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This is to certify that the

thesis entitled

THE IMPACT OF ETHNICITY ON GRIEF:
IMPLICATIONS FOR BEREAVEMENT SUPPORT

presented by

Sheila Kane Ording

has been accepted towards fulﬁllment
of the requirements for

Master Of Artidegree in Wplinary
Health and Humanities

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THE IMPACT OF ETHNICITY ON GRIEF:
IMPLICATIONS FOR BEREAVEMENT SUPPORT
By

Sheila Kane Ording

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

MASTER OF ARTS

Department of Interdisciplinary Programs in Health and Humanities

1997

ABSTRACT

THE IMPACT OF ETHNICITY ON GRIEF:
IMPLICATIONS FOR BEREAVEMENT SUPPORT

By

Sheila Kane Ording

The problem addressed in this thesis is the challenge of providing
appropriate bereavement support, especially for members of ethnic groups
whose norms for grieving may be signiﬁcantly different from those of the
dominant culture. This paper reviews and synthesizes literature from
psychology and anthropology to identify factors which put ethnic group
members at risk for complicated grief: lack of access to traditional mourning
rituals, perceived lack of social support, and social and economic
disadvantage. The grief work hypothesis, which dominates Western grief
intervention strategies and prescribes cognitive grief work, fails to
acknowledge somatization as a legitimate form of grief work. The conclusion
reached is that there is a need for bereavement support programs targeted to
speciﬁc ethnic groups in which the full range of possible reactions to grief can

be afﬁrmed.

ACKNOWLEDGMENTS

The encouragement of my committee is sincerely appreciated:
Jacob Climo, Ph.D., thesis director, Department of Anthropology;
Cynthia Morgan, Ph.D., Department of Psychiatry; and
Peter Vinten-Johansen, Ph.D., Department of History.
The ﬁnancial assistance and outstanding educational experience made
possible through a Graduate Assistantship with the Center for Integrative

Studies in the Arts and Humanities is gratefully acknowledged.

iii

PREFACE

I am an Ele's Place volunteer. Ele's Place is a nonproﬁt community
based organization that provides bereavement support for grieving children
and their families following the loss to death of a family member or important
friend. Ele's Place provides support from trained volunteers, peers, and
professionals; Ele's Place does not provide therapy. When an individual
appears to be suffering complicated or pathologic grief, a referral to a mental
health professional is considered appropriate.

As a volunteer interested in learning more about grief, I became familiar
with a range of popular and professional literature on the subject. I became
intrigued with the frequency with which ethnicity appears on lists of factors
that influence the course of grief and bereavement. Yet, almost universally
lacking was much explanation of just what that inﬂuence might be. Thus
emerged the subject of this thesis.

My initial expectation about the direction the topic would take was to
identify examples of distinctive cultural norms and practices that may alter the
course of bereavement. However, while the anthropological literature is
fascinating in its description of exotic mourning rituals and bereavement

practices (public displays), it rarely deals with the personal experience of grief

iv

of individuals either in exotic cultures or in the US. A direction which
seemed more fertile was to identify factors which are common across ethnic
groups, factors that are related directly to the experience of ethnicity, and
which influence the private, emotional reaction to a loss. Thus, factors such
as perceived lack of social support and the stress of uprootedness, which are
frequently experienced by members of ethnic groups and which have critical
relevance as risk factors in complicated mourning, have become central in this
work.

My early intention had been to focus on grief very narrowly, that is, as
the reaction to the loss to death of a signiﬁcant other. However, parallels
between grief in response to the loss of a loved one and grief in response to
other kinds of losses--divorce, illness, retirement-~occupy a prominent place in
current grief literature. Further, unresolved prior losses other than to death
are of critical importance in cultural bereavement, a phenomenon frequent
among ethnic minorities.

It is my hope that this thesis will be of practical value to individuals
involved directly in bereavement support efforts as well as to a variety of
health care professionals whose work brings them in contact with bereaved
individuals of diverse ethnic backgrounds. Given the frequency with which
somatization is the form into which the distress of grief becomes translated,
the conclusions of this thesis have particular relevance for primary care

physicians to whom somatizing individuals frequently appeal for help.

TABLE OF CONTENTS

INTRODUCTION

CHAPTER ONE: GRIEF THEORY

Terminology

What Grief Looks Like

Linear Models

Criticism of Linear Models
Non-Linear Models

Pathological Grief

Risk Factors in Pathological Grief
Summary of Chapter One

CHAPTER TWO: ETHNICITY AND GRIEF

The Scope of the Problem: Ethnic Population Trends
Clariﬁcation of Terms

Enumeration Difﬁculties

Operational Deﬁnition of Ethnicity

Disadvantaged Social Position

Cultural Uprootedness

Assimilation Theory

Ethnicity and Stress

Summary of Chapter Two

CHAPTER THREE: GRIEF: A CROSS-CULTURAL PERSPECTIVE

Is Grief Universal?

Biological Evidence

Cross-Cultural Evidence

Mourning Rituals

Key Factors in the Course of Bereavement

The Grief Work Hypothesis

Western Notions of Mental Health

Somatization

Cross-Cultural Assessment of Pathological Grief
The Role of Primary Care Physicians

vi

m

11
17
20
22
26
28

30
31
33
34
35
37
39
42
43

45
45
48
55
58
61
63
67
71
73

A Culture-Bound Somatic Syndrome 75
Summary of Chapter Three 79

CHAPTER FOUR: BEREAVEMENT SUPPORT

What Helps? 81
Desirable Outcomes 84
The Role of Religion 87
Ethnic Bereaved: The Myth of Social Support 90
Ethnicity and Bereavement Support Groups 92
Summary of Chapter Four 97
SUMMARY AND CONCLUSIONS 99

BIBLIOGRAPHY 102

vii

INTRODUCTION

Almost uniformly, researchers and the public identify the death of a
loved one, and the ensuing grief, as among the most potent stressors an
individual may experience. Further, there is general agreement that high levels
of stress are negatively correlated with both physical and mental health
(Osterweis, Solomon and Green, 1984). By 1980 the interest in grief as a
factor in overall health had risen to the point that, at the request of the Ofﬁce
of Prevention of the National Institute of Mental Health, the Institute of
Medicine appointed a committee to study the factors that affect the
bereavement process and its impact on general and mental health. Among the
signiﬁcant factors identiﬁed as inﬂuencing grief and mourning was the ethnic
afﬁliation of the bereaved. Among the conclusions and recommendations of
the report was the warning that ”professionals should use great caution in
interpreting the bereavement experience of refugees, immigrants, and
traditionally oriented ethnic group members as deviant because of the
possibility that the norms for these groups may differ from their own [the
professionals'] and from those of the mainstream culture" (p. 210).

Unfortunately, the text offers no further illumination of just how it is

that ethnicity impacts grief and the course of bereavement. The professional in

 

search of a body of literature which would offer insight into the potential
impact of ethnicity will ﬁnd the literature sparse indeed (Eisenbruch, 1984b).

Some writers suggest that it is the responsibility of grief specialists to
acquaint themselves with the mourning Observances in different cultures
(Webb, 1993). According to Osterweis, Solomon and Green (1984),
"Bereavement specialists...should be instructed in cultural differences in the
bereavement process in an attempt to reduce the potential for cross-cultural
miscommunication and iatrogenic effects” (p. 210). While instruction in
cultural differences may be helpful in increasing sensitivity to cultural norms
which may differ from the therapists', several authors (McGoldrick et al., 199];
Rosenblatt, 1988; Shapiro, 1994) warn that superﬁcial treatment of ethnic
minority beliefs, values, and behavioral norms may in fact create another
problem--the stereotyping of individual members of ethnic groups.
Stereotyping may result in expecting individuals to react and behave in
predictable ways based on traditional, published norms for their group. Kalish
and Reynolds (1976) assert, however, that there is as much intra-ethnic
diversity in reaction to death and dying as there is inter-ethnic variability.

An understanding of the role of bereavement support programs
demonstrates the importance of appreciating the potential impact of ethnicity
on bereavement. Bereavement support programs do not offer psychotherapy;
they offer support. Of particular signiﬁcance to the bereavement support

worker is the challenge of distinguishing between normal and pathologic grief,

 

since according to much of the bereavement support literature, when a
bereaved individual is showing signs of pathologic grief, it is appropriate that a
referral to a mental health professional be made (Schiff, 1986). The
determination of when grief is pathologic, however, is not unequivocal. For
members of the white, Anglo-Saxon, Protestant (WASP) dominant group in the
US. the determination is complicated enough (Rynearson, 1990). For
members of ethnic minority groups the determination is even more challenging
(Eisenbruch, 1984b). Given that cultural inﬂuences shape the mode of
expression of emotion, it is imperative that consideration be given to the
possibility that a passionate, wailing expression of grief, while outside the
norm for the WASP majority, may be entirely within the norm for an ethnic
minority individual (e.g., Italian, Greek). Conversely, an individual's cultural
norm may severely restrict the expression of sadness and discourage the
articulation of anger, as is the case for Asians. Such individuals may
internalize the expectation placed upon them by well-intentioned caregivers
that they must ”get in touch with and verbalize their pain" and in the process
experience this contradictory expectation as an additional complication in their
quest for resolution of their loss.

Not only is the determination of pathologic grief equivocal, the
expediency of referral to mental health professionals is also debatable. Some
writers caution that the referral of some grieving individuals to professional

mental health practitioners may have negative rather than positive

 

consequences (McGoldrick et al., 1991; Qureshi, 1994). Traditional Asians,
for instance, are concerned that to seek help from a mental health professional
may negatively inﬂuence their chance of arranging marriage for their daughters,
or will escalate the required dowry.

In addition to implications for bereavement support professionals and
volunteers, issues of grief and its impact on health are signiﬁcant to other
health care workers. It is widely accepted that a high proportion of patient
visits to primary care physicians in the US. are related to psychosocial distress
translated into somatic complaints. It has been estimated that the proportion
may be as high as 75% (Rasmussen and Avant, 1989). Burnell and Burnell
(1989) suggest that circumstances which bring individuals to physicians' ofﬁces
with multiple somatic complaints are more likely among members of the
working class of certain ethnic groups in which somatization of grief is
culturally approved. According to Kleinman (1982), extensive workups for
such patients are generally unnecessary and sometimes even harmful. Many of

these patients, perhaps even the majority (McGoldrick et al., 1991), strongly
doubt the value of psychotherapy.

The challenge, then, is how to provide appropriate bereavement support
to individuals whose mode of expression of grief may be quite different from
that of the dominant culture. It is argued that the cognitive grief work which
predominates in Western mental health therapeutic approaches fails to respond

to the needs of individuals whose culturally-approved distress idiom is

 

somatization. Further, it is critical to devise strategies which will help to
overcome the reticence of ethnic minorities to participate in mainstream social
services programs.

Chapter One reviews the various theoretical models which have been
formulated to describe the typical course of grief beginning with the
psychoanalytic (Freud) and proceeding through attachment and loss (Bowlby
and Parkes), psychosocial (Parkes), death and dying (Kubler-Ross), holistic
(Schneider), and family systems (Rosenblatt, Shapiro, Walsh and McGoldrick).
After describing what normal grief may look like, a consideration of pathologic
grief is offered, including the factors which put an individual at risk for
pathological grief. Among these factors are unresolved prior losses and the
absence of social support, factors frequently present in ethnic individuals.

Chapter Two explores ethnicity, with particular attention to those
dimensions of ethnicity which put individuals at risk for complicated
bereavement. Lack of access to traditional mourning rituals, perceived lack of
social support, and social and economic disadvantage weigh heavily in this
picture. The concept of ”cultural bereavement" is introduced, suggesting the
prevalence of unresolved previous losses related to uprootedness among ethnic
minorities.

Chapter Three looks at grief cross-culturally. The ﬁrst question posed
is the extent to which grief is universal. Evidence from both non-human

primate research as well as cross-cultural studies is presented. An analysis of

the grief work hypothesis and its applicability to the grief experience of
individuals other than white-Anglo-Saxon-Protestants (WASP) is presented.
The assertion is made that somatization is a more pervasive distress idiom for
ethnic minorities than the cognitive or psychologizing idiom which
characterizes the grief models which dominate the literature. The percentage
of primary physician encounters which result from somatic complaints is
discussed, with the speculation that a high percentage of these complaints
represent the somatization of unresolved grief. The importance of a
comprehensive psychosocial history of patients presenting with somatic
complaints is discussed. Especially signiﬁcant for the ethnic minority patient is
the involvement of the patient's family or some member of the ethnic
community in the treatment plan.

Chapter Four considers bereavement support and speciﬁcally what
bereaved individuals ﬁnd helpful. Bereavement support groups are shown to
be helpful in providing both emotional support and an opportunity to work
through the role ambiguity which results from the loss of a signiﬁcant other.
The role of religion as a source of support is explored, ﬁnding that the
participation in religious activities is of greater comfort than the content of the
religious belief system. The importance of being supported by persons who
have had comparable life experiences and who are of an individual's same
ethnic group is discussed. Contrary to the widely held notion that ethnic group

members take care of their own, in times of stress, physical and emotional

 

resources may be stretched to the point that necessary support may not be
available. The design of ethnically speciﬁc bereavement support programs
which may overcome the reticence of ethnic minorities to participate in
mainstream social programs is discussed.

Finally, the summary and conclusions of this study are presented. Many
ethnic minority individuals are believed to be at risk of persistent somatic
illness resulting from a variety of unresolved grief issues. Referral of these
individuals by primary care physicians to mental health professionals will in
many cases not be as helpful as facilitating their access to community support
networks. The myth of the availability of informal, effective social support
among ethnic communities is challenged. Given the reticence of ethnic
minorities to participate in mainstream social programs, the importance of

designing and implementing ethnically targeted support groups is argued.

 

CHAPTER ONE
GRIEF THEORY

Terminology

The term grief as used in the death and dying (thanatology) literature
refers to the reaction to the loss to death of a signiﬁcant other or to the
anticipation of one's own death or that of a loved one (Kubler-Ross, 1969;
Wass et al., 1988). When used in this way, a distinction between grief,
bereavement, and mourning is useful. According to Rosenblatt, Walsh, and
Jackson (1976), grief is the sorrow, mental distress, emotional agitation,
sadness, and suffering caused by a death; grief is distinctly personal and
private. Bereavement refers to the period of time following a death during
which grief is occurring. Mourning refers to the culturally prescribed
behaviors that are customarily employed following a death; mourning is more
public and social than is grief. These general distinctions between grief,
bereavement, and mourning will be used in this thesis.

The distinction between grief and mourning is, of course, of only limited
usefulness, as it has been well demonstrated that even the experience of
emotion, for adults, is heavily inﬂuenced by culture (Stroebe and Stroebe,

1987; Eisenbruch, 1984a). This fact is one which makes the measurement of

grief so complex. However, the focus of this work is not on mourning rituals,
as such, but on grief, as it is the personal, emotional response to loss which has
the potential for directly impacting health. The inﬂuence of mourning practices
on health is indirect, as the availability of and participation in traditional
mourning rituals are among the important factors in individuals' personally
coming to terms with loss.

A broader use of the term grief which gained popularity with the work
of Parkes (1971) includes the reaction to any major change in one's life. His
psychosocial transitions theory asserts that whenever a major change occurs in
one's life space (people, places, or things), individuals must restructure their
ways of looking at the world in which they live. In this view, a wide array of
life changes--divorce, retirement, illness, becoming a parent--are among the
events which may precipitate the reaction known generally as grief. According
to Schneider (1984, 1994), any changes, even positive ones, involve loss. No
matter what is ahead, something must be left behind. Grief is the reaction to
the loss of whatever is left behind. This broader concept of the possible bases

of grief is the one adopted in this thesis.

