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This is to certify that the

dissertation entitled

The Relationship Between
Grief and Depression in a

Group ofp‘gggflgbbsurvivors

Timothy Ting—Kuo Chiang

has been accepted towards fulfillment
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, Counseling

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Ph.D.

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THE RELATIONSHIP BETWEEN
GRIEF AND DEPRESSION
IN A GROUP OF POLIO SURVIVORS

by
Timothy Ting-Kuo Chiang

A DISSERTATION

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

DOCTOR OF PHILOSOPHY

Counseling Psychology Program
Department of Counseling, Educational Psychology
and Special Education

1995

 

 

5-2

rel ti

ABSTRACT
THE RELATIONSHIP BETWEEN

GRIEF AND DEPRESSION
IN A GROUP OF POLIO SURVIVORS

by
Timothy Ting—Kuo Chiang

The purpose of this study was to investigate the
relationship between grief and depression in a group of
polio survivors. A Beck Depression Inventory, a Response to
Loss Inventory, and a Biographical Data Questionnaire were
administered by mail to a group of former polio research
participants. Background information on these individuals
was also collected through an existing database at the
University of Michigan. Based on a comprehensive model of
reactions to loss, responses from this convenience sample of
33 men and 44 women were examined in terms of the
hypothesized relationship between depression and each of the
seven phasic components of grief. In addition, the
potential impact of 6 selected demographic, 8 health, 8
biographical, and 12 disability variables on these
relationships was explored in a series of post-hoc analyses.

The results or the study indicate that depression was
positively correlated with the coping- and experience-
oriented components and unrelated to the healing- and_
growth-oriented aspects of the grieving process. The
generalizability of these relationships was supported by the

overall results of post-hoc analyses. Given the extended

as th.
provi:
accozg
disab
meani;

d9VEll

OVEra'
t0 be

heali,

period of time from the participants’ initial polio
diagnosis, and the end of their best post-polio physical
functioning, these results were consistent with the
predominant view in the psychological literature that
conceptualizes depression as a trait rather than a state and
as the failure to mourn. Among alternative interpretations
provided here is a suggestion that, instead of a task to be
accomplished once and for all, psychological adjustment to
disability may be a cyclical process of responding to new
meanings of disability in the context of changing
developmental needs across the life span.

Post-hoc analyses of interaction effects indicate that,
overall, the relationships between grief and depression seem
to be stable across background variables, especially for the
healing- and growth-oriented phases of grief.

Suggestions for further research are provided.

PenCh

 

and ha
the tea

great a

DEDICATION
To my loving parents, Mr. Chyuan-Her Chiang and Mrs.
Fen Chen Chiang, who introduced me to the human condition
and have encouraged me to learn from the storms and the sun,
the tears and laughters, and the support and challenge of a

great adventure called "life."

iv

ACKNOWLEDGEMENTS

The completion of this dissertation is the result of
the collective efforts of a number of individuals and
organizations, to whom a word of sincere gratitude has been
long overdue. As the chair of my research committee, Dr.
Michael Leahy has been an effective facilitator for this
project. He has provided a tremendous amount of help in
removing road blocks, managing the loose ends and ensuring
that my research work proceed in an organized and systematic
manner. Dr. John Schneider has been a valuable resource of
ideas, practical wisdom, enthusiasm about the value of
research and, above all, a precious friend. His
comprehensive model of research has constituted the main
thrust of this dissertation research, and he has been my
research director for years before I started this project.

I feel fortunate to have Dr. Nancy Crewe on my research
committee. She is a well respected researcher with a
national reputation. Throughout this dissertation process,
she has repeatedly ensured that I never lose sight of
predominant views in the field of rehabilitation psychology
no matter how much I may be inclined to think in terms of
theories of counseling and clinical psychology. The quality
of this research project has benefitted a great deal from
the methodological expertise of Dr. Richard Coelho. As a
research committee member, he has asked many thought-
provoking questions that forced me to be precise and

thorough in my research design. Dr. Denise Tate has been

V

instri
of pol
She ha
polio
T
the ex
of the
Hichig
and mo:
and the
Kasim c
MSW pr:
the Sta
rqu'ESs
C“Pute
technic.
knowled,
He SUCCE
for Stat
“Soul-Ce
y“ Sand.

editing 1

forth by

A in:

The 138th

instrumental in introducing me to the idea of using a group
of polio survivors instead of an acute disability group.
She has also been an indispensable liaison for me to the
polio participants in this study.

The quality of this project has also been enhanced by
the expertise of a number of consultants. Mr. Kyle Fahrbach
of the Measurement and Quantitative Methods Program at
Michigan State University has been most directly involved
and most helpful in ensuring accurate interpretation of data
and the precision of my statistical terminology. Mr. Rafa
Kasim of the Measurement and Quantitative Methods Program at
MSU provided some initial and general explanations regarding
the statistical reasoning of correlational and multiple
regression analyses. Several consultants at the MSU
Computer Laboratory have also been helpful in resolving
technical difficulties. Mr. Randy Fotiu has been a
knowledgeable user of the SPSS-PC+ software and has helped
me successful detect a number of problems in my programming
for statistical analysis. Mr. Jim Lebay has been a valued
resource person for me on the use of the dBase IV software.
Ms. Sandra Gross has been very helpful in proof-reading and
editing my manuscript and making sure that the format of
this report is consistent with accepted standards as set
forth by the American Psychological Association and the MSU
Graduate School. .

A word of thanks is also due to several organizations.

The Institutional Review Board at the University of Michigan'

VJ.

Hedica
and al
assist
the Ce
grante
duplice

of this

Medical Center had a thorough review of my research proposal
and allowed me conduct this study successfully with the
assistance of staff at their facility. Dr. Aaron T. Beck at
the Center for Cognitive Therapy in Philadelphia also
granted permission to me as a graduate student to reproduce
duplicates of the Beck Depression Inventory for the purpose
of this study. Crucial funding for this study has been
provided through a grant from the Michigan Health Care
Education and Research Foundation, the philanthropic
affiliate of Blue Cross-Blue Shield of Michigan.

A special word of thanks is also due for Ms. Joyce
Schultz and Ms. Ladye Hahn. As members of the secretarial
and support staff, they have facilitated my contact with my
committee in an efficient manner.

Most important of all, I am deeply grateful to the
participants of this study for sharing a personal and often
painful part of their life experience with me. I am also
grateful to people like Dr. Arnold Beisser who have
courageously shared their experiences with a debilitating
condition.

Finally, this acknowledgement section would not be
complete without expressing my gratitude to people who have
struggled with me. My classmate and friend, Peggy Parker,
has been a wonderful peer and a cheer leader. My parents
and my sisters probably have most accurate account on day-
to-day struggle with this project. The bitterly strong
Chinese tea that my parents have often fixed for my midnight

vii

integr

grief .

oil burning sessions has served as a wonderful reminder that
true happiness often comes after a series of difficult and
challenging experience, both of which are parts of an
integrated life. What a wonderful metaphor for the study of

grief and depression, Thank you!

TABLE or CONTENTS

LIST OF TABLES . . . . . . . . . . . . . . .
CHAPTER
1. THE PROBLEM . . . . . . . . . . . .

2.

3.

Introduction . . . . . . . . .
Statement and Significance of the
Problems . . . . . . . . . . . .
Purpose of the Study . . . . . . .
Definition of Terms . . . . . . .

The Concept of Adjustment . . . .
Disability as an Experience of Loss
and Change . . . . . . . . . .
The Post-Polio Condition . . . .
Grief and Physical Disability . .
Depression and Physical Disability
A Need for Conceptual Clarity . .
The Study of Grief . . . . . . . .
A Comprehensive Model of Grief . .
Depression . . . . . . . . . . . .
Similarities and Differences Between
Grief and Depression . . . . . .
Relationship Between Grief and
Depression . . . . . . . . . . .
A State Versus Trait Distinction .
Acceptance of Disability . . . . .
Influence of Biographical and
Demographic Variables . . . . .

DESIGN OF THE STUDY . . . . . . . .

Research Design . . . . . . . . .
Subjects . . . . . . . . . . . .
Measures Used in the Study . .
Biographical Data Questionnaire
Beck Depression Inventory . . .
Response to Loss Inventory . . .
Research Questions and Hypotheses
Research Procedures . . . . . . .
Statistical Analysis . . . . . . .
Limitations of the Study . . . . .

ix

A CRITICAL REVIEW OF RELEVANT LITERATURE

Page

xi

10
15

18
19

20
21
23
25
27
3O
34
37

38

43
55
56

58
61

61
62
66
66
67
68
72
75
78
84

CHAP‘I

CHAPTER

RESULTS . . . . . . . . . . . . . . .

