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To cite this article: James A. Houck PhD (2007) A Comparison of Grief Reactions in Cancer, HIV/AIDS, and Suicide
Bereavement, Journal of HIV/AIDS & Social Services, 6:3, 97-112, DOI: 10.1300/J187v06n03_07
To link to this article: http://dx.doi.org/10.1300/J187v06n03_07
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INTRODUCTION
A common misconception about grief is that it is one-dimensional, that
is, experienced solely as an emotional turmoil. Instead, grief is a multifaceted experience, causing a disruption in a persons physical, emotional,
spiritual, social, and philosophical well-being. Worden (2004) proposes
that the grief reaction can be categorized into four areas:
1. Feelings: sadness, anger, guilt, anxiety, etc.
2. Physical Sensations: tightness in the chest and throat, lack of energy, dry mouth, etc.
3. Cognitions: disbelief, confusion, preoccupation, sense of presence, etc.
4. Behaviors: sleep and appetite disturbances, social withdrawal, etc.
These experiences are considered normal reactions of grief, which
usually diminish in intensity over time ( Sadock & Sadock, 2003).
Review of Grief Reactions: Normal and Complicated
Although it is affirmed by many in the field of mental health that grief
is considered a normal reaction to any type of loss, and can be experienced on many different levels, there is, however, a point when grief is
considered abnormal. This phenomenon occurs when grief and mourning
become complicated as the level of impairment escalates to the point of
severely limiting the day-to-day functioning of one who mourns a loss.
From a cognitive perspective, Neimeyer, Prigerson, and Davies (2002)
suggest that complicated grief occurs when a person is unable to assimilate the loss into his/her personal life narrative; in other words, reconstruct a meaningful personal reality (p. 236) by relearning assumptions
about the world, roles in the family, etc., challenged by the loss.
Lazare (1979) suggests that abnormal, or pathological, grief occurs
when one or more of the following symptoms are evident: (1) when a
person is not able to talk about the deceased without experiencing a
fresh grief reaction; (2) when minor events trigger an intense emotional
response; (3) when the death of the loved-one is often the topic of conversation; (4) when there is a reluctance to remove the loved ones
James A. Houck
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were distributed which provided a 43% return rate. The participants included 105 women (67.9%) and 45 men (32.1%). Ethnicity in the sample was 10% Hispanic, 43% Caucasian, and 47% African-American.
The range of ages was from 19 to 79 years with a mean age of 44.65
years. Income ranged from $20,000 to $60,000, with a mean income of
$36,000. The education levels for the total sample were 30.9% completed high school, 51.2% attended college, and 17.9% attended graduate school. When comparing any of the socioeconomic demographics to
the grief reactions, no significance correlation (.30), which could distinguish one bereavement group from another, was found.
Specific Grief-Related Demographics
Participants were asked to indicate their relationship to the deceased,
how much time had passed since the death of their loved-one, whether
they attended support groups for their grief, and their current HIV status.
Participants relationship to the deceased included the following:
24% lost a parent, 21% lost a spouse, 15.4% lost a sibling, 13.6% lost
children, 10.5% lost a close friend, 7.4% lost a life-partner. Another 9%
lost an extended family member such as an uncle or grandparent. At the
time of completing the testing packet, participants were asked how
much time had passed since their loved ones death. The range for this
question was 3 months to over 5 years with a mean of 24.3 months. These
specific grief-related demographics were evenly distributed throughout
the three bereavement groups.
A stepwise discriminant analysis identified overall significance for
the GEQ variables, p < .001 for each of the group means. This significance indicates that despite the type of the death, these groups have similar grief reactions albeit varying degrees. For example, out of the 11
variables, 2 were identified as contributing to the discrimination between each of the bereavement groups, namely unique reactions to suicide and stigmatization, accounting for 88.6 and 11.4% of the variance,
respectively. In addition, these characteristics were calculated with a combined Chi-square = 217.03, p < .000. Even after removal of the strongest
characteristic, unique reactions to suicide, there was still strong association between the groups and the predictors, Chi-square = 39.097, p <
.000. Therefore, based on the analysis that the grief reactions differed
depending on which type of grief participants were experiencing, the
null hypothesis of no differences between the three groups was rejected.
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In order to determine to what degree the bereavement groups are similar or different, the most significant functions (Unique Reactions to
Suicide and Stigmatization) were analyzed at the group means for each
type of death (Table 1). For example, the variable Unique Reactions to
Suicide (Function 1) separated the responses of the suicide bereavement
group (1.911) from those of the cancer (1.829) and AIDS-related
(.082) bereavement groups. Barrett and Scott (1989) assert that a defining characteristic for unique reactions to suicide is attributed to a survivor concealing the circumstances surrounding the death in order to
avoid the sensitivity of perhaps having the cause of death broadcast in
the media. The expectation was that the suicide group would score
higher in this particular category. In addition, HIV/AIDS bereavement
may have only slight characteristics similar to suicide bereavement.