What Grief Looks Like
The typical reactions to the death of a loved one include a broad range
of physical, emotional, behavioral, and cognitive manifestations (Worden,

1982). The physical symptoms may include tightness in the chest, hollowness

10

in the stomach, tightness in the throat, shortness of breath, muscle weakness,
numbness, and lack of energy. Emotional responses may include sadness,
anger, guilt, anxiety, loneliness, yearning, and a sense of helplessness. Among
the behavioral changes which may occur are sleep disturbances, appetite
disturbances, absent-mindedness, social withdrawal, searching for the lost one,
and crying. Cognitive reactions may include disbelief, confusion,
preoccupation with the loss event, sense of presence of the deceased, and
hallucinations. No single grieving individual will necessarily experience all of
these symptoms, but most experience many of them. For the purposes of this
paper, it is sufﬁcient to acknowledge that the distinctions between the four
major groups of symptoms are fuzzy. That they all may occur in the course of
a normal grieving process is the important point.

The literature generally agrees that not all losses are of the same
signiﬁcance to the bereaved and consequently there is wide variation in the
intensity of grief experienced by individuals (Aiken, 1994; Osterweis, Solomon
and Green, 1984; Rando, 1993; Wolfelt, 1992). Among the factors
acknowledged to impact the intensity and the course of bereavement are: 1) the
nature and quality of the lost relationship; 2) the characteristics of the death or
loss; 3) the personal characteristics of the bereaved, including gender; 4) the
available support system; and S) ethnic/cultural/religious afﬁliation. Further
discussion of these factors will be included in the section dealing with the

distinctions between normal and pathologic grief.

 

11

Linear Models

Various models have been proposed to describe the course of grief and
bereavement. Rather than representing rigidly different schools of thought, the
models are overlapping. They differ in the emphasis placed on different
dimensions of the reaction (Shapiro, 1994; Stroebe, Stroebe, and Hansson,
1993). The models range from the somewhat simplistic linear models through
the complex family systems model.

An early linear model is Freud's, published in Mourning and
Melancholia in 1917. According to Freud, grieving presents a dilemma
because there is a need to acknowledge the absence of the love object in order
to complete the grieving process, but "letting go" of the deceased involves
considerable emotional pain. The predictable pattern is for the bereaved
person to initially deny that the loss has occurred, become preoccupied with
thoughts of the deceased, and lose interest in the outside world. However,
over time, as memories are reviewed and grief work is done, the bereaved's
bond with the deceased is weakened, and the bereaved regains emotional
energy which is now available to invest in new relationships (Osterweis,

Solomon and Green, 1984). In Freud's words:

In what, now, does the work which mourning performs
consist?...Reality testing has shown that the loved object no
longer exists, and it proceeds to demand that all libido shall be
withdrawn from its attachments to that object. This demand
arouses understandable opposition...This opposition can be so
intense that a turning away from reality takes place and a clinging
to the object through the medium of a hallucinatory wishful
psychosis. Normally, respect for reality gains the day.
Nevertheless its orders cannot be obeyed at once. They are

12

carried out bit by bit, at great expense of time and cathectic
energy, and in the meantime the existence of the lost object is
psychically prolonged. Each single one of the memories and
expectations in which the libido is bound to the object is brought
up and hypercathected...when the work of mourning is completed
the ego becomes free and uninhibited again (p. 52).

Of signiﬁcant inﬂuence on subsequent models of grief was F reud's belief that
bereavement is concluded with the relinquishment of all ties to the lost object
(Shapiro, 1994). Also signiﬁcant is this ﬁrst appearance of the concept "the
work of mourning,” which is referred to by other authors as ”grief work"
(Stroebe, 1992-93; Wortman and Silver, 1989).

Freud's psychoanalytical model has had enduring inﬂuence on much of
the psychiatric and sociological literature dealing with grief and mourning
written since that date (Gorer, 1965). Freud's distinction between normal grief
(which he refers to as healthy mourning) and pathologic grief (which he calls
melancholia) is that in mourning it feels like the external world is empty; in
melancholia it feels like the internal world is empty. Freud's aim was to
develop a hypothesis concerning the pathological condition of melancholia. He
gave less attention to the ”normal" emotions which he termed mourning. The
attention given is interesting, however, in light of the current use of the term
grief to describe the reaction to losses other than to death. Freud also
recognized the experience of mourning in response to losses other than the
death of a beloved. He said: "Mourning is regularly the reaction to the loss of
a loved person, or to the loss of some abstraction which has taken the place of

one, such as one's country, liberty, an idea, and so on” (p. 51).

 

13

Another inﬂuential model of grief is that described by Lindemann
(1944). While frequently cited in the literature as a study of survivors of the
Coconut Grove disaster (a ﬁre in 1942 in a famous Boston restaurant in which
many perished), Lindemann's study included patients in four groups:

1) psychoneurotic patients who lost a relative during the course of treatment;
2) relatives of patients who died in hospital; 3) relatives of members of the
armed forces; and 4) bereaved disaster victims (of whom 13 were survivors of
Coconut Grove). Lindemann identiﬁed ﬁve responses common to the entire
group: 1) somatic distress, 2) preoccupation with the image of the deceased,
3) guilt, 4) hostile reactions, and 5) loss of patterns of conduct. His
observation supported the earlier hypothesis of Freud--that being willing to
feel the pain of the loss was necessary to eventual healing. In Lindemann's

words:

The duration of a grief reaction seems to depend upon the
success with which a person does the grief work, namely
emancipation from the bondage of the deceased, readjustment to
the environment in which the deceased is missing, and the
formation of new relationships. One of the big obstacles to this
work seems to be the fact that many patients try to avoid the
intense distress connected with the grief experience and to avoid
the expression of emotion necessary for it (p. 144).

In addition to afﬁrming Freud's concept of grief work, an important legacy of
Lindemann's work was the notion that grief is time-limited. He reported that in
the majority of cases the acute manifestations of grief lasted approximately 5-6
weeks. This overly optimistic picture of the time-limitedness of grief has

endured in much of the literature which attempts to assess the duration of

14

normal grief. Likewise, he contributed to the notion that there is a quite
deﬁnite end-point to the process of grieving.

The attachment model emerged in the late 1960's. This model was
reached independently by two separate researchers, Bowlby (1969) and Parkes
(1972). Regarding their subsequent collaboration, Parkes says: ”Our

collaboration has been close since, and it is difﬁcult to sort out who deserves

 

credit or blame for many of the ideas that make up the overall theory" (Parkes,
1972, p.28). Their attachment theory maintains that during the course of
normal development, individuals form distinctive bonds or attachments, ﬁrst
between child and parent; later between adults. They posit that when such
bonds are threatened, powerful behaviors aimed at preserving the bonds are
activated, such as clinging, crying, and angry protest. They argue that the
severing of such a bond by physical absence/death evokes comparable behavior
even though the behavior is aimed at reuniting when there is no possibility of
success.

Based on available literature and on Bowlby's observations of young
children's separation from parents, they maintained that successful bereavement
involves passing through four major phases. The ﬁrst phase is characterized by
the stunned, numb reaction to the apparent absence and anger in protest of it.
The second phase includes intense yearning and searching, evidence of the
determination to ﬁnd and reunite with the lost one. Eventually, behaviors

aimed at reuniting with the absent loved one diminish and the third phase is

l is.

15

reached. This is characterized by withdrawal of energy and disinclination to

look to the future. Finally, having given up hope of reattachment and having
broken down that bond they are able to begin to establish new ties to others

and to experience a gradual return of previous interests (Bowlby, 1980).

In a work published somewhat earlier, Engel (1961) described the stages
of grief in a comparable way, identifying 1) an initial phase of shock and
disbelief, in which the sufferer attempts to deny the loss and to insulate himself
against the shock of the reality; 2) a stage of developing awareness of the loss,
marked by the painful effects of sadness, guilt, shame, helplessness or
hopelessness; 3) a stage characterized by a sense of loss and emptiness,
including loss of interest in one's usual activities and associates; and 4) ﬁnally,
a prolonged phase of restitution and recovery during which the work of
mourning is carried on, the trauma of the loss is overcome, and a state of
health and well-being re-established. Engel's work has been prominent in
discussions of the extent to which even normal grief is a "disease” (Gorer,
1965)

The psychosocial model builds on concepts from both the
psychoanalytical and the attachment models. This model emphasizes the
process by which the bereaved creates a new identity. Parkes and Weiss
(1983), in extensive work with widows and widowers in both England and
Boston, concluded that grieving adults' initial denial of the reality of the death

of their spouse, followed by the gradual acknowledgment of it, buys time for

 

16

the main task of adult grief--reconstructing their identity in a world in which
the partner is not physically present.

Kubler-Ross's (1969) ﬁve stage model gained great popularity and did
much to diminish the taboo of death as a topic of polite conversation. Her
model is based on observations of and interviews with hundreds of patients
coming to terms with their own impending deaths. Kubler-Ross identiﬁed
different responses that individuals exhibit when they are faced with the tragic
news of a terminal diagnosis. She grouped these types of reactions, defense
mechanisms in psychiatric terms, into ﬁve categories which she termed
”stages.” The ﬁve stages she identiﬁed are: denial, anger, bargaining,
depression, and acceptance. While her model became very popular and has had
broad inﬂuence on conceptualizing the grieving process, a methodological
weakness in the model is that it suggests that each individual griever
progresses through those ﬁve stages. However, she did not conduct multiple,
sequential interviews on single individuals progressing through those stages;
rather, she devised the model based on single observations of multiple patients
at various ”stages" in their coming to terms with their terminal diagnoses.
Thus, the conclusion that most individuals progress through those ﬁve stages
in somewhat that order is not warranted by her work.

A notion closely related to that of the stages of grief is that of the tasks
of grief. According to this model, there are tasks (which roughly correspond

to the stages proposed by other authors) which must be completed before the

 

17

bereaved individual can fully recover from the loss. These tasks are: 1) to
accept the reality of the loss; 2) to experience the pain of grief; 3) to adjust to
an environment in which the deceased is missing; and, 4) to withdraw
emotional energy and reinvest it elsewhere (Worden, 1982). This model

contributes to the notion that there is a deﬁnite end point to the grieving

Criticism of Linear Models

It is agreed by most authors that both the stage and the task models are
only to be used as guides, not as prescriptions, and that the grief experiences
of individuals are distinctly their own (Aiken, 1994; Schneider, 1984, 1985;
Stroebe and Stroebe, 1987; Wolfelt, 1992). Signiﬁcantly, Kubler-Ross
acknowledged that the stages which she described were not to be thought of as
discrete or absolute. Speaking of her own model of grief associated with death
and dying, she said: "We have discussed so far the different stages that people
go through when they are faced with tragic news...These means will last for
different periods of time and will replace each other or exist at times side by
side” (p. 122). Parkes (1972) likewise described the tendency of individuals to
oscillate back and forth between the phases: "Grief...involves a succession of
clinical pictures which blend into and replace one another...each of these stages
of grieving has its own characteristics and there are considerable differences

from one person to another as regards both the duration and the form of each

stage" (p. 7).

18

The usefulness of the conceptualization of the course of grief as
occurring in stages, phases, or tasks is limited. While bereaved individuals may
appreciate knowing that the symptoms they are experiencing are normal and
that their reactions ﬁt a model which describes the journey of many through
their grief, they may be highly resentful of the implied suggestion that there is
some particular way they should be feeling or some rate of progress which they
are expected to achieve (Berardo, 1988). As a tool for use in the education
and training of volunteers and professionals for working with the bereaved, the
models do help in the organization of a vast amount of material into a
somewhat coherent schema. They also provide an important frame of reference
in distinguishing between normal and pathologic grief, since both intensity and
duration of symptoms ﬁgure in that assessment. However, the danger is that
the concepts will become prescriptive and the grief counselor may
unconsciously be expecting some particular sequence of reactions (Stroebe and
Stroebe, 1987).

Other criticisms of stage models of grief have been made. Corr (1993)
points out, speciﬁcally with regard to the Kubler-Ross model, that it pays
attention to only the intrapersonal aspects of the dying person and focuses
totally on the dying process to the exclusion of other events which are
occurring and other persons who are present in his/her world. Corr contends
that a good model should provide an improved basis for understanding all of

the dimensions and all of the individuals who are involved in coping with

 

19

dying, not just the dying person. He insists a helpful model should emphasize
the shared aspects of coping with dying, thus providing guidance for family
members and care providers in their optimal participation in the process. He
further contends that a really good model would describe both that which is
universal and that which is individual in the process. He is critical that stage
models, because they are generalizations, risk stereotyping both individuals and
the process of dying. Kastenbaum (1977) also suggests that the Kubler-Ross
model, by limiting itself primarily to feelings and psychosocial reactions,
attends mainly to selected aspects of the coping person's life and does not offer
a holistic perspective.

Similar criticisms may be made of all the stage models of grief--that
their single-dimensionality fails to account for the rich variety of possible
responses to loss and does not suggest the wide range of behaviors which the
helping person may be called on to validate. Another feature of the stage
models which is subject to criticism is linearity, suggesting a beginning point
and a deﬁnite end point to the grieving process. Recently writers have
emphasized that one never fully recovers from a loss; rather, that the process
of redeﬁning one's relationship with the deceased (Moss and Moss, 1984-85;
Myerhof, 1978) and of reformulating one's view of the world never ends
(Parkes, 1993; Schneider, 1994). Myerhoff (1978) suggests that for the
elderly, recovery from grief involves integrating memories and values of the

deceased into current life, not replacement. Likewise Moss and Moss

20

(1984-85), based on work with widows and widowers, speculate that in healthy
bereavement, themes of the marital tie continue throughout widowhood. In
contrast with Freud, who held that holding on to the tie with the deceased is
pathologic, this view emphasizes the potential for enhancing the widow(er)'s

identity and well-being by maintaining the tie.

Non-Linear Models

A model which progresses beyond linearity and single-dimensionality is
the holistic model proposed by Schneider (1984, 1994). According to his
model, life includes a continuing series of changes and losses to which the
individual is constantly in the process of adapting. He emphasizes the potential
for growth which loss provides, including optimally the power of grief to
transform one's life view. According to Schneider, from this transformed
perspective, rather than viewing loss as limiting, an individual may see it as an
opportunity. In Schneider's words: ”Transforming loss allows us to discover
new ways to relate, understand, create and commit ourselves to an ongoing
process of renewal and discovery" (1994, p. 23).

Schneider's model is non-linear, suggesting that grieving is an ongoing
process without a deﬁnite end point, and emphasizing that a new loss may
occur at any point in the process of adjusting to earlier losses. A new loss,
however, demands one's attention with more immediacy that an older loss

which one has integrated to some extent. Schneider sees the process of

21

grieving with respect to a particular loss to include: coping with an awareness
of the loss; gaining a perspective of what is lost and what remains; integrating
the loss, that is, remembering restoring and recreating; reformulating, that is,
exploring what is now possible; and ﬁnally, transforming, that is, recognizing
forces beyond the individual ego. He emphasizes that throughout the process
there is continuing vacillation between limiting awareness of losses and being
aware of them. Coping strategies include ﬁght (holding on to whatever
connects us to our old world, our social part, energy using) and ﬂight (letting
go, our solitary part, energy conserving).

Schneider's model, in addition to being non-linear, is multi-dimensional.
Each of the phases (awareness, perspective, integrating, reformulating,
transcending) is experienced in several ways--behavioral, cognitive, emotional,
physical and spiritual. He emphasizes that the key role helpers can play in
facilitating progress along a transformative path is to validate the unique
experience of the bereaved at any point along the way on any of these
dimensions.

While Schneider's holistic model allows for a richer description of the
experience of the bereaved, it still focuses on the experience of the individual
griever. Some writers emphasize that grief is a family process which is best
understood in the context of family systems theory (Rosenblatt, 1988; Shapiro,
1994; Walsh and McGoldrick, 1991). The family systems approach meets an

important criticism of Corr discussed earlier, acknowledging that more than a

22

single individual is at the center of the grief event. Family systems theory
emphasizes that family rules and patterns shape a loss experience and that a
signiﬁcant loss is played out in a system of family relationships (Rosenblatt,
1988). The death of a 50 year old man may mean the loss of a spouse, father,
son, brother, etc. Each of the bereaved experiences the loss individually, but
also as a part of a family system. The individual family members may not
experience their grief in the same way but how each experiences their grief
impacts how each of the others experiences theirs.