Subject Characteristics . . .
Response Rate . . . . . .
Basic Demographics . . . . .
Health Characteristics . . .
Disability Characteristics .
Biographical Characteristics .

Primary Research Instrument Score

Distribution . . . . . . . .

Beck Depression Inventory

Response to Loss Inventory
Hypothesis Testing . . . . .
Post-Hoc Analyses . . . . .
Summary of Findings . . . .

DISCUSSION I O O O O O O O O O O O O O

A Summary of the Theoretical Rationale
Interpretation of Results . . . . .
Hypothesis Testing Results .
Post-Hoc Analyses . . . . .
General findings . . . .
Specific post-hoc results
Nonsignificant findings .
A word of caution . . . . .
Differentiation Between Grief
and Depression . . .'. . . . . . .
Implications for Clinical Practice
Suggestions for Future Research . .
A Concluding Statement . . . . . . .

APPENDICES

A.

B.

BIOGRAPHICAL DATA QUESTIONNAIRE . . .
RESPONSE TO LOSS INVENTORY . . . . .

BECK DEPRESSION INVENTORY . . . . . .
SUBJECT OVERALL RATING SHEET . . . . .

'LETTER or INVITATION To PROSPECTIVE
PARTICIPANTS . . . . . . . . . . . . .

CONS m FORM 0 O O O O O O O O O O O O
FOLLOW-UP LEN ERS O O O O O O O O O O

Page

87

87
87
88
88
92
97

101
101
103
107
112
126

128
128
129
129
146
146
151
154
155
156
163

177
182

185
191
201

204

205
207
208

216

TABLE

10.

ll.

12.

TABLE

10.

11.

12.

LIST OF TABLES

Page
Selected Participant Demographic
Characteristics . . . . . . . . . . . . . . 89
Selected Participant Health
Characteristics . . . . . . . . . . . . . . 91

Selected Participant Disability
Characteristics . . . . . . . . . . . . . . 93

A Matrix of Correlations Among Selected
Indicators of Severity of Disability . . . . 96

Selected Participant Biographical
Characteristics . . . . . . . . . . . . . . 98

Distribution of Scores on the Beck
Depression Inventory and the Response
to Loss Inventory . . . . . . . . . . . . . 102

A Matrix of Correlations Among Seven
Subscales of the Response to Loss
Inventory 0 O O O O O O O O O O O O O O O O 1 06

Results of Hypothesis Testing . . . . . . . 108

Relationships Between Grief and
Interaction Effect Variables . . . . . . . . 114

Relationships of Grief and Depression
and Subject Background Variables . . . . . 116

Interaction Effect Regression Analysis
I Statistics 0 O O O O O O O O O O O O O O 119

Test of Interaction Effect Levels of
Statistical Significance . . . . . . . . . . 121

xi

 

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Rap;
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interest:

l"Alli/mm

CHAPTER 1-
THE PROBLEM
Introduction

Adjustment to physical disability has long been an area
of interest for practitioners and researchers in the field
of rehabilitation psychology and rehabilitation counseling.
A multitude of criteria have been used to define adjustment
and the appropriateness of each of these criteria seems to
depend on the helping model, philosophy, and roles selected
by individual professionals (e. g., Poll & De Nour, 1980;
Russell, 1981). Individuals embracing the medical model
tend to use longevity and physical survival as a way of
defining ultimate adjustment while vocational rehabilitation
research often focuses attention on the employment status of
individuals with disabilities. Other definitions of
adjustment range from emotional coping, adaptation, and life
satisfaction ratings by persons with disabilities to
functional independence, successful management of activities
of daily living, and the level and frequency of physical and
social activities (Trieschmann, 1988).

Rapid advances in recent years in medical and
rehabilitation technology have resulted in a great deal of
interest in the physical treatment and management of
individuals with physical disabilities. However, there
appears to be a need for continued emphasis on the
psychological aspects of the adjustment process for a number

of practical, ethical, as well as theoretical reasons.

1

 

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2
First, there have been a number of studies which suggest a
relationship between emotional reactions of persons with
disabilities and their ultimate functional adjustment to the
physical impairment (e. 9., Anderson & Andberg, 1979; Fogel
& Rosillo cited by Woodbury, 1978; Heijn & Granger, 1974).
Second, although medical treatment and physical management
constitute a major component of intervention, especially in
the early phases of the rehabilitation process, many
adjustment problems experienced by the individuals with
disabilities are psychological in nature (Fitzgerald, 1983).
Furthermore, studies have shown that certain indicators of
adjustment such as the level and frequency of physical and
social activities are not necessarily correlated with
adequate psychological adjustment to physical disability.
An implication of this finding is that our attempts to
facilitate the functional adaptation and social integration
of individuals with disabilities may be insufficient in
fostering their emotional well-being.

Third, an ethical dilemma which frequently confronts
helping professionals is the issue of determining if
treatment goals and interventional efforts are primarily
based on the experience of our clients, the recommendations
of the helping expert, or the values and standards of our
society (Ivey, 1980). The relevance of this dilemma to
rehabilitation is apparent when one considers the medical
complications which frequently accompany physical
disabilities and the predominant roles of medical management

3
and expert judgement in the treatment process. A recent
development in the area of general clinical psychology which
emphasizes the importance of the client's perspective is the
emergence of a phenomenological approach to the facilitation
of the grieving process for individuals suffering from
traumatic experiences (Schneider, 1984, 1994). This
approach is characterized by a high degree of affective
sensitivity and an adequate understanding, appreciation and
validation of feelings and coping needs as they are
experienced by the traumatized individual.

Finally, it has been suggested both in clinical and
rehabilitation literature that lack of sophistication and
abilities on the part of the helping professional in
recognizing, understanding, and working with the feelings of
the client can result in significant interference with the
individual’s process of behavioral change and psychological
adjustment. For example, a significant proportion of the
clinical psychological literature deals with the traditional
psychoanalytic concept of countertransference (Cashdan,
1988), which explains difficulties of clinicians in dealing
with certain emotional reactions of their clients due to
their need to avoid or act on related feelings of their own.
A similar concern has been raised in the bereavement
literature by Kubler-Ross, who points out that hospitals are
not adequately designed to deal with the anger, bargaining
and grief of terminally ill patients. She indicated that a
potential contributing factor of this problem is the need of

helpin
death .
T:
contril
rehabil
nature
environ
these p
process
their 01
hour. in;
Si uatic
denands
greater
helper I
disabil i
a thcrou
of adlus

e:phaSiz

4
helping professionals to avoid their own feelings about
death and dying.

Trieschmann (1988) stated that a frequently neglected
contributing factor of anger and depression seen in some
rehabilitation patients may be the unnatural and impersonal
nature of the treatment procedures and the hospital
environment. It is conceivable that emotional reactions of
these patients can be misinterpreted as part of the mourning
process in order to help professionals avoid implications of
their own inadequacies. The concept of the "requirement of
mourning" as introduced by Wright (1960, 1983) describes
situations where helping professionals impose unnecessary
demands to grieve on their clients and reflects the need for
greater sensitivity and understanding on the part of the
helper regarding the personal meaning of a physical
disability for the individual. The importance of acquiring
a thorough understanding regarding the psychological aspects
of adjustment to physical disabilities can not be over-
emphasized.

Statement and Significance of the Problems

One of the widely accepted and frequently discussed
concepts in the field of rehabilitation has been the process
of loss and grief. In our attempts to account for the
emotional reactions of individuals with disabilities, it is
believed that adequate adjustment to disabilities depends on
the successful completion of the grieving process. The

linkage between adjustment and grief has not been

erpir.

 

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and co
monitc
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the fail

instrur

 

to have
focus e.
process
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Client ,
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5
empirically substantiated, however, for at least two
reasons. First, it was not until recently that a systematic
and comprehensive model existed for conceptualizing,
monitoring, and facilitating the grieving process.
Accompanying this lack of holistic conceptual knowledge is
the fact that an extremely limited number of viable grief
instruments have been developed, most of which do not seem
to have satisfactory psychometric properties and tend to
focus exclusively on one or two components of the grieving
process. The lack of an objective, comprehensive and
adequate measure of grief makes it necessary for clinicians
to resort to their personal observations and clinical
judgement, which may often be inaccurate. This observation
is consistent with reported findings that staff ratings of
client emotional reactions and psychological adjustment
relate poorly to either the results of psychological
inventories or self-ratings of individuals with disabilities
(e. g., Albrecht 8 Higgins, 1977).