Stigmatization (Function 2) separates the responses of the AIDSrelated bereavement group (.775) from the cancer (.413) and suicide
bereavement (.362) groups. Again, Barrett and Scott (1989) define stigmatization in bereavement as society having a negative perception of
the survivor as a result of the death of his/her loved-one. It is not surprising that the HIV/AIDS group scored highest in this category, because
the literature spoke of HIV/AIDS as being a highly stigmatized disease
(Burkett, 1995; Shilts, 1988; Snyder, Omato, & Crain, 1999). Yet, what
is noteworthy is how similar cancer and suicide bereavement are in
terms of stigmatization. Unlike HIV/AIDS bereavement, where it appears that the stigma is transferred to surviving loved-ones, suicide and
cancer bereavement did not demonstrate this characteristic as strongly.
Perhaps one reason why stigma appears in the cancer group may be
related to how the person developed the disease (e.g., excessive smoking, not taking care of oneself, etc.). At one time society viewed suicide
as a highly stigmatized death, however, that trend seems to be changing. What may be attributing to this lack of stigmatization currently is
the way society has become more sympathetic in their understanding
TABLE 1. Function of Significant Grief Reactions for Each Group
Type of Death
Function 1
Unique Reactions
to Suicide
Function 2
Stigmatization
1.829
.413
AIDS
.082
.775
Suicide
1.911
.362
Cancer
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HIV/AIDS
n (%)
Suicide
n (%)
0 (0)
47 (94)
3 (6)
AIDS (N = 50)
10 (20)
33 (66)
7 (14)
3 (6)
4 (8)
43 (86)
Suicide (N = 50)
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Additional Data
Comparison of Means. When comparing the 11 GEQ variables mean
scores between the three bereavement groups, an obvious separation
between the groups occurred (Table 3). For the most part, the lowest
mean scores occurred in the cancer group, with the HIV/AIDS group
scoring much higher. The highest mean scores of the three occurred
in the suicide group and may be indicative of a more intensified grief reaction resulting from a sudden and unexpected death of a loved-one.
Furthermore, although cancer and HIV/AIDS are classified as lifethreatening diseases, the level of stigmatization is significantly lower
in the cancer group than in the HIV/AIDS group. Yet despite this contrast, the variable search for explanation is slightly higher in the cancer
group mean scores (2.432) than the HIV/AIDS group mean scores
(2.396). Perhaps the higher score in the cancer group may indicate how,
despite research and awareness, many bereft loved-ones still struggle
with not only the mysteries of the origins of cancer, but also perhaps the
rapid spread of this disease within the body.
Cancer (N = 50)
AIDS (N = 50)
Suicide (N = 50)
Somatic reactions
2.176
2.442
2.552
2.056
2.386
2.720
2.432
2.396
3.412
Loss of support
1.572
2.322
2.932
Stigmatization
1.172
2.305
2.822
Sense of guilt
1.928
2.517
3.116
Sense of responsibility
1.320
1.890
2.560
Sense of shame
1.316
2.241
2.496
Sense of rejection
1.172
2.212
2.816
Self-destructive behavior
1.348
1.940
2.360
1.292
1.992
2.828
5-point response scale: (1) Never, (2) Rarely, (3) Sometimes, (4) Often, and (5) Almost always.
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DISCUSSION
Major Contributions
This study examined whether three separate bereavement groups,
cancer, HIV/AIDS, and suicide have their own distinct grief reactions.
Although the discriminant analysis supports three distinct bereavement
groups, one major contribution of this study reveals that stigmatization
is significantly higher in HIV/AIDS bereavement than cancer or suicide
bereavement, accounting for 11.4% of the variance.
According to the GEQ (Barrett & Scott, 1989), stigmatization is defined as how society looks upon people and is measured by the following questions:
1. Think that people were gossiping about you or the (deceased)
person.
2. Feel like people were probably wondering about what kind of personal problems you and the (deceased) person had experienced.
3. Feel like others blamed you for the death.
4. Feel like the death somehow reflected negatively on you or your
family.
