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Grief Perspectives
Scholar's Corner
Resource Review
Your Professional Library

Social Support's Vital Role in Grief

by William G. Hoy
Recent research studies have borne out what clinicians have known intuitively for many years—there is a decided difference between the ways people resolve losses when they are connected to a supportive community. While good social networks do not prevent all complication in the bereavement process, the right support from the right people seems to be an effective tool in managing crises and loss.


 
A Finnish study from several years ago interviewed 52 bereaved mothers, revealing that the study participants felt most supported by family and close friends. Interviews and surveys conducted at least one year after the child’s death showed evidence of greater personal growth, less blame and anger, and less disorganization for the mothers who had good personal support versus the mothers who had little personal support or received only professional assistance.
 
The mothers in this study overwhelmingly reported that, if they were in a support group, they wanted it to be a support group of parents with similar experiences since in their opinion, only fellow sufferers would understand the experience of losing a child. The negative support reported by these mothers consisted primarily of interference from other family members and the dissolution of long-time friendships (Laakson & Paunonen-Ilmonen, 2002).
 
More than a decade ago, Howard Stone and colleagues (Stone, Cross, Purvis & Young, 2004) at the Brite Divinity School of Texas Christian University studied how church members supported each other during crisis. Similar to the results of previous research, Stone and his colleagues found that the social support afforded by active involvement in a faith community was a strong buffer against many of the long-term negative effects of the crisis. Reflecting on the ways their interviewees felt supported by the community, the presence of caring friends spoke volumes. The researchers wrote, “One of the most striking themes of the interviews in our sample was the immediate and profound impact of these (acts of kindness). Indeed, the simplest acts—merely showing up at the grieving person’s house and doing the dishes, for example—appear to be the most profoundly helpful to those in crisis” (pp. 413-415).
 
In the congregation studied, every active member belonged to a shepherd group, a small “family” of 20 to 30 people with a trained leader. On a number of occasions reported by the interviewees, members of the person’s shepherd group actually arrived at the hospital or home before the subject’s own family members. The researchers first saw the “acts of kindness” as helpful because they removed some of the “burden” of the crisis so that the subject could focus on more pressing needs. “Soon, however, we became aware that they were perceived as acts of solidarity or support—a physical way of expressing concern, love, and care” (p.418).
 
A third study pointing to the efficacy of social support was one engaged in by Lauren Vanderwerker and Holly Prigerson at the Yale University School of Medicine. In their study (Vanderwerker & Prigerson, 2004), 293 bereaved individuals were interviewed during the first year after the death. While Vanderwerker and Prigerson were examining the role of technologically advanced systems for support (i.e. cellular telephone and internet use), the study conclusively demonstrated that overall social support was protective against Major Depressive Disorder, Post-Traumatic Stress Disorder, and complicated grief, as well as being associated with an overall better quality of life.
 
Interestingly, the word often used to describe these kinds of technologies—“connectivity”—implies the presence of and importance of social support. Vanderwerker and Prigerson demonstrate amply the important benefits to bereaved people of such technologies as online grief support chat rooms and the ready accessibility to others that cellular phone service provides, making it possible to largely banish isolation. With the rapid growth of Facebook, Instagram, and other social networking sites since the publication of this study, one might expect this technological support factor to have become more significant.
 
Swedish researchers (Benkel, Wijk, & Molander, 2009) interviewed spouses, adult children, siblings and friends of deceased palliative care patients. Study participants were interviewed shortly after the death and again at one year post-loss. Confirming earlier studies, survivors indicated they both needed and generally received good support from family members and friends. Those who described dysfunctional or non-existent support networks tended to need more professional support than those who had functional support systems in place before the death.
 
Ghesquiere (2013-14) interviewed older adults who were participating in a randomized clinical trial for an intervention support group for people with bereaved people. Prior to enrollment in the 13-week group, these subjects sought social support and viewed the group intervention positively, but had generally found support lacking from family and friends. None of the study participants received ongoing support from a religious community and most described attempts of family and friends to “change the subject” when the deceased’s name came up (p. 11). Prior to finding the complicated grief treatment group, participants had generally been frustrated in attempts to connect with mental health professionals, usually because the focus of treatment was not specific to grief or because the therapist seemed to lack experience with grief. In some cases, participants described mental health professionals’ incompetence with one quoting a therapist as saying, “’In three months you will feel better; in one year you will be better.’ But three months and a year went by and I felt worse” (p. 12).
 
