Statistic Std. Statistic Std. Error Communication (AEE) F 54 .753 .325 .745 .639 M 54 .799 Error.325 .968 .639
Grief Reaction (RGEI) F 54 -.372 .325 -.662 .639 M 54 .303 .325 -.569 .639
Guilt F 54 .489 .325 -.727 .639 M 54 .129 .325 -.677 .639
Relationship Satisfaction F 54 1.693 .325 2.544 .639 (GDS) M 54 1.238 .325 2.353 .639
Time since Death in Years F 54 2.220 .325 5.850 .639 M 54 2.183 .325 5.712 .639 Note. F=Female, M=Male
Tables 2 and 3 represent the descriptive statics for the variables. For the sample
(N=54), average score for Female Communication was 48.28 (SD = 11.972, Range 25 to
81, skewness statistic .753, standard error = .325, kurtosis statistic = .745, standard error
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.639). Average score for Male Communication was 54.31 (SD = 11.510, Range 33 to 88, skewness statistic .799, standard error = .325, kurtosis statistic = .968, standard error
.639).
Average score for Female Grief Reaction was 79.06 (SD = 24.842, Range 26 to
119, skewness statistic -.372, standard error = .325, kurtosis statistic = -.662, standard error .639). Average score for Male Grief Reaction was 63.63 (SD = 24.518, Range 26 to
127, skewness statistic .303, standard error = .325, kurtosis statistic = -.569, standard error .639).
Average score for Female Guilt was 14.22 (SD = 4.951, Range 6 to 25, skewness statistic .821, standard error = .325, kurtosis statistic = -.321, standard error .639).
Average score for Male Guilt was 11.98 (SD = 4.263, Range 5 to 21, skewness statistic =
.129, standard Error = .325, kurtosis statistic = -.677, standard error .639).
Average score for Female Relationship Satisfaction was 55.70 (SD = 2.758,
Range 53 to 64, skewness statistic = 1.693, skewness standard error = .325, kurtosis statistic = 2.544, standard error .639). Average score for Male Relationship Satisfaction was 57.41 (SD = 3.219, Range 51 to 67, skewness statistic = 1.238, standard error = .325, kurtosis statistic = 2.353, standard error .639).
Average score for Female Time since Death was 5.93 (SD = 5.959, Range 0 to 30, skewness statistic = 2.220, skewness standard error = .325, kurtosis statistic = 5.850, standard error .639). Average score for Male Time since Death was 5.98 (SD = 5.967,
Range 0 to 30, skewness statistic = 2.183, standard error = .325, kurtosis statistic = 5.712, standard error .639).
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To test whether the distribution of scores deviated from a comparable normal distribution, the Shapiro-Wilk’s test of normality was employed. This test was chosen based on the sample size of 54 couples. The Shapiro-Wilk (SW) test, developed by
Shapiro and Wilk, is considered to be an appropriate and powerful test in most situations
(Mendes & Pala, 2003). In recent years, the SW test has become the preferred test of normality because of its good power properties as compared to a wide range of alternative tests (Mendes & Pala, 2003).
Table 4–Test of Normality
Variable Gender Kolmogorov-Smirnova Shapiro-Wilk Statistic df Sig. Statistic df Sig. Communication (AEE) F .128 54 .028 .956 54 .045 M .104 54 .200* .952 54 .031
Grief Reaction (RGEI) F .082 54 .200* .966 54 .000 M .096 54 .200* .964 54 .002
Guilt F .150 54 .004 .937 54 .007 M .094 54 .200* .966 54 .133
Relationship Satisfaction (GDS) F .235 54 .000 .794 54 .000 M .205 54 .000 .864 54 .000
Time since Death in Years F .206 54 .000 .769 54 .000 M .201 54 .000 .776 54 .000 Note. F=Female, M=Male
Given that several results were skewed, kurtotic, or not normally distributed, histograms (see figures 9-13 in Appendix I), boxplots (see figures 14-18 in Appendix I), and Normal Quantile Quantile Plots (Q-Q Plot) (see figures 19-22 in Appendix I) were reviewed. The simplest and perhaps the oldest graphical display for one-dimensional data is the histogram, which divides the range of the data into bins and plots bars
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corresponding to each bin, the height of each bar reflecting the number of data points in the corresponding bin (Oztuna, Elhah, & Tuccar, 2006).
The boxplot offers an excellent visual summary of many vital aspects of a distribution. Tukey developed the boxplot display, based on the 5-number summary
(minimum, first quartile, median, third quartile, maximum) of the data (Oztuna et al.,
2006). Suspected outliers appear in a boxplot as individual points o or an x outside the box. If these emerge on both sides of the box, they suggest the likelihood of a heavy- tailed distribution. If they appear on only one side, they imply the possibility of a skewed distribution (Oztuna et al., 2006).
The Q-Q plot may be the single most valuable graphical aid in diagnosing how a population distribution appears to differ from a normal distribution (Oztuna et al., 2006).
Normal Q-Q plots plot the quantiles of a variable’s distribution against the quantiles of the normal distribution (Oztuna et al., 2006). For values sampled from a normal distribution, the normal Q-Q plot has the points all lying on or near the straight line drawn through the middle half of the points. Scattered points lying away from the line are suspected outliers that may cause the sample to fail a normality test (Oztuna et al.,
2006).
Female/male communication, female/male grief reaction, and female/male guilt were moderately skewed, while female/male relationship satisfaction and female/male time since death were highly skewed; however, only female relationship satisfaction and both female/male time since death had kurtosis issues. The following instruments were not normally distributed: female/male communication, female/male relationship
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satisfaction, female/male time since death, and female guilt, while and female/male grief reaction, and male guilt were normally distributed.
Female and male communication had outliers indicating that both sexes had individuals who engaged in more negative attitudes toward/participation in emotional expression, for example, more stoic behaviors, beliefs, and attitudes; however, the mean for males was higher. Also, on the high side were both female/male relationship satisfaction and female/male time since death, signifying that there were individuals who were dissatisfied with their relationship. Additionally, both female/male relationship satisfaction and female/male time since death had extreme outliers demonstrating that there were individuals who were highly dissatisfied with their relationship or it had been a long time since the child’s death.
With a small sample size, the violation of the normality assumption should not cause major problems, as this implies that we can use parametric procedures even when the data are not normally distributed (Elliott & Woodward, 2007). The Central Limit
Theorem (CLT) states that the sampling distribution of the sample means approaches a normal distribution as the sample size gets larger (Taras, Stephan, & Nestor, 2019). One can look for normality visually by using normal plots (Altman & Bland, 1995). In large samples, the sampling distribution tends to be normal, regardless of the shape of the data
(Field, 2009). Given the number of couples in the study (54) normality was deemed acceptable to proceed. Prior to conducting the research question investigation of a bivariate analyses was conducted to determine whether there is association between the variables and, if so, what the strength of this association may be.
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Bivariate Analysis
Pearson’s correlations coefficient (r) was used to examine the relationship between communication and other variables. The table below highlights whether a significant linear relationship between the variables. The strength of the linear relationship will be discussed, i.e. how close the relationship is to a perfectly straight line.
Next, the direction of the linear relationship will be examined. The values can range -1 to
1 (Leech, Barrett, Morgan, 2008). Negative 1 is a perfect negative relationship, 0 there is no relationship, and 1 is a perfect positive relationship (Leech et al., 2008). A negative relationship implies that higher scores on one variable and lower scores on the other variable (Leech et al., 2008). A positive relationship implies that higher score on one variable is associated with a higher scores on the other variable (Leech et al., 2008). A score close to 0 indicates a weaker relationship, while |1| indicates a stronger relationship
(Leech et al., 2008).
Table 5–Pearson’s (Correlations)
Variable r 2 3 4 5 6 7 8 9 10 (1) F AEE r -.130 .417** .061 .225 -.217 .177 .115 -.008 .001 (2) M AEE r .116 .107 .145 -.048 .144 .061 .061 .060 (3) F RGEI r .497** .323* .403** .130 .249 -.340* -.334* (4) M RGEI r -.087 .343* -.054 -.006 .013 .012 (5) F Guilt r .162 .208 .167 -.172 -.173 (6) M Guilt r -.023 .002 -.184 -.184 (7) F GDS r .462** -.097 -.105 (8) M GDS r -.202 -.214 (9) F TSD r .999** (10) M TSD r Note. F= Female, M = Male, AEE=Communication, RGEI=Grief Reaction **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).
Research Question One is detailed below. 128
Research Question One
Research question one asked whether there would be a statistically significant difference in average score between genders for grief-related communication, grief reaction, guilt, and relationship satisfaction. Because the question is referring to gender outcomes, an independent two-sample t-test was chosen. However, since Kamm (1999) introduced the new topic of time since death in her results section, and used communication, time and the interaction of communication by time for all of her predictors in all analyses, so directionality was not possible in this study. Her results have been presented here for informational purposes only. For gender, communication, and grief reaction Kamm (1999) found the overall equation for men statistically significant, while for women it was not significant. For guilt, the overall equation was significant (using the same predictors - communication, time, and the interaction of communication and time) for men and women. For relationship satisfaction (again using the same predictors - communication, time, and the interaction of communication and time), Kamm (1999) found no statistical difference for men but found the overall equation significant for women. Due to the differences in statistical approaches to the research questions, Kamm’s (1999) findings were not able to be used for directionality.
The results for communication are described below.
Communication
Using the equal variance formula for the independent two-sample t-test, there is sufficient evidence at the 5% significance level of a significant difference in the average total communication score between female (�̅ = 48.3) and male (�̅ = 54.3) participants (t
= 2.67, p-value = 0.009). The results from Table 6 indicated that males scored
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significantly higher on communication than females, which implies that males hold a more negative attitude towards emotional expression. To explore further, it can be estimated with 95% confidence that, on average, males scored between 1.56 and 10.52 points higher than females on total communication score.
Table 6–Results of t-test and Descriptive Statistics for Communication by Sex
Sex 95% CI for Female Male Mean Difference M SD n M SD n t df Communication 48.3 12.0 54 54.3 11.5 54 1.56, 10.52 2.67* 106 Note. * p < .05.
The results for grief reaction are described below.
Grief Reaction
Using the equal variance formula for the independent two-sample t-test, there is sufficient evidence at the 5% significance level of a significant difference in the average total grief reaction score between female (�̅ = 79.06) and male (�̅ = 63.63) participants (t
= 3.248, p-value = 0.002). The results from Table 7 indicated that females scored significantly higher in grief reaction than males. To explore further, it can be estimated with 95% confidence that females score, on average, between 6.009 and 24.843 points higher than males on total grief reaction score.