Walsh and McGoldrick (1991) assert that the emotional impact of the
loss of a family member can reverberate through a family system for
generations. Shapiro (1994) argues for a transformation of attachment to,
instead of detachment from, the deceased family member in sustaining and
enhancing family development. While a family systems approach does not lend
itself to a handy four word or four stage description of the course of
bereavement, it does provide a schema within which to consider ethnicity as a
factor inﬂuencing the course of bereavement, given the extent to which family
and ethnic afﬁliation are intertwined. This topic will be explored more fully in

Chapter Two.

Pathological Grief
Among the elusive concepts in grief and bereavement is that of

pathological grief. Some of the popular literature suggests that the distinction

23

between normal and pathological grief is rather straightforward. For example,
Schiff (1986) says: "Sometimes a facilitator will be faced with a situation
where he sees quite clearly that individual counseling is necessary" (p. 240).
Yet she gives no guidelines for what that situation might look like.

Difﬁculties in distinguishing between normal and pathological grief
stem from both the idiosyncratic nature of normal grief and the lack of
objective criteria for what constitutes pathological grief. Neither duration nor
intensity of grief reaction, by themselves, signal pathological grieving; rather,
it is the interplay of quality and quantity of reactions over time that suggest
pathology (Osterweis, Solomon, and Green, 1884). Schneider ( 1980) suggests
that there should be no drastic obstruction to the conduct of daily life after an
average time of six months after the loss. Worden (1982) emphasizes progress,
suggesting that grief is pathological when the individual is overwhelmed and
remains in the state of grief without progressing in the grieving process toward
completion. Parkes and Weiss (1983) describe pathological grief as the
bereaved becoming stuck in the grieving process. According to Parkes and
Weiss, grieving becomes pathological when the inability or unwillingness to
work through grief seems preferable to the absolute hopelessness anticipated
should they relinquish the lost relationship.

Rynearson (1990b) suggests three general syndromes of pathological
grief: 1) dependent; 2) unexpected loss; and 3) conﬂicted. The ﬁrst, the

dependent grief syndrome, occurs in response to an over-reliant attachment in

24

which one's image of self is dependent upon the availability of another, who is
now absent and will not return. This absence deprives the bereaved of the
continuing interchange with his partner which had been necessary in
maintaining his image of self as whole and acceptable. A pathologic shift in
self-image occurs, with the bereaved's sense of self now seen as weak and
incompetent.

The second, the unexpected loss grief syndrome, occurs when the
circumstances of the death itself are sudden and/or unnatural and therefore
traumatic. The event of the death may have been so horrendous as to preclude
the bereaved's ability to assimilate and accommodate. When this occurs, due to
close identiﬁcation with the lost person, the image of the bereaved
himself/herself is perceived as fragmented or annihilated. This syndrome is
characterized by the posttraumatic stress syndrome of hyperactivity; recurrent
intrusive recollections of the death event alternating with compensatory
psychic numbing; and the loss of sense of control over one's destiny.

The third, the conﬂicted grief syndrome, occurs following the death of
an ambivalently valued ﬁgure. The ambivalent investment in the lost person is
now internalized within the bereaved himself or herself, a self now experienced
as guilty and defective. A formulation which is common to all three syndromes
is, according to Rynearson: "...an enduring emotion that draws one toward
something or someone who is missing, whose absence is accompanied by a

dysfunctional revision of assumptions of self and future" (1990b, p.300).

25

Rynearson's description of pathologic grief syndromes is intrapsychic and does
little to help the bereavement support worker identify behaviors which suggest
the need for professional help.

The concept "return of ordinary function" is used by Weiss (1988) to
signal a healthy grieving process. If after a reasonable period of time (his work
suggests that two years for widows is not unusual) there is not progress toward
return of ordinary function, pathological grief may exist. He suggests ﬁve
indicators which may be representative of ordinary function: 1) ability to give
energy to daily life, demonstrating a willingness to invest in the present;

2) psychological well-being as evidenced by relative freedom from the distress
of disturbing thoughts and feelings; 3) ability to experience pleasure when
hoped-for or desirable events occur; 4) hopefulness regarding the future; being
able to care about plans; and, 5) ability to function with reasonable adequacy in
social roles as spouse, parent, and member of the community.

Weiss emphasizes that there is no universally accepted set of criteria for
ordinary levels of effective functioning. He asserts, however, that constructing
a framework of recovery is useful in sorting out the various aspects of personal
and social functioning, and makes it possible to identify areas in which

recovery may be incomplete.

 

26

Risk Factors Which Predispose to Pathological Grief

Various formulations have been suggested to predict which bereaved
individuals may be at high risk for pathological grief. Rando (1993) identiﬁes
seven factors which increase the risk of grief becoming complicated:
l) a sudden, unexpected death, especially if it is traumatic, violent or
mutilating; 2) death from an overly lengthy illness; 3) death of a child; 4) the
bereaved's perception of the death as preventable; S) a relationship of the
bereaved with the deceased which was ambivalent or overly dependent; 6)
unaccommodated prior losses; and 7) the bereaved's perceived lack of social
support. Given the scope of this thesis, attention will be focused on
unaccommodated prior losses and perceived lack of social support.

According to Rando (1992-93), contemporary sociocultural and
technological trends are increasing the risk that recovery from grief will be
complicated. Among the factors she cites are increased urbanization,
industrialization, technicalization, secularization, deritualization, and social
and geographic mobility. The consequences of these trends include the loss of
the traditional sources of comfort which are present in some form or other in
all cultures everywhere-- religious beliefs, family, and close friends. She
suggests, further, that there is an exclusivity in some American families which
fosters unusually intense emotional involvement as compared to other societies
and which results in an overidentiﬁcation and overdependence among family

members. Then, when separated, for example as a result of geographic

27

mobility, a bereavement episode leaves them especially vulnerable.

The following case example, ”A Pathological Grief Reaction with a
Positive Outcome," appears in a current text book on bereavement (Aiken,
1994). It illustrates the confusion which is perpetuated about what constitutes

normal v. pathological grief.

Nadine, a 66-year-old former high school teacher, lived
with Charles, age 67, her husband of 40 years (also a retired
teacher). The couple had been nearly inseparable since they
met--they even taught at the same schools during most of their
teaching careers. They lived in a semirural community where they
had worked and had raised their children, all of whom married and
moved to a large metropolitan area about 100 miles away. For
years they had planned their retirement and had hoped to travel
around the country visiting friends. A week before their fortieth
anniversary, Charles had a heart attack and, after ﬁve days in the
intensive care unit, had a second heart attack and died

Nadine took Charles's death quite hard. Even though she
had a great deal of emotional support from her many friends and
her children, she had great difﬁculty adjusting. Elaine, one of her
daughters, came and stayed a few days and encouraged her to
come to the city for a while. Nadine declined the persistent
invitation even though she had little to do at home. Friends called
on her frequently, but she seemed almost to resent their presence.
In the months following the funeral, Nadine's reclusive behavior
persisted. Several well-wishers reported to Elaine that her mother
was not doing well and was not even leaving the house to go
shopping. They reported that Nadine sat alone in the darkened
house-mot answering the phone and showing reluctance to come
to the door. She had lost interest in activities she had once
enjoyed.

Greatly worried about her mother's welfare, Elaine
organized a campaign to get her mother out of the house and back
to doing the things she had formerly enjoyed. Each of Nadine's
children and their families took turns visiting and taking her
places until she ﬁnally began to show interest in living again. In
time, Nadine agreed to come to each of their homes for visits.
This proved a therapeutic step since Nadine had always been fond
of children and took pleasure in the time spent with her eight
grandchildren--she actually extended the visits longer than she
had planned ( p. 336).

28

The information provided in this example is insufﬁcient to render a
diagnosis of pathological grief. Critically, the time dimension is not clear.
”Months" may suggest four, or may suggest twenty-four. If four, then the
reticence to engage socially is not unusual. If twenty-four, the feature of
pathologic grief which Parkes and Weiss (1983) describe as stuck would appear
more likely. Also not clear is the extent to which Nadine's children visited her
in those early months. It is not unusual for bereaved individuals to prefer the
support of immediate family, as Rando has suggested (above). If her children,
even at a distance of 100 miles, failed to visit her during those months after the
funeral, Nadine may well have felt abandoned by those most important to her.
Another feature of pathological grief which it is not apparent in Nadine's case
the dysfunctional revision of assumptions of self and future which Rynearson
(1990b) describes. This is not to say that it may not be present; only that the
information provided is insufﬁcient to make that assessment. Given
Rynearson's (1990a) caution that the stamp of pathological be reserved for the
"rare and rigorous circumstances of the disease” (p. 294), it is not clear that

Nadine qualiﬁes.

Summary of Chapter One
The linear models of grief, which have dominated the psychology
literature since Freud, fail to account for the wide range of reactions to a loss

which individuals may exhibit. Further, the linear models perpetuate some

29

misconceptions about healthy grieving, including that there is a distinct end
point which is accomplished by severing all ties with the deceased. These
misconceptions contribute to the difﬁculty of distinguishing between normal
and pathological grief. The holistic models, while non-linear and
multi-dimensional, still place a single individual at the center of the grief event,
a feature which limits consideration of the broad range of interconnected
reactions to the loss occurring throughout the individual's family. Family
systems theory provides a perspective which acknowledges that most deaths
leave several bereaved individuals, whose strategies for coping with the loss
impact each other. This perspective is important in understanding some of the

special challenges of ethnic bereaved which will be explored in later chapters.

CHAPTER TWO
ETHNICITY AND GRIEF

The Scope of the Problem: Ethnic Population Trends

Contrary to the melting pot theory, which anticipated that the US.
would eventually become a society in which the several ethnic groups who
emigrated here would intermarry and result in a single, homogenous culture, it
has become increasingly evident that such is not the future of the US. Nor is
it apparently the future condition of humanity, at least not in the foreseeable
future (Sokolovsky, 1990b). Scholars note that pluralistic societies are on the
rise throughout the world (C001, 1987). Thus, people within any given society
must increasingly interact socially and politically with individuals who
represent different ways of living and thinking.

According to the US. Census in 1990, one in four American residents
were members of ethnic minorities, that is nearly 62 million people. In 1980
that ratio had been one in ﬁve. This increase in racial composition changed to
a greater degree between 1980 and 1990 than during any other decade in this
century (Irish, Lundquist, and Nelson, 1993). Within large ethnic groups,
several differing cultures are represented. The Asian group, numbering 7.3
million in 1990, consists of Chinese, Filipino, Japanese, Vietnamese, East

Indian, Korean, and Laotian-Hmong and show an increase of 108 percent since

30

31

1980. Hispanics, numbering 22.4 million in 1990, consist of Mexican, Puerto
Ricans, and Cubans, as well as immigrants from Central and South America.
As a group their numbers have increased 53 percent since 1980. African
Americans, numbering 30 million in 1990, increased 13 percent over 1980
ﬁgures.

Michigan's population proﬁle reﬂects comparable ethnic minority trends
(Michigan Dept. of Public Health, 1988). In 1980 the non-White population
constituted 14 percent of the total in Michigan. By 1985 that percentage had
grown to 15 percent, a number which does not take into account the signiﬁcant
disproportionate undercounting of minority group members which is an
acknowledged feature of census data. In addition to the large numbers of
Asian, Hispanic, and African Americans represented in the population, a
signiﬁcant ethnic population in Michigan are Arab Americans, who numbered
70,000 in 1980. Of these, 75 percent live in the Detroit area. They are a
culturally diverse group, with representatives identifying themselves as

Lebanese, Assyrian, Syrian, and Iraquis.

Clariﬁcation of Terms

The reader will note that the census data presented above uses
interchangeably the terms racial and ethnic. This usage reﬂects the way in
which the terms have been utilized by the authors cited. Ethnic groups have

been as broadly deﬁned as ”social groups that are distinguished on the basis of

32

race, religion, or national origin” (Markides and Mindel, 1987, p. 13).
However, this deﬁnition is very misleading. Consider that both a black Kenyan
international student and a black Detroit factory worker would be categorized
by the same racial distinction, yet culturally are worlds apart.
Correspondingly, an upper-class Boston Irishman and a migrant Hispanic may
both be Catholic, yet their cultural heritage is signiﬁcantly different. And
regarding national origin, immigrants from South Africa might include either
socially advantaged white Afrikaners or severely disadvantaged blacks.

While such a broad deﬁnition of the term ethnic blurs signiﬁcant
dimensions of ethnicity which are the focus of this paper, to point out that the
terms are sometimes used imprecisely provides a perspective from which to
appreciate the difﬁculties in constructing accurate demographic data upon
which to base decisions regarding health and social programs which are
sensitive to speciﬁc ethnic groups. Not only do inaccurate numeric proﬁles
result, but such imprecise usage effectively perpetuates the commonly held
belief that race and culture are somehow synonymous. Regarding enumeration
difﬁculties, often the category "non-White" is offered as a catchall for all
non-caucasian racial groups (Markides and Mindel, 1987). In this usage,
non-White may be assumed to refer to Black, but not all non-Whites are Black.
As noted in the Michigan population proﬁle above, non-White includes, in
addition to Black, large numbers of Asians, Hispanics, and Arabs. The large

ethnic group referred to collectively as Hispanics includes individuals of

33

Mexican, Cuban, Puerto Rican, Central and South American ancestry. To lump
them with each other suggests cultural homogeneity, a very misleading
suggestion. To include them with Blacks in a count of non-Whites further
limits what can be inferred from such an enumeration. This practice is not
unusual, however, in studies by governmental entities collecting demographic

and socioeconomic data.

Enumeration Difficulties

Very different enumerations result depending on the method used to
identify ethnicity. The Mexican-American group provides an example. The
various possibilities for how to identify persons of Mexican ethnicity include:
1) persons born in Mexico or of Mexican parentage; 2) use of Spanish as the
household language; 3) Spanish surname; and 4) the respondent's identiﬁcation
of him or herself by origin (Harwood, 1981). Each method contains its own
difﬁculty. The ﬁrst tends to underenumerate, as it excludes persons whose
grandparents, great-grandparents, etc. came to the US. The second method
tends to overenumerate, as it includes immigrants and descendants of other
Spanish-speaking groups (e. g., Puerto Ricans, Cubans). The third method
mixes under- and over-enumeration potential. It eliminates from the count
persons of Mexican ancestry who have married and relinquished their Hispanic
surnames. In contrast, it includes, perhaps inappropriately, individuals who

still carry Hispanic surnames but who trace their origins to regions of New

34

Mexico and Colorado previously part of New Spain and who do not identify
with the Mexican-American community. Method four is subject to variability
based on the subjective experience of the respondents, who one day may feel an
afﬁnity for their Mexican-American ancestry, while another day may strongly
identify with the WASP culture to which they have become acculturated to

some degree.

Operational Definition of Ethnicity

To develop a concept of ethnicity which provides a framework for
considering the inﬂuence of ethnicity on the course of grief and bereavement,
it is necessary to reach beyond the dimensions of race, religion, and national
origin. That is not to say these dimensions will be excluded; rather, that others
will be identiﬁed from which ethnicity derives its potential to inﬂuence grief
and bereavement. The notion of sense of identity is central to this potential.
For the purposes of this thesis, an individual is ethnic to the degree to which
they emotionally identify with a group who share race, religion, and/or national
origin. Sokolovsky (1990b) describes ethnicity as ”social differentiation
derived from cultural criteria such as a shared history, a common place of
origin, language, dress, food preferences, and values that engender a sense of
exclusiveness and self-awareness of membership in a distinct social group” (p.
201). In this sense, ethnicity fulﬁlls a deep psychological need for identity and

historical continuity.