5. Feel somehow stigmatized by the death.
The role stigmatization plays in discriminating the HIV/AIDS bereavement group from the other two groups may be attributed to societys
continued discomfort, fear, and intolerance surrounding the disease. For
example, in addition to the deceased, the surviving loved-one also feels
somehow morally depraved and flawed because of his/her association to
the deceased (e.g., spouse, life-partner, parent, sibling, caregiver, etc.).
A second contribution of this study involves the differences between
the HIV/AIDS and suicide bereavement groups. Previously classified
by Doka (2002), as types of death that result in disenfranchised grief,
the HIV/AIDS and suicide groups were further differentiated in this
study by the GEQ category of unique reactions to suicide. This uniqueness accounts for 88.6% of the variance and is measured by the following questions:
1. Wonder about your loved-ones motivation for not living longer?
2. Feel like your loved-one was somehow getting even with you by
dying?
3. Feel that you should have somehow prevented the death?
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4. Tell someone that the cause of death was something different than
what it really was?
5. Feel like the death was a senseless and wasteful loss of life?
In the past, society may have placed some of the blame for the suicide
on the family members, thus offering less social support than it would
for survivors of a natural death. As a result, survivors may have felt
alienated from their friends and acquaintances, because of the blame,
rejection, and lack of understanding on the part of society. Calhoun and
Allen (1991) discovered that surviving family members tended to be
more psychologically disturbed, less trusting, and more blameworthy
than family members grieving nonsuicidal deaths. Therefore, to cope
with the sudden and unexpectedness of the suicide, family members
may have refused to discuss the death with friends or coworkers, or may
have attempted to recreate events mentally leading up to the death. Yet,
a unique feature this study demonstrated by the discriminant analysis
was that those who grieve a loved-ones death from suicide, may not be
experiencing the same level of stigma, versus cancer, or HIV/AIDS
grief, as survivors once did throughout history (Berman & Jobes, 1997;
Rubel, 2003). This change in societys perception toward those whose
loved-one died from suicide, may be attributed to a growing understanding of the complexities surrounding why people commit suicide,
for example, mental illness, inability to cope with overwhelming circumstances, etc.
Implications for Mental Health and Health-Care Providers
Disenfranchised grief poses significant problems for people when
faced with the death of a loved-one, but are not afforded the right, role,
or capacity to openly grieve as other members of society. For mental
health and health-care providers, being aware that such stigma still exists within society is vital to helping people work through their grief. In
fact, this understanding can also be assimilated into a therapists preferred bereavement paradigm (e.g., stages of grief: Kbler-Ross, 1969;
phases of bereavement: Parkes, 1972; or tasks of mourning: Worden,
2004), in order to educate survivors on issues that might inhibit the process of mourning.
For example, people who grieve the loss of a loved-ones death to
cancer, HIV/AIDS, or suicide may often feel neglected and forgotten.
Yet they have specific bereavement needs. One need, in particular, is to
become enfranchised by the therapist (Corr, 1998). Giving people
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Deal with the mourners feelings about not getting needs for support and why those needs are not getting met.
Review the mourners expectations for support to determine whether
they are appropriate, and help them readjust these if inappropriate,
for example, self-medicating through drugs or alcohol.
Assess the lack of support to determine whether it is owing to a
lack of assertiveness or other psychological issues.
Educate the mourner that support for disenfranchised grief often
can be found in support groups and/or printed material. Refer them
to these sources.
Educate the mourner on unrealistic expectations or incorrect information about the mourners needs.
Religious/Spiritual Needs and Support
Pargament, Koenig, and Perez (2000) notes that a grieving persons
religion and spirituality have become important issues to address in
counseling. Whether it is existential issues related to God or the Divine,
relationships with others, or finding peace, many pastoral professionals
help bereft people understand the significance of religious/spiritual
coping in their grief. As in any bereavement setting, listening to a survivors story, especially ones religious/spiritual story is a critical part of
the process of mourning. To this end, Paragament et al. states that religion/spirituality can function in the following ways:
Preservation: To use religion/spirituality not necessarily to change
but to survive, or to provide stability in everyday life.
Reconstruction: To use religion/spirituality to rebuild prior beliefs
about God and the world that may have been challenged by the
death of a loved-one.
Re-Valuation: Using religion/spirituality to help people discover
new sources of significance, e.g., letting go of old attachments to
the loved-one and discovering new ways to invest themselves in
other people or endeavors.
Re-Creation: Using religion/spirituality as a means of transforming a persons core significance and his/her approach to life, e.g.,
giving up of avoidant strategies in search for a closeness with God
and others.
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By focusing on the grieving persons specific religious/spiritual coping methods, pastoral professionals may be able to identify the different
ways religion/spirituality enhances or hinders the mourning process. In
fact, this awareness will make it possible to integrate religion/spirituality
more fully and effectively in counseling.