Table 7–Results of t-test and Descriptive Statistics for Grief Reaction by Sex
Sex 95% CI for Female Male Mean Difference M SD n M SD n t df Grief Reaction 79.06 24.84 54 63.63 24.51 54 6.00, 24.84 3.24* 106 Note. * p < .05.
The results for guilt are described next.
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Guilt
To determine if there is a significant difference in average total guilt score between males and females, an equal variance formula for the independent two-sample t- test was conducted. At the 5% significance level, there is sufficient evidence of a significant difference in the average total guilt score between female (�̅ = 14.22) and male (�̅ = 11.98) participants (t = 2.52, p-value = 0.013). These results indicated that females scored significantly higher in guilt than males. To explore further, it can be estimated with 95% confidence that females score, on average, between 0.478 and 4.003 points higher than males on total guilt score.
Table 8–Results of t-test and Descriptive Statistics for Guilt by Sex
Sex 95% CI for Female Male Mean Difference M SD n M SD n t df Guilt 14.22 4.95 54 11.98 4.26 54 0.478, 4.003 2.52* 106 Note. * p < .05.
The results for relationship satisfaction are described below.
Relationship Satisfaction
To determine if there is a significant difference in average total relationship satisfaction between males and females, an equal variance formula for the independent two-sample t-test was conducted. At the 5% significance level, there is sufficient evidence (see table 9) of a significant difference in the average total relationship satisfaction score between female (�̅ = 55.70) and male (�̅ = 57.41) participants (t =
2.954, p-value = .004). These results indicated that females scored significantly higher in relationship satisfaction than males. To explore further, it can be estimated with 95%
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confidence that females score, on average, between .560 and 2.847points higher than males on the total relationship satisfaction score.
Table 9–Results of t-test and Descriptive Statistics for Relationship Satisfaction by Sex
Sex 95% CI for Female Male Mean Difference M SD n M SD n t df GDS 55.70 2.758 54 57.41 3.219 54 .560, 2.847 2.954 106 Note. GDS = Relationship Satisfaction, * p < .05.
Research question two is discussed below.
Research Question Two
This question addressed whether there were a statistically significant relationship between grief-related communication and grief reaction among couples. The Actor
Partner Interdependence Model (APIM) with distinguishable dyads was applied to determine the impact of couples’ communication on their own grief reaction, as well as their partner’s grief reaction. The analyses uses structural equation modeling (SEM) with maximum likelihood estimation using the program lavaan (Rosseel, 2012). The model fit was assessed using four indices: Tucker-Lewis Index (TLI), Comparative Fit Index(CFI)
Standardized Root Mean Square Residual (SRMR) and Root Mean Square Error of
Approximation (RMSEA). The results showed that the base model fit the data very well
(TLI=1.00, CFI=1.00, SRMR=0.000, RMSEA= 0.000). Since the current study is the first known study to analyze this research question using both female and male data simultaneously via dyadic data analysis, directionality was not possible.
To make sure that gender was empirically distinguishable, meaning, there was a statistically meaningful difference, a model comparison was performed with distinguishable members and a model with indistinguishable members via the APIM
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2 SEM application, which yielded χ 6 = 32.892 (p < .001) thus concluding that the members can be statistically distinguished based upon the variable gender. Below is the APIM model with standardized parameter estimates.
APIM Diagram
Figure 1 depicts the APIM with standardized parameter estimates of the couple dyad in which there are two variables from each in the dyad: Communication (exogenous or independent variable) and Grief Reaction (endogenous or dependent variable, i.e. outcome variable). It answers the question how well one’s own “Communication” predicts one’s own “Grief Reaction” outcomes (actor effects), whereas, partner effects measures the extent to which a partner’s “Communication” predicts the partner’s “Grief
Reaction” outcomes.
Figure 1–Research Question Two: APIM Diagram
Communication 0.12 (0.29) Grief Reaction E1 Man Man
0.08 (0.28)
-.013 0.51*** 0.17 (0.26)
0.44 (0.25)*** Communication Grief Reaction E2 Woman Woman
* p < .05; ** p < .01, ;*** p < .001. This figure was copied from the APIM SEM app.
There are two important correlations in this model. The single‐headed arrows represent causal or predictive paths, with horizontal lines in the middle as actor effects and diagonal lines as partner effects. The curved line that connects the independent
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variable “Communication Man” and ‘Communication Woman” indicates how similar the partners are on the predictor variables, which might be due to a compositional effect (i.e., when shared attributes become more similar than randomly selected individuals in a given population) (Fitzpatrick et al., 2016). The double‐headed arrow between
“Communication Woman” and “Communication Man” represents its covariance.
The second correlation between E1 and E2 indicates the residual non- independence of Y1 (“Grief Reaction Man” ) and Y2 (“Grief Reaction Woman”) (c2). The latter is a common practice used in SEM because endogenous variables cannot directly correlate with one another (Fitzpatrick et al., 2016). As such, the correlations between the error terms of the dependent variables take into account the correlations of Y1 and Y2 not accounted by the predictors, as well as the compositional effect over and beyond what can be explained by the partner and actor effects included in the model (Fitzpatrick et al.,
2016). It represents the correlation between the scores of the two partners on the dependent variables (Fitzpatrick et al., 2016). APIM actor and partner results are discussed below.
APIM: Results for Actor, Partner
Based on the APIM model, the actor effects for Women is equal to 0.913 (p <
.001, 95% CI [0.41, 1.41], beta (s) = 0.44. The actor effects for Men is equal to 0.248 (p
= .391, 95% CI [-0.32, 0.82], beta (s) = 0.117). This means there is statistically significant (p < .001) actor effect for a women’s communication on her own grief reaction, however for men, their communication did not influence their own grief, meaning it was not significant. The partner effect from Men to Women is equal to 0.374
(p = .157, 95% CI [-0.14, 0.89], beta = 0.076), while the partner effect from Women to
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Men was equal to 0.156 (p = .576, 95% CI [-0.39, 0.7], beta (s) = 0.173). Men’s communication does not influence his partner grief reaction nor does a women’s communication does not influence her partner grief reaction.
Table 10– Research Question Two: APIM Actor, Partner Effects
Woman (n=54)
Beta (s) Estimates Std. Error z - value p (> |z|) Actor’s Communication 0.44 0.913 0.254 3.591 0.000 *** Partner’s Communication 0.173 0.156 0.279 0.559 0.576 k 0.410 0.297 1.380 0.618 Note.* p < .05; ** p < .001; ;*** p < .001
Table 11– Research Question Two: APIM Actor, Partner Effects (cont.)
Man (n=54)
Beta (s) Estimates Std. Error z - value p (> |z|) Actor’s Communication 0.117 0.248 0.290 0.857 0.391 Partner’s Communication 0.076 0.374 0.264 1.416 0.157 k 0.628 1.257 0.499 0.618 Note. * p < .05; ** p < .001; ;*** p < .001
APIM: Results for Covariance and Correlations
Figure 2–Research Question Two: APIM Covariance and Correlations
0.12 Communication Grief Reaction Man Man
0.08 0.51 -0.13
0.17
0.44 Communication Grief Reaction Woman Woman
This figure was copied from the APIM SEM app. 135
Figure 2 is the full APIM with standardized parameter estimates figure which displays all variables in the fitted model, including possible additional independent variables or covariates. This figure uses color coding with positive estimates indicated by green arrows and negative estimates by red arrows.
In APIM, the curved line that connects the independent variables indicates how similar the partners are on the predictor variables and for the outcome variables, the correction between the error or residual terms, which represents the non-independence that is not explained by the APIM. The predictor variable (Man Communication -
Woman Communication) is -0.13, the red arrows indicates that the female pattern is not similar to the male pattern who engaged in more negative communication (more negative attitudes toward/participation in emotional expression, i.e. more stoic behaviors, beliefs, and attitudes) and not statistically significant. The residual nonindependence in these outcome scores or the covariance between their corresponding two error terms is 0.51 (p
< 0.001), which is statically significant. For the outcome variable (Grief Reaction Man-
Grief Reaction Woman), the arrow is green, which indicates a strong positive correlation between grief reaction for both men and women. When grief reaction goes up (or down) for one it goes up (or down) for the partner.
Table 12–Research Question Two: APIM Covariance
Estimates Std. Error z - value p (> |z|) F Comm – M Comm -0.13 18.560 -0.947 0.344 F RGEI – M RGEI 0.51 80.792 3.339 0.001*** Note. F=Female, M=Male, Comm=Communication; RGEI=Grief Reaction; * p < .05; ** p < .01, ;*** p < .001.
Tables 10 and 11 depicts the magnitude of the correlation between the variables.
Regarding actor effects, for women their own communication was statistically significant
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and moderately positively correlated to their own grief reaction (0.01 < |r < .0.4), while for men their own communication is not correlated with their own grief reaction (r =
.107), i.e., it was not statistically significant. When it comes to partner effects, male communication is not correlated with female grief reaction (r =.116), and the same is true for female communication upon male grief reaction (r = .061). Both are positively correlated and not statistically significant. The covariance between female grief reaction and male grief reaction is moderately positively correlated (0.01 < |r| < .0.4) and statically significant, which means that when grief reaction increases for one it increase for the other and when it decrease for one it decreases for the other. Female communication and male communication is not correlated (r = -1.30), but the correlation is negative and not statistically significant.
Table 13–Research Question Two: APIM Correlations
Variable 2 3 4 1. F Communication -.130 .417** .061 2. M Communication .116 .107 3. F Grief Reaction .497** 4. M Grief Reaction Note. F = Female, M = Male **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).
Research question three is addressed next.
Research Question Three
This question addressed whether there was a statistically significant relationship between grief-related communication and guilt among couples. The Actor Partner
Interdependence Model (APIM) with distinguishable dyads was applied to determine the impact of couples’ communication on their own guilt, as well as their partner’s guilt. The
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analysis uses structural equation modeling (SEM) with maximum likelihood estimation using the program lavaan (Rosseel, 2012). The model fit was assessed using four indices:
Tucker-Lewis Index (TLI), Comparative Fit Index(CFI) Standardized Root Mean Square
Residual (SRMR) and Root Mean Square Error of Approximation (RMSEA). The results showed that the base model fit the data very well (TLI=1.00, CFI=1.00,
SRMR=0.000, RMSEA= 0.000). Since the current study is the first known study to analyze this research question using both female and male data simultaneously via dyadic data analysis, directionality was not possible.