One of the problems significantly complicating the
assessment of psychological reactions to physical
disabilities is the difficulty in distinguishing grief from
reactive depression. Contributing to the confusion seems to
be a number of similarities between the two conditions in
terms of their symptomatic manifestation. In addition to
the dysphoric mood which is readily apparent to the
observer, it was noted as early as 1917 by Freud that both

grief and depression involved a lack of interest in the

outsid
in act
betwee
Diagno
IV) cl
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Rental
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the he:
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6
outside world, a loss of capacity to love, and an inhibition
in activity. In contrast, important differences exist
between grief and depression. The fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV) clearly separates the grief reactions of uncomplicated
bereavement from the affective disorder of depression.
Mental health practitioners frequently define depression as
anger turned inward towards the self and it has been
generally accepted in the clinical literature that
depression differs from grief in that it involves a lowering
of self-regard, self-reproach, and the expectation of
punishment (Schneider, 1980).

Perhaps one of the most compelling reasons for the
differentiation of grief and depression lies in its clinical
implications for the provision of appropriate treatment.
Grief is generally considered to be a normal reaction to a
significant loss. The concept describes the adjustment of
the human organism to drastic changes in the psychosocial
environment. Depression frequently results from the complex
interaction of biological, genetic, developmental, and
environmental factors. It involves a diverse set of
symptoms such as dejection, apathy, sleep disturbances, and
decreased sexual interest (Deutsch, 1982). These symptoms
often interfere with the day-to-day functional behavior of
the individual, suggesting the pathological nature of its
developmental process. It has been discussed in the

literature that early object loss and experiences of

helpl
the cl
contr;
1982) .
inter;
acre d
cognit
and ho
Tl
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grief a
Based c
exF’erie
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reports
Variar
STOUps

Separat

7
helplessness due to lack of adequate role models who foster
the child's development of mastery over one's fate
contribute to adult vulnerability to depression (Deutsch,
1982). The grieving process is facilitated by validating
interpersonal support, whereas depression tends to require
more direct and rigorous interventions which range from
cognitive behavioral therapy to pharmacological treatment
and hospitalization.

The importance of differential diagnosis and the use of
differential therapeutics have been supported by a number of
recent publications which suggest a relationship between
grief and depression in the process of their development.
Based on his model of grief as a normal reaction to loss
experiences, for example, Schneider (1980) described
depression as the inability to grieve. Deutsch (1982)
reported that although depression accounted for 36.37% of
variance in the awareness component of grief for two sample
groups of college students who suffered from bereavement or
separation from a family member or romantic partner, there
appears to be a linkage between depression and avoidance of
the normal grieving process through the separation of
cognitive and emotional experience of loss. Furthermore,
while individuals who are undergoing grief tend to elicit
supportive response from others (Schneider, 1980), research
based on interpersonal theories of depression (Coyne, 1976;
JLewinsohn cited by Segrin, 1994) also indicates that

depressed individuals tend to generate more negative

feed
Valic
(1984

griei

resea
psych
in tin
defin;
have c
disagz
indivi
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Prereqt
been c‘g
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descri]

8
feedback and less social support from others (Segrin, 1994).
Validating support of others is described by Schneider
(1984, 1994) as an important facilitating factors of normal
grieving.

Grief and depression are familiar concepts for
researchers and practitioners in the area of rehabilitation
psychology. While these terms have been used very loosely
in the literature, it appears that a lack of appropriate
definitions and differentiation between these two conditions
have contributed to a great deal of confusion and
disagreement regarding proper psychosocial treatment of
individuals with physical disabilities. Traditional
psychological perspectives in rehabilitation consider the
resolution of loss and grief issues as an important
prerequisite for disability acceptance, and depression has
been characterized as a major symptom associated with the
grieving process. Many stage theories of adjustment also
describe depression as one of the reactions which precede
the acceptance of disability (e. g., Dunn cited by Woodbury,
1978; Feld cited by Woodbury, 1978; Hohmann, 1975; Peter
cited by Woodbury, 1978; Seybold cited by Woodbury, 1978).
On the other hand, beliefs in a linkage between depression
and psychological resolution are inconsistent with the
results of recent research. Fitzgerald (1983) reported, for
example, that a significantly negative relationship exists
between depression and acceptance of disability for a group

of individuals with spinal cord injuries. similar

dis

IE

time
be a
spec
grea
be C

SUCC!

9
discrepancies can be found in the area of psychological
treatment. Fordyce (1971) recommended, for example, that
instead of allowing the person with a disability to have
time to mourn for his/her loss, withdrawal behavior should
be actively interrupted by presenting the individual with
specific rehabilitation tasks. Siller (1969) expressed a
great deal of concern that such a treatment procedure would
be counterproductive and interfere with the individual's
successful adjustment to his/her disability.

A highly controversial issue in the field of
rehabilitation medicine is the prescription of psychotropic
medications such as major tranquilizers to counteract the
massive depression which some physicians believe would be
undesirable following the onset of a physical disability
(Trieschmann, 1988). It has been pointed out by Hohmann and
Munoz-Mellowes (cited by Woodbury, 1978), for instance, that
the use of MAO inhibitors with rehabilitation patients has
hypertensive side effects which can be dangerous. Even the
use of anti-depressants for a short period of time can
result in significant side effects (Trieschmann, 1988) and
psychopharmacological intervention without careful diagnosis
and treatment planning can conceivably introduce unnecessary
interference with normal grieving and significant negative
outcome.

Although there exists a great deal of confusion and
disagreement in the psychosocial literature in

rehabilitation, a conceptual analysis emphasizing

clar
esta
depr

loss

10
appropriate differentiation and relationship between grief
and depression appears to offer some promise for
clarification and consistency. For example, if it can be
established that the mood of sadness commonly referred to as
depression is actually a symptom of heightened awareness of
loss during a process of active grieving, then a plausible
interpretation of Fitzgerald's (1983) results is that
depression and disability acceptance are negatively
correlated since, as suggested by Deutsch (1982), depression
may interfere with the normal grieving process. As of
today, however, there has been no documentation of
systematic research efforts directed at substantiating the
validity of this conceptual distinction between grief and
depression on an empirical basis.
Purpose of the Study

The purpose of this study is to explore the
relationship between grief and depression in the process of
adjusting to a physical disability in a group of
rehabilitation patients. Rather than considering grief as a
unitary entity, the primary focus of the study was placed
upon a systematic examination of the relationships between
depression and each phasic component of the grieving process
for a group of individuals with post-polio conditions.
Furthermore, attempts were made to explore the
generalizability or consistency of these relationships
regardless of variations in the life circumstances and

experiences of these individuals.

11

Since both similarities and differences exist between
grief and depression as reactions to loss and stressful
events and since grief is a highly complex multidimensional
process, Schneider's comprehensive model was used in the
conceptualization of grief (Schneider, 1984, 1994).
According to this model, the grieving process consists of
the phases of coping, awareness, healing, and growth. These
phases can be divided into the components of holding on to
one’s will to fight, the escape response of letting go,
awareness of the loss, gaining perspective, mobilization and
integration of resources for resolution, self-empowerment
and transformation of one’s world view. Moreover, reactions
associated with each of these grief components can be
categorized into the physical, behavioral, cognitive,
emotional and spiritual dimensions. Assessment procedures
based on Schneider’s conceptual model yielded a matrix of
indices instead of a single score regarding the grief
reactions of the individual.

Two general research questions were explored in
accordance with the purpose of this study. Seven research
hypotheses were tested to address the issue of whether
systematic patterns of relationships exist between
depression and the seven phasic components of the grieving
process. Secondly, a series of post-hoc analyses of
interaction effects were performed to determine, as a

preliminary test, if these patterns of relationships were

12
generalized across a number of demographic and biographical
variables.

It is believed that the results of this study can be
used in a number of ways. At the most basic level, the use
of a comprehensive psychometrically based instrument of
grief is intended to operationalize and substantiate
empirically the concept of grief as a process and the
generalizability of this general clinical concept to a
rehabilitation population. The findings can be used to test
the clinical working hypothesis that despite their
remarkable similarities, grief and depression are two
distinct types of reactions to stress and loss. As noted
earlier, the validity of this hypothesis would have
significant diagnostic and treatment implications in the
provision of psychological services in mental health as well
as rehabilitation settings.