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specifically, in the areas of stigmatization and unique reactions to suicide. Despite over 20 years of HIV/AIDS education and awareness,
stigma still surrounds this disease. In fact, stigma appears to be transferred to surviving loved-ones in bereavement, to a greater extent than
in cancer and suicide. However, survivors of a loved-ones suicide more
than likely will purposefully conceal the circumstances of the death
from the media in order to avoid societys judgment as distinguished
from cancer and HIV/AIDS deaths. The result is that both the suicide
and HIV/AIDS groups may be forced into a silence regarding grieving
their losses openly. Nonetheless, for those who offer grief counseling,
providing a safe and accepting, nonjudgmental environment where these
survivors can tell their story helps facilitate the steps toward healing.
To this end, the field of research within disenfranchised grief is vast
and limitless. Cultural nuances and societal attitudes may change frequently. In fact, what is considered taboo in one society may be considered normal behavior in the other culture. However, what does not
change is an ongoing commitment to study of disenfranchised grief in
the context of social, political, religious, and economic arenas. Although tremendous strides have been made in the area of education, research, and awareness, fear and public opinion can combine for an
overwhelming way in which stigma and isolation is fed. Nevertheless,
there is hope for grieving people to be empowered to rise above such
shunning behavior when practitioners, researchers, policymakers, and
clergy become more aware of the grief and stigma factors these persons
face, and when thought is given to the types of supports those grieving
persons need at that time.
REFERENCES
Barret, T. W. & Scott, T. B. (1989). Development of the grief experience questionnaire
(GEQ). The Journal of Suicide and Life-Threatening Behavior, 19, 201-215.
Berman, A. & Jobes, D. (1997). Adolescent suicide assessment and intervention.
Washington, DC: American Psychological Association.
Burkett, E. (1995). The gravest show on earth: America in the age of AIDS. Boston,
MA: Houghton Mifflin.
Calhoun, L. G. & Allen, B. G. (1991). Social reactions to the survivors of suicide in the
family: A review of the literature. Omega, 23(2), 95-97.
Catalan, J. (1995). Psychiatric problems associated with grief. In L. Sherr (Ed.), Grief
and AIDS. Chichester, UK: Wiley Press.
Corr, C. (1998). Enhancing the concept of disenfranchised grief. Omega, 38, 1-20.
112
Corr, C., Nabe, C., & Corr, D. (2005). Death and dying, life and living (5th ed.).
Belmont, CA: Wadsworth Publishing.
Doka, K. (Ed.). (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press.
Doka, K. & Morgan, J. (Eds.). (1993). Death and spirituality. Amityville, NY: Baywood
Publishing Company, Inc.
Jacobs, S. (1999). Traumatic grief: Diagnosis, treatment, and prevention. Philadelphia,
PA: Taylor and Francis.
Sadock, B. J. & Sadock, V. A. (2003). Kaplan and Sadocks synopsis of psychiatry:
Behavioral sciences/clinical psychiatry, 9th edition. Baltimore, MD: Lippincott
Williams & Wilkins.
Kbler-Ross, E. (1969). On death and dying. New York: Macmillan.
Lazare, A. (1979). Unresolved grief. In A. Lazare (Ed.), Outpatient psychiatry: Diagnosis and treatment (pp. 498-512). Baltimore, MD: Williams and Wilkins.
Paragament, K. I., Koenig, H. G., & Perez, L. (2000). The many methods of religious
coping: Development and initial validation of the RCOPE. Journal of Clinical Psychology, 56, 519-543.
Parkes, C. M. (1972). Bereavement: Studies of grief in adult life. New York: International Universities Press, Inc.
Rando, T. (2000). Clinical dimensions of anticipatory mourning: Theory and practice
in working with the dying, their loved ones, and their caregivers. Champaign, IL:
Research Press.
Rubel, B. (2003). The grief response experienced by the survivors of suicide. Retrieved
on November 6, 2002, from www.griefworkcenter.com.
Shafranske, E. P. (1997). Religion and the clinical practice of psychology. Washington,
DC: American Psychological Association.
Shilts, R. (1988). And the band played on. New York: Penguin Books.
Snyder, M., Omoto, A. M., & Crain, A. (1999). Punished for their good deeds: Stigmatization of AIDS volunteers. American Behavioral Scientist, 42, 1175-1192.
Worden, J. W. (2004). Grief counseling and grief therapy: A handbook for the mental
health practitioner (3rd ed.). New York: Springer Publishing Company.
doi:10.1300/J187v06n03_07