To make sure that gender was empirically distinguishable, meaning there was a statistically meaningful difference, a model comparison was performed with distinguishable members and a model with indistinguishable members via the APIM
2 SEM application, which yielded a χ 6 = 23.622 (p < .001), thus concluding that the members can be statistically distinguished based upon the variable gender. The APIM diagram is detailed next.
APIM Diagram
Figure 3 depicts the APIM of the couple dyad in which there are two variables from each in the dyad: Communication (independent variable) and Guilt (outcome variable). It answers the question how well one’s own “Communication” predicts one’s own “Guilt” outcomes (actor effects), whereas, partner effects measures the extent to which a partner’s “Communication” predicts the actor’s “Guilt” outcomes.
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Figure 3–Research Question Three: APIM Diagram
Communication -.0.08 (0.05) Guilt E1 Man Man
-0.23 (0.05)
-.013 .0.24
0.18 (0.06)
0.25 (0.05) Communication Guilt E2 Woman Woman
* p < .05; ** p < .01, ;*** p < .001. This figure was copied from the APIM SEM app.
APIM: Results for Actor, Partner
Based on the standard APIM model, the actor effects for Women was equal to
0.102 (p = .060, 95% CI [0 , 0.21] beta (s) = 0.248). The actor effects for Men was equal to -0.029 (p = .562, 95% CI [ -0.13, 0.07] beta (s) = -0.077). The actor effects for both
Women and Men are not significant meaning their own communication does not impact their guilt. The partner effect from Men to Women was equal to -0.081 (p = .089, 95%
CI [ -0.17, 0.01] beta (s) = -0.227), while the partner effect from Women to Men was equal to 0.076 (p = .177, 95% CI [-0.03, 0.19.] beta (s) = 0.178). Both were not statistically significant. A man’s communication does influence his partner’s guilt and a woman’s communication does not influence her partner’s guilt.
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Table 14–Research Queston Three: APIM Actor, partner
Woman (n=54) Beta (s) Estimates Std. Error z - value p (> |z|) Actor’s Communication 0.248 0.102 0.054 1.883 0.060 Partner’s Communication 0.178 -0.081 0.048 -1.702 0.089 k 0.746 0.637 1.172 0.241 Note. * p < .05; ** p < .001; ;*** p < .001
Table 15–Research Queston Three: APIM Actor, partner (cont)
Man (n=54) Beta (s) Estimates Std. Error z - value p (> |z|) Actor’s Communication -0.077 -0.029 0.049 -0.580 0.562 Partner’s Communication 0.227 0.076 0.057 1.350 0.177 k 2.281 4.929 0.572 0.567 Note. * p < .05; ** p < .001; ;*** p < .001
APIM: Results for Covariance and Correlations
Figure 4–Research Question Three: APIM Covariance and Correlations
0.08 Communication Guilt Man Man
0.18
-0.13 0.24 -0.23
0.25 Communication Guilt Woman Woman
This figure was copied from the APIM SEM app.
Figure 4 is the full APIM figure which displays all variables in the fitted model, including possible additional independent variables or covariates. This figure uses color
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coding with positive estimates indicated by green arrows and negative estimates by red arrows. In APIM, the curved line that connects the independent variable indicates how similar the partners are on the predictor variables and for the outcome variables.
Table 16–Research Question Three: APIM Covariance
Estimates Std. Error z - value p (> |z|) F Comm – M Comm -0.13 18.560 -0.947 0.344 F Guilt – M Guilt .24 2.704 1.719 0.086 Note. F=Female, M=Male, Comm=Communication, * p < .05; ** p < .01, ;*** p < .001.
The predictor variable (Man Communication - Woman Communication) is (-
0.13), red arrows indicate that the female pattern is not similar nor statistically significant to the male pattern which engaged in more negative communication (more negative attitudes toward/less participation in emotional expression. The residual nonindependence in these outcome scores or the covariance between their corresponding two error terms is .24 and not statically significant. For outcome variable (Guilt Man-
Guilt Woman), the arrow is a green, which indicates a strong positive correlation between guilt for both men and women, however, it was not statistically significant. When guilt goes up (or down) for one it goes up (or down) for the partner.
Table 17 depicts the strength of the correlation between the variables. Regarding actor effects, for women their own communication was correlated with their own guilt (r
= .225), this correlation was positive and not statically significant. For men their own communication was not correlated with their own guilt (r = -.048) and not statically significant, but the correlation was negative. When it comes to partner effects, male communication is not correlated with female guilt (r = -.145). The same is true for female communication effects upon male guilt (r = -.217). Interestingly, the male to female partner effect was positive, while the female to male was negative, however both
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were not statically significant. Female guilt and male guilt are not correlated (r = -.217); female communication and male communication are also not correlated (r = -1.30). Both were not statically significant.
Table 17–Research Question Three: APIM Correlations
Variable 2 3 4 1. F Communication -.130 .225 -.217 2. M Communication .145 -.048
3. F Guilt .162
4. M Guilt Note. F = Female, M = Male **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).
Research Question Four is presented below.
Research Question Four
This question addressed whether there was a statistically significant relationship between grief-related communication and relationship satisfaction among couples. The
Actor Partner Interdependence Model (APIM) with distinguishable dyads was applied to determine the impact of couples’ communication on their own relationship satisfaction, as well as their partner’s relationship satisfaction. The analysis uses structural equation modeling (SEM) with maximum likelihood estimation using the program lavaan
(Rosseel, 2012). The model fit was assessed using four indices: Tucker-Lewis Index
(TLI), Comparative Fit Index(CFI) Standardized Root Mean Square Residual (SRMR) and Root Mean Square Error of Approximation (RMSEA). The results showed that the base model fit the data very well (TLI=1.00, CFI=1.00, SRMR=0.000, RMSEA= 0.000).
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Since the current study is the first known study to analyze this research question using both female and male data simultaneously via dyadic data analysis, directionality was not possible.
To make sure that gender was empirically distinguishable, meaning there was a statistically meaningful difference, a model comparison was performed with distinguishable members as was a model with indistinguishable members via the APIM
2 SEM application, which yielded χ 6 = 21.78 (p < .001). This concluded that the members could be statistically distinguished based upon the variable gender. More details about the APIM diagram are reported below.
APIM Diagram
Figure 5 depicts the APIM of the couple dyad in which there are two variables from each in the dyad: Communication (independent variable) and Relationship
Satisfaction (outcome variable). It answers the question how well one’s own
“Communication” predicts one’s own “Relationship Satisfaction” outcomes (actor effects), whereas, partner effects measures the extent to which a partner’s
“Communication” predicts the actor’s “Relationship Satisfaction” outcomes.
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Figure 5–Research Question Four: APIM Diagram
Relationship Communication 0.08 (0.04) Satisfaction E1 Man Man
0.17 (0.03)
-.013 .0.45** 0.12 (0.04)
0.2 (0.03) Relationship Communication Satisfaction E2 Woman Woman
* p < .05; ** p < .01, ;*** p < .001. This figure was copied from the APIM SEM app.
APIM: Results for Actor, Partner
Based on the standard APIM model, the actor effect for Woman was equal to
0.046 (p = .135, 95% CI [-0.01 , 0.11], beta (s) = 0.199). The actor effect for Man was equal to 0.021 (p = .572, 95% CI [ -0.05, 0.1], beta (s) = 0.77). The actor effect for both women and men were not significant. The partner effect from Man to Woman was equal to 0.041 (p = .202, 95% CI [ -0.02, 0.1], beta (s) = 0.125), while the partner effect from
Woman to Man was equal to 0.033 (p = .360, 95% CI [-0.04, 0.11], beta (s) = 0.0170).
Both were not statically significant. A man’s communication does not influence his partner’s relationship satisfaction nor does a woman’s communication influence her partner’s relationship satisfaction.
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Table 18–Research Queston Four: APIM Actor, partner
Woman (n=54) Beta (s) Estimates Std. Error z - value p (> |z|) Actor’s Communication 0.199 0.046 0.031 1.494 0.135 Partner’s Communication 0.170 0.041 0.032 1.275 0.202 K 0.888 0.855 1.039 0.299 Note. * p < .05; ** p < .001; ;*** p < .001
Table 19–Research Queston Four: APIM Actor, partner (cont)
Man (n=54) Beta (s) Estimates Std. Error z - value p (> |z|) Actor’s Communication 0.077 0.021 0.038 0.565 0.572 Partner’s Communication 0.125 0.033 0.037 0.916 0.202 k 1.558 3.046 0.512 0.609 Note. * p < .05; ** p < .001; ;*** p < .001
APIM: Results for Covariance and Correlations
Figure 6 is the full APIM figure which displays all variables in the fitted model, including possible additional independent variables or covariates. This figure uses color coding with positive estimates indicated by green arrows and negative estimates by red arrows.
Figure 6–Research Question Four: APIM Covariance and Correlations
Relationship Communication 0.08 Satisfaction Man Man
0.17 -0.13 0.45 0.12
Relationship Communication 0.20 Satisfaction Woman Woman This figure was copied from the APIM SEM app.
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In APIM, the curved line that connects the independent variable indicates how similar the partners are on the predictor variables and for the outcome variable, the correction between the error or residual terms, which represents the non-independence that is not explained by the APIM. The predictor variable (Man Communication -
Woman Communication) was -0.13, the red arrows indicates that the female pattern was not similar and not statically significant to the male pattern which engages in more negative communication (more negative attitudes toward/less participation in emotional expression, i.e. more stoic behaviors, beliefs, and attitudes). The residual nonindependence was statically significant in these outcome scores or the covariance between their corresponding two error terms is 0.45 (p < .01). For outcome variable
(Relationship Satisfaction Man-Relationship Satisfaction Woman), the arrow is green which indicates a strong positive correlation between relationship satisfaction for both men and women. When relationship satisfaction goes up (or down) for one it goes up (or down) for the partner.
Table 20–Research Queston Four: APIM Covariance
Estimates Std. Error z - value p (> |z|) F Comm – M Comm -0.13 18.560 -0.947 0.344 F GDS – M GDS 0.45 1.248 2.998 0.003*** Note. F=Female, M=Male, Comm=Communication; GDS = Relationship Satisfaction; * p < .05; ** p < .01, ;*** p < .001.
Table 21 depicts the magnitude of the correlation between the variables.