The validity of different clinical assumptions and
theoretical conjecture can then be examined regarding the
various developmental, personality, and environmental
factors associated with the differences between grief and
depression. Further investigation can also be conducted to
explore the differential effectiveness of specific
interventions in the care of depressed and grieving
individuals. Monitoring the individuals's rate and extent
of change in the dimensions of grief and depression as a
part of the intervention program would provide a reliable

method of assessing treatment progress and a credible source

 

unsubst

rehabil.
individt

depressi

 

what are
more res.
their att

will over

in impel-1
proc953 :1
“dress :
sitptOms
the frame
clirlical

at ,
.‘tentl 0:

13
of information in the formulation and modification of
treatment plans.

As discussed above, a recent trend in clinical research
is the investigation of resilience shown by some individuals
in the face of extreme stress. It has been observed that a
wide range of individual differences exist in the ability to
deal with stressful or traumatic life events. An
unsubstantiated parallel perspective can be found in the
rehabilitation literature which argues that not all
individuals with disabilities have to experience grief or
depression. A number of questions remain, however, as to
what are some of the adjustment processes utilized by the
more resilient individuals. For example, do they focus
their attention on their strength and the belief that they
will overcome the various impediments imposed upon them by
their disabilities? Do they rely on a way of cognitively
minimizing the significance or impact of their disability
experience or do they use other healthy adaptation
strategies?

An adequate clarification of these issues would serve
an important purpose since discussions of the grieving
process in the rehabilitation literature today largely
address some of the most apparent behavioral signs and
symptoms such as shock, denial, anger, and sadness. Within
the framework of a comprehensive model of grief found in the
clinical literature, however, the exclusive focus of

attention on one’s ability to overcome the loss may be

 

this st

from gr

to griei

 

exhibiti

l4

conceptualized as a fighting response while excessive
investment of energy in minimizing the significance of the
experience can be viewed as a flight response, both of which
are commonly observed coping reactions during the early
phases of the grieving process. By making use of the
procedures of assessing grief, and depression proposed in
this study, we may begin our attempts to separate depressed
from grieving individuals as well as those who do not need
to grieve from those who are actually grieving without
exhibiting the most commonly recognized or obvious symptoms
of grief. Researchers can then engage in a systematic
exploration of resilience factors, predict who would need
professional attention to the issues of loss and grief and
identify rehabilitation patients who are at risk for
developing psychopathological conditions such as depression.

Finally, it may be noted that the methodological
aspects of the study have been designed to address a number
of limitations in previous research. For example, instead
of comparing average group scores which emphasize
homogeneity of observations within a given disability group,
a multiple regression analysis was used in the study in
order to take into consideration individual differences.
Rather than focusing on the variation of emotional reactions
based on types of physical disabilities, the study attempts
to explore patterns of the intensity of grief based on a
clinically relevant concept of depression, which has been

well accepted by mental health practitioners and empirically

 

grief u

similar
aanifes‘

theoreti

 

have re
that th
differen

°°3P0nent

Cons;

“tent to

15
established. The emphasis on the process aspects of
psychosocial adjustment to physical disabilities is
reflected in the measurement of grief as a multiphasic
response rather than a unidimensional entity.

It is believed that this comprehensive definition of
grief would be important given the fact that both
similarities and differences exist in the symptomatic
manifestation of grief and depression and that the
theoretical relationships between these two conditions today
have remained at the level of speculation. It is likely
that the result of this study would be a profile of somewhat
different relationships between depression and the various
components of grief, which may be consistent or inconsistent
with some of the theoretical postulates which have been
suggested in the literature. We can also be hopeful that
such an empirically derived profile of relationships would
have some heuristic value to rehabilitation researchers in
encouraging further theoretical development on the issues of
grief and depression.

Definition of Terms

Brief definitions of terms used in this study are
provided below:

Loss: The absence of people, places, ideals or objects
considered to be meaningful or valuable (Deutsch, 1982).

The extent of the loss is determined by the intensity of the
attachment, love, or bondedness to the loss object and the

extent to which the life routine of the person who

 

this cc

dynamic
Schneid

awarenes

 

the be“.
dimensio
9&2
the indi
his/her
divided
attempts
1053. L

A'fi
itieving
individu

9a
PrecesS
the inte

iivided

the Gain

l6
experiences the loss is disrupted (McGovern, 1983). For the
purpose of this study, loss in rehabilitation patients
refers to an absence or a compromise of physical functioning
as a result of a disabling condition.

griefi: The process of a natural human response to the
experience of a loss. Observable behavior associated with
this complex loss reaction is the product of internal
dynamics and the grieving process has been described by
Schneider (1984, 1994) as involving the phases of coping,
awareness, healing, and growth, each of which consists of
the behavioral, cognitive, emotional, physical and spiritual
dimensions.

seeing: An initial phase of grieving characterized by
the individual's efforts to limit his/her vulnerability and
his/her awareness of his/her loss. This phase can be
divided into two components. Helging_en reflects people's
attempts to overcome or to see themselves as beating the
loss. Le;;ing_ge reflects people's attempts to escape from
the stress and burden of their grief.

Ageneneee: A phase traditionally associated with
grieving which deals with the extensiveness of the
individual’s actual experience of the loss.

Heeling: A phase of grieving characterized by a
(process of recovery and the initiation of detachment from
'the intensity and stressfulness of grief. This phase can be

divided into two components. 2215222311: is associated with
‘the gaining of insights about the meaning and significance

 

to phi
of the

conpone

 

one's
reflect
one’s u
functio
9e
constel
which i
Presenc
(MCGQve

l.

17
of the loss. IDSEQIALIQD is related to the mobilization of
resources to remember actively the loss, to "finish
business" with it, or to make restitution, forgive, or begin
rehabilitation.

fireggh: A phase of grieving associated with the extent
to which people attribute subsequent growth and realization
of their potential to the loss. This phase includes two
components. fieljzempegezmene refers to the increase of
one's resourcefulness, flexibility, and responsivity as a
reflection of the loss. Tgenefegmegieh refers to changes in
one’s world view and the nature of losses in general as a
function of the loss.

DBRI£§§1233 An affective disorder characterized by a
constellation of symptoms of at least one month in duration
which involves no other major psychiatric disorder, the
presence of dysphoria and five or more of the following
(McGovern, 1983):

1. Decrease in appetite/weight

2. Agitation or retardation

3. Sleep difficulty (hypersomnia or insomnia)

4. Loss of interest in usual activities or libido

5. Recurrent thought of death or suicide

6. Guilt, self-reproach

7. Loss of energy, easy fatigue

8. Decreased ability to think or concentrate

CHAPTER 2.
A CRITICAL REVIEW OF RELEVANT LITERATURE

This chapter presents a review of the literature
pertaining to the relationship between grief and depression
and the role of this relationship in the process of
adjusting to a physical disability. The review begins with
a definition of adjustment. The impact of physical
disabilities such as post-polio conditions is described in
terms of the experience of loss and attempts are made to
document the presence and role of grief and depression as
responses to the loss. An observation is made regarding the
pervasive confusion of terminology in the rehabilitation
literature as it pertains to the distinction between grief
and depression.

Attention is then turned to the clinical psychological
literature where the relationship between grief and
depression is addressed on two separate levels-~the
similarities and differences in the manifestation of grief
and depression and various theoretical speculations
regarding the mediating function of different developmental
and process variables in the differential development of
grief and depressive reactions. It is observed that the
failure to mourn or unresolved grief as a contributing
factor of depression is a general theme common to virtually
all theoretical perspectives discussed. Conceptual
parallels are drawn between this general assumption and the

theory of disability acceptance.

18

19

As a basis for the post-hoc analysis of interaction
effect proposed in Chapter 3, the final section of this
review is concerned with the potential association between
demographic and biographical variables and specific
reactions of individuals with a physical disability. It is
argued that although there has been research on the
relationship between demographic variables and psychological
reactions of the individual, little research has addressed
the potential influence of these variables on the
association between two psychological phenomena such as
grief and depression.