35

The presence of a larger social context against which the ethnic
differences stand in contrast is a dimension emphasized by Cool (1987).
Stated another way, "To be an ethnic minority requires sociocultural contrast
for its validation..." (Elsass, 1992, p.220). Further, ethnicity evokes deep
feelings, with discussions about and/or between ethnic groups frequently
becoming polarized. The "we" and ”they" touches on something basic in the

human psyche (McGoldrick, Pearce, and Giordano, 1982).

Disadvantaged Social Position

In addition to cultural distinctiveness, exclusivity, and emotional
content, virtually all ethnic groups in the US. have been impacted by their
immigration histories and the ongoing social, economic, and political forces
which result from American class stratiﬁcation (Sokolovsky, 1990b). Their
immigration histories include both what they came to and what they left behind.
Of particular signiﬁcance in this regard is that most immigration to the US.
has been in response to the US. need for labor and/or the promise of
opportunity. Immigrants thus have long been a valuable commodity in the
labor market, but have been destined to a bottom rung on the socioeconomic
ladder (Worsley, 1984). Immigrants have traditionally been willing to take
undesirable jobs which the longer-settled Americans (the now acculturated
mostly Anglo-Saxons of previous generations) have been unwilling to perform.

For example, the Chinese and the Irish came in the 1860's to build the

36

railroads, putting their lives at risk while dynamiting through entire mountains.
The Mexicans came in the 1960's to work as farm laborers, earning a pittance
for back-breaking, labor-intensive harvesting of crops.

For these immigrants, their lack of command of the spoken language,
their inability to read, their lack of experience of the local social institutions,
their distinctive style of clothing, and their unfamiliar customs alienated them
socially from the mainstream culture. Many immigrants reacted to this social
exclusion by emphasizing their ethnicity--living together in barrios, organizing
recreational associations, and in some cases organizing trade unions and
political parties (Worsley, 1984). What might be viewed as a healthy sense of
tradition-~attachment to the past as a value in itself--may also be viewed as a
”nostalgic spiritual contrast to present disprivilege" (p. 249). While this
retreat into an insulated haven of comfort and afﬁrmation reduced the
immediate pain of the situation, it served to delay the learning of language,
social skills, and customs which were necessary if the disadvantaged position
was to be overcome.

It is from this view of the immigrant as valued labor commodity but
disvalued social entity that the category ethnic minority takes on particular
meaning. Minority can be used to indicate power relationships within a
society, not numerical magnitude. For the entire world, those of the white race
constitute a distinct minority numerically; "people of color” are the vast

majority (Irish, Lundquist, and Nelsen, 1993). However, in both the past and

37

the present, numerical minorities sometimes maintain power over nonwhite
majorities, such as in South Africa, controlling the circumstances under which
the latter live. In the US, white majorities have dominated and discriminated

against nonwhite minorities.

Cultural Uprootedness

In addition to the disadvantaged social position to which ethnic minority
members came and to which they continue to be relegated, what they left
behind also has enormous signiﬁcance. For some groups, the reason for
emigration was to ﬂee for their lives, as was the case for the Jews during
World War II and for the Cambodians during the Pol Pot regime in the 1970's.
The atrocities to which they were subjected prior to their ﬂight resulted for
many in severe stress reactions. Quite aside from the reaction to the atrocities,
the loss of homeland was in itself monumental. Uprooting cannot be
understood merely as physical relocation. According to Marris (1974)
uprooting disrupts the continuity of an individual's concept of selﬂiood as well
as the individual's ”structure of meaning,"--how the individual organizes and
understands one's environment. He likens the reaction to uprooting to the grief
reaction more typically thought of as accompanying the bereavement which
results from the loss to death of a signiﬁcant other.

Eisenbruch (1984a) uses the term "cultural bereavement” to describe

the phenomenon of grief reaction to the massive social loss caused by

38

uprooting. Marris (1980) asserts that the anxieties which accompany such
losses center on the struggle to defend or recover meaningful patterns of
relationship. According to Marris, the nature of grieving shows that meaning
is a whole--the loss of any crucial relationship tends to undermine the sense of
all relationships. The Psychosocial Transitions theory of Parkes (1971)
supports this view. Parkes asserts that whenever a major change occurs in
one's life space (people, places, or things), the individuals must restructure
their ways of looking at the world in which they live. The signiﬁcance of any
particular change, according to Parkes, depends on its inﬂuence on our
”assumptive world,"--our assumptive world being the total set of assumptions
which we build up on the basis of past experience. Studies of adult refugee
groups from eastern Europe, Taiwan, Latin America, and Cuba suggest that
even after apparently successful early adjustment, there may be a high rate of
subsequent physical and mental breakdown (Eisenbruch, 1984a and 1984b). He
found that advancing age, personal bereavements, and the social isolation of
immigrants may promote a renewed sense of exile and reactivate the trauma of
the original uprooting.

In summary, the dimensions of ethnicity which have been identiﬁed as
speciﬁcally salient to issues of grief and bereavement are: 1) emotional
identiﬁcation with a group who share race, religion, and/or nationality;

2) distinctive language, dress, and customs of that group which are in contrast

to the dominant culture; 3) a disadvantaged social position within the larger

 

39

society; and 4) cultural uprootedness with potential for unresolved cultural
bereavement. These dimensions, however, should not be thought of as existing
uniformly among all individuals of all ethnic afﬁliations. The extent to which
an ethnic group and/or individual members within that group have become
acculturated to the dominant WASP culture is dependent upon a number of

variables. These variables are the subject of the following section.

Assimilation Theory

Traditional assimilation theory views ethnicity and minority status as
temporary. According to this view, while ethnic groups coming to the US.
may enter at the bottom of society, they are able to gradually rise to the middle
class, losing both their subordinate status and their cultural distinctiveness on
the way (Markides and Mindel, 1987). This view predicts that within an
immigrant family, younger generations born in the US. can be expected to
replace the ethnic groups' traditional values and customs with the more
modern, WASP social patterns of their peers.

Another theory, that of "cultural pluralism," suggests that differences
between ethnic groups and the dominant culture tend to persist despite some
assimilation by some members of their groups (Trela and Sokolovsky, 1979).
Two models within this theory are ”integrated pluralism” and ”invidious
pluralism." Integrated pluralism refers to the coexistence of distinct ethnic

groups without patterns of subordination of any group by any other. This

 

40

model generally explains the persistence of cultural distinctiveness among
European-origin White ethnic groups such as the Irish in Boston and the Polish
in Detroit. In contrast, invidious pluralism focuses on the effects of
subordination and discrimination of minority groups (Markides and Mindel,
1987). This model explains the situation of the Blacks in Detroit, the Mexicans
in Los Angeles, and the Puerto Ricans in New York City.

In common usage, the distinction between ”multi-ethnic" and
"multi-cultural" is frequently blurred. Irish, Lundquist and Nelsen (1993)
suggest that both terms refer to societies in which multiple cultural groups
exist but with varying degrees of assimilation and subordination. According to
their distinction, a multi-ethnic society consists of identiﬁable cultural groups
that exist quite separately from and subordinate to a majority population. Such
groups are not appreciably assimilated and do not receive equal respect from
the majority, and thus lack equal access to opportunities within the society. In
contrast, a multi-cultural society includes groups that are somewhat
distinguishable in the sharing of some common customs and values, but who
are able to share fully in the wider society's resources and opportunities. While
the Irish, German, Italian, Polish, and others qualiﬁed as ethnic minorities early
in their immigration history, this distinction no longer applies as they have
made their way up the socioeconomic ladder and have become more or less
fully acculturated. To varying degrees, however, they retain their cultural

distinctiveness. In contrast, the ethnic groups who retain the distinction of

41

minority status in the sense of subordination are, signiﬁcantly, non-White
groups including Mexican, Asian, Black, and Native American (Markides and
Mindel, 1987).

Speed of apparent acculturation is a multi-faceted phenomenon.
Individuals and families who migrated alone have had a greater need to adapt
to the new situation, and their cultural bereavement is more hidden. This is the
case of the educated immigrants who came for professional positions in the
US. While they have been apparently successful in the sense of learning the
language of their new home and participating without discrimination in
economic opportunities, their lack of access to others with whom they can
speak their native language or share customs and rituals is especially
problematic in the event of a new signiﬁcant loss beyond their uprootedness.

The place of residence of the family also impacts the rate of
acculturation. Large cities with large numbers of ethnic minorities are more
likely to have ethnic neighborhoods which cushion against the stress of
migration but which also tend to slow the rate of adaptation to the customs and
values of the US. For families living in such neighborhoods, the choice for
individual family members between upward mobility and ethnic loyalty can be a
source of severe identity conﬂict (McGoldrick et al., 1991). The intensity of
one's identiﬁcation with an ethnic group is likely to be inversely correlated
with education, income, and socioeconomic class (Markides and Mindel,

1987). As immigrants becomes more educated, receive a higher income, and

 

42

move upward socioeconomically, their identiﬁcation with their ethnic heritage

tends to weaken, at least in their day-to-day activities.

Ethnicity and Stress

Apparent acculturation may collapse under conditions of emotional
distress, however, with a reversion to sense of ethnic identity surfacing. It is
not unusual for a married couple to tolerate differences, perhaps even to ﬁnd
them endearing. Under stress, however, one's tolerance for difference
diminishes (McGoldrick et al., 1991). Rosenblatt (1988) asserts that
Americans frequently act as though ethnic differences don't extend beyond food
preferences and holiday celebrations. For some married couples of different
backgrounds, when a signiﬁcant loss occurs may be the ﬁrst time the
differences in ethnicity become problematic as different norms for deﬁning and
dealing with the loss become evident. Unfortunately, at that time, individuals
may lack the focus, energy, or ﬂexibility to deal with their relationship. They
may use their ethnic customs or religious values selectively to justify an
emotional position within a family or against outsiders, or, couples may react
to each other as though the other's behavior were a personal attack rather than
a difference rooted in ethnicity.

Eisenbruch (1984b) suggests that there are parallels between the coping
strategies in response to cultural uprootedness and pathological outcomes of

bereavement due to death. He sees excessive clinging to the culture from

43

which one has been uprooted, with an inability to move on to form new
attachments and learn new customs, as similar to the overidealization and
overidentiﬁcation with the deceased which can be seen in pathological grief.

In contrast, the opposite reaction, with rapid and apparently smooth
assimilation into the host society, may be seen as similar to the abrupt
immersion in a new relationship and marriage which may occur after the loss of
a spouse but prior to coming to terms with the multiple meanings of the lost
relationship with the deceased.

The interplay among ethnic identity, religion, and family life are
complex. The family may be thought of as the focus of ethnic identity because
it is within this sphere that ethnic values and behaviors are perpetuated. But it
is important to see family life and religion as distinct and separate aspects of
ethnic identity. Poles, Italians, and Irish may all be Catholic, but the ﬂavor of
religious Observances will differ signiﬁcantly. Conversely, long after an
individual member of those families may have rejected Catholicism
intellectually, their identiﬁcation with the family's ethnic heritage may be

intense.

Summary of Chapter Two
Ethnic population trends suggest that the presence of diverse ethnic
groups in the US. is on the rise. The reliable enumeration of these groups is a

challenge which must be acknowledged in the design of social programs. The

44

dimensions of ethnicity which are identiﬁed as having particular relevance to
grief and bereavement are: emotional identiﬁcation with the minority group;
customs which contrast with those of the larger society; a disadvantaged social
position; and cultural uprootedness. Cultural bereavement, the grief reaction
to the massive social loss which accompanies uprootedness, is among the
factors predisposing ethnic group members to complicated grief when
confronted with additional losses. Degrees of apparent acculturation are seen
to collapse during times of emotional distress, with reversion to stronger

identiﬁcation with individuals' ethnic roots.

CHAPTER THREE
GRIEF: A CROSS-CULTURAL PERSPECTIVE

Is Grief Universal?

Grief theorists generally agree that grief is universal: that to make
attachments, to have them disrupted by death or separation, and to experience
distress as a result of that disruption is part of the human condition (Counts
and Counts, 1991; Eisenbruch, 1984a; Schneider, 1984, 1994). Some insight
into the extent to which the human species experiences grief universally can be
gained by considering the relative contributions of biology and culture. Insight
so gained can also help to assess the extent to which the response of an

individual to distress has been conditioned by his/her cultural experience.

Biological Evidence

Some arguments have been made that grief has a biological basis.
Darwin (1872/1965) compared in human infants and monkeys the facial muscles
which were involved in expressions of apparent protest and pain. He also
collected detailed information from colleagues who observed facial expressions
associated with apparent emotional distress in indigenous peoples in Australia,

India, and Africa. He found that the same sets of facial muscles are universally

45

46

used by human infants, monkeys, and adults in situations believed to be cause
for grief, suggesting a biologic basis for grief.

Darwin was careful not to generalize from observations of blacks in
America as he recognized the extent to which their reactions might be
inﬂuenced by the responses they observed in the white world in which they
were immersed. Darwin likewise believed that observing infants is more
reliable than observing adults, noting that infants exhibit many emotions with
extraordinary force, whereas in adults, some expressions no longer reﬂect the
pure and simple source from which they spring in infancy.

Further support for a biologic basis for grief is found in the work of
Averill (1968). Averill hypothesized that grief is a biological reaction, the
evolutionary function of which is to ensure group cohesiveness in species
where a social form of existence is necessary for survival. This cohesiveness is
accomplished by making separation from the group, or from speciﬁc members
of the group, an extremely stressful event both psychologically and
physiologically. This stress is particularly pronounced when the separation
breaks a dependent relationship such as parent/child, mated pair, or mutually
supportive friendship.

Consistent with the work of Bowlby (1969) already discussed, Averill
observed that attachment is a necessary predecessor to grief, and that the
strength of that attachment is correlated with the intensity of grief. His work

with monkeys separated from their mothers demonstrated that protest,

47

yearning, and searching behaviors are typically evoked in the absence of their
mothers. When rhesus macaque monkeys are compared with bonnett macaque
monkeys, it is noted that rhesus display more intense separation grief than do
bonnetts. Averill argues that this difference exists because rhesus form close,
one-to-one mother-infant attachments, while among the bonnetts, mothering is
widely shared among the females of the clan.

Similarities in the physiological reactions of humans and those of
non-human primates following the loss of a mate, parent, and offspring have
been found by Zeller (1991). The depression of the immune systems of both
humans and macaques as a result of prolonged corticol elevation follows
separation from signiﬁcant attachment ﬁgures. Interestingly, in examining both
the physiology and behavior of humans and monkeys it has been found that
there may be a lack of correlation between these two indicators of stress. In
adult humans as well as both rhesus and squirrel monkeys, behavioral agitation
can decrease but levels of pituitary adrenaline may still remain elevated. This
lack of correlation between physiology and behavior has implications for
deciding what outcomes should be used to indicate successful recovery from
grief.

Signiﬁcantly, many studies reported as ”primate” research have been
done on monkeys, acknowledged to be evolutionarily and genetically less
proximate to humans than the higher primates--chimps, orangutans, and

gorillas. This may suggest that the ﬁndings are not as generalizable to humans

48

as might be possible if the research were done on higher primates. However,
the monkeys' shorter life-span makes them more desirable laboratory animals
than are higher primates, whose life-span parallels that of humans. While
studies of higher primates are less numerous, observations of chimps and
gorillas strongly suggest grief reactions upon separation from their young
comparable to those of human mothers. These observations provide even
stronger support for a biologic basis for grief in humans than do monkey
studies. A zoo chimp who consistently lost her infants because she had
unsufﬁcient milk was observed huddled in a corner for weeks after the death of
her infants (Zeller, 1991). A zoo gorilla was observed to carry, pat, and
gently encourage nursing in a stillborn infant for four days before she would
allow the zookeepers to remove the partially decomposed corpse. Afterward,
she became lethargic, just sitting With her head against the wall with a facial

expression resembling a grieving human.