Regarding actor effects, for women their own communication was not correlated nor statically significant with their own relationship satisfaction (r = .177), for men their own communication was not correlated nor statically significant with their own relationship
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satisfaction (r = .061). For partner effects, male communication was not correlated with female relationship satisfaction (r = -144). The same was true for female communication upon male relationship satisfaction (r = .115). Both were not statically significant. The covariance between female relationship satisfaction and male relationship satisfaction was moderately to largely correlated (.462 < r < .001) and statically significant, while female communication and male communication was not correlated (r = -1.30) nor statically significant.
Table 21–Research Question Four: APIM Correlations
Variable 1 2 3 4 1. F Communication 1 -.130 .177 .115 2. M Communication -.130 1 .144 .061 3. F Relationship Satisfaction .177 .144 1 .462** 4. M Relationship Satisfaction .115 .061 .462** 1
Note. F= Female, M = Male **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).
Research question five is addressed next.
Research Question Five
This question addressed whether there was a statistically significant relationship between grief-related communication, time since death, and grief reaction. Because this question requires moderation a hierarchal regression was employed. Beginning with a linear causal relationship in which the variable X (communication) is presumed to cause the variable Y (grief reaction). A moderator variable M (time since death by gender) is a variable that alters the strength of the casual relationship (Frazier et al., 2004). Most moderator analysis measure the casual relationship between X and Y by using a
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regression coefficient (Frazier et al., 2004). Moderators address ‘when’ or ‘for whom’ a predictor is more strongly related to an outcome, mediators establish ‘how’ or ‘why’ one variable predicts or causes an outcome variable (Frazier et al., 2004). More specifically, a mediator is described as a variable that clarifies the relation between a predictor and an outcome (Baron & Kenny, 1986). In other words, a mediator is the mechanism through which a predictor influences an outcome variable (Baron & Kenny, 1986).
Table 22–Hierarchical Regression: Males
B β t pv MComm .165 .078 .428 .671 M TSD Years -.886 -.215 -.242 .809 MTSDxMComm .015 .227 .252 .802 Dependent Variable: F RGEI Note. M=Male, Comm=Communication, TSD=Time since Death, RGEI=Grief Reaction, * p < .05
Table 23–Hierarchical Regression: Females
B β t pv FComm .240 .116 .565 .575 F TSD Years -7.567 -1.815 -2.150 .036* FTSDxFComm .126 1.520 1.768 .083 Dependent Variable: F RGEI Note. F=Female, Comm=Communication, TSD=Time since Death, RGEI=Grief Reaction, * p < .05
Males. Table 22 indicates the results for males. To determine if communication and time since death effects grief reaction for males, a hierarchal regression was run using SPSS. The dependent variable was Grief Reaction and the independent variables were Communication, Time Since Death (in years), and the interaction or
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Communication by Time since Death. These three predictor variables (communication, time, and communication by time) were entered as a single block into the regression model. The regression results indicate that this overall model does not significantly
2 2 predict male grief reaction [R = .013, R adj = -.047, F(3, 50) = .214, p = .886). This model accounted for 1.3% of the variance in male grief scores.
Females. Table 23 indicates the results for females. To determine if communication and time since death effect grief reaction for females, a hierarchal regression was run using SPSS. The dependent variable was Grief Reaction and the independent variables were Communication, Time Since Death (in years), and the interaction or Communication by Time Since Death. These three predictor variables
(communication, time, and communication by time) were entered as a single block into the regression model. The regression results indicate that this overall model does
2 2 significantly predict female grief reaction [R = .329, R adj = .289, F(3, 50) = 8.185, p <
.001). This model accounted for 32.9% of the variance in female grief scores. The variable Time Since Death was a significant predictor to female grief reaction. On average, for each additional year since death, the female grief score decreases by 1.815 points, holding all other variables constant.
Summary
Chapter IV presented the statistical findings of the present study. It began with a restatement of the problem, a reporting of the pre-analysis data screening, sample, participant demographics, descriptive statistics for the variables, and inferential statistics.
Normality, skewness, and kurtosis were addressed. The remaining part of Chapter IV presented the results from the study. Due to the paucity of literature, present and past,
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along with the differences in statistical approaches from this study and Kamm’s 1999 dissertation, directionality was not applicable for all of the research questions.
Research question one addressed whether there would be a statistically significant difference in average score between genders for grief related communication, grief reaction, guilt, and relationship satisfaction. All of the variables found sufficient evidence at the 5% significance level of a significant difference in the average total score between females and males. For communication, males scored significantly higher on communication than females, which implied that males have a more negative attitude toward emotional expression. For grief reaction, guilt, and relationship satisfaction females scored significantly higher in grief reaction, guilt, and relationship satisfaction than males, which implies that females have a more intense grief reaction, more guilt, and more relationship satisfaction than males.
Research questions two through four utilized APIM for analysis. As this is the first known study to analyze these research question using both female and male data simultaneously via dyadic data analysis, Kamm’s (1999) findings and prior literature cannot be used to determine directionality of this hypothesis. Research question two asked whether there was a statistically significant relationship between grief-related communication and grief reaction among couples. This study found that there was a statistically significant actor effect for a woman’s communication on her own grief reaction, however for men it was not significant, suggesting that a woman’s communication does influence her own grief reaction, while a man’s communication does not influence his own grief reaction.
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The Partner effects were not significant for both men to women and women to men. The results suggest that a man’s communication does not influence his partner’s grief reaction and a woman’s communication does not influence her partner’s grief reaction. The predictor variable (Man Communication - Woman Communication) was not significant and negatively correlated. This means that the female communication pattern is not similar to the male pattern, which included more negative attitudes toward/less participation in emotional expression. The outcome variable (Grief Reaction
Man-Grief Reaction Woman) was statistically significant. This signified that there was a strong positive correlation between grief reaction for both men and women meaning that when grief reaction goes up (or down) for one it goes up (or down) for the partner.
Research question three asked whether there was a statistically significant relationship between grief-related communication and guilt. The actor effect, for both women and men were not significant. This means that a woman’s communication does not influence her own guilt. Likewise, a man’s communication does not influence his own guilt. Partner effects were not significant for both men to women and women to men. This result signifies that a man’s communication does not influence his partner’s guilt and a woman’s communication does not influence her partner’s guilt. Partner effects were not significant for both men to women and women to men. These results signify that a man’s communication does not influence his partner’s guilt and a woman’s communication does not influence her partner’s guilt. The outcome variable (Guilt Man-
Guilt Woman) was not significant. However, the relationship was positive, which indicates that when guilt goes up (or down) for one it goes up (or down) for the partner.
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For guilt, the correlation for female actor effect were positively correlated, but for men it was negatively correlated, however, both were not statically significant. Higher scores indicate more negative attitudes toward emotional expression, for example, more stoic behaviors, beliefs, and attitudes. This means that when a woman’s communication is less expressive her guilt increases, but when she is more expressive her guilt decreases.
When a man’s communication is less expressive, his guilt goes down, but when his communication is more expressive his guilt increases.
For the partner effects the correlation for male to female partner effect were positively correlated, while the correlation for female to male partner effect were negatively correlated. This was an interesting finding, although both were not statistically significant. So, when the male is less expressive, it increases the female’s guilt and when he is more expressive it decreases her guilt. However, when a female is less expressive the male’s guilt decreases and when she is more expressive his guilt increases.
Research question four asked whether there was a statistically significant relationship between grief-related communication and relationship satisfaction. The actor effect for both women and men was not significant. This means that a woman’s communication does not influence her relationship satisfaction and a man’s communication does not influence his own relationship satisfaction. Partner effects were not significant for both men to women and women to men. The results suggested that a man’s communication does not influence his partner’s relationship satisfaction and a woman’s communication does not influence her partner’s relationship satisfaction. The predictor variable (Man Communication - Woman Communication) was not significant,
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but moderately negatively correlated, however. This means that the female pattern is not similar with the male pattern who engaged in more negative communication with more negative attitudes toward/participation in emotional expression. The outcome variable
(Relationship Satisfaction Man-Relationship Satisfaction Woman) was statically significant (p < .01). This signified that there was a strong positive correlation between grief reaction for both men and women. When grief reaction goes up (or down) for one it goes up (or down) for the partner.
Research question five was assessed by hierarchical regression. The regression results indicate that this overall model does significantly predict female grief reaction [R2
2 = .329, R adj = .289, F(3, 50) = 8.185, p < .001). This model accounted for 32.9% of the variance in female grief scores. On average, for each additional year since death, the female grief score decreases by 1.815 points, holding all other variables constant. The variable time since death was a significant predictor to female grief reaction. However, the regression results indicate that this overall model does not significantly predict male
2 2 grief reaction [R = .013, R adj = -.047, F(3, 50) = .214, p = .886). This model accounted for 1.3% of the variance in male grief scores.
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CHAPTER V
DISCUSSION
A discussion and interpretation of the results of the present study are presented in this chapter. This chapter is organized into five sections. The first section includes a statement of the problem, a summary of the results, along with an interpretation of statistical results. A Comparison to Kamm’s 1999 study is in the second section. There were several limitations of the study and these are presented in the section three.
Suggestions for future research are discussed in section four. Finally, section five summarizes the current study and concludes the chapter.
Statement of the Problem
This study was concerned with extending research on communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction in bereaved parents. To accomplish this goal, this research study utilized a valid and reliable quantitative measure of communication that specifically targets couple communication as well as appropriate quantitative measures of grief reactions, guilt, and relationship satisfaction. As described in the literature review, minimal to no research has examined the relationship between grief-related communication on grief reaction, guilt, and relationship satisfaction in bereaved couples after the death of a child in the field of Couple and Family Therapy (CFT).
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The purpose of this study was to gain a better understanding of the relationship between grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It also examined whether parental gender and time since death have implications for those relationships.
There is a lack of research, current and past, on the relationship between couples’ grief- related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child from a Bowenian perspective. This study aids relevant and necessary research to the field of CFT, as the majority of the research investigates individual (particularly mothers) that have dealt with the death of a child.
Participants (n=108 or 54 couples) in this study completed the following: a demographic questionnaire, the Attitudes towards Emotional Expression Scale to measure communication, the Revised Grief Experience Inventory to measure grief reaction, the Guilt subscale of the Grief Experience Questionnaire to measure guilt, and the Marital Satisfaction Inventory-Revised to measure relationship satisfaction.
Research Questions
Sherrie Kamm’s 1999 dissertation was the framework for this study and her general research questions were used for this study. The first research question was assessed by an independent t-test for two samples and asked whether there was a statistically significant gender difference in grief-related communication, adaptation
(grief reaction), adaptation (guilt), and relationship satisfaction. Due to the differences in statistical approaches and the lack of research with these variables Kamm’s (1999) findings were not able to be used for directionality.
