Living With Grief

Who We Are How We Grieve

Kenneth J. Doka, Joyce D. Davidson, Kenneth J. Doka, Joyce D. Davidson

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317758471
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychische Gesundheit in der Psychologie

Produced as a companion to the Hospice Foundation of America's fifth annual National Bereavement Teleconference, this volume examines how key aspects of identity affect how individuals grieve. Variables explored include culture, spirituality, age and development level, class and gender.

PART III

Varied Experience: Gender, Development, Class, and Cultural Influences on Grief

Throughout this book we have broadly defined culture as a “way of life.” Sometimes that distinct way of life emerges from a shared belief system or common ethnicity. Yet ways of life can emerge from a variety of contexts including shared occupations, classes, genders, or even common sets of experiences. Not only may such variables define categories or people who share such a way of life, they profoundly affect the ways that we grieve, again offering factors that both complicate and facilitate the grieving process.

Social class is one such factor. Will Rogers was once reported to quip, “The rich are different—they have more money.” This piece of humor may express a common American perspective of class: In the end, class differences are relatively unimportant. Yet such a distinction ignores the bare reality of class long emphasized in sociological studies (e.g., Warner, 1959; Hollingshead, 1949). Social class dramatically affects the ways we live our lives, from the likelihood of our being born to how and when we die. It even affects where we are buried (Warner, 1959). Moreover, class influences nearly every aspect of life in between: where we go to school, whom we marry, how many children we have, where we live, as well as our values, spirituality, and lifestyle.

In fact, many variables that we attribute to ethnicity are actually more closely related to social class. It is little wonder that Gordon (1978) has defined “ethclass,” or the conjunction of the two critical variables of ethnicity and social class as they define a person within his or her society So, for example, a middle-class African American will share a common experience with all middle-class persons regardless of ethnicity and with all African Americans, irrespective of class.

Given the pervasive influence of class, it would be naive to expect that it would not affect the grieving process in both manifest and subtle ways. For example, Coles (1977), in his study of privileged children, addresses the unique aspects of a psychology of entitlement that wealth entails. In Coles’ study, this led to higher self-esteem and self-confidence, as well as greater coping skills. We can infer that these qualities may suffer as one copes with loss.

Similarly, wealth also may provide the sophistication and resources to utilize effectively other sources of support. Yet at the same time, the psychology of entitlement may serve to make certain losses, particularly those that are sudden, traumatic, or developmentally out of sequence, incomprehensible.

In one case, a very wealthy woman struggled with her young husband’s cancer. At the beginning of his illness, she was confident that their socio-economic status would facilitate his survival—after all, they could afford the best care. Even as his condition deteriorated she remained confident, since their connections made available experimental protocols. When he died in spite of such resources, she had a difficult time accepting his death.

Murphy’s chapter insightfully explores the other end of social class, identifying complementary sets of strengths and limitations found in the midst of poverty.

Gender, too, marks a major division in social life. The socialization and experiences of men and women differ from birth. It is reasonable to assume that such differences may affect the grieving process. Both Sanders’ and Martin and Doka’s chapters explore those effects. Sanders’ review of research offers support to Martin and Doka’s theorizing about masculine grief. Both suggest that these may be different patterns of grieving—related to gender though not determined by it. And both these chapters repeat a common refrain: These are differences, not deficiencies, as each style offers complementary strengths and weaknesses. Sanders, and to a lesser extent, Martin and Doka, emphasize how differences in socialization can affect the grieving process, suggesting that attention be paid to the developmental process.

Corr provides an overview of this process, reminding us of the ways in which distinct developmental issues in each of the major periods of life (childhood, adolescence, adulthood, and old age) affect the grieving process. He challenges us, in our desire to be sensitive to cultural differences, not to neglect other critical variables, such as developmental needs. Corr does not imply that developmental periods are unrelated to culture. Culture informs these distinct periods of human development with all their biological, social, and historical force, defining these periods in their own unique way. So caregivers and grief counselors need to understand both developmental differences and the ways they are perceived in a given culture. Nonetheless, as Corr so clearly indicates, developmental levels do affect grieving.

This point is reiterated in Lavin’s chapter on an often neglected population, the developmentally disabled. Here she notes how cognitive deficiencies, overprotection, disenfranchisement, and limited communication, support, and experience, can complicate grieving. Beyond developmental disabilities, Lavin’s chapter suggests sensitivities to a variety of conditions that may complicate adjustment to loss. And she offers a reminder to caregivers to enfranchise all those who may be (because of such differences) disenfranchised in their grief.