Cross-Cultural Evidence.

Moving on from the evidence which suggests a biologic basis for the
universality of grief, the cross-cultural evidence for universality will be
explored. A classic study which is central to the anthropology literature is the
work of Rosenblatt, Walsh, and Jackson (1976). They studied grief and
mourning in seventy-eight cultures which varied widely in complexity, degree

of contact with Western civilization, and major religious systems. They studied

49

the ethnographic descriptions of those cultures which had been done by other
anthropologists and evaluated the attributes which were of interest to them.
Among the attributes studied was the frequency of crying by bereaved adults in
each society. Each society was rated on a scale from one to ﬁve with one
signifying crying absent to ﬁve signifying crying very frequent. Some societies
were not ratable because of methodological problems. Of the sixty nine
societies who could be rated reliably, sixty-seven were rated as at least four,
that is, displaying frequent crying at death. Only were the Balinese rated as
one, that is, crying absent. Signiﬁcantly, the Javanese, who are geographically
and culturally proximate to the Balinese, was the only other society not rated
as displaying crying frequently. For them the rating for crying was two, that is
"rarely present."

In a follow-up study conducted by an observer on site for twenty-four
days to gain insight into the apparent lack of crying in Bali, two women and
many children were observed to cry, but in each case the crying ended more
abruptly than it typically would in the US. This phenomenon may be
explained, at least in part, by the Balinese religious belief that encourages
people to be calm and undisturbed. It is also consistent with the ﬁndings of
others who suggest considerable differences between public and private
expressions of feeling (Counts and Counts, 1991; Eisenbruch, 1984b). Three
Balinese men were observed to smile or laugh during the telling of very sad

events in their lives (one had lost three children to death). They explained that

50

if they did not laugh, they surely would cry. While such a strategy to avoid
crying also occurs in the US, it appears to be a common pattern in Bali.
Rosenblatt, Walsh and Jackson concluded that the experience of grief seems to
be the universal cost of having enjoyed long-term contact and interdependence
with other human beings. Further, they concluded that crying is the almost
universal private reaction to the loss to death of someone important.

Another study which looks at crying behavior was done by Briggs
(1970), who conducted a 17-month ﬁeld study among a band of Utku. This
band was composed of between 20 and 35 individuals who lived intermittently
at the mouth of the Back River, northwest of Hudson Bay. Briggs lived as an
adopted daughter, sharing an igloo with a family. She described the care with
which children are taught to control the expression of all emotion, thus
maintaining the absolute equanimity in the camp which is necessary for the
survival of the whole under harsh and isolated conditions. She reported an
example of a minute infraction: when a very ill adult man was leaving to be
taken to hospital by government plane, perhaps to never return, "a tear had run
down the nose of his fourteen-year-old son, and this incontinence was reported
as amusing by the boy's older sister on her visits to the neighbors" (p. 258).
Such behavior by the older sister would be considered insensitive, if not
blatantly cruel, in mainstream U.S. culture. However, for the Utku this
behavior is representative of the type of social sanction which molds their

children into adults who are models of equanimity.

51

A study which looked at the extent to which the reaction to pain is
culturally inﬂuenced was conducted by Zborowski (1969). He studied four
groups of patients in a large Veterans Administration hospital in New York
City during the years 1951 through 1954. The composition of the groups were
of Jewish, Italian, Irish, and "Old American" origin. The term Old American
was used by Zborowski to refer to patients of Anglo-Saxon origin, usually of
Protestant religion, whose ancestors had lived in the US. for more than three
generations. He considered this group to be the social group which
represented the dominant cultural model in the US. The research techniques
employed consisted of participant observation and both formal and informal
interviews. Zborowski was interested in whether there were discernible
differences between cultural groups in their reaction to pain, that is, in their
behavioral and observable response to the stimuli.

One level of reaction to painful stimuli is heavily biologically determined
and independent of human consciousness. For example, painful stimulation can
provoke physiological manifestations such as changes in respiration, heartbeat,
perspiration, or reﬂex muscular contraction in an experimental setting. In
actual clinical settings, reﬂex reactions such as twitching or wincing are helpful
in determining the presence of pain; but the speciﬁc qualities of the
sensation--such as intensity, location, and duration--are greatly inﬂuenced by

the patients' emotions and anxieties, which are reﬂected in their overall

52

behavior and in the ways they describe the experience. It is this pain
experience which is subject to cultural inﬂuence.

The appropriate reaction to painful stimuli is learned from the norms of
acceptable behavior in speciﬁc circumstances in the social group to which the
individual belongs. For example, in the US, pain exclamations may be
expected in the hospital during the repair of a football related injury, but might
be considered out of place on the football ﬁeld. Likewise, in some primitive
tribes, men are expected to tolerate ritually inﬂicted pain in silence but are
allowed to moan and groan when their pain is illness related (Bentsen, 1989).
This is not to say, however, that all members of a given cultural group embrace
universally all of the published norms. Anthropologists are increasingly aware
of the extent to which our notions of group norms have been shaped by
narratives provided by the powerful and the articulate within groups
(Lewis-Fernandez and Kleinman, 1995). The experience of the less powerful,
less visible members of a group may be quite (different.

Zborowski found that both the ethnographic data gathered and the
statistical measures employed showed signiﬁcant differences among ethnic
groups in how they reacted to pain. On measures of both emotionality and
intensity, the Italian and Jewish groups were more emotional in describing their
pain and ”played it up." They most often described their pain as very severe,
whereas the Old Americans and the Irish frequently differentiated between

slight, moderate and severe pain. While Irish and Old American patients most

53

frequently indicated they prefer to hide their pain, the Jewish and Italian
patients freely admitted they show their pain and they do it by crying, moaning,
being demanding, and stating clearly that they could not tolerate pain.
Interestingly, the Jewish patients seemed most future oriented about the course
of their pain, being concerned with its implication for the future. In contrast,
the Italian patients were very present-oriented, indicating more frequently than
any other patients that their pain was present all of the time. Further, they
seemed concerned almost exclusively with the pain dimension of their illness,
rather than being concerned with the other symptoms of their illness.

The conclusions of Zborowski's study were afﬁrmed subsequently by
other social and medical scientists who investigated the role of ethnicity in
inﬂuencing individuals' responses to pain and illness. Of particular relevance
was a study which tested Old American, Irish, Jewish, and Italian housewives
and found parallel differences in pain attitudes to those found by Zborowski
(Sternbach and Tursky, 1965). This study was a laboratory one, comparing the
women's response to electric shock. Sternbach and Tursky found, for
example, that Italian women participants reacted expressively to the pain of the
electric shocks while the Old American participants attempted to mask their
discomfort.

One of the few empirical studies reported which attempted to look
speciﬁcally at differences between how members of different ethnic groups

grieve is that of Luborsky and Rubenstein (1990). They studied widowers of

54

three ethnic groups--Irish, Italian, and Jewish-- (culturally distinctive, though
not disadvantaged) to ﬁnd out how they had reorganized their lives two years
after the deaths of their spouses. The study revealed that regardless of ethnic
background, elderly widowers suffered some general features of widowerhood,
most signiﬁcantly a sense of isolation after the loss of their intimate conﬁdant.
For each there was only a slight decrease in the sense of attachment to their
wives over time.

The distinctive ethnic heritage of the widowers was found to be the basis
for involvement in current activities, both family and community. Ethnic
identity can provide a sense of continuity through both identiﬁcation with
traditional values, sentiments, and practices, and as a guide as to what to do in
times of stress. Such identiﬁcation can provide a desired sense of rootedness
in a time of turmoil. Unfortunately, revitalizing ethnic and family traditions in
some cases also awakens past difﬁculties or brings into focus current tensions.
For example, Luborsky's study described the case of Mr. McGraw, an Irishman
and recovered alcoholic for years before his wife's death. He began drinking
again after his wife's death, certainly a self-destructive behavior, but
nonethelsss a way to rekindle a sense of earlier family life and Irish tradition.
A more positive immersion in ethnic heritage was seen in the case of Mr. Stern.
He and his wife had regularly attended synagogue and kept Sabbath
observances at home. Subsequent to her death, traditional mourning customs

provided a daily structure to his life as well as a vehicle through which to

55

honor her memory. Signiﬁcantly, he reported these religious practices also
provided an opportunity to meet other people who were also dealing with

losses.

Mourning Rituals

A consideration of the variety of mourning rituals which have been
observed by anthropologists can provide a context within which to consider the
possible meanings of a range of behaviors subsequent to the death of a
signiﬁcant other. Van Gennep (1909/1960) surveyed funeral and bereavement
practices across the world and noticed similarities in the structure of practices
within most societies. He identiﬁed three basic aspects of the practice: rites of
separation; a transition or liminal phase; and rites of incorporation. Among
the rites of separation he observed were such practices as transporting the
corpse, burning the deceased's house or possessions, and various rites of
puriﬁcation. He characterized the transition or liminal phase as a period
during which both the mourners and the deceased comprise a special group,
situated between the world of the living and the world of the dead. How soon
living individuals leave that group depends on the closeness of their
relationship with the dead person as well as how long the spirit of the deceased
remains. During this liminal period, social life is suspended for all those
affected by the death. The third part, the rites of incorporation, signal the end

of the mourning period and include such practices as shared meals and ritually

56

prescribed intercourse of the surviving spouse with the partner(s) designated as
appropriate by the group. Van Gennep described the rites of separation and
those of incorporation as, while not uniform, not nearly as complex or diverse
as the transition rites.

A death disrupts a community in several ways: 1) through the loss of one
of its members, a loss that must be accommodated for the restoration of group
functioning; 2) by altering the roles of the bereaved kin, roles that must now be
redeﬁned; and 3) by forcing the community to confront the existential reality of
death, a reality which is addressed in symbolic rituals consistent with the belief
system of the group (Counts and Counts, 1991). Bereavement rituals create
avenues for the public articulation of deeply felt emotions such as sorrow and
anger and provide community support for the expression of those emotions.
They help in restoring the social order disrupted by the death (Shapiro, 1994).

The norm in the US. has been moving increasingly toward the
dominant WASP model which minimizes expression of emotion and formal
rituals for dealing with death (McGoldrick et al., 1991). Through public health
regulations and employment leave practices, considerable social control is
exercised over the funeral process. The funeral industry has commercialized
and uniformalized the preparation of the body and has taken over the elaborate
religious funeral rituals previously performed by the family or appropriate
group members. The typical employment leave policy severely limits the

performance of traditional bereavement practices. ”Scientiﬁc management" and

57

prescribed personnel practices have limited the length of the period of
mourning to three days for immediate family and do not formally acknowledge
any mourning period for friends (Pratt, 1981). Thus, mourning has become
increasingly private and the responsibility of immediate family.

The extent to which the Western world is a death-denying culture is
portrayed in the work of both Gorer (1965) and Becker (1973). Both contend
that the topic of death has replaced the topic of sex as the major taboo in
polite conversation. Becker challenges Freud's theory of sexual repression as
underlying all intrapsychic difﬁculties, suggesting that it is actually the
repression of the notions of death and of one's own eventual annihilation which
is the underlying problem.

In addition to the diminished funeral rituals, increasing disregard in the
US. of a formal mourning period has meant that bereaved individuals get little
support from society at large beyond the funeral itself. Furthermore, there is
no culturally prescribed process for redeﬁning the social roles of the bereaved.
Parkes (1972) contends that the cultural evolution that has made marriage an
integral part of our social organization has done little to ensure that the
functions that it performs will be adequately carried out after its dissolution.
He cites the custom of levitate marriage--automatic remarriage to the
husband's eldest brother, once the custom among the Jews--as an example of a
bereavement practice which, while it may not have solved the personal grief of

the widow, it must have ensured that many of her essential needs were met and

58

protected her from the loneliness, poverty, rolelessness, and insecurity which
are the lot of many modern widows.

The failure to carry out mourning rituals contributes to bereaved
individuals' inability to come to terms with their losses (Walsh and
McGoldrick, 1991). Because of the US. dominant culture's tendency to
minimize the need for rituals, individuals may not have opportunities to feel
supported in their own exploration of the personal meaning of losses. Lack of
access to comforting, supportive ritual is potentially all the more problematic
for ethnic group members whose ethnic identity is in transition as a result of
uprootedness and/or partial acculturation to the WASP norms. The potential

for pathological grief is great under these circumstances.

Key Factors in the Course of Bereavement

Key factors in variations in mourning rituals and bereavement practices
which are of particular relevance in distinguishing between normal and
pathological grief are: l) the duration of the prescribed mourning period, and
2) the form of expression of emotion sanctioned. Both factors are dependent
on belief systems about what happens to an individual aﬁer death as well as
what is believed about the relationship between the expression of emotion and
health of the bereaved individual as well as the entire group. The following

examples, while admittedly sketchy and simplistic, illustrate these factors.

59

The duration of public mourning periods reported by anthropologists
varies from the extremely short period which was typical of the Navajo to the
extended period customary for the Hurons. The Navajo limited the mourning
period to four days, during which expressions of grief and speaking of the
deceased were allowed (Stroebe and Stroebe, 1987). Excessive show of
emotion even during this period was discouraged. After the four day period it
was expected that the bereaved return to their ordinary way of life, not
grieving, not speaking of the deceased, and not referring in any way to their
loss. Underlying this practice was the Navajo fear of the power of the spirit of
the dead person and their belief that to continue to refer to the deceased would
increase the potential that that spirit would harm the living.

In contrast, the Hurons believed that death occurred in stages including

dying, just dead, and "dead and gone” (Ramsden, 1991). The just dead stage

to the Hurons meant that the individual's body was partly dead, and through
physical decomposition the individual continued to die. They believed the
spirit of the just dead continued to stay in the village and to take part in the
activities of the living. It was their practice, therefore, to place the just dead
so the living would have easy access to them. This included, in some instances,
keeping them in the but with the living, where they would be periodically
bathed, "fed,” and visited. The ﬁnal burial of the corpse did not occur until all
the ﬂesh had rotted away from the skeleton. Intense public mourning occurred

at the time of this burial, in spite of the fact that the individual may have been

 

60

partly dead for as long as ten years.

An example which shows a contrast in the socially sanctioned expression
of emotion is provided by the work of Wikan (1988) in two Muslim
communities. She found that while the Muslim religious belief system frowns
on excessive expression of grief (to do so would be behave as if one does not
agree with God's will), the practice which accompanies this belief is culturally
shaped very differently in Bali than in Cairo. A Muslim mother in Cairo who
loses a child is expected to scream, yell, beat her breasts, and to be beyond
herself for weeks. After that, to sit speechless and listless for three to seven
months would not be considered unusual. In contrast, a Muslim mother in Bali
with a comparable loss would cry softly for a while, but would strive to be
composed, even laughing and joking cheerfully at times. Wikan's interpretation
of this contrast is that Egyptians live in a world where to express one's
unhappiness and anger is believed to be necessary for health and to attain one's
social dues. The Balinese, in contrast, believe that to be sad is dangerous to
your health. They believe that when you are sad, you are weak and vulnerable,
have no energy, and cannot think and plan for your life.

These examples of the differences in the culturally sanctioned duration
of the mourning period and expression of emotion underscore the limited
usefulness of these factors in determining whether an individual's visible

reaction to the loss of a signiﬁcant other may be pathological.