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The second research question was assessed by the Actor Partner Interdependence
Model (APIM) and asked whether there was a statistically significant relationship between grief-related communication and grief reaction among couples. Since the current study is the first known study to analyze this research question using both female and male data simultaneously via dyadic data analysis, Kamm’s (1999)findings and prior literature cannot be used to determine directionality of this hypothesis.
The third research question was assessed by APIM. It asked whether there was a statistically significant relationship between grief-related communication and guilt among couples. Since the current study is the first known study to analyze this research question using both female and male data simultaneously via dyadic data analysis, Kamm’s findings and prior literature cannot be used to determine directionality of this hypothesis.
The fourth research question was assessed by APIM and asked whether there was a statistically significant relationship between grief-related communication and relationship satisfaction among couples. Since the current study is the first known study to analyze this research question using both female and male data simultaneously via dyadic data analysis, Kamm’s (1999) findings and prior literature cannot be used to determine directionality of this hypothesis.
The fifth research question was assessed by hierarchal regression as this question requires moderation. This research question inquired whether there was a statistically significant relationship between grief-related communication, time since death, and grief reaction.
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Summary of the Results
General Research One
Grief-Related communication was measured via the Attitudes Toward Emotional
Expression Scale (AEE; Joseph, Williams, Irwing, & Cammock, 1994) to determine communication style; the Revised Grief Experience Inventory (RGEI) (Lev, Munro, &
McCorkle, 1993) was administered to assess grief reaction; participants were the given the Guilt subscale of the Grief Experience Questionnaire to assess guilt; and relationship satisfaction was measured by the Marital Satisfaction Inventory-Revised (MSI-R; Snyder,
1997). An independent sample t-test was employed to measure the differences in average scores for the variables. All the variables (communication, grief reaction, guilt, and relationship satisfaction) showed sufficient evidence at the 5% significance level of a significant difference in the average total scores.
Interpretation of Statistical Results for Research Question One
Communication. There was a statistically significant difference between the two gender groups. Results revealed that males scored significantly higher on communication than females. To explore further, it could be estimated with 95% confidence that, on average, males scored between 1.56 and 10.52 points higher than females on total communication scores. In summary, the findings indicated that males are less expressive than females.
Grief Reaction. There was a statistically significant difference between the two gender groups. The results indicated that females scored significantly higher in grief reaction than males. To explore further, it could be estimated with 95% confidence that females score, on average, between 6 and 24 points higher than males on total grief reaction score. These results indicate that females have more intense grief reactions than males.
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Guilt. There was a statistically significant difference between the two gender groups.
The results suggested that females scored significantly higher in guilt than males. To explore further, it could be estimated with 95% confidence that females score, on average, between 0.478 and 4.003 points higher than males on total guilt score. This indicates that females had more guilt than their male partners.
Relationship Satisfaction. There was a statistically significant difference between the two gender groups. The results indicated that females scored significantly higher in relationship satisfaction than males. To explore further, it can be estimated with 95% confidence that females score, on average, between 0.560 and 2.847 points higher than males on total relationship satisfaction. Therefore, the results indicate that females are more satisfied with the relationship than males. However, based on the means for their global distress scale (GDS), (females -�̅ = 55.70, males �̅ = 57.41) there is a significant levels of relationship struggle for both woman and men.
General Research Two
Grief-Related communication was measured via by the Attitudes Toward
Emotional Expression Scale (AEE; Joseph, Williams, Irwing, & Cammock, 1994) to determine communication style and the Revised Grief Experience Inventory (RGEI)
(Lev, Munro, & McCorkle, 1993) was administered to assess grief reaction. The actor partner Interdependence model (APIM) was used to compare and identify different types of dyadic patterns that can depict the interpersonal influences of actors and partners. The following section will review the interpretations of the statistical results for research question two.
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Interpretation of Statistical Results for Research Question Two
Actor Effects. There was a statistically significant (p < .001) actor effect for a women’s communication on her own grief reaction, however for men it was not significant. The results indicate that a woman’s communication does influence her own grief reaction, however, a man’s communication does not influence his own grief reaction.
Partner Effects. Partner effects were not significant for both men to women and women to men. The results suggest that a man’s communication does not influence his partner’s grief reaction and a woman’s communication does not influence her partner’s grief reaction.
Predictor Variables. The predictor variable (Man Communication - Woman
Communication) was not significant and was negatively correlated. This means that the female communication pattern is not similar with the male pattern who engaged in more negative communication with more negative attitudes toward/participation in emotional expression, for example, more stoic behaviors, beliefs, and attitudes.
Outcome Variables. The outcome variable (Grief Reaction Man-Grief Reaction
Woman) was statistically significant (p < .001). This signified that there was a strong positive correlation between grief reaction for both men and women. When grief reaction goes up (or down) for one it goes up (or down) for the partner. The next section will review research question three, followed by the interpretations of the statistical results.
General Research Three
Grief-Related communication was measured via by the Attitudes Toward
Emotional Expression Scale (AEE; Joseph, Williams, Irwing, & Cammock, 1994) to determine communication style, while participants were the given the Guilt subscale of
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the Grief Experience Questionnaire to assess guilt. The actor partner Interdependence model (APIM) was used to compare and identify different types of dyadic patterns that can depict the interpersonal influences of actors and partners.
Interpretation of Statistical Results for Research Question Three
Actor Effects. The actor effect for both women and men was not statistically significant.
This means that a woman’s communication does not influence her own guilt. Likewise, a man’s communication does not influence his own guilt. Although not statistically significant, interestingly, the correlation for female actor effect was positively correlated, while for men it was negatively correlated.
Partner Effects. Partner effects were not significant for both men to women and women to men. These results signify that a man’s communication does not influence his partner’s guilt, and a woman’s communication does not influence her partner’s guilt.
However, the correlation for female to male partner effect was non-significant but negatively correlated, while the correlation for male to female partner effect was non- significant but positively correlated.
Predictor Variables. The predictor variable (Man Communication - Woman
Communication) was not significant and negatively correlated. This means that the female pattern is not similar to the male pattern, which showed more negative communication with more negative attitudes toward/less participation in emotional expression.
Outcome Variables. The outcome variable (Guilt Man-Guilt Woman) was not significant. However, the relationship was positive but weakly correlated, which indicates that when guilt goes up (or down) for one it goes up (or down) for the partner.
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The next section will review research question four, followed by the interpretations of the statistical results.
General Research Four
Grief-Related communication was measured via by the Attitudes Toward
Emotional Expression Scale (AEE; Joseph, Williams, Irwing, & Cammock, 1994) to determine communication style, while relationship satisfaction was measured by the
Marital Satisfaction Inventory-Revised (MSI-R; Snyder, 1997). The actor partner
Interdependence model (APIM) was used to compare and identify different types of dyadic patterns that can depict the interpersonal influences of actors and partners.
Interpretation of Statistical Results for Research Question Four
Actor Effects. The actor effect for both women and men was not significant. This means that a woman’s communication does not influence her relationship satisfaction and a man’s communication does not influence his own relationship satisfaction.
Partner Effects. Partner effects were not significant for both men to women and women to men. The results suggested that a man’s communication does not influence his partner’s relationship satisfaction and a woman’s communication does not influence her partner’s relationship satisfaction.
Predictor Variables. The predictor variable (Man Communication - Woman
Communication) was not significant, but negatively correlated. The results indicate that the female pattern is not similar to the male pattern, which tends toward engagement in more negative communication with more negative attitudes toward/less participation in emotional expression, for example, more stoic behaviors, beliefs, and attitudes.
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Outcome Variables. The outcome variable (Relationship Satisfaction Man-Relationship
Satisfaction Woman) was statistically significant (p < .01). This signified that there was a strong positive correlation between relationship satisfaction for both men and women.
When relationship satisfaction goes up (or down) for one it goes up (or down) for the partner. The next section will review research question five, followed by the interpretations of the statistical results.
General Research Five
Grief-Related communication was measured via by the Attitudes Toward
Emotional Expression Scale (AEE; Joseph, Williams, Irwing, & Cammock, 1994) to determine communication style and the Revised Grief Experience Inventory (RGEI)
(Lev, Munro, & McCorkle, 1993) was administered to assess grief reaction, while time since death was measured by answers to the demographic questionnaire specifically asking how long it had been since the child died. Hierarchical regression was used to access this question.
Interpretation of Statistical Results for Research Question Five
The regression results indicate that this overall model does not significantly
2 2 predict male grief reaction [R = .013, R adj = -.047, F(3, 50) = .214, p = .886). This model accounted for 1.3% of the variance in male grief scores. The regression results indicate that this overall model does significantly predict female grief reaction [R2 = .329,
2 R adj = .289, F(3, 50) = 8.185, p < .001). This model accounted for 32.9% of the variance in female grief scores. The variable “Time Since Death” was a significant predictor to female grief reaction. On average, for each additional year since death, the female grief score decreases by 1.815 points, holding all other variables constant.
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Comparison to Kamm’s Results
Kamm’s (1999) results included the new concept of time and its critical role in the grieving process, which was not discussed earlier in her 1999 dissertation nor included in her research questions. Kamm (1999) argued that the interaction between communication and time, and their impact on the dependent variables was important.
As a result, for each of Kamm’s (1999) research questions she utilized the following predictor variables: couples’ communication, time since the child’s death, and communication by time interaction. Due to the differences in statistical approach, the results for her study could not be compared to the results of this study.
Upon further reflection, and with hindsight that can only arrive after execution of one’s plan, this writer has identified areas for change and improvement in this study.
First and foremost, this researcher would have selected fewer research questions from
Kamm’s (1999) dissertation. The number of survey items, and resulting overall complexity, became difficult to manage.
This researcher would have kept the independent two-sample t-test as it provided an overall view of the data. The need to analyze female and male data simultaneously via
APIM would remain. Kamm (1999) also used median splits for communication and time since death, which can answer questions about the impact of more and less time since death along with more and less expressive communication, which this researcher finds useful for our field. The Marital Satisfaction Inventory-Revised (MSI-R; Snyder, 1997) would still have replaced the Index of Marital Satisfaction (IMS; Hudson, 1992). Still, this researcher struggled with use of the MSI-R in the context of this study due to its length. The low rate of return might have resulted from the large number of questions.
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However, this researcher also finds positive aspects in participants completing the entire instrument, because the large volume of resulting data provides ample opportunity for extended data analysis.