Disenfranchised grief exists when a loss is not socially sanctioned, openly acknowledged, or publicly shared. The individual grieves, but others may not acknowledge that person’s right to grieve. There may be a number of reasons for this. The loss may not be acknowledged, the relationship unrecognized, the griever or manner of grieving discounted, among others (Doka, 1989).

The latter category may include not just the developmentally disabled but also those who are critically ill, confused or disoriented, and young children, all of whom may express their grief in ways other than those deemed appropriate in a given society. Yet, all grieve. The concept of disenfranchised grief can also be extended to masculine grievers or those from different cultures who do not grieve or mourn according to societal norms.

Unexplored in this book, but a factor as well, is regional difference. Garreau (1981), for example, identifies nine distinct cultures within North America, noting that each region has its own distinct population mix, history, values, and norms. These norms will influence grief, shaping funeral customs, expressions of grief, and expectations of support. Similarly, one could identify generational differences, noting that each generation group (e.g., baby boomers, depression-era babies, etc.) also has unique historical experiences that shape identity, values, and norms.

Sometimes a shared group identity and experiences can define a common culture. These chapters consider how categories formed by a shared disability, sexual orientation, or occupation can lead to distinct cultural identification. Zieziula, for example, explores Deaf customs, noting how a shared impairment and language have combined to form a very distinct culture. Wilder considers how sexual orientation may affect the experience of grieving. And, finally, Carroll discusses the unique aspects of loss in military culture.

Together these chapters reiterate a series of points. First, they emphasize the many factors that shape the experience of grief. Certainly other chapters could be added about the ways in which different physical or sensory impairments or challenges can affect the grieving process. And just as surely other categories, such as occupational groups (e.g., police or firefighters) may be said to share a common culture that affects the mourning process as well.

Second, they all speak to the issue of disenfranchised grief. For example, relationships within the gay community do not have the same societal acceptance and sanction as heterosexual relationships. While a widow has broad recognition and support in her grief, a lover, even in a long-term relationship, may not have the same support, especially outside the gay community Similarly, Carroll describes how the common advice extended to the bereaved may ring hollow for military survivors. Zieziula, too, notes how the hearing community may disenfranchise deaf survivors by assuming that they cannot process complicated information.

All of these pieces then stress the critical role of validation. Sometimes, as Zieziula suggests, this can be done by sensitive and sensitized professionals within and outside the community. Sometimes, as Wilder and Carroll suggest, this can be best provided with a support group or individuals who share the common experience. However it is done, all recognize the critical role of validation in normalizing grief and in reminding survivors, whatever their circumstances or differences, that they do not grieve alone.

NINE

Dying and Grieving in the Inner City

Patricia A. Murphy and David M. Price

Patricia A. Murphy, PhD, RN, CS, FAAN, is Clinical Specialist in Bereavement and Ethics at Newark Beth Israel Medical Center. Dr. Murphy also maintains a private practice and is a speaker on bereavement and end-of-life care.

David M. Price, MDiv, PhD, teaches professional ethics at New Jersey Medical School and is the hospital ethicist at St. Barnabas Medical Center. He is a founding member of the ethics committees of several hospitals, nursing homes, and a hospice.

The experiences of death, dying, and grieving are universal. Yet few who read these words have lived through loss in the circumstances of urban poverty.

This chapter is written not by sociologists but by health professionals with long experience in the inner city. For the most part, that experience has been in one inner-city community. Readers can decide the extent to which these observations can be generalized to other poor and under-served populations.

Children

This is not Mr. Rogers’ Neighborhood. While there are unquestionably kind and concerned adults in the environment, it is filled with danger. Doors are triple-locked. Knowing too much about what goes on next door can get you killed, like it did your cousin Kenneth. Rasheeda’s mother always made her come in off the stoop as soon as the streetlights came on, but a stray bullet found her in the parlor anyway. Most third graders know someone who has been a victim of street violence. For many, the violence has claimed someone in their families, if not as a victim, then as a perpetrator now in jail.

AIDS has decimated families. Many children live with grandparents or in foster homes because both parents are dead, and many of those children acquired the virus at birth. Some of these are or have been very sick. Some die, others expect to die soon.

AIDS came to the inner city in all the well-known ways, but overwhelmingly by way of intravenous drug abuse. Drugs and drug dealing are everywhere. The dealers have cars and sharp clothes. They provide employment opportunities, even to kids too small to push a lawnmower or babysit. The money is far better than anybody ever earned babysitting. The glamour and the pride of good pay for easy work seduces many children into underestimating the dangers.

More than a few children have multiple primary caretakers while growing up. Death, jail, drug-related disability, and mental illness, sometimes in combination, interrupt the continuity of parenting. Large numbers of children are in foster care; many more are placed indefinitely with aunts and grandmothers “until the mom can get straightened out.”