The Concept of Adjustment

Adjustment to physical disability has long been a topic
of interest for researchers and practitioners in the field
of rehabilitation. A thorough understanding of the
adjustment process has not been easy to accomplish, however,
partly due to the comprehensive and multifaceted nature of
this concept. Mechanic (cited by Bracken & Shepard, 1980)
described what he believed to be three fundamental
components necessary for successful adjustment. According
to Mechanic, the adjusted individual has to have adequate
coping abilities, be motivated to meet environmental
demands, and maintain psychological equilibrium. A similar
definition has been proposed more recently by Trieschmann
(1980) who stated that adjustment or coping is a combination
of survival skills, harmonious living, and productivity.

Based on this perspective, adjustment is a term used to

descr

tine ;‘
|

 

study:

contex

Gil

of char
rehabil
persona.

of a ph}

 

conceptu
describe
well-be:

nest sho.
consider€
functionE
Pedretti

3 Physics.
hart Or- f

occ“patio

20
describe a multitude of the individual's behavior across a
time period and it can not be assessed adequately by
studying only one aspect of the individual's life out of the
context of the person-environment interaction.
Disability as an Experience of Loss and Change

Consideration of a physical disability as an experience
of change and loss appears to be a pervasive theme in the
rehabilitation literature. In addition to the numerous
personal and anecdotal accounts of the subject, the impact
of a physical disability has been discussed from several
conceptual perspectives. Bracken and Shepard (1980)
described physical disability as the passage from physical
well-being to total or partial paralysis which is among the
most shocking of all human experiences. Siller (1969)
considered the person’s ties to the lost body part of
functions, which are represented by hundreds of memories.
Pedretti and Zoltan (1990) described the various impacts of
a physical disability beyond the individual’s loss of a body
part or functions, including changes in the familial,
occupational, and social spheres of life. They also
discussed the necessity for the individual to give up
autonomy and self-sufficiency temporarily or permanently.

Winston, Hirschenfang, Fine, and Stern (1969) addressed
the loss of masculinity which is frequently associated with
a physical disability. Trieschmann (1988) called attention
to the loss of the "I am’s" as a result of a disability.

From a behavioral perspective, Michael (1970) and Fordyce

 

of con‘

conflic
availah
there w
Psychos

while 0}

 

 

 

with di.
CTailor
”Pulati
describe
Perfecti
(Bruno 5

I .
x.ledma

21
(1971) view the onset of a disability as a punishment which
is defined as the loss of positive reinforcers or the onset
of adversive stimuli.
Tl E !'E J' : a.!.

One of the most well-known early studies on the
psychological impact of polio was conducted by Davis (1963).
Among the issues addressed in his study were the need for
children with polio and their family for maintaining a sense
of continuity and stability in their lives as well as
conflicts between the hospital structure and home. With the
availability of the Salk and Sabin vaccine in the 19603,
there was a period of relative moratorium in polio-related
psychosocial literature until the early 1980s (Kohl, 1987).
While observed to be employed at a higher rate than people
with disability as a group (Codd, Mulder, Kurland, Beard, &
O’Fallon, 1985) and better educated than the general
population (Frick, 1985), adult polio survivors have been
described as competitive overachievers with a
perfectionistic tendency, experiences of chronic stress
(Bruno & Frick, 1987), and exhibiting type A behavior
(Friedman & Rosenman, 1974).

Among the other psychosocial issues of polio survivors
discussed in the literature are unrealistic expectations for
themselves and the medical community (Kohl, 1987); -
uncertainty about their functional capability in the context
of increasing age in the polio survivors themselves as well

as their physical care providers (Kaufert & Kaufert, 1984);

thes

 

inde;
Kaufe:
(Fricl
unendi
psychc.
survive
there h
the adj

literati

 

Provide
lW'ter
needs in
resource

llie
conditim
Arnold Be
disabilit
this Cond
aSpects o
perceptio.

‘A 5301
usociatEC
typically
mg‘lasq
disability

6
~0
9st w01':

22
the social consequences of a lifelong disability; loss of
independence; a sense of heightened vulnerability (Locker &
Kaufert, 1988); the psychology of a "second disability"
(Frick, 1985); and chronic emotional stress, dependency, and
unending struggle (Lewis, 1992). Based on a review of the
psychosocial literature pertinent to the adjustment of polio
survivors, Lewis (1992) reported a general impression that
there has been limited research beyond firsthand accounts of
the adjustment experience and the polio support group
literature. She suggested that polio survivors could
provide valuable insights into their unique experience and
long-term disability. Particular areas of unmet research
needs included coping and adaptational processes, supportive
resources, and the meaning of illness.

The impact and stress associated with the polio
condition as a loss experience was eloquently described by
Arnold Beisser (1989) in a personal account of his
disability adjustment process. The debilitating effect of
this condition could profoundly change the most basic
aspects of his moment-to-moment consciousness such as the
perception of time, space, and relationships with others.

A potentially significant stress consideration
associated with the post-polio condition is that it is
typically considered and experienced as a chronic illness--a
long-lasting disease often associated with some degree of
disability (Anderson & Bauwens, 1981), incurable and likely

to get worse over time (Perlmutter & Hall, 1985). According

SOC

P5?

1..."
Air

eie:
unc:
to :
of 1

up;

Stra

23
to Lubkin (1986), the experience of chronic illness has
significant impact on all facets of the self, including the
social, cultural, economic, physical, as well as
psychological dimensions. The problem of chronicity also
impacts on the family and community. Among the common
elements of most chronic conditions are the intrusive,
uncertain, and long-term nature of their impact, a tendency
to involve multiple diseases, requirement for a great deal
of palliation, and many frequently expensive and fragmented
supportive services (Anderson & Bauwens, 1981; Gerson &
Strauss, 1975; Strauss, Corbin et al., 1984).
Grief and Physical Disability
It appears that although many early studies on
psychological reactions to a physical disability appear to
utilize a number of traditional psychological and somewhat
pathology-oriented labels such as dependency, psychotic and
psychopathic reactions (Nagler, 1950), a regressive trend
(Dorken cited by Woodbury, 1978; Mosak cited by Woodbury,
1978; Ryan cited by Woodbury, 1978), pseudo-hysteria (Weiss
8 Diamond cited by Woodbury, 1978; Kaplan, Powell, Grynbaum,
& Rusk cited by Woodbury, 1978), autistic dream content and
substance abuse (Wittkower, Gingras, Mergler, Wigdor, &
Lepine, 1954), a significant proportion of the psychosocial
literature has been concerned with normal reactions to
disabilities as an abnormal situation (Hohmann, 1975).
Until recently, the rehabilitation literature has been

dominated by a large number of publications on the stage

24
theory of adjustment (Trieschmann, 1988). Many stage
theories have been introduced and discussed (e. g., Cohn
cited by Woodbury, 1978; Dunn cited by Woodbury, 1978; Feld
cited by Woodbury, 1978; Hohmann, 1975; Kerr 8 Thompson,
1972; Peter cited by Woodbury, 1978; Seybold cited by
Woodbury, 1978).

Conceptual parallels have been suggested between these
stage theories and Kubler-Ross’s bereavement theory (Bracken
8 Shepard, 1980; Vincent cited by Woodbury, 1978). For
example, application of this widely recognized stage theory
was made in Beisser's reflections on his own adjustment to
post-polio problems (Beisser, 1989). According to Bracken
and Shepard (1980), research on disability adjustment has
yielded a general agreement regarding the presence of and a
lack of consensus on the sequence of these stage reactions.
Bracken and Shepard also indicated a consensus of opinions
in the literature regarding the normality of these
reactions. Arguments have been made for the use of stage
theories as a conceptual guide to our understanding of the
adjustment process, lack of current knowledge and need for
further research (Bracken 8 Shepard, 1980) and to the
monitoring and support of client adjustment (Kerr 8
Thompson, 1972).