Linking Theory to Outcomes
Grief-Related Communication
Brown (1989) wrote that many family emotional reactions and long-term adjustment difficulties arising from death originate in the lack of openness in the system.
A couple’s level of differentiation is related to their level of openness or closedness in communication and the ability to communicate impacts the level of differentiation
(Bowen, 1978). In this study males were found to be less expressive, however there was a strong connection between expressiveness and lower grief reaction regarding both actor effects and partner effects.
Grief Reaction
According to Bowen, individuals or families with low differentiation levels are more likely to respond poorly to stress (Titelman, 1998). The literature finds women have more intense grief reactions (Murphy, Shelvin, & Elkit , 2014; Vollbehr, 2011).
This study found that females scored significantly higher in grief reaction than males, which implies that females have more intense grief reaction than males. In fact, on average, females score between 6 and 24 points higher than males.
Guilt
Guilt can hinder the healthy progression of mourning (Buckle & Fleming, 2011) and forecast the level of bereavement intensity experienced by the parents (Ducan &
Cacciatore, 2015). Feelings such as guilt may be a surface awareness of emotions (Kerr
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& Bowen, 1988). Factors such as stressful life events (like the death of a child) and emotional support (from a partner) can play a part in the relationship between psychological symptoms and differentiation (Krycak, Murdock, & Marszalek, 2012).
An interesting outcome in this study was the impact of communication on guilt seeing different patterns between females and males. Actor effects for females were positively correlated, while males were negatively correlated. Partner effects for male to female were positively correlated, while female to male were negatively correlated.
Relationship Satisfaction
There is a link between differentiation and the ability to cope with stressful events
(Murdock & Gore, 2004). Kerr and Bowen (1988) proposed that lower levels of differentiation are the cause of psychological and interpersonal difficulties. Based on their mean score, the couples in this study were found to be in distress and struggling
(female (�̅ = 55.70) and male (�̅ = 57.41)).
Implications for Couple and Family Therapists
The results of this exploration contribute to the field of couple and family therapy in several ways. First, the findings of this study contribute to the existing knowledge of the relationship between grief related communication, parental adaptation (grief reaction, parental adaptation (guilt), and relationship satisfactions of bereaved parents. Second, the research frames the constructs facing bereaved couples through the lens of Bowen Family
Systems Theory (BFST). When stress and anxiety are high, it would seem reasonable to expect symptom management, differentiation, and long-term adjustment to be impacted.
Also, the actual helpfulness of communication in supporting positive dyad grief adjustment should be of interest to CFTs. Gains in knowledge related to complex
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interactions of grief, guilt and communication may prove helpful for development of therapeutic approaches in the CFT field. For individual therapists, providing insight regarding the relationship between grief-related communication, grief reaction, guilt, and relationship satisfaction, along with gender differences and time since death, may support their complex work with grieving clients. Since Kamm’s dissertation in 1999, the variables of grief related communication, grief reaction, guilt, and relationship satisfaction have been sadly ignored and there is no research using these variables through BFST.
Third, the study heightened the significance of the impact of a child’s death on bereaved parents. Grief is complex. There is discomfort in discussing death in our society, especially surrounding the death of a child as it breaks the typical life cycle.
Four, the results of this study also provide implications for couple and family therapists who are working with bereaved parents who are impacted by the death of child. It is this researcher’s belief, that our field can do better to meet the needs of bereaved parents.
This topic should be highly relevant in the caring sciences.
Fifth, bereaved parents of adult children are often overlooked. There exists the implication that the death of a younger child has a greater negative impact on parents
(Gamino, Sewell, & Easterling, 2000). This researcher nearly made the same error (i.e. not including parents who adult child had died), but while contacting support groups to gauge interest in participation, it was repeatedly pointed out to this researcher by support group facilitators that parents whose adult child had died suffer the same feelings of guilt, helplessness, hopelessness, depression and experienced a lifelong change that is like those parents who lost a younger child. When it comes to the death of an adult child,
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much of the research has to do with suicide (Maple, Edwards, Plummer, & Minichiello,
2010). Dyregrov, Nordanger, and Dyregrov (2003) confirmed the results of other researchers, that sudden and traumatic circumstances surrounding a child’s death have a long-lasting and devastating impact on the survivors. Unnatural as compared to natural deaths are assumed to be associated with more complicated grieving processes in the bereaved (Parkes, 1998).
Bereaved parents face unique challenges in grief-related communication, grief reaction, guilt, and relational satisfaction due to experiencing one of the greatest and most challenging losses known. Limitations are presented below.
Limitations of the Study
As with all research investigations, the present study has limitations that can potentially influence the conclusions. The following limitations exist for this study and should be considered when interpreting the results:
1. A survey response return rate of 31% was considered to be a limitation of this
study.
a. Nonresponse error threatens the external validity and statistical conclusion
validity of inferences made in research using questionnaires (Sivo,
Saunders, Chang, & Jiang, 2006).
b. Future research should include the best way to deal with nonresponse error
and how to increase response rate.
c. The complex nature of grief and its relational strain may have inhibited the
rate of return.
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2. It is possible that the large number of questions (206) that the participants were
asked to answer hindered response rates.
3. The participants were predominantly Caucasian (81% of females, 80% of males)
thereby limiting the generalizability of the study’s findings to couples of other
races.
a. Future research should include a more diverse sample to understand if
there are any cultural implications to these constructs on grief in relational
systems.
b. Other avenues beyond support groups could be utilized to tap into diverse
populations.
4. The majority of participants were married couples (98%).
a. The sample underrepresented same-sex couples and cohabitating couples.
b. The sample size underrepresented cohabitating couples.
5. The prevailing religion for the participants was Christian (74% of female
participants, 65% of male participants) which may impact the ability to generalize
the study’s findings. The sample size underrepresented other religions.
a. This study did not consider the benefits or limitations of faith, which may
impact relationship satisfaction or guilt.
b. The relationship between religious beliefs and grief is inconsistent
(Becker, Xander, Blum, Lutterback, Momm, Gysels, & Higginsons, 2007;
Cowchock, Lasker, 2010).
6. The participants were well educated (For females: 28% with a bachelor’s degree,
26% with a master’s, and 8% with a doctorate level or professional degree; For
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males: 26% with a bachelor’s degree, 20% with a master’s, and 10% with a
doctorate level or professional degree), which may influence the ability to
generalize the study’s findings.
a. It would be worth investigating if socioeconomic status impacts the
bereavement process for parents.
b. Educational attainment may be important on mental health, particularly
depression and post bereavement.
7. A majority of the participants belonged to a support group (78% of female
participants, 57% of male participants), which may influence the ability to
generalize the study’s findings.
8. As with all convenience samples, the fact that participants actively volunteered
for the study may impact the generalizability of the results.
a. This sample may not be representative of all bereaved parents.
b. Understanding the factors related to bereaved parents not volunteering is
crucial for future similar research.
9. Regarding time since death (TSD), it is unclear whether answers to question could
be distorted due to TSD whether it comes from the rawness of the recent death or
the familiarity that time may provide.
10. The participants were not assessed regarding previous counseling experiences or
other interventions that may have contributed to grief-related communication,
grief reaction, guilt, or relationship satisfaction.
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a. Future research should include questions pertaining to counseling services
obtained after the loss of the child, as this could impact the process of
grief.
b. Including research as to what a bereaved parent may need during the
counseling process may be of use to the CFT field.
11. There was no way to know the couple’s relationship satisfaction level prior to
death of the child.
a. Riches and Dawson (2002) suggested that marital patterns of interaction
before the bereavement should be studied in order to better understand
marital conflict and breakdown after the bereavement.
12. The lack of directionality for the research questions, left this dissertation
ungrounded and provided a lack of focus.
13. Since the program that this researcher is enrolled in is a clinical program instead
of a research program, there were several demographic questions that, in
hindsight, may have been poorly constructed.
a. For example, participant reports of income did not clarify per individual or
per couple.
Recommendations for Future Research
Couples who present to clinics for treatment also need to participate in empirical research studies that examine the relationship between grief related communication, parental adaptation (grief reaction, guilt), and relationship satisfactions of bereaved parents. The usefulness of treatment to improve communication to decrease grief reaction, to decrease guilt, and to improve relationship satisfaction also needs to be
170
examined. Research on support groups to determine if there are outcome differences between in-person and online support groups should be considered. Given the gender differences in membership to a support group, the benefits of belonging to a support group by gender may be beneficial. Although the role of religion was not important to this researcher others may be more interested as to the benefits and limitations in terms of relationship satisfaction and guilt should be explored.
It was beyond the scope of this study as it was not looking at the relationship between grief reaction and guilt, but there appears to be a correlation between female grief reaction and female guilt. The results of the correlational analysis indicate a significant positive relationship between grief reaction and guilt. An increase in grief reaction was associated with an increase in guilt for females (r = 0.323, pv = 0.017) and an increase in grief reaction was associated with an increase in guilt for males (r = 0.343, pv = 0.011) meaning a significant positive relationship between grief reaction and guilt for men. It was also found that an increase in male guilt was associated with an increase in female grief reaction (r = 0.403, pv = 0.003), which should be investigated.
The result for the full APIM that dealt with the relationship between grief-related communication and guilt although non-significant was interesting. The full APIM results for grief-related communication and grief reaction along with grief-related communication and relationship satisfaction both had positive correlations (non- significant) for both female and male actor effects and partner effects (male to female; female to male), while for guilt, the correlation for female actor effect were positively correlated (non-significant), but for men it was negatively correlated (non-significant).
Higher scores indicate more negative attitudes toward/less participation in emotional
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expression, i.e. more stoic behaviors, beliefs, and attitudes. This means that when a woman’s communication is less expressive her guilt increases, but when she is more expressive her guilt decreases. When a man’s communication is less expressive, his guilt goes down, but when his communication is more expressive his guilt increases.
For the partner effects the correlation for male to female partner effect were positively correlated (non-significant), while the correlation for female to male partner effect were negatively correlated (non-significant). So, when the male is less expressive, it increases the female’s guilt and when he is more expressive it decreases her guilt.
However, when a female is less expressive the male’s guilt decreases and when she is more expressive his guilt increases. Since guilt can hinder the healthy progression of mourning (Buckle & Fleming, 2011) and guilt appears to be more problematic for men
(Ducan & Cacciatore, 2015), couple and family therapist should be aware of this potential pitfall regarding communication. Titus and de Sourza (2011), found that parents who were expressive and open expected their partners to be the same, while couples who were closed had a great deal of conflict and strain in their relationship. In this study, the mean for women was 55.70, while for men it was 57.51. These scores for the sample indicate the couples were experiencing relationship struggles with males being even less satisfied than women. The factors associated with relationship satisfaction following the death of a child needs to be explored.