These research studies reflect varied approaches to learning about social support from individuals whose loved ones died from a diversity of causes and reflecting differing relational statuses. Social support is extremely important in most (though not all) cases. However, counselors and other helpers must still grapple with two important issues: 1) how do we know whether a bereaved client senses support? and 2) what do we do when perceived support is lacking?
 
How to assess levels of social support. While most bereaved individuals seem to readily admit the level of social support or the lack of it, helpers must be sensitive to those who do not. I have worked with many older adults who initially indicate they have “wonderful” support from their adult children. Upon further inquiry, however, these same adults sometimes admit to feeling alone in grief. The questions I have learned to ask to assess levels of support are these:
  1. Who is “in your camp?” In other words, who do you feel like is really “there for you” in loss?
  2. What specifically do these people do to communicate their concern and help?
  3. Would you like connections to more people or to receive different kinds of support?
 
In addition to conversations designed specifically to assess levels of social support, helpers need to listen attentively to words used to describe other aspects of the bereaved individual’s relationships with others. Sometimes bereaved people will say things like, “I used to be involved in this great church…” or “People always thought we were a close family…” Learning the “rest of the story” after such comments can provide important details about present levels of social support.
 
What to do in the absence of strong social support. While never disparaging support that is perceived by the bereaved person to be helpful and adequate, helpers will want to be ready to offer suggestions for support outside his or her natural support system; bereavement support groups provide one possible avenue for such support. Helpers should point out to bereaved individuals, however, that every group develops its own “personality” and not every bereaved person fits well within every group. Knowing the support groups presently operating in a community, how they are structured (open to participants at any time; meeting for a set duration of time; focused on a particular loss) is essential.
 
Interaction with a caregiving professional may also be beneficial, but again, knowledge of the credentials and approaches used by various professionals is essential. When interviewing potential clinicians and other caregiving professionals, I ask questions about how they view the role of loss in mental health, who the bereavement theorists and clinicians are who have most influenced their thinking, and what specific training they have received about dealing with loss. A common theme heard in both research (Ghesquiere, 2013-14) and clinical practice is disappointment with some professionals’ experience with grief. When asked to refer bereaved individuals to resources outside of my geographical area, I begin by searching the membership directory and the “Find a Specialist” link maintained by the Association for Death Education and Counseling (www.adec.org).
 
For those of us who provide care to bereaved people, these studies and our own clinical observations provide conclusive evidence. Our work with bereaved people is most effective when we help them connect—with families, friendship circles, faith communities, and support groups of people who have experienced similar losses. Indeed, grief is not intended to be a solitary, isolated issue. We are made for community, and we grieve best when that loss is supported by a network of social support.
 
References.
 
Benkel, I., Wijk, H., & Molander, U. (2009). Family and friends provide most social support for the bereaved. Palliative Medicine, 23, 141-149.
 
Ghesquiere, A. (2013-14). “I was just trying to stick it out until I realized that I couldn’t”: A phenomenological investigation of support seeking among older adults with complicated grief. Omega: Journal of Death & Dying, 68 (1), 1-22.
 
Laakso, H. & Paunonen-Ilmonen, P. (2002). Mothers’ experience of social support following the death of a child. Journal of Clinical Nursing, 11, 176-85.
 
Stone, H.D., Cross, D. R., Purvis, K.B. & Young, M. J. (2004). A study of church members during times of crisis. Pastoral Psychology, 52, 405-421.
 
Vanderwerker, L.C. & Prigerson, H. G. (2004). Social support and technological connectedness as protective factors in bereavement. Journal of Loss & Trauma, 9 (1), 45-57.
The Author: For more than three decades, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide effective care. After a career in congregation, hospice, and educational resource practice, he now holds a full-time teaching appointment as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas where he has taught since 2012. His most recent book is Bereavement Groups and the Role of Social Support: Bridging Theory, Research, and Practice (Routledge, 2016).


Resource Review

Caring Info
. Bereaved individuals, dying patients, and volunteer caregivers can all benefit greatly from the end-of-life, advance care planning, and bereavement resources available free at www.CaringInfo.org, the consumer advocacy website of the National Hospice and Palliative Care Organization. Downloadable brochures and resources are available in both English and Spanish and include such topics as understanding grief, helping children, and supporting friends in grief. Printable materials are both useful and attractively designed.
Your Professional Library
Doka, K.J. (2016). Grief is a journey: Finding your path through loss. New York, NY: Atria Books.
 