Young Adults

Older teens and young adults in great numbers come unprepared to adult roles. They have few marketable skills and poor educational backgrounds. If they expected to get a job at age 18, they find that there are none, or at least far fewer than there are people just like them who are looking. Unless they have grown up in one of the too few households with consistent role models and expectations for achievement through hard work, these young people are ill-prepared for either continued schooling or successful competition in today’s job market. The manufacturing base that once absorbed large numbers of the young, marginally educated urban poor has long since moved elsewhere, typically to underdeveloped countries.

That so many young adults seem directionless, discouraged, and disaffected is no surprise, given their circumstances and the circumstances of their childhood. Loss has been a constant companion and hope a stranger. Like young people everywhere, they do not think about the distant future or imagine themselves growing old. Unlike their privileged counterparts, they do not expect the near future to be better and many expect to die young.

Grandmothers

Without grandmothers, the children of the inner city would be in unimaginably worse shape. Because AIDS, violence, and imprisonment have removed so many parents and because emptied-out mental hospitals have freed so many under-treated, but fertile, young adults to “begin their own families,” middle-aged women (and, where those women are married, middle-aged men) are raising their second set of children. They are doing so out of duty and love, not preference. In many instances, their intervention is saving the children from chaos and likely disaster. In some cases, it is too late.

Such grandmothers are well acquainted with grief. They have lost their children to gunfire or prison or drugs or mental illness or “the virus.” Now they try to protect and nurture children who have themselves known too much loss and may even be fatally wounded in body or spirit by their perilous early lives.

There are many, many such grandmothers in the inner city. Just what will be the long-term consequences of this truncated generational cycle is hard to imagine. In the short run, one cannot help but be relieved that these often quite remarkable middle-aged women are able and willing to catch the children that fall from the tatters of their own children’s lives.

Obstacles to Dying and Grieving

It is perhaps easy to see some of the barriers to successful coping that are associated with life in poor neighborhoods of American cities. For many people, there is a deep sense of fear. Crime, especially drug-related crime, truly is reason to be fearful. One must be on guard. Many children really do feel that they are safer if they carry knives or guns. The incidence of crime is probably under-reported because of fear.

Fear breeds distrust. So does the reality of authority figures who fail to protect—or care. The service system, from schools to clinics to police to child protective agencies, is sometimes corrupt, often fragmented, and always overburdened. Gains in one segment seem to be matched by losses in another. The safety net, never very reliable, has recently developed new holes.

The attitudes of self-reliance, self-worth, and social competence that middle-class parents, teachers, and health professionals attempt to instill in all children are a hard sell among urban poor children in the 1990s. There seems to be a pervasive sense that control lies elsewhere than in oneself, that neither effort nor goodness is rewarded, and that external forces, not individual choices, will prevail. Even those souls whose faith allows them to believe that goodness and peace and spiritual riches will abound are inclined to think that this will come about by God’s agency, not by humankind’s, and surely not by theirs. Resignation reigns.

Institutions serving the urban poor also tend to be poor. From schools to grocery stores to motor vehicle agencies, the inner-city service sector outlets are understaffed and shabby. Even those whose staff members do not share in the resignation and defeat of their clientele often lack the combination of extra money and community support that seems to make the crucial difference between a school and a good school, between a clinic that is merely open for business and a clinic that is a healing environment.

Consider the experience of Hessie, a 59-year-old, single, licensed practical nurse who had lived all her life in a poor neighborhood of a poor city. Hessie had a 24-year-old son with “mental problems” who shared her household. She developed lung cancer, which spread to the brain and bones.

Hessie was clear that she wanted to be cared for at home, with no aggressive treatment of her already advanced disease, but with vigorous attention to pain and other symptoms. Hospice home care was arranged with Hessie’s son, Ben, as the principal caregiver, though Hessie had expressed concern about whether Ben could manage.

One night soon after the home care plan was implemented, Hessie became quite confused, presumably as a result of her brain tumor. She would not allow Ben to care for her and accused him of trying to kill her. In a panic, Ben called 911 and Hessie was taken to a local hospital. When her confusion cleared, Hessie refused to return home, insisting that Ben “can’t handle it.”

Financial barriers proved daunting as the hospital staff tried to arrange an inpatient hospice placement. Hessie had a private managed care policy through her employer, but it would not cover indefinite inpatient hospice care. A covered “transitional” program was limited to fourteen days. Hessie was too young for Medicare, too “wealthy” for Medicaid, and too poor to pay. The nearest hospice that would provide free inpatient care had a waiting list and was in another state, too far for frequent visits by friends and family.

Accordingly, a...