61

The Grief Work Hypothesis

Among the critical debates/issues in the grief literature is the extent to
which it is necessary to do grief work in order to be able to progress from the
initial shock of a loss to eventual resolution (Stroebe, 1992-93; Stroebe, van
den Bout, and Schut, 1994; Wortman and Silver, 1989). The grief work
hypothesis asserts that time alone does not heal, but rather that the bereaved
individual must actively and cognitively confront the loss (Lindemann, 1944;
Osterweis, Solomon and Green, 1984; Worden, 1982). Proponents of the grief
work hypothesis hold that it is necessary to consciously feel the pain of the
loss and to articulate it in order to adjust to the loss of a loved one without
lasting detriment to mental and/or physical health. The grief work considered
therapeutic, according to this view, would include such cognitive experiences
as reviewing the events proximate to and at the actual time of death, reviewing
memories of the deceased, and of consciously working toward detachment from
the deceased. This view of the necessity of grief work has long been a central
construct in both bereavement research and clinical intervention programming
(Stroebe, van den Bout, and Schut, 1994). It has invaded both the popular
literature and lay beliefs about recovery from grief.

In recent years there has been increasing clinical evidence and research
suggesting that there are many individual and family pathways for coping with
grief and that the exploration of distressing feelings is in some instances quite

disruptive ( Weiss, 1988). Though some grief therapists assume that the open

62

sharing of intense, emotional feelings is a necessary part of healthy
bereavement, the ﬁrst priority for a grieving family may well be reestablishing
the stable family patterns that make day-to-day functioning possible (Shapiro,
1994). Furthermore, it is now accepted by some grief theorists that the
absence of apparent distress post loss, previously thought to signal denial and
pathology, may be attributable to adaptive coping strategies and/or
philosophic life-views which permit relatively smooth accommodation to new
realities (Janoff-Bulman, 1992).

Signiﬁcantly, the insistence on cognitive grief work requires that the
bereaved must be able to articulate verbally regarding the source of their pain.
However, according to Lewis-Fernandez and Kleinman (1994), the great
majority of the world's people, including many in North America, are limited in
their capacity to differentiate between somatic and psychological experience,
and thus to cognitively conceptualize and verbalize their pain. They warn of
the possibility of iatrogenic harm if an expectation for cognitive grief work is
imposed on an individual whose predominate cultural mode of dealing with
pain is somatic. Schiff (1986), in contrast, suggests that the role of the
bereavement support worker is to facilitate the bereaved individual's getting in
touch with and verbalizing what they are feeling and to refer to a professional
if the course of bereavement seems beyond the norm.

This interpretation of the role of the bereavement worker reﬂects two

critical Western assumptions about the course of bereavement: 1) that it is

63

desirable/necessary for the bereaved to verbalize their feelings; and 2) referral
for professional counseling is appropriate when reactions other than those
expected in Western models occur. Schiff makes no mention of the possibility
that cultural factors may be inﬂuencing the mode of expression of the pain of
grief or that referral to a professional may be negatively perceived by

individuals of some cultural traditions.

Western Notions of Mental Health

It is important to consider the grief work hypothesis in the Western
cultural context in which it has evolved. Among the values which characterize
Western culture are rationality (logic of the mind); individualism/egocentrism;
independence/self-reliance; competition; future orientation; progress/change;
and the verbalizing of feelings (McGoldrick et al., 1991). In contrast,
non-Western cultures value more highly a "logic of the heart”; suppression of
individuality; mutual dependence and collective responsibility; conformity and
harmony; reverence for the past; emphasis on conservation over change; and
the suppression of emotion. Western values predominate in both the
theoretical constructs of mental health in the US. and in the therapeutic modes
emphasized (Shapiro, 1994).

Furthermore, Shapiro points out that the grief work hypothesis was
developed based on observations of clinical populations, that is, individuals

who had identiﬁed themselves as needing professional help and who would

64

have been characterized as ”stuck” in their grief based on such indicators as
denial of reality and overidentiﬁcation with the deceased. In contrast, the vast
number of bereaved individuals (probably the majority) who are able to devise
coping strategies which allow them to continue in a relatively healthy,
functional manner and thus to not seek professional help are virtually
unstudied. Thus, the grief work hypothesis does not reﬂect the various
strategies employed by them to adjust to a reality in which the deceased is no
longer physically present.

For Western-trained therapists, the healing process emphasizes the
following concepts: individual growth and change achieved through individual
efforts; goal setting and future accomplishments; verbal, intimate,
self-disclosure of emotional states; and clear distinctions between physical
symptoms and mental processes (McGoldrick et al., 1991). In contrast, many
non-Western cultures believe that mental health is achieved through
self-discipline, exercise of will power, and the avoidance of morbid thoughts.
In such cultures, for example the Chinese, there may be considerable shame
attached to being seen as mentally distressed. Disclosing mental distress to
anyone outside the family results in a loss of social status.

Contributing to the taboo against expressing negative emotions is the
predominance of Buddhism in many non-Western cultures. Buddhist
philosophy sees suffering as a natural part of life and emphasizes that it is that

attachment to things which causes sorrow (Obeyesekere, 1985). Meditation

65

and acceptance of reality is seen as the way to reach understanding and
overcome suffering. Individuals well grounded in Buddhist tradition would
accept the loss to death of a signiﬁcant person as a natural reﬂection of the
vicissitudes of life. While their external behavior might appear listless and
apathetic, this would not be viewed negatively or given an illness construct,
because it would be a response consistent with the existential reality as
perceived by them. This life view is in marked contrast to the Western
philosophic orientation which seeks to avoid suffering by control of the
external world and which emphasizes attachment of individuals to each other.
Lewis-Fernandez and Kleinman (1994) assert that three culture-bound
assumptions underlie concepts of mental health and illness in North America:
1) the egocentricity of the self; 2) mind-body dualism; and 3) science as
immutable reality. Regarding the ﬁrst assumption, an egocentric view of the
self sees the individual as a totally self-contained entity, with a set of internal
attributes that determine behavior. In contrast, most of the world holds a more
sociocentric view (Schweder, 1991), seeing the self as developing and behaving
within networks of social relationships that become the locus of self-worth,
self-fulﬁllment, and self-control. For example, both Chinese and Hispanic
societies are more sociocentric than is the US. In Chinese society,
self-assertion is valued in relation to the extent to which it advances family
rather than individual interests. In Hispanic culture, in situations which evoke

strong emotion, the reaction may include an outburst for which the individual is

66

not considered the agent (Lewis-Fernandez and Kleinman, 1994). The behavior
is interpreted as occurring beyond the self as agent. During episodes of acute
bereavement, the reaction may take shape as an ataques de nervios (attacks of
nerves). These attacks may be experienced as trembling, bouts of screaming,
aggressive behavior, and hyperventilation. A common phrase reﬂectingthe
basis of the behavior is "eso no estaba en mi", which translates to ”that
[outburst] was not part of me" (p. 70).

The second assumption, mind-body dualism, evolved from Descartes'
attempt to reconcile the scientiﬁc advances of the 17th century with the
Catholic theology which was dominant at the time. Descartes constructed a
paradigm which distinguished clearly between bodily, material, physical,
mechanistic phenomena and the non-physical phenomena which are the purview
of the mind or soul. This separation makes possible the explanation of
experience as arising in either the mind or the body, of distress as being either
distinctly emotional or distinctly physical. Contrary to this model, the great
majority of the world's population experiences human suffering in an
integrated, somatopsychological mode, as simultaneous mind and body distress
(Kleinman, 1982). According to Lewis-Fernandez and Kleinman (1994), ”the
dualistic professional model systematically misinterprets the nondualistic
cultural experience of patients as reﬂecting a lack of introspection or a
so-called primitive cognitive style and forces a differentiation between

psychological and somatic experience where none exists” (p. 67).

67

The third Western assumption, science as immutable reality, views

culture as a set of beliefs superimposed upon a bedrock of scientiﬁc reality.
As opposed to belief, which acquired the connotation of falsehood, science has
been seen as synonymous with reality, the touchstone against which all false
views are tested, rather than as an equally cultural enterprise. This view fails to
recognize that the scientiﬁc view characteristic of Western thought is itself a
belief system. This assumption leads to a discounting of the disease categories,
illness experiences, and healing practices of people of non-Western cultures.

Fortunately, all three assumptions are coming under increasing
challenge in the ﬁelds of cultural psychiatry and medical anthropology.
However, an indication of the limited impact to date of cultural psychiatry on
clinical psychiatry is the recent failure to culturally validate the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) in spite of considerable

evidence of the need and clear recommendations otherwise.

Somatization

The cross-cultural work of Kleinman and Good (1985) has demonstrated
that there is a signiﬁcant difference between Western and non-Western cultures
in the extent to which distress is psychologized or somatized. Further, they
contend that somatization is not unusual even in the US. They believe that a
more somatizing expression of distress is associated with lower socioeconomic

and educational levels, rural origins, and active and traditional religious

68

afﬁliation. They further contend that somatization was even more prevalent
prior to the emergence of an increasingly psychological idiom of distress. They
see the emergence of this trend toward psychologizing as related to the cultural
transformation of modernism which emphasizes analysis and rationalization.
They contend that affect as it is experienced among the middle class in the
West is shaped as psychological experience and rationalized into discretely
labeled emotions that prior to modernism would have been principally felt as
bodily experiences.

Kleinman and Kleinman's model (1985) posits that prior to cognition,
affective states are an essential psychobiological phenomenon with
physiological correlates. It is at this level that response to stress is universal
across the human species. However, it is culture which determines how an
individual evaluates a stimulus; what is perceived as a stressor in one culture
may not be so in another. Ever since Zborowski's 1969 study (previously
discussed) of the effects of culture on how pain is reported, researchers have
been interested in how cultural group afﬁliation affects how physical and
psychological states are interpreted (Angel and Guarnaccia, 1989).

Beiser (1985) asserts that the dimension of sociocentrism versus
egocentrism in a culture contributes to whether a somatizing or a
psychologizing idiom predominates. According to him, egocentric societies
tend to legitimize and permit the expression of affect. As societies become

more egocentric, the expression of inner emotional life becomes part of the

69

expected behavior for a greater part of the total population. Beiser's view is
supported by the work of Lock (1987) in Japan, a sociocentric society in which
the direct expression of emotions is discouraged.

A somatic illness in modern Japan described by Lock (1987) is moving
day depression. Moving day depression is a syndrome which afﬂicts Japanese
women, frequently upon moving to a new place (almost always in connection
with their husband's work) or upon being separated from their husbands whose
work has taken them far away for an extended period of time. The syndrome
includes numerous generalized complaints (headaches, fatigue, dizziness).
Women who seem most susceptible to the syndrome are women who take
particular pride in their housework and in the organization of their family life.
They report feeling that their personalities have changed and that they will no
longer be able to maintain their homes at the standard they consider acceptable.

The social context in which moving day depression occurs is the
Japanese exploitation of individuals and families by the expectation that
personal needs be subordinated to the demands of business and industry. When
the stress which results to families and individuals who are physically separated
by the demands of the husband's employment (or by the stress of being
uprooted to follow him to a new place of employment) is translated into
somatic expression, it can then be viewed as a physical problem, thus diverting
attention from the larger social issues involved. It may be acceptable to talk

about dizziness, palpitations, and tingling sensations, and thus gain the

70

sympathy of others. Yet it may be totally unacceptable to articulate or
challenge the stress-producing situation in which the symptoms occur.

In contrast to Japanese sociocentrism and insistence on low affect,
among the Kaluli, tropical forest people of Papua, New Guinea, expression of
affect is encouraged (Schieffelin, 1983). A man's inﬂuence is related to his
individual energy and assertiveness in supporting his friends and inspiring the
cooperation of others. The dominant dimensions of their emotional life are
anger and grief. Anger is both feared and admired, and is a societally valued
affect aimed at inﬂuencing others by intimidation. The grief affect, expressed
in wailing or sobbing, is a societally acceptable manner in which to attempt to
evoke compassion and support. Generally, for the Kaluli, every reason to be
angry or sad--any loss, injury, or disappointment--is interpreted in terms of
reciprocity. The behaviors associated with anger project power--stamping of
feet, yelling. Those associated with grief project vulnerability--wailing and
weeping. They both provide access to the redress to which they are entitled
within the cultural context of reciprocity.

Kaluli ceremonial life is passionate and expressive. Ceremonies are
structured to purposely evoke intense feelings of loss anger, rage, and sadness.
The images of lost loved ones and times past which are evoked by song become
so poignant that many of the listeners are deeply moved to tears. Then they
may become so angry at the anguish they have been made to feel, they may leap

up, grab a torch from a bystander, and stamp it out on the back of a dancer.

71

This pattern is repeated throughout the night until dawn. Finally, the dancers
pay compensation to those in the audience whom they caused to weep, and
everyone returns home in a mood of exuberance. While acknowledging that it
can be difﬁcult to distinguish normal aches and pains from depressively induced
somatization, Schieffelin concludes that depression/somatization is rare among
the Kaluli, apparently related to the culturally successful response to loss

provided by their special brand of reciprocity and expressiveness.

Cross-Cultural Assessment of Pathological Grief

Given the wide variety of culturally appropriate expressions of response
to loss, how can a Western caregiver tell if an individual of another culture is
experiencing pathological grief? There is not an easy answer. People in
societies where death is considered to be the work of malevolent spirits do not

consider it pathological to express rage in their grief (Counts and Counts,

T».

1991). Instead, for them, grief work includes assessing guilt and exacting
retribution. Reid's (1979) work with the Yolngu of Australia suggests that p.

indicators of pathological grief among that group of indigenous peoples include

 

conspicuous alterations in relationships to others, lasting loss of patterns of
social interaction, behavior detrimental to the individual's or his/her
dependents' social and economic welfare, and suicidal tendencies. But can an

individual not fully acquainted with both the individual's pre-loss behavior and

72

the norms of the culture make this determination? Several authors suggest the
answer is no.

Much of the psychology literature ignores the signiﬁcance of cultural
factors in an individual's response to grief. In 1990, an entire issue of
Psychiatric Annals was devoted to the topic of pathologic grief. None of the
six articles mentions ethnic or cultural considerations. Eisenbruch (1984b)
attests to the absence of clinically-based, culturally-speciﬁc literature on
pathological grief, and emphasizes the need for research to determine whether
there are culturally-speciﬁc manifestations of, in his words, ”had grief."
Though his 1984a and 1984b articles include no original research, consisting
entirely of literature review and hypotheses derived from that review, they are
the most current, most frequently referenced articles dealing with
cross-cultural considerations in grief. He points out the difﬁculty in gaining
access to bereaved members of communities who do not regard bereavement as
something potentially requiring professional services, or who do not know
where to get help. Even if the obstacles to access are overcome, practitioners
face the difﬁculty of deciphering sets of physical and mental symptoms that
come from a cultural code different from their own. Kleinman and Good
(1985) believe that a patient's condition must be evaluated by his/her social
support group in order to get an accurate picture of the meaning of the

condition.

73

The Role of Primary Care Physicians

It has been estimated that as many as 75% of patients utilizing primary
care clinics have psychosocial precipitants as opposed to biomedical problems
as the main cause of their visit (Rosen, Kleinman, and Katon; 1982). Each
society and each family has different norms and rules for coping with problems,
including emotional ones. It is within the family circle that children learn
appropriate responses to their external world--their environment and their
social network--and to their inner world--their emotions. Infants are unable to
distinguish between physical and psychological distress, and it is through
repeated interactions with their external world that the distinction is learned.
In many families, negative sanctions against expressions of emotions exist
whereas physical complaints are responded to with concern and nurturance. In
these families children learn to use somatic complaints to seek attention and
comfort. As a result, emotional and physical problems become fused, and a
psychological language for internal mood states does not develop.

It is the nature of the subculture of biomedicine to diagnose and treat
physical ailments. When a patient presents a somatic complaint to a physician,
the physician's emphasis is on ruling in or out an organic basis for the
symptoms. Typically the process is completed when an organic basis is ruled
out. The patient is reassured that nothing is wrong and is dismissed. This both
reinforces the somatization--the patient knows that seeking care requires a

physical symptom--and fails to result in a meaningful diagnosis and treatment

74

plan. Rosen, Kleinman, and Katon assert that the accurate diagnosis of a
somatizing patient requires a shift from the biomedical model to a
biopsychosocial one in which the psychosocial and cultural dimensions of the
illness are seen as legitimate health care concerns.