Additionally, there are a number of articles describing
adjustment reactions such as shock (e. g., Bracken 8
Shepard, 1980; Gunther, 1969), denial (e. g., Guttmann,

1976; Mueller 8 Thompson, 1950; Roberts, 1972), and anger

(e. 9
disc:
disab

physi:

 

closed

nourni.
the inc
Leviton
for par‘
1971).

should p

 

individu.
WHealis)
Wright (1

POSitions

25
(e. 9., Vincent; 1975). An assumption underlying the
discussions on grief reactions of individuals with
disabilities appears to be that as with the healing of a
physical wound, which needs to be first anesthetized, then
closed up with the least amount of scarring, grief and
mourning needs to be experienced and resolved in order for
the individual to be adjusted to the disability (Dembo,
Leviton, 8 Wright, 1975; Siller, 1969) and gain motivation
for participation in the rehabilitation process (Heijn,
1971). Roberts (1972) argued that helping professionals
should provide accurate information on the prognosis of the
individual’s condition to avoid helping him/her set
unrealistic expectations and postpone the grieving process.
Wright (1983) cautioned that acceptance of such theoretical
positions would require experimental verification.
Depression and Physical Disability

There appears to be some disagreement regarding the
relationship between physical disabilities and depression.
The presence of depression has been reported as a reaction
to physical traumatization (e. g., Bracken 8 Shepard, 1980;
Dinardo, 1971; Feld cited by Woodbury, 1978; Judd, Burrows,
8 Brown, 1986; Kalb, 1971; Lawson cited by Woodbury, 1978;
stson, 1976, 1978; MacDonald, Nielson, 8 Cameron, 1987;
Mueller, 1962; Mueller 8 Thompson, 1950; Nagler, 1950;
Siller, 1969). In contrast, depression appears to be
evident mostly in the initial phases of disability

adjustment and the occurrence of prolonged or severe

26
depression has been considered to be rare (Guttmann, 1976;
Mueller 8 Thompson, 1950; Nagler, 1950; Richards, 1986;
Trieschmann, 1988; Vincent, 1975).

Attempts have been made to provide explanations for the
occurrence of depression (e. g., Fordyce, 1971). Based on
stage and coping theories, it has been suggested in the
rehabilitation literature by a number of individuals that
depression is a normal, expected, and even necessary part of
the adjustment process (Bracken 8 Shepard, 1980; Roberts,
1972; Siller, 1969; Weiss 8 Diamond, 1966) and that the
absence of depression should be a matter of concern (Siller,
1969; Weiss 8 Diamond, 1966). This perspective has been
challenged (e. g., Goldiamond, 1973) and Woodbury (1978) has
pointed out that data are quite limited at present regarding
the validity of this argument.

Empirical findings have also been inconclusive
regarding the role of depression in disability adjustment.
In general, there appears to be no concrete support for the
hypothesis that the experience of depression would
contribute to the adjustment process. However, it has been
reported that little relationship exists between depression
experienced by individuals with a physical disability, such
as spinal cord injury, during their hospitalization and life
adjustment after discharge from the hospital (Kalb, 1971).
In fact, research suggests the presence of a negative
relationship between depression and satisfactory progress in

rehabilitation (Heijn, 1971; Stern 8 Slattery cited by

appear

1978),

observ
extend

than ar

 

by Wood

27'
Woodbury, 1978), activities of daily living (Richards,
Meredith, Nepomuceno, Fine, 8 Bennet, 1980), social
activities (MacDonald, Nielson, 8 Cameron, 1987), ratings of
adjustment by hospital personnel (Dinardo cited by Woodbury,
1978), and acceptance of disability (Fitzgerald, 1983). It
appears that interference with progress in rehabilitation is
observed especially when the reactive depression has
extended to the rehabilitation phase and occurred on more
than an episodic basis (Heijn, 1971; Stern 8 Slattery cited
by Woodbury, 1978).
A Need for Conceptual Clarity

A critical review of current rehabilitation literature
on the topics of grief and depression appears to reveal a
great deal of confusion and inconsistency. For example,
depression has been described in the rehabilitation
literature as a stage of the normal grieving process,
although depression and grief are considered to be two
separate reactions in general clinical psychology and in the
Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 1994). The theoretical
assumption that grief is facilitative of adjustment to
physical disability has been contradicted by reports of an
inverse relationship between time spent in mourning and
rehabilitation progress and community adjustment (e. g.,
Lawson, 1978). The early hypothesis concerning the
association of denial with an absence of depression has been

challenged (e. g., Dinardo, 1971), and the traditional

 

adjust:

1954) j
denial

(Triesc.

 

It
clinical
filsl‘aan,
disagree
the sign
heel-tan
1983) a1
Vastly o
reWESts
cut that

the MOS:

28

belief in the facilitative role of depression appears to be
inconsistent with recent findings of a negative relationship
between depression and acceptance of disability (e. g.,
Fitzgerald, 1983). There has also been some confusion
regarding the nature of specific psychological reactions on
the normality-pathology continuum. For example, one of the
more recent criticisms of the early description of
adjustment (Wittkower, Gingras, Mergler, Wigdor, 8 Lepine,
1954) is the equating of the psychopathological response of
denial with the normal and healthy reaction of hope
(Trieschmann, 1988).

It appears that confusion also exists in the area of
clinical diagnosis and treatment in rehabilitation.
Cushman, Dijkers, and Harrison (1985) reported a
disagreement among rehabilitation professionals regarding
the signs and symptoms of depression and the relative
importance of these symptoms. Ince (cited by Trieschmann,
1988) also found that the rehabilitation staff tend to
vastly over-estimate the occurrence of depression in their
requests for psychiatric consultation. It has been pointed
out that the pathologically labeled symptoms may actually be
the most sensible behavior possible under the difficult
circumstances of the disability (Goldiamond, 1973) and that,
based on Kalb's defining criteria, the term "grief“ rather
than "depression" would seem to be a more appropriate
descriptive label (Trieschmann, 1988). Using Seligman's

learned helplessness conceptualization of depression

dif
act.
ind:
COnc
Who

dire

29
(Seligman, 1975), in contrast, Trieschmann (1975, 1976,
1978, 1980, 1988) suggested that the unnatural physical and
social environment of the hospital treatment setting may
contribute to the development of depression. Goldiamond
(1973) points out that defining the patient's negative
reactions can help the professional avoid looking at the
effect of their own behavior.

In terms of treatment provision, it appears to be
proposed by most traditional perspectives that individuals
with disability should be allowed to react to and mourn for
the loss. In this context, it would appear somewhat.
difficult to understand Fordyce’s (1971) recommendation of
actively interrupting the withdrawal behavior of the
individual through the provision of rehabilitation tasks. A
conceptual bridge has been provided by Trieschmann (1988),
who noted that Fordyce's approach was similar to Seligman's
directive therapy for the treatment of learned helplessness
and depression (Seligman, 1975). What appears to be a
contradiction between Fordyce’s approach and the traditional
perspectives of grief-oriented treatment actually may not
exist since the former may be specific to the treatment of
depression as a mental health problem whereas the latter
constitutes an appropriate helping response in the normal
process of grieving. In other words, grief and depression
can be considered as two distinct psychological phenomena
requiring different treatment strategies, which may

adequately explain the discrepancy between Fordyce's active

trea

 

pars;

(1988
point

on th
mourni
zoltan
may be
the ind
Fullert
hollert
Brown (
Should ;

used.

In
literau
and 118;:
t0 4

$.56er

fliniCal

30
treatment recommendation and most grief-oriented traditional
perspectives.

In attempting to resolve the confusion, Trieschmann
(1988) advocated the use of more precise terminology. She
points out that at present there is not unanimous agreement
on the definition of depression, which is often defined as
mourning for the loss of functions (e. g., Pedretti 8
Zoltan, 1990). Trieschmann suggested that the word "grief"
may be a better alternative in describing the reactions of
the individual and that, using the research reports of
Fullerton, Harvey, Klein, and Howell (1981), Howell,
Fullerton, Harvey, and Klein (1981) and Judd, Burrows, and
Brown (1986) as positive examples, specific definitions
should be provided in cases where the word "depression" is
used.

In reviewing the current status of the rehabilitation
literature, it appears that the distinction between grief
and depression is not very clear and what Woodbury (1978)
once said about our lack of knowledge regarding the role of
grief and depression may still be valid. In the search for
a sense of conceptual clarity, our attention is now turned
to theoretical writings and empirical findings in the
clinical psychological literature.

The Study of Grief

It was not until recently that the study of grief was

given a legitimate and important emphasis in the

'psychological literature and in the training of helping

31
professionals. The first systematic exploration of the
grieving process is represented by Freud's writing on
mourning and melancholia (Freud, 1917). The result of this
systematic exploration was later integrated into his view on
anxiety and inhibition symptoms. Although Freud affirmed
that missing someone who is loved and longed for is the key
to understanding anxiety, he believed that mourning was not
a pathological process and, therefore, did not require
medical treatment. Mourning was considered to be a natural
process of recognizing that the dead person would no longer
be a source of satisfaction and need fulfillment. It was
also noted that mourning could occur with the loss of an
ideal such as the fatherland or freedom.