Summary
This chapter included a review of the research problem and a summary of the research procedures and methods. The research questions were briefly summarized, and the implications of these results were presented. Implications of the research findings and
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suggestions for future research were also discussed. Finally, the limitations of the study were presented in the last section. The goal of this study was to empirically examine and to extend the research on the relationship between spousal grief-related communication, parental adaptation (grief reaction), parental adaptation (guilt), and relationship satisfaction after the death of a child. It also examined whether parental gender and time since death have implications for those relationships. Results from this study support the need for clinicians to gain a deeper understanding of the difficulties that bereaved couples face.
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APPENDICES
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APPENDIX A
IRB APPROVAL LETTER
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APPENDIX B
INFORMED CONSENT
You are invited to participate in a research project conducted by Michelle Bowes, a doctoral candidate in the School of Counseling at The University of Akron in Akron,
Ohio. The purpose of this study will be to examine the relationship between grief-related communication, grief reactions related to parental adaptation, guilt reactions related to parental adaptation, and relationship satisfaction after the death of a child. It will also examine whether parental gender and time elapsed since death have implications for those relationships. I am hoping for couples to fill out the questionnaires; however, individuals are still encouraged to participate. The Bowen Family System Theory
(BFST) will be the theoretical framework for this study. Intact couples (meaning no divorced or separated couples) who are over the age of 18, who have experienced child deaths are requested for participation in this study. Child deaths for participant couples can range from fetal death (death prior to delivery, irrespective of the duration of the pregnancy) up to adult children age 55.
If you agree to participate, you will be asked to give general information that describes you, your grief related communication, grief reaction, guilt, and relationship satisfaction via four online assessment tools. Please discuss your and your partner’s participation in this study as you will be asked to provide your partner’s name in the demographic section. You will be asked for your partner’s name so that resulting assessment data can be correlated and analyzed for each couple, based on their individual
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assessment results. Providing your partner’s name without their consent could potentially violate the privacy of your partner, who might not necessarily have consented to participate in this study. You should understand that providing partner names, as is being requested, can also violate your anonymity by connecting your provided data to your partner’s name. After participants provide requested information, a company called
Qualtrics will then make it available only to the researcher, and the assessment data will not otherwise reveal any identifying information. That is why it is critical that participants provide requested partner name information, so that partner results can be matched and analyzed. Please note that the researcher will be the only person to have access to the raw data that includes partner names. The data will also be masked (no identifiable data) when any other members of the dissertation committee review study results. Confidentiality will be maintained using a number code system that will be assigned to online responses. Additionally, once the researcher has linked the surveys, the names will be removed, so that the data will be anonymized as soon as possible.
The assessment data will be stored on a solid-state jump drive, which will be password protected and will remain locked when not in use. However, with any type of internet communication system, there may be risks related to the transfer of information from one party to another. Your completion of the online survey will serve as your acceptance of the information provided in this informed consent document and your consent to participating in this study.
The first assessment has 20 questions and measures communication. The second assessment has 22 questions and measures bereavement reaction. The third assessment has five questions and measures guilt. The fourth assessment has 150 questions and
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measures relationship satisfaction. Your participation may add to the body of knowledge and understanding regarding relationship grief-related communication, parental adaptation (bereavement reaction and guilt), and relationship satisfaction after the death of a child. Your participation in this study is voluntary. You are free to refuse to participate or to withdraw at any time, with no negative consequences.
Due to the topic of this research (the death of a child) it may cause participants some level of distress, including undesired changes in thought processes and emotion.
For participants who maintain connection with existing support groups, please consider seeking support if required. Also, if you become triggered or suicidal, please make contact as appropriate through one of the following resources: National Suicide
Prevention Lifeline at (800) 273-8255, NAMI Helpline at 800-950-NAMI (800-950-
6264) or www.nami.org, National Drug and Alcohol Treatment Referral Service at 800-
662-HELP (800-662- 4357), SAFE (Self-Abuse Finally Ends) at 1-800-DONT-CUT (1-
800-366-8288) or www.selfinjury.com, Domestic Violence at 800-799-7233, http://www.crisischat.org, or 211.org.
This study has been approved by The University of Akron’s Institutional Review
Board (#20171203). For additional questions regarding the rights of research participants, please contact the IRB at (330) 972-7666. If you have any questions about this study, please contact study principal Michelle Bowes via email, at [email protected], or by telephone (234) 206-1221. You may also contact Dr.
Karin Jordan, Ph.D., Dissertation Chair and Professor, at the University of Akron, in
Akron, Ohio at [email protected] or by telephoning her at (330) 972-551
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APPENDIX C
AUTHOR-DEVISED DEMOGRAPHIC QUESTIONNAIRE
1. What is your gender: female male other? 2. What is your age: 18-24 25-34 35-44 45-54 55-64 or 65 or older or decline to answer? 3. What is your employment status: full time, part time, homemaker, unemployed, retired, student, other, or decline to answer? 4. What is your occupation: executive/advanced professional, business manager/lower professional/teacher, administrative personal/small business owner skilled manual, semi-skilled/machine operator, unskilled, clerical/sales/technical, student, other, or decline to answer? 5. What is your relationship status: Married Cohabitating Other? 6. What is your current relationship length: less than one year, one year, two years, three years, four years, five years, Six, Seven, Eight, Nine, 10 years, 15 years, 20 years, 25 years, 30 years, 35 years, 40 years, 45 years, 50 years, over 50 years? 7. What is your highest education level: less than a high school diploma, Some high school, high school, some college, technical school, Associate degree, bachelor’s degree, master’s degree, professional degree (e.g. MD, DDS, DVM), doctorate degree, or decline to answer?. 8. What is your ethnicity: American Indian or Alaska Native, Asian-American, African-American (Black), Hispanic and Latin-American, European- American (Caucasian), Native American, Native Hawaiian or Other Pacific Islander, Other, Decline to Answer? 9. What is your religious affiliation: Seventh-day Adventist, Agnostic, Atheist, Buddhism, Christianity, Hinduism, Islam, Judaism, Mormonism, Sikhism, Other, Decline to Answer? 10. Do you and your partner share the same religious affiliation? Yes No Decline to Answer? 11. What is your household income: under $20,000, $20,000 – 39,999, $40,000 – 59,99, $60,000 – 79,999, $80,000 – 99, 999, $100,000 or more, or Decline to Answer? 12. What was the sex of your child that died: female, male, other, unknown? 13. Was the decease child a result of infertility treatments? Yes No? 14. How many infertility treatments did you have? participant could fill in answer Decline to Answer
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15. What is the length of time since your child’s death: less than one year; one year, two years, three years, four years, five years, Six, Seven, Eight, Nine, 10 years, 15 years, 20 years, 25 years, 30 years, 35 years, 40 years, 45 years, 50 years, over 50 years? 16. What was the age of the deceased child at death: fetal death (death prior to delivery, irrespective of the duration of the pregnancy); infant death (<1 to 364 days); deaths between the ages of 1 through 18; or deaths of adult children age 1 through 55 17. What was the cause of your child’s death: accident, homicide, suicide, illness (e.g. cancer) medical (e.g. SIDS), unknown, Other? 18. Do you have other children: Yes, No (If yes, complete 19)? 19. Are you affiliated with a support group for bereaved parents: Yes, No?
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APPENDIX D
THE ATTITUDES TOWARD EMOTIONAL EXPRESSION SCALE (AEE;
JOSEPH, WILLIAMS, IRWING, & CAMMOCK, 1994)
The following statements relate to thoughts and behaviors concerning the expression of emotions. Please read each one and SD D NDA A SA indicate how much you agree or disagree with it: 1. I think you should always keep your feelings under control. 1 2 3 4 5 2. I think you out not to burden other people with your problems. 1 2 3 4 5 3. I think getting emotional is a sign of weakness. 1 2 3 4 5 4. I think other people do not understand your feelings. 1 2 3 4 5 5. When I am upset, I bottle up my feelings. 1 2 3 4 5 6. You should always keep your feelings to yourself. 1 2 3 4 5 7. Other people will reject you if you upset them. 1 2 3 4 5 8. My bad feelings will harm other people if I express them. 1 2 3 4 5 9. If I express my feelings, I am vulnerable to attack. 1 2 3 4 5 10. You should always hide your feelings. 1 2 3 4 5 11. When I am upset, I usually try to hide how I feel. 1 2 3 4 5 12. I seldom show how I feel about things. 1 2 3 4 5 13. Turning to someone else for advice or help is an admission of 1 2 3 4 5 14. Itweakness. is shameful for a person to display his or her weaknesses. 1 2 3 4 5 15. I should always have complete control over my feelings. 1 2 3 4 5 16. If other people know what you are really like, they will think 1 2 3 4 5 17. Whenless of Iyou. get upset, I usually show how I feel. 1 2 3 4 5 18. People will reject you if they know your weaknesses. 1 2 3 4 5 19. If a person asks for help it is a sign of weakness. 1 2 3 4 5 20. I do not feel comfortable showing my emotions. 1 2 3 4 5
Note. 1=Strongly Disagree (SD), 2=Disagree (D), 3=Neither Disgree nor Agree (NDA), 4=Agree (A), 5=Moderately Agree (MA), 6=Moderately Agree (MA), 6=Strongly Agree (SA)
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APPENDIX E
THE REVISED GRIEF EXPERIENCE INVENTORY (RGEI; LEV, MUNRO, &
MCCORKLE, 1993)
Read each item and decide quickly how you feel about it; then circle the number of the item that best describes your feelings. NOTE – first determine if you AGREE or DISAGREE with the ITEM and then determine to what extent you feel with this answer (SLIGHT, MODERATE, OR STRONG)
SD MD SLD SLA MA SA Question
1. I tend to be more irritable with others. 1 2 3 4 5 6 2. I frequently experience angry feelings. 1 2 3 4 5 6 3. My arms and legs feel very heavy. 1 2 3 4 5 6 4. I have feelings of guilt because I was spared, and the deceased was 1 2 3 4 5 6 taken. 5. I feel lost and helpless. 1 2 3 4 5 6 6. I have frequent headaches since the death. 1 2 3 4 5 6 7. I cry easily. 1 2 3 4 5 6 8. Concentrating on things is difficult. 1 2 3 4 5 6 9. I feel extremely anxious and unsettled. 1 2 3 4 5 6 10. Sometimes I have a strong desire to scream. 1 2 3 4 5 6 11. Life has lost its meaning for me. 1 2 3 4 5 6 12. I am not feeling healthy. 1 2 3 4 5 6 13. I frequently feel depressed. 1 2 3 4 5 6 14. I have the feeling that I am watching myself go through the 1 2 3 4 5 6 motions of living. 15. Life seems empty and barren. 1 2 3 4 5 6 16. I have frequent mood changes. 1 2 3 4 5 6 17. Small problems seem overwhelming. 1 2 3 4 5 6 18. I have lost my appetite. 1 2 3 4 5 6 19. I seem to have lost my energy. 1 2 3 4 5 6 20. I seem to have lost my self-confidence. 1 2 3 4 5 6 21. I am unusually unhappy. 1 2 3 4 5 6 22. I am awake most of the night. 1 2 3 4 5 6 Note. 1=Strongly Disagree (SD), 2=Moderately Disagree (MD), 3=Slightly Disagree(SLD), 4=Slightly Agree (SLA), 5=Moderately Agree (MA), 6=Moderately Agree (MA), 6=Strongly Agree (SA)
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APPENDIX F
GRIEF EXPERIENCE QUESTIONNAIRE (GEQ) (BARRETT & SCOTT,
1989): GUILT SUBSCALE
Since the death of your child, how often do you… N R S O AA
1) Think of times before the death when you could have made your child’s life more 1 2 3 4 5 pleasant.