Among the clearest voices about grief in our generation is that of Ken Doka. Developing such key concepts as disenfranchised grief and instrumental vs. intuitive styles of grieving, Doka’s contributions have been broad and deep. Now, in this highly readable book, he again offers a thoughtful treatment of the grief process, seasoned by years of personal and professional experience with bereavement. In Grief is a Journey, he sets out to identify some key myths about grief that we have all heard proceed from the mouths of our patients and certainly in the pages and websites of western media. He decries the reliance on one-size-fits-all models and the ubiquitous stage approaches to the grief process so often popularized in contemporary loss. So goes the first part of the book as Doka attempts to help readers understand the terrain of grief.
 
In the second part of the book, Doka examines different types of loss: spousal, parental, child, and adult siblings. Each of these losses carry their own unique characteristics, he writes, and he offers practical wisdom at each turn. I think the chapters of parts one and two make the book especially helpful for grieving individuals themselves, especially since his writing style is informal, almost chatty.
 
Part 3 of the volume is where Doka becomes the “self” for which he is best known: the teacher helping students understand the realities and complexities of disenfranchised grief, paying particular attention to the unacknowledged losses of this experience. In Part 4, the chapters turn to such nuts-and-bolts issues as planning funerals and seeking professional resources when self-help is not enough.
 
For those familiar with the now-famous “styles of grief (continuum of intuitive to instrumental), chapters three and four will prove especially helpful. Here, the author summarizes the work he and a colleague (Doka & Martin, 2010) have done and offers a quick self-assessment for bereaved individuals to better understand their own style of grieving. One highlight for me of the book is that here he has distilled key concepts in his work in a readable, inexpensive volume. Because his work on disenfranchised grief and styles of grieving have been heretofore available only in scholarly journals and expensive academic/professional books, even clinicians have often had a hard time getting access to his work in his own words. However, I bought Grief is a Journey for Kindle for $ 13.99 and it is available in hardcover (also from Amazon) for less than $ 20; cost is no longer a prohibitive factor.
 
I highly recommend this volume. It will provide a useful summary of some of Ken Doka’s most salient concepts while offering another source to help our patients, clients, and students make sense of an often confusing universe of grief.
 
References.
 
Doka, K.J. (Ed.) (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press.
 
Doka, K.J. & Martin, T.L. (2010). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Routledge.
Research that Matters
Hirooka, K., Fukahori, H., Taku, K., Izawa, S., & Ogawa, A. (2019). Posttraumatic growth in bereaved family members of patients with cancer: A qualitative analysis. Supportive Care in Cancer, 27(4), 1417-1424. doi:10.1007/s00520-018-4440-6
 
As a descriptive concept in psychotherapy, the notion of posttraumatic growth owes its genesis to the work of Richard Tedeschi and Richard Calhoun. The two of them defined PTG as the positive psychological changes that come about as a result of the struggles in highly challenging life circumstances [9]. Their PTG Inventory sought to measure the construct quantitatively. While numerical “counts” are helpful, the nuances of individual experiences can only be tallied through qualitative research methods where patient/survivor stories are heard and themes elucidated. The current study is just such an effort.
 
Hirooka, et.al. analyzed the open-ended question on a bereavement follow-up survey sent to Japanese hospice families after the patient’s death. Of the 955 surveys returned complete, 391 contained responses to the open-ended prompt, “Please describe anything you have noticed or thought about as a result of losing your family member because of cancer” (p. 1418). The responses were analyzed by three researchers independently, and then the responses were classified into several overarching themes or topics. Several respondents indicated they thought more about their own mortality, had a heightened interest in learning about the afterlife, had a better understanding of death, had more awareness/interest in managing one’s own health and of appreciating the value of the family. Others indicated they were gratified by support received by others, strengthened family bonds, and had even discovered in self the desire to care for others. Several respondents indicated they had developed new interests or had discovered the strength to try to new challenges.
 
Like with other qualitative measures, the purpose of this study is not to rank the responses by importance or number of times cited by respondents. Rather, the purpose of this kind of study is to discover the breadth of possible responses and potential ways for the bereaved to describe their experiences. This study’s genesis in Japan potentially helps North American readers better appreciate the cultural diversity of our own caregiving settings.
GriefPerspectives is published monthly by Grief Connect, Inc. Copyright ©2017. All rights reserved, including publication or distribution in any form, electronic or printed. For reprint permissions or suggestions for content, please email us at GriefResources@msn.com.
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