A diagnostic approach which they suggest, admittedly time-consuming,
is to have patients describe their problems in their own terms. Such
descriptions may offer clues to the complex meaning and signiﬁcance of the
symptomology. Merely asking patients if they are depressed is inadequate, as
they may lack a language for describing mood states and/or may risk social
sanction for articulating them. Rosen et al. recommend the following list of
questions to elicit a description of the problem as the patient attaches meaning
to it: 1) What do you think has caused your problem? 2) Why do you think it
started when it did? 3) What does your illness do to you? 4) What kind of
treatment should you receive? 5) What results do you expect from your
treatment? 6) What are the chief problems caused by your sickness? 7) What
do you fear most about your illness? This mode of questioning both yields a
precise picture of the problem as the patient sees it and demonstrates the
physician's concern. It also can be the beginning point for negotiating a
treatment plan.

In addition to patients' descriptions of their problems, important
information can be derived from knowing how the patients' families respond to

their problems. For example, a patient may be rewarded more for illness than

75

for health, as in being relieved of responsibilities when ill but being expected to
work long hours when healthy. Another critical dimension to be explored is
the availability of a network of social support. Are contacts with family and/or
friends frequent? And signiﬁcantly, what is the quality and intensity of those
contacts? That contacts may be frequent does not necessarily mean that they
are supportive.

The identiﬁcation of community resources such as clubs, churches, and
senior centers which may be called upon to supplement the available family
support is a crucial part of the treatment plan. Shapiro (1994) suggests that
facilitating access to a social support network is in most cases more
appropriate and potentially more beneﬁcial than referral to a mental health
professional. A critical link between the ethnic minority patient and community
resource utilization has been found to be the patient's immediate family. In
studies of both black and Hispanic elderly populations it has been found that
there is a causal link between the use of formal social services and contact with
the informal kinship group, a link not found with the white elderly (Markides

and Mindel, 1987).

A Culture-Bound Somatic Syndrome
An example of a culture-bound somatic syndrome which may be
encountered by physicians is "ataques de nervios," literally, attacks of nerves

(Guarnaccia, DeLaCancela, and Carrillo, 1989). Ataques are a syndrome

76

observed most frequently among Puerto Rican and Central American immigrant
populations. Ataques de nervios have some features in common with epileptic
seizures, but are without any organic or physiologic basis. A typical ataque de
nervios includes such symptoms as shaking, heart palpitations, the sensation of
heat in the chest rising into the head, and numbing of the hands. The afﬂicted
individual may shout, swear, and strike out at others before falling to the
ground and displaying either convulsive body movements or lying unmoving as
if dead.

It is usual for these ataques to occur at times of great stress such as
during funerals, when coming upon the scene of an accident, or during a family
conﬂict. When the ataque occurs within the context of the individual's social
support network, their response is to focus attention on the individual in some
way, such as praying over them and/or by rubbing their face with an alcoholic
substance. If these ministrations resolve the episode, it is not given an illness
construct by the indigenous group and there is no reason seen by them to seek
the advice of anyone in the medical/professional sector.

Articles describing ataques began appearing in the late 19503, frequently
involving Puerto Rican recruits into the US. military. Ataques were seen as
being evoked in the context of strongly conﬂicting values--the traditional
strong family ties among Puerto Ricans and the breakdown of the family due to
industrialization of the Island, mandatory military service, high rates of

unemployment, and resulting high rates of migration to the US. mainland.

77

While ataques were previously considered pathologic by Western biomedical
professionals, emphasis is more recently being given to appreciating the
cultural meaning and social factors which provide the context in which ataques
occur. Ataques can be seen as expressions of sadness, anger, and grief in
response to the disruption of family systems as a result of migration out from
peoples' countries of origin and the lack of traditional social support which
ensues.

A study was conducted to explore the meaning of ataques de nervios
among Latinos living in the urban US. who visited either the physician or the
psychologist members of the research team. They were interviewed by the
anthropologist member of the team who used an open-ended interview format
(similar to the Rosen et al. format described earlier) as follows: 1) What do
you call your problem? 2) What are the typical features of this problem that
allow you to identify it? 3) What do you think has caused your problem?

4) Why do you think this problem started when it did? 5) What does this
problem do to you? What effect will it have? 6) What are the chief problems
these episodes have caused for you? 7) What kinds of healers have you
consulted for this problem? What did those healers do? Signiﬁcantly, each of
the research subjects, in response to these questions, told stories of their
families and of their migration without being directly questioned about these

facets of their lives. The common themes which emerged in the stories

78

included the emotions of grief, anger, fear of being alone, and the experience
of the death of a loved one.

A case example which illustrates these themes is that of Sra. Gomez.
She is an elderly woman from Central America who has lived in the US. for 10
years. Her only episode of ataques occurred upon receiving the news of the
death of her 38-year-old daughter who still resided in Central America. She
was very distressed at not being able to arrive in Central America sufﬁciently
before the funeral to be involved in preparing for it or to be able to mourn with
her family.

Though she had only one full-blown ataques de nervios, she continues to
suffer from a milder version, simply called nervios. She attributes these
symptoms to her disappointment with her children's lack of attention to her.
She worked hard to bring all of her children here and to give them a better life,
but they have all turned their backs on her. "Her children are now married and
have established independent lives, as is the US. cultural expectation. Her
children do not respond to her cry for help expressed in her nervios. Thus, she
turns to the medical care system for help and support” (Guarnaccia,
DeLaCancela, and Carrillo, 1989, p. 53).

In all of the cases studied, the families failed to respond in culturally
expected ways to the patients' calls for help and support. Thus, the ataque did
not bring an end to the stressful situation. In each of the cases, health care

providers were sought out to replace the lost social support network of these

79

patients. When recently migrated Latinos present in emergency rooms or in the
ofﬁces of primary care physicians, the individual's symptoms may be labeled in
medical or psychiatric terms with inattention to the meaning of the symptoms,
leading to the medicalization of what are essentially social problems. Even
when the health care professionals recognize the social dimension of the
problem, they may be powerless to restore the traditional social supports and

thus feel powerless to assist in any way.

Summary of Chapter Three

Evidence for a biologic basis for grief has been shown, suggesting that
there are some aspects of the reactions to the separation from signiﬁcant others
which are universal across the human species. Some reactions, however, have
been shown to be heavily culturally shaped, with considerable variation in both
the duration of the mourning period and the form of expression of the felt
emotion. This variation complicates the already challenging task of
differentiating between normal and pathological grief, especially for members
of ethnic groups whose norms for grief and mourning are signiﬁcantly different
from those of the dominant WASP culture. The predominance of
psychologizing as a distress idiom among middle- and upper-class, educated
individuals in the US. contrasts with the somatizing idiom which predominates
among much of the rest of the world, including rural and lower-class,

less-educated groups in the US. The grief work hypothesis which dominates

80

Western grief intervention strategies and prescribes cognitive grief work fails
to acknowledge somatization as a legitimate form of grief work. It is seen as
essential that primary care physicians adopt a biopsychosocial perspective in
the diagnosis and treatment of grief-related somatization. Referral of ethnic
patients to sources of social support is seen as preferable to referral to mental

health professionals.

CHAPTER FOUR
BEREAVEMENT SUPPORT

What Helps?

In the past few decades, interest in bereavement support has grown in
the United States, hand-in-hand with increasing awareness of the long-term
impact of unresolved grief on over-all health of bereaved individuals
(Osterweis, Solomon, and Green, 1984). Individuals who experience the loss
of loved ones are increasingly turning to formal support systems to ﬁll the gap
which would earlier have been ﬁlled by family, church, and neighbors. In an
attempt to understand just what it is that the bereaved ﬁnd helpful, a study was
conducted of 94 individuals who had lost either a spouse or a child in a motor
vehicle accident 4 to 7 years earlier (Lehman, Ellard, and Wortman; 1986).
They were asked to recall what they had found helpful or unhelpful about
support attempts by others. Most frequently cited as helpful was contact with
a similar other, that is, another who has experienced a similar life crisis. It
appears that similar others may be less threatened and upset by signs of distress
from the bereaved and may therefore be less likely to close off discussion of
feelings or to push toward a quick recovery. Further, advice or suggestions
may be less likely to be perceived as judgmental when offered by a person who

has been through a comparable experience. In fact, direct advice giving and

81

 

82

encouraging recovery were the two supportive attempt strategies most
frequently mentioned as unhelpful.

Another perspective from which similar others can be seen as
particularly helpful is when considering the role ambiguity which results from
the loss of a signiﬁcant other. Role ambiguity is known to be a source of
considerable stress, since order and deﬁnition are what allow individuals to go
about their daily tasks with habitual unconsciousness (Keith, 1987). During
the transition from the role of spouse to the role of widow or widower,
individuals ﬁnd themselves in ambiguous status, not knowing what is expected
of them. Sorting out the various options for appropriate behavior in the
company of others who have found themselves in comparable situations
provides an opportunity for mutual development of strategies for resolving
their role ambiguities. Consistent with van Gennep's view of bereaved
individuals as being in a state of liminality, the stressfulness of the ambiguity is
eased by solidarity with others in the same circumstances.

A signiﬁcant development in bereavement support in the past few
decades has been the proliferation of support groups (Schneider, 1994). By
the early 1970's, self-help groups had become a major ingredient in the human
services scene with major implications for the future of mental health delivery
(Levy, 1976). It was becoming clear that self-help groups were providing the
social support once performed by the family, the church, and the neighborhood.

Levy conducted a study of the psychological processes involved in the

83

activities of self-help groups. His parameters for what qualiﬁed as a self-help
group were that the agenda and direction of the meeting were under he control
of members (though they may have access to professional guidance) and the
members themselves, rather than professionals, have primary control over
group functioning. At the outset, he acknowledged that it would not be
possible to quantitatively assess their effectiveness, as few such groups kept
systematic records. The fact that such groups were ﬂourishing, however,
presented reason enough to speculate that at least their members felt them to
be effective in some way.

Levy distinguished four general types of groups: 1) those who share a
common status or predicament which entails some degree of stress; 2) those
which were attempting to overcome some discriminatory practice (e. g. gay
rights and black pride); 3) those whose members were attempting behavioral
control; and 4) those whose members share a common goal of personal growth
and enhanced effectiveness. The seven processes which he discovered to be
operating in all four types of groups were: 1) providing increased
understanding of their distress; 2) provision of instrumental information and
advice; 3) expansion of the range of alternatives for coping with their situation;
4) enhanced discriminative abilities regarding cause/effect contingencies in
their lives; 5) support for changes in attitudes about one's self; 6) reduction of
the sense of isolation regarding the members' dilemma through social

comparison and validation; and, 7) development of a social structure within

84

which members can develop new deﬁnitions of their personal identities and new
norms upon which they can base their self-esteem.

From the perspective provided by Levy of what self-help groups can
accomplish, the proliferation of bereavement support groups is understandable.
As discussed earlier, critical challenges during the grieving process include
redeﬁning one's relationship with the deceased; redeﬁning one's sense of
identity; resolving the role ambiguity which results from the loss; and
developing a renewed sense of self-worth which has been diminished by the

sense of powerlessness to protect a loved one from death.

Desirable Outcomes

The literature which attempts to evaluate the effectiveness of both
bereavement support programs and other types of bereavement intervention is
hampered by the lack of agreement concerning what parameters are appropriate
to measure, how to measure them, what constitute healthy coping strategies,
and what to consider as endpoints (Osterweis, Solomon, and Green; 1987). In
order to determine the effectiveness of a speciﬁc bereavement support group,
there must be agreement as to the desirable outcomes and how they will be
assessed. Among the possibilities are: self-reported psychological distress;
physiological indicators of stress (depressed immune system); self-reported
personal growth; formation of new social relationships; and testimonials by

members of the group of the beneﬁt derived. The section in Chapter Three

85

regarding biological aspects of grief discussed the non-correlation which may
exist between physiological and behavioral indicators. Such non-correlation
demonstrates that bereaved individuals may be apparently doing much better
as measured by their venturing out to form new relationships; yet, may be in
continued distress and risk to health as measured by still elevated levels of
corticol and the resultant depression of the immune system. Some examples to
demonstrate these difﬁculties follow.

A study by Tait and Silver (1989) found that a "persistent search for
meaning" by the bereaved is inversely related to psychological recovery and
positively related to the occurrence of intrusive and distressing ruminations
about the death. They contend that when a meaningful and acceptable
interpretation is not forthcoming the search may persist for extended time
periods. They are using the phrase ”search for meaning" as attempting to ﬁnd
meaning in the speciﬁc negative event, that is, the death. In contrast, Yalom
and Lieberman (1991) used the concept "search for meaning” to connote a
struggle with the existential question of the meaning of life. They found that a
group of bereaved who identiﬁed themselves as having been struggling with the
question of whether life has meaning or purpose as experiencing personal
growth to a signiﬁcantly greater degree than a group who reported they were
not dealing with that question. Interestingly, the increased existential
awareness did not protect them from anxiety, depression, or intrusive thoughts

of the dead spouse. They continued to be as distressed by those measures as

86

were the non-existentially aware. But on indicators of personal growth such as
doing new things, visiting new places, and exploring new relationships they
scored signiﬁcantly higher than the non-existentially aware.

A study of participants in Compassionate Friends, a bereavement support
program for parents who have lost children, produced a comparable result
(Videka-Sherman and Lieberman, 1985). The study compared a cohort of
participants in Compassionate Friends with a cohort of non-participants. At
the completion of the study, non-joiners reported fewer somatic symptoms and
greater life satisfaction than the group joiners. However, though participation
had no positive impact on depression, involved members did report sustained
personal growth over time while nonmembers and the less involved were unable
to identify any positive changes in themselves after the loss.

These examples are provided, not to attempt to prove or to disprove the
effectiveness of bereavement support groups, but rather to illustrate how
complicated evaluation of their effectiveness is. This should not be surprising,
however, considering the Schneider (1984, 1994) holistic model of grieving
which demonstrates that grief is being experienced simultaneously in ﬁve
dimensions: cognitive, behavioral, emotional, physical, and spiritual. Progress
may be occurring in one or more dimensions while in others there may be little
or none.

Parkes (1980) concluded, after a comprehensive review of the

literature on bereavement support efforts, that professionally supported

 

87

voluntary and self-help services are capable of reducing the risk of psychiatric
and psychosomatic disorders resulting from bereavement. He concluded that
such services are most beneﬁcial among bereaved who perceive their families

as unsupportive, or who, for other reasons, are thought to be at special risk.

The Role of Religion

While studies providing evidence for the importance of social support in
moderating the effects of psychological distress have occupied the literature
for decades (Cobb, 1976; Turner, 1983), empirical evidence for the association
between religion and psychological well-being is less clear. A recent study
(Thearle et al., 1995) compared families who had experienced the death of an
infant with a control group of parents who had had no such loss, on measures
of anxiety, depression, and church attendance. Of the group who lost a child,
60% of those who attended church weekly manifested high anxiety compared to
66% who never attended church. A similar pattern was found among the
controls who had not lost a child: 32% of church attenders had high anxiety;
38% of those who never attended experienced high anxiety. This study found
that those who never attended church, whether bereaved or not, reported only
a 6% greater incidence of high anxiety than those who attended regularly. This
difference is not statistically signiﬁcant enough to conclude that church
attendance, in itself, is a post-bereavement anxiety reducer. This is not to say

however, that other beneﬁts may not accrue to church attendance.

88

Another study compared anxiety as measured by blood pressure in a
group of church-going immigrants and a group of non-church-going immigrants
(Walsh, 1980). The church-going group were found to have, on average, blood
pressures 5 mm's Hg lower than the non-church going group. While caution is
necessary in drawing conclusions from this study, the author speculates there
to be a correlation between assimilation of the immigrant into the culture of
his/her new home and lower blood pressure. Walsh acknowledges that the
temporal sequence is not known--whether the immigrant felt sufﬁciently
assimilated to attend church, or whether church attendance contributed to
smooth, speedy assimilation.