As a result of her observations on the terminally ill,
Kubler-Ross (1969) developed a five-stage theory of dying,
which has been very popular among helping professionals.
She subsequently expanded this model to include certain
transcendental phenomena such as the afterlife. Part of the
value of this aspect of her model is the concept of
potential for growth from a loss experience.

Engel’s study of the grieving process (Engel, 1961,
1962, 1967) was primarily concerned with the psychological
processes involved in health and illness. He stated that
object loss was a major psychological stressor which would
elicit a psychological response or adaptation leading to

health or illness. Much of his work was concerned with

3211
sepa

CIEE

std:

Unit

32
attempts to delineate factors influencing the outcome of
mourning and its complications.

Lindemann (1944, 1945) developed a model of mourning
based on observations of the 101 Coconut Grove fire
survivors and their relatives. Observations were also made
of individuals who had lost a significant person through
war. The result of this work was the postulation of a set
of distinct phenomena resulting from sudden traumatic loss.
Concerned particularly with the biological manifestations of
grief, Lindemann believed that mourning was caused by
separation reactions, especially when the separation was
created by death.

Parkes (1965a 8 b, 1972, 1981) carried out a number of
studies on widows and widowers in Great Britain and in the
United States. Through the use of controlled studies, the
primary emphasis of his research was to distinguish typical
grief and its variants. He investigated antecedent and
concurrent variables which determined the course of
mourning. Parkes considered mourning to be a response to
the loss of a loved person through separation or death,
although it could also be caused by the loss of a job,
becoming physically disabled or divorce.

Marris (1958, 1974) made certain important
contributions to a theoretical understanding of mourning,
using widows and slum clearance as focused loss situations.
He considered grief to be a response to the loss of

something (death of a loved one, loss of housing) that gave

dur
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abil
and
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GEVe

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33
life meaning and structure. Marris has been noted for the
introduction of several key principles in grieving, such as
the concept of denial as a conservative impulse.

Bowlby (1980) observed the attachment behavior of young
children and primates. His phasic theory of healthy
mourning emphasized the cognitive bias of the individual
learned through interaction with early attachment figures
during childhood development. These biases interact with
other conditions affecting response to loss. Another
contribution of Bowlby is his emphasis on the information-
processing aspects of healthy mourning, which involves the
ability of the individual to process accurately, completely
and quickly information brought about by loss. This ability
is affected and interacts with the cognitive biases
developed in early attachment.

It appears that until recently the establishment of an
objective basis for scientific inquiries into the grieving
process has been somewhat difficult partly due to the lack
of general measures which can be used to assess response to
a variety of loss experience. Until the development of
Schneider’s Response to Loss Inventory, there have been two
major studies in the past 20 years which are concerned with
systematic assessment of grief reactions (Schneider,
McGovern, 8 Deutsch, 1991). Parkes (1987) developed an
interview-based approach to the assessment of grief. This
procedure was used to compare widows in Boston and London

who had sustained sudden losses with widows matched for age

but

has

grie

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1(ch

grie

Part;

let,

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\ev

34
but whose losses were anticipated. This longitudinal study
has been seen as an important beginning for research in
grief. Parkes does not concern himself with generalizing
grief issues beyond widows and does not consider the
potential growth outcome of grief.

Saunders, Mauger, and Strong (cited by Schneider,
McGovern, 8 Deutsch, 1991) developed a 136 item true/false
grief experience inventory, making it possible to compare
and contrast objectively the experiences among individual
bereaved persons as well as groups. Again, the focus of
this instrument is on grief resulting from deaths,
especially those of spouse, parents, and children. Also,
the theoretical model underlying the development of this
particular scale does not take into account the dimensions
of "growth" and "transformation." Additionally, the
true/false format did not consider shifts in the degree of
experience. Other attempts to assess the grieving process
have been generated by single issues, such as the response
of a parent to the death of a child. In general,
instruments and approaches to the assessment of grief have
been generated based on practitioners' clinical experience
with a particular population from particular theoretical
frameworks which tend to emphasize potential risk of
pathological outcome (Schneider, McGovern, 8 Deutsch, 1990).

A Comprehensive Model of Grief
Based on a combination of comprehensive literature

review and his own clinical work with individuals who have

 

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35
suffered from loss experiences, Schneider (1984) developed a
holistic model of normal grieving which involves the major
phases of coping, awareness, healing, and growth.
Subcomponents exist for three of the four major phases and
each of these phases is conceptualized to consist of the
behavioral, cognitive, emotional, physical, and spiritual
dimensions. The spiritual dimension is concerned with the
impact of the loss on the person's values, attitudes,
beliefs, and will to live. The other dimensions are
categories of responses through which the individual's
reactions to the loss experience are expressed. The
"coping" phase of the grieving process is characterized by
the individual's tendency to limit his/her vulnerability and
awareness of the loss. Schneider identified two forms of
coping response. "Holding on" is a "fight" response which
helps the individual maintain a perception of beating the
loss by keeping busy (behavioral), being angry (emotional),
or believing that the loss is reversible (spiritual). The
"letting go" response, in contrast, involves avoidance of
stress and grief by excessive drinking (behavioral), using
distraction (cognitive), being disgusted (emotional) or
sleeping (physical).

"Awareness" is the second phase which involves many
obvious signs and symptoms traditionally associated with the
grieving response. "Healing" is the third phase of grieving
in which the individual experiences a sense of recovery from

the intensity and stress of grief. As one of the two major

IF
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the

resou
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and o

36
components of this phase, "perspective" is associated with
the gaining of insights about the meaning and significance
of the loss. "Integration" refers to the mobilization of
resources to remember the loss actively, to "finish
business" with it or to make restitution, to forgive oneself
and others, and to rehabilitate oneself.

The final phase of the grieving process is referred to
by Schneider as "growth," in which the person attributes
subsequent growth and utilization of their potential to the
loss. Two categories of growth response has been described
by Schneider (1984). "Self-empowerment" refers to the
increase of one’s resourcefulness, flexibility, and
responsivity as a reflection of the loss. "Transformation"
is associated with changes in one's world view and the
nature of losses in general as a function of this loss. A
careful analysis would reveal that Schneider’s model appears
to be highly related to the disability acceptance theory of
Dembo, Leviton, and Wright (1975), which emphasizes the
acceptance of loss as a series of value changes. The
concept of transformation and growth has been integrated in
both perspectives and the theory of accepting disability
assumes that acceptance is the result of resolved loss
issues.

The Response to Loss Inventory is a self-rating
instrument developed based on Schneider's comprehensive
model of grief. Representing an objective approach to the

assessment of grief reactions, the result of this inventory

37
yields a matrix of subscale scores, each corresponding to
the various phasic as well as the dimensional components of
the grief process. Split-half forms of the instrument are
now available. Information regarding the statistical
properties, reliability, and validity of the measure is
presented in Chapter 3 of this report.
Depression

Depression is generally considered to be an affective
disorder. There has been a great deal of controversy
regarding the etiology of depression. Some authorities
believe that it is psychogenic in origin; many others
maintain that depression is an organic disorder. Still,
there are those who argue for the social origin of
depression while the others would accept the validity of all
premises (Wetzel, 1984). According to Wetzel, the symptoms
of depression can be divided into the affective, cognitive,
behavioral, and physical areas. The affective symptoms
include dysphoric mood, fearfulness, anxiety, inadequacy,
anger, resentment, rage, guilt, confusion, tiredness,
hopelessness, and irritability. Symptoms associated with
the cognitive thought processes of the individual include
negative view of the self, the world, and the future;
irrational beliefs; recurrent thought of helplessness,
hopelessness, and worthlessness; recurrent thoughts of death
or suicide; self-reproach; low self-esteem; denial;
indecisiveness; slow thinking; disinterest in activities,

people, and pleasure; confused thought; poor concentration;

9

and
sub:

skil

38

and agitation. Behavioral symptoms may include dependence,
submissiveness, non-assertiveness, poor communication
skills, control by others, crying, withdrawal, inactivity,
careless appearance, retarded motor response, poverty of
speech, slowed body movements, and agitated motor response.
The symptoms in the physical category include low energy,
weakness, fatigue, sleep disturbance, insomnia or
hypersomnia, weight loss or gain, appetite disturbance,
indigestion, constipation, diarrhea, nausea, muscle aches
and headaches, tension, agitated or slowed psychomotor
reflexes, and sex drive disturbance.