2) Wished you had not said or done certain things during your relationship with your 1 2 3 4 5 child.
3) Feel like there was something very important you wanted to make up to your child. 1 2 3 4 5
4) Feel like maybe you did not care enough about your child. 1 2 3 4 5
5) Feel somehow guilty after the death of your child. 1 2 3 4 5
Note. 1=Never (N), 2=Rarely (R), 3=Sometimes (S), 4=Often (O), 5=Almost Always (AA)
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APPENDIX G
THE MARITAL SATISFACTION INVENTORY-REVISED (MSI-R; SYNDER,
1997)
This material is copy right protected.
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APPENDIX H
DEMOGRAPHICS TABLES
Table 24–Race
Female Male Variable N (%) N (%) African-American 2 4% 3 6% Asian-American 0 0% 2 4% European-American 44 81% 43 80% Hispanic or Latin-American 2 4% 1 2% Native American 0 0% 0 0% Native Hawaiian or Other Pacific Islander 1 2% 1 2% Other 3 6% 3 6% Decline to answer 2 4% 1 2% Total 54 100% 54 100%
Table 25–Age
Female Male Variable N (%) N (%) 25-34 5 9% 8 15% 35-44 14 26% 13 24% 45-54 13 24% 9 16% 55-64 13 24% 14 26% 65 or older 9 17% 10 19% Total 54 100% 54 100%
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Table 26–Location (by Couple)
Variable N (%)
Alabama 1 2% Arizona 1 2% Australia 1 2% California 4 7% Florida 1 2% Hawaii 1 2% Illinois 1 2% Kansas 1 2% Massachusetts 1 2% Michigan 2 4% Nevada 1 2% New England 1 2% New Mexico 1 2% New York 2 4% North Carolina 3 6% Ohio 10 19% Oklahoma 1 2% Oregon 2 4% Pennsylvania 2 4% South Dakota 1 2% Texas 10 19% Utah 1 2% Vermont 1 2% Virginia 2 4% Wisconsin 2 4% Total 54 100%
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Table 27–Employment Status
Female Male Valuable N (%) N (%) Full-time 30 56% 33 61% Part-time 5 9% 1 2% Retired 11 20% 15 28% Self-employed 2 4% 3 6% Student 1 2% 0 0% Unemployed 4 7% 1 2% Other 1 2% 0 0% Decline to answer 0 0% 1 2% Total 54 100% 54 100%
Table 28–Occupation
Female Male Variables N % N % Administrative personal/small business owner 7 13% 2 4% Business manager/lower professional/teacher 15 28% 12 22% Clerical/sales/technical 4 7% 5 9% Executive/advanced professional 18 33% 16 30% Other 5 9% 5 9% Retired 0 0% 1 2% Skilled manual 2 4% 9 17% Student 1 2% 0 0% Decline to answer 2 4% 4 7% Total 54 100% 54 100%
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Table 29–Income
Female Male Variable N % N % 20,000 – 39,999 4 7% 4 7% 40,000 – 59,999 4 7% 4 7% 60,000 – 79,999 6 11% 7 13% 80,000 – 99,999 5 9% 6 11% 100,000 or more 28 52% 30 56% Decline to Answer 7 13% 3 6% Total 54 100% 53 100%
Table 30–Relationship Status
Female Male Variable N % N % Married 53 98% 53 98% Cohabitating 1 2% 1 2% Total 54 100% 54 100%
Table 31–Infertility Treatment
Female Male Variable N (%) N (%) Yes 3 6% 3 6% No 51 94% 51 94% Decline to answer 0 0% 0 0% Total 54 100% 54 100%
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Table 32–Number of Infertility Treatments
Females Males
N % N % One 2 67% 2 67% Decline to Answer 1 33% 1 33% Total 3 100% 3 100%
Table 33–Education Level
Female Male Variable N % N % Less than a high school diploma 0 0% 1 2% High school diploma or GED 5 9% 8 15% Some college 9 17% 10 19% Technical school 2 4% 2 4% Associate degree 5 9% 3 6% Bachelor’s degree 15 28% 14 26% Master’s degree 14 26% 11 20% Professional degree (MD, DDS, DVM) 3 6% 2 4% Doctorate degree 1 2% 3 6% Decline to Answer 0 0% 0 0% Total 54 100% 54 100%
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Table 34–Relationship Length
Female Male Variable N (%) N (%) Less than 1 year 0 0% 0 0% One year 0 0% 0 0% 2 years 0 0% 0 0% 3 years 1 2% 1 2% 4 years 0 0% 0 0% 5 years 0 0% 1 2% 6 years 1 2% 0 0% 7 years 0 0% 0 0% 8 years 0 0% 1 2% 9 years 3 6% 1 2% 10 years 7 14% 7 13% 15 years 8 15% 10 19% 20 years 4 7% 3 6% 25 years 8 15% 8 15% 30 years 5 9% 4 7% 35 years 4 7% 5 9% 40 years 5 9% 5 9% 45 years 4 7% 5 9% 50 years 3 6% 2 4% Over 50 years 1 2% 1 2% Total 54 100% 54 100%
Table 35–Sex of the Deceased Child
Female Male Variable N (%) N (%) Female 17 31% 17 31% Male 36 67% 36 67% Unknown 1 2% 1 2% Total 54 100% 54 100%
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Table 36–Religious Affiliation
Female Male Variable N (%) N (%) Seventh-day Adventist 0 0% 0 0% Agnostic 3 6% 2 4% Atheist 1 2% 5 9% Buddhism 0 0% 1 2% Christianity 40 74% 35 65% Hinduism 0 0% 0 0% Islam 0 0% 0 0% Judaism 3 6% 4 7% Mormonism 2 4% 2 4% Sikhism 0 0% 0 0% Other 2 4% 2 4% Decline to Answer 3 6% 3 6% Total 54 100% 54 100%
Table 37–Same Religion
Female Male Variable N (%) N (%) Yes 41 76% 43 80% No 9 17% 9 17% Decline to Answer 4 7% 2 4% Total 54 100% 54 100%
Table 38–Age of the Deceased Child
Female Male Variable N (%) N (%) Fetal 7 13% 7 13% Infant 6 11% 6 11% Child (1 through 18) 19 35% 19 35% Adult child (19 through 55) 22 41% 22 41% Total 54 100% 54 100% 211
Table 39–Reason for Death
Female Male Variables N (%) N (%)
Accident 15 28% 15 28% Medical (e.g. SIDS) 17 31% 17 31% Other 8 15% 8 15% Unknown 6 11% 6 11% Homicide 4 7% 4 7% Suicide 4 7% 4 7% Total 54 100% 54 100%
Table 40–Other Children
Female Male Variable N (%) N (%)
Yes 50 93% 53 98% No 4 7% 1 2% Total 54 100% 54 100%
Table 41–Length of Time since Death
Female Male Variable N (%) N (%)
Less than 1 year 5 9% 5 9% One year 3 6% 2 4% 2 years 9 16% 10 18% 3 years 3 6% 3 6% 4 years 8 15% 8 15% 5 years 3 6% 2 4% 6 years 5 9% 6 11% 7 years 6 11% 4 7% 8 years 3 6% 5 9% 9 years 3 6% 3 6% 10 years 0 0% 0 0% 15 years 3 6% 3 6%
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20 years 1 2% 1 2% 25 years 1 2% 1 2% 30 years 1 2% 1 2% 35 years 0 0% 0 0% 40 years 0 0% 0 0% 45 years 0 0% 0 0% 50 years 0 0% 0 0% Over 50 years 0 0% 0 0% Total 54 100% 54 100%
Table 42–Member of a Grief Support Group
Female Male Variable N (%) N (%)
Yes 42 78% 31 57% No 12 22% 23 43% Decline to answer 0 0% 0 0% Total 54 54
Table 43–Which Organization
Female Male Variable N (%) N (%)
Compassionate Friends 29 69% 23 74% The Mothers Enduring Neonatal Death (M.E.N.D.) 5 12% 2 6% Hospice Support Group 2 5% 2 6% Church 1 2% 1 3% Local Hospital Organization 1 2% 1 3% KARA 0 0% 1 3% Share 0 0% 1 3% Helping Parents Heal 2 5% 0 0% Multiple 1 2% 0 0% Parents of Murdered Children (POMC) 1 2% 0 0% Total 42 100% 31 100%
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APPENDIX I
HISTOGRAMS, BOXPLOTS, Q-Q PLOTS
Figure 7–Communication Histograms
Figure 8–Grief Reaction Histograms
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Figure 9–Guilt Histograms
Figure 10–Relationship Satisfaction Histograms
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Figure 11–Time since Death (in Years) Histograms
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Figure 12–Commutation Boxplots
Figure 13–Grief Reaction Boxplot
Figure 14–Guilt Boxplot
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Figure 15–Relationship Satisfaction Boxplot
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Figure 16–Time since Death (in Years) Boxplot
Figure 17–Communication Q-Q Plots
Figure 18–Grief Reaction Q-Q Plots
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Figure 19–Guilt Q-Q Plots
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Figure 20–Relationship Satisfaction Q-Q Plots
Figure 21–Time since Death (in Years) Q-Q Plots
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