A study by McIntosh, Silver, and Wortman (1993) attempted to discern
whether there are aspects of religiosity which are more helpful than others in
coming to terms with the loss of an infant. They studied two components of
religion (religious participation and religious importance) and related them to
three coping-process variables (perceived social support, cognitive processing
of the loss, and ﬁnding meaning in the death). They found that both the
cognitive dimension and the participative dimension were related to greater
well-being and less distress 18 months after their infants' deaths. The authors
reported that greater religious participation was also associated with increased
meaning found in the death. They speculate that this may be the result of a
shared sense of understanding of the death that may be offered by the religious

community.

89

Scholars of comparative religions have developed paradigms which may
prove useful in the consideration of the role of religion in bereavement
support. Leach (1972) suggests that all religious activity is concerned with
two universal concerns: the maintenance of life, and reconciliation with death.
According to him, these concerns are organized around three levels: 1) the
deva or supernatural power, embodying both creation and destruction, birth
and death; 2) the devata or mediators; and 3) humans, with their everyday
concerns with the maintenance of life. The deva are too awesome to be
approached by mortal man; the devata mediate with the deva on man's behalf.

Leach's paradigm is consistent with Obeyesekere's (1985) analysis of
Buddhism, with religious activities grouped into two major traditions, the
greater and the lesser. The great tradition, Theravada, is practiced by ascetic
monks, and is Buddha, deva, death, next-life, and perfection emphasizing. It
contrasts with the little tradition, Mahayana, which is practiced by the
villagers, the uneducated masses, who are concerned with maintaining life.
Each of these traditions employs very distinct categories of rituals. The
Theravadic ones emphasize puriﬁcation ceremonies and are attended mostly by
the elderly, who most imminently face their own deaths. The majority of the
villagers pay little attention to these deva- and death-focused rituals. They
concentrate their attention on the local devata rituals, focused on

life-sustaining concerns such as fertility, sex, and harvest.

90

This distinction between greater and lesser, elite and masses, has
corollaries in many religious traditions. Leach contends that ordinary members
of religious congregations are not greatly concerned with the subtleties of
theology. What matters to them is that their religious experience should offer
emotional comfort and a sense of meaning when pure theology is inadequate to
the task. This comfort is provided by the symbols and rituals which their
religious experience provides. This explanation is consistent with the
speculation of McIntosh, Silver, and Wortman (1993) that the positive
inﬂuence of the participative aspect of religion is in being able to ﬁnd

community meaning in the death of an infant.

Ethnic Bereaved: The Myth of Social Support

According to Sokolovsky (1990b), the literature which portrays ethnic
afﬁliation as a source of support has been overly optimistic. He sees this
undeserved optimism as particularly misleading in the areas of family
interactions and informal social supports. With remarkable candor, Sokolovsky
references his own early work in which he had described the great beneﬁts
accruing to ethnic inner-city elderly from the social networks available to them.
He states: "Having recently completed the longitudinal and applied extensions
of these studies, I am certainly more pessimistic that I was in the late 1970's,
when some of my publications helped feed 'informal support systems' euphoria'"

(p. 210). He explains that research instruments frequently consist of mass

91

survey questionnaires which are capable of giving fairly accurate information
along such indices as frequency of contact with friends, or the geographic
proximity of elderly parents to their children's houses, but reveal very little
about the quality of those contacts or to what extent they help or hinder the
functioning of the elderly in the family and community.

A widely published study done by Bengston and Morgan (1987)
illustrates this point. They compared middle-aged and elderly white, black, and
Hispanic populations using four quality-of-life indicators: income, perception
of health, life satisfaction, and social interaction. The dimensions of the social
interaction indicator consisted of frequency of contact with 1) children,

2) grandchildren, 3) other kin, and 4) friends, neighbors, and acquaintances.
The results showed for Hispanics the highest frequency of contacts between the
elderly and younger generations but the lowest frequency of contacts with
friends and neighbors. Bengston and Morgan concluded from this that the
greater frequency of familial interaction among the ethnic minority
respondents, particularly Mexican Americans, suggested that primary group
needs of Mexican-American aged are more likely to be met within the extended
family than are those of white or black aged. Such a conclusion assumes that a
contact with a family member has a positive beneﬁt to the elderly member.

Yet Sokolovsky (1990b) warns that although it has been assumed that social
relations are inherently satisfying and reduce the impact of life stress, it

appears that, at least in some instances, such social ties may enhance rather

92

than reduce feelings of distress. For example, a study of Irish, Polish, and
Italian families in Chicago found that there was actually a signiﬁcant negative
correlation between frequency of social contact and self-reported life
satisfaction for women embedded in dense social networks with adult offspring
and other close relatives (Cohler, 1983).

A comparable popular misconception regarding black families is that
when faced with a crisis they can take care of their own because of a closely
knit supportive kin network (Eisenbruch, 1984b). While it is true that there is
a sense of extended kinship among blacks, in practice these kinship supports
may not be available (McGoldrick et al., 1991). Due to the pressures of
poverty and the predominance of the female-headed single-parent family unit, it
is not always possible for a black family to provide the needed instrumental and

emotional aid to a bereaved family member (Henderson, 1990).

Ethnicity and Bereavement Support Groups

If for many bereaved ethnic minorities the family and other informal
support networks are inadequate, do they utilize formal bereavement support
programs? No literature which directly addresses this issue was located.
Drawing from the literature dealing with ethnicity and aging, however, it seems
reasonable to speculate that ethnic minorities may not typically take advantage
of bereavement support programs for some of the same reasons that they

under-utilize other social services programs. Factors such as lack of

 

93

transportation, perceived procedural complexity, and lack of knowledge of the
existence of programs are frequently cited (Markides and Mindel, 1987). One
study found that blacks feared a loss of social security beneﬁts if they
participated in an Area Agency on Aging program (Watson et al., 1981).
Further, for ethnic minorities, the perception of self as a disvalued,
second-class citizen may cast a shadow of doubt as to the extent one is
welcome in mainstream programs.

Researchers have repeatedly found that effective service delivery to
ethnic minorities requires a conscious effort to respond to the cultural
uniqueness of the populations (Markides and Mindel, 1987). One may infer
that for the ethnic bereaved, faced with the task of redeﬁning their identity,
issues of cultural distinctiveness would be magniﬁed. Culturally prescribed
relationships between males and females, sex roles, language differences, and a
variety of nuances of cultural etiquette which would be unknown to an ethnic
outsider would ﬁgure prominently in the ethnic minorities' sense of propriety.

A study which attempted to gain insight into what could be done to
increase black students' perception of available services as responsive to their
needs looked at black students' use of counseling services at Michigan State
University (June, Curry, and Gear; 1990). A proﬁle was constructed showing
which kinds of counseling services were utilized for what kinds of identiﬁed
problems over an 11-year period. Among the counseling services available

were: academic advising, health services, learning resources, career

94

information, counseling center, minority aides, and the Multi-Ethnic
Counseling Center Alliance (MECCA). Among the kinds of problems for
which help was sought were: ﬁnancial aid, academic status, living situation,
career concerns, and emotional-psychological concerns.

The proﬁle revealed that for students who identiﬁed use of counseling
services for emotional-psychological problems, 23% used the counseling
center, 33% used MECCA (a branch ofﬁce of the university counseling center
staffed by ethnic minority psychologists and counselors), and 71% used
minority aides (minority students housed in the residence halls and trained to
assist residents by peer advising). This preference for ethnic peers for help
with emotional difﬁculties supports the view that individuals seek out similar
others, similar in both ethnicity and in life situation, in times of distress (Keith,
1987)

One of the few reports located which discusses ethnic participation in
support groups of any kind is a study of support groups for caregivers of
Alzheimer Disease (AD) sufferers (Henderson et al., 1993). In an earlier
assessment of the situation, Henderson (1990) had contacted professionals
working with aging minority populations in large urban areas which offered AD
support groups. He found nearly zero participation in the existing support
groups by ethnic group members in spite of their presence in high numbers in
the general population. He noted that the need for cultural speciﬁcity in

Hispanic health interventions is widely acknowledged (Valle and Mendoza,

 

 

95

1978). Some investigators have suggested that family support group
intervention may violate the Hispanic concern with privacy and thus be doomed
to failure (del Valle and Usher, 1982). On the other hand, as pointed out by
Sokolovsky (1990b), ethnicity-based informal supports may be stretched to the
point of dysfunction due to changing urban conditions and multiple demands on
the physical and emotional resources of the family. Therefore, help beyond the
family may be welcomed. Furthermore, Acosta (1982) asserts that an
all-Hispanic group can overcome the reticence of Hispanics to discuss publicly
their family's medical problems, with the similarity in culture and lifestyle
providing an environment that encourages openness and understanding.

Henderson et al. embarked on a project aimed at encouraging minority
participation in AD groups. They set out to speciﬁcally recruit Hispanic and
African American participants by responding to their particular cultural
realities. Their hypothesis was that there were sociocultural disincentives
which deterred ethnic minority populations from attending the predominantly
Anglo AD groups. The disincentives which they identiﬁed included: 1) lack of
"ethnic competence” on the part of staff; 2) insufﬁcient personal contact in
recruitment and maintenance of group members; 3) insufﬁcient attention to
both geographic convenience and symbolic factors of location of meetings; and
4) preference for ethnocultural homogeneity of meetings.

The ﬁrst disincentive was overcome by a commitment to ethnic

competence by project staff, that is, by assuring that they were well acquainted

 

1 fl

96

with the ethnocultural reality of the target population. This was accomplished
by extensive targeted ethnographic survey of the ethnic minority community.
Repeated interviews with open-ended questions and the recording of signiﬁcant
vocabulary, phrasing, and idioms allowed for an increased appreciation for the
shades of meaning of their language and the nuances of cultural etiquette of the
ethnic group members. To overcome the second disincentive, multiple personal
contacts by phone, home visit, and a ﬂier announcing the meeting a few days
prior to each monthly meeting were utilized.

Regarding location, the original project design called for the meetings of
the African American group to be held at one of the African American
churches. The minister of this church, a volunteer group facilitator from this
church, and a member of the project staff made educational/recruitment
presentations at several black churches. Alas, no one attended for three
consecutive meetings which were held at the original African American church.
Project staff realized they had asked these prospective group members to
violate congregational loyalty boundaries. ”The allegiance to one's church and
pastor is exceedingly strong and to acknowledge the initiative and visibility
accruing to the original church site and its leadership would by default cast a
slight taint or pallor on the nonoriginating church and its leadership" (p. 412).
Locations which were found to be both geographically convenient and

symbolically appropriate were local community centers and libraries.

 

97

Finally, to overcome the disincentive posed by ethnically-mixed groups,
ethnically-speciﬁc groups were formed. An African-American woman said of
her earlier one-time attendance at a predominantly Anglo support group that
though she didn't exactly feel uncomfortable there, the all-black group she
joined later felt more like family. Correspondingly, the Hispanic support group
elected to conduct the meetings in Spanish even though most were ﬂuent and
articulate in English. For the same reasons that they generally spoke Spanish
at home, in the support group they chose the language that communicated their
heritage as well as facilitated their expression of subtle aspects of emotion and
meaning.

While no rigorous evaluation of the success of the groups was
attempted, they were judged successful as measured by sustained participation
of members, development of interpersonal linkages between members,
recruitment of new members by long-standing members, and direct reports of

the comfort received from participants in support group meetings.

Summary of Chapter Four

The lack of agreement among grief theorists and clinicians as to what
constitute desirable outcomes in grief recovery poses a challenge in evaluating
the effectiveness of bereavement support interventions. The critical factor
identiﬁed as essential in bereavement support is the availability of social

support, particularly support from others similar in both ethnic afﬁliation and

98

in the shared experience of a loss. The comfort gained from the participative
aspect of religion was shown to be more important than the intensity of
identiﬁcation with the content of the belief system. The notion that ethnic
group members can take care of their own was found to be unsupported, given
the realities of poverty, single-headed households, and emotional and physical
resources stretched to their limits. It was speculated that ethnic group
members do not participate in mainstream bereavement support programs due
to a variety of disincentives. It was demonstrated that these disincentives can

be overcome, however, by designing ethnically-targeted programs.

SUMMARY AND CONCLUSIONS

The linear models of grief, which have dominated the psychology
literature since Freud, fail to account for the wide range of reactions to a loss
which individuals may exhibit. The holistic models together with family
systems theory provide a perspective from which the highly idiosyncratic
nature of grief can be more fully appreciated.

Lack of precise and consistent use of terminology by grief theorists and
clinicians coupled with lack of agreement on desirable outcomes has resulted in
much confusion in the grief literature as well as apparently contradictory
research ﬁndings. Evidence suggests that there are some aspects of the
reaction to separation from a signiﬁcant other which are universal across the
human species. Some reactions, however, have been shown to be heavily
culturally shaped. This variation complicates the already challenging task of
differentiating between normal and pathological grief, especially for members
of ethnic groups whose norms for grief and mourning are signiﬁcantly different
from those of the dominant WASP culture.

The predominance of psychologizing as a distress idiom among middle-
and upper-class, educated individuals in the US. contrasts with the somatizing

idiom which predominates among much of the rest of the world. The grief

99

100

work hypothesis which dominates Western grief intervention strategies and
prescribes cognitive grief work fails to acknowledge somatization as a
legitimate form of grief work. Given that as many as 75% of patient visits to
primary care physicians in the US. are related to psychosocial distress
translated into somatic complaints, it is essential that primary care physicians
adopt a biopsychosocial perspective in the diagnosis and treatment of
somatization. However, even when health care professionals recognize the
social dimensions of somatization, they may be powerless to restore the
traditional social support whose absence is contributing to the distress, and
thus may feel powerless to assist.

Given the disincentives which deter ethnic minorities from participating
in mainstream social services programs, a major conclusion of this thesis is,
therefore, that there is a need for bereavement support programs which are
targeted to speciﬁc ethnic groups. Especially among adults who lose spouses,
critical tasks include the reconstruction of their identity, resolution of their
role ambiguity, and the formulation of new norms upon which to base their

self-esteem. This can best be accomplished in the company of others who

 

share both their ethnicity and their dilemma. The unspoken nuances of cultural
etiquette and subtle aspects of shared emotion and meaning which can ﬂourish
in an ethnically speciﬁc group can provide to the ethnic bereaved an
environment of comfort and trust in which to explore the multiple dimensions

of their dilemmas.

101

Large urban areas with high densities of ethnic populations are fertile
ground for such programs. A greater challenge is meeting the needs of ethnic
bereaved who live in smaller cities or rural areas where their low numbers
indicate that it is not feasible to conduct ethnically-targeted groups. In these
areas, ethnic individuals could be encouraged to attend mainstream support
groups by accommodating to as many of the identiﬁed disincentives as
possible. Attention could be given to increased personal contact in both
recruitment and maintenance of group members. Careful choice of location of
the meetings to be both geographically and symbolically accessible would also
encourage greater participation. The design of the meetings themselves should
reﬂect the multiple dimensions of grief reactions. In addition to opportunities
for cognitive processing of losses, programming should include activities
which provide a context within which behavioral, emotional, physical and
spiritual reactions can be experienced and afﬁrmed. Such programming would
also respond to the needs of the many WASP individuals whose predominant
idiom of distress is non-cognitive.

Given the current emphasis on cost-containment in health care, increased
attention to strategies which would reduce the number of frustratingly (to both
patient and physician) unhelpful primary care visits is in order. In this age of
Managed Care and computer data ﬁles, there must be a way to make it possible
for individuals with similar dilemmas and similar ethnic afﬁliation to ﬁnd each

other and to provide to each other invaluable social support.

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