Similarities and Differences Between Grief and Depression

Perhaps one of the predominant views on grief and

depression most frequently discussed in the clinical
literature has been Freud's well-known early work negxning
eng_nelenenelie (Freud, 1917). Freud noted that grief and
depression were similar to each other in that both involved
"a profoundly painful dejection, cessation of interest in
the outside world, loss of the capacity to love and the
inhibition of all activity." However, he observed that
depression could be distinguished from grief by a lowered
self-regard "to a degree that finds utterance in self-
reproaches and self-revelings and culminates in the
delusional expectation of punishment." Another critical,
but less apparent, distinguishing feature of depression

discussed by Freud is ambivalence towards the lost person or

object.

399385

l

and ma;

39

Although the differentiation between grief and
depression has not been a focused area of attention in the
clinical literature until more recently, there have been a
number of publications since Freud's 1917 work which
acknowledge the similarities and emphasize the differences
between grief and depression (e. g., Akiskal 8 Lemmi, 1983;
Hagglund, 1981; Lehmann, 1983; Smith, 1985; Winokur, 1973;
Wool, 1990a 8 b). At present, most clinicians appear to
agree that grief reactions can be differentiated from
depression and such a view is reflected in the inclusion of
both uncomplicated bereavement and depressive disorders as
separate categories in the Diagnostic and Statistical Manual
of Mental Disorders (American Psychiatric Association,
1994).

One of the most systematic attempts at the
identification of clinically significant differences between
grief and depression is represented in Schneider’s 1980
publication. In an updated version of this publication,
which was presented at a recent conference on transformative
grief (Schneider 8 Deutsch, 1992a 8 b), the differences
between grief and depression were described based on a
consideration of the literature, ongoing research on the
issue of grief, and direct clinical observations.

Depression is believed to be different from grief in that it
may or may not involve the identification of a specific
loss; the cognitive focus of the individual is on the self

and may involve persistent and distorted perceptions of the

40
self, experiences, and the future; the affected person has
negative fantasies and imageries rather than vivid, clear,
and sometimes comforting dreams of the loss which tend to
contribute to negative thinking and an intensified physical
response; and the unmodulated physical response of the
individual may lead to bodily damage and increased
vulnerability to illness.

When compared with the depressed person, the individual
undergoing the process of grief experiences a range of
emotions in the same day instead of fixed mood of despair
and withdrawal; shows variable rather than persistent
restriction of pleasure; responds to interpersonal warmth
and reassurance instead of promises, pressure, or urging;
and feels reassured by the presence of close friends rather
than losing connection with the self and others. In the
spiritual dimension, the grieving person feels connected
with something beyond the self and allows challenges to
previously held beliefs, whereas the individual with
depression experiences a persistent failure to find meaning
and focuses on the unfairness of the loss.

Schneider and Deutsch (1992a 8 b) also compared the
degrees of change and growth in grief and depression based
on a set of criteria which roughly correspond to the phasic
components of Schneider’s grief model (Schneider, 1984).
They indicated that grief does not require extensive use of
denial, but typically involves the activities of initiating

awareness of the loss, coping through both the fight and

41
flight responses, experiencing awareness of the loss,
healing, gaining perspective, integrating the loss,
reformulating the loss and transforming the loss. In
contrast, depression is often associated with denial; may or
may not entail the initiation of loss awareness; may be
concerned with the flight but not the fight response; may or
may not involve the experience of loss awareness; and does
not result in healing, gaining perspective, integration,
reformulation, and transformation of the loss.

A number of investigations have been reported on the
similarities and differences between grief and depression.
Most of these studies can be found in the bereavement
literature and involve observations of bereaved individuals,
comparisons of bereaved and nonbereaved control subjects,
the differentiation of uncomplicated bereaved individuals
from bereaved depressives, comparisons of bereaved subjects
with nonbereaved depressives and comparisons between
bereaved depressives with nonbereaved depressives (Robinson
8 Fleming, 1989). Based on a systematic review of these
investigations, Robinson and Fleming (1989) reported a
general consensus that the symptomatology of grief may be
similar to a clinical depression up to the end of the first
year of bereavement. It has been pointed out that the
typical bereavement reactions of appetite and sleep
disturbances, dysphoria, fatigue, and a loss of interest in
previously enjoyed activities as discussed by Blanchard,

Blanchard, and Becker (1976), Carey (1977), Clayton,

42
Desmarais, and Winokur (1968), Lindemann (1944), Maddison
and Viola (1968), Harris (1958), Parkes (1972, 1975), Parkes
and Brown (1972), and Sanders (1979, 1980, 1989) are noted
in the DSM-IV as criteria for major depressive episode
(American Psychiatric Association, 1994).

With regard to the differences between grief and
depression, Clayton, Desmarais, and Winokur (1968),
Lindemann (1944) and Parkes (1972, 1975) reported a relative
absence of several symptoms in the grief response such as
persistent condemnation of self, suicidal thoughts and
general negative perceptions of the self. These symptoms
have been observed as part of the clinical picture of a
significant depression (American Psychiatric Association,
1994; Beck, Rush, Shaw, 8 Emery, 1979). A smaller number of
disconfirming findings have also been discussed in the
literature, although it appears that these findings tend to
qualify rather than invalidate certain early statements
concerning the difference between grief and depression.

Based on a review of relevant empirical evidence, for,
example, Bowlby (1980) challenged Freud's view that
ambivalence is present only in pathological states such as
depression. His research showed that ambivalence toward the
lost person waspresent in many cases in which mourning
followed a healthy course, although he acknowledged that the
ambivalence was more intense and more persistent in those
that developed pathologically. Clayton, Herjanic, Murphy,

and Woodruff (1974) compared the symptoms of 34 patients

43
with diagnosed primary affective disorders and 34 matched
individuals who had lost their spouses by death for less
than a month. Although the psychiatric patients exhibited
more symptoms than the bereaved individuals, it was
concluded that the two groups could not be differentiated
due to a great deal of symptomatic overlap. It may be
pointed out that an assumption underlying the design of the
study is the homogeneity of psychological reactions within
each of the two groups. In other words, the group of
bereaved individuals were referred to as "grieving normals"
while the psychiatric patients were assumed to have
pathological conditions or disorders. Given the increasing
number of publications in the literature regarding the
accuracy and consistency of professionals' clinical
judgment, the validity of this assumption appears to be a
viable topic for further investigation.
Relationship Between Grief and Depression

Most of the available theoretical writings on the
relationship between grief and depression are based on the
psychodynamic framework. A review of these perspectives
seems to point to Freudian concepts as a central point of
reference. The self-criticisms observed in the '
symptomatology of depression lead Freud to the idea of the
"critical agency" and, subsequently, the concept of the
superego (Pedder, 1982). According to Freud, the self-
reproaches are "reproaches against a loved object which have

been shifted away from it on the patient's own ego."

44
Therefore, "the shadow of the object falls upon the ego"
(Freud, 1917), and "both ego and object fall under the
harsh judgement of the critical agency" (Pedder, 1982, p.
329). In other words, there is an identification of the ego
with the lost object. Relevant to the individual’s
experience of ambivalence, Freud believed that the extent of
hate combined with the feeling of love toward the lost
object was related to the sadism of the internalized self-
criticisms, as exemplified most dramatically by the
internalization of murderous impulses, suicidal ideation,
and self-destructive behavior.

An important follow-up to Freud's work on mourning and
melancholia was undertaken by Melanie Klein (1940), who
contended that the individual’s course of mental health and
vulnerability to depression in the face of loss later in
life depends on the satisfactory negotiation of the
"depressive position" with the establishment of good
internal objects. As a major Kleinian concept, the
depressive position is defined as a phase of human
development in which "the infant recognizes a whole object
and relates himself to this object" (Segal, 1964, p. 55).
With the recognition of the primary caregiver such as the
mother as a separate and whole person and the source of
positive as well as negative experiences, the child comes to
the realization that "his own destructive impulses may harm
the object that he loves and totally depends on" and

associated new feelings of "mourning and pining for the good

45
object felt as lost and destroyed, and guilt, a
characteristic depressive experience which arises from the
sense that he has lost the good object through his own
destructiveness" (p. 57).

According to Klein (1940), "this early mourning is
revived whenever grief is experienced in later life" (p.
311). Good early relationship experience results in the
establishment of good internal objects in the world of the
infant. This established internal representation of caring
persons would then serve to help the individual in dealing
with significant traumas in later life (such as the actual
loss of loved persons) through which the strength of good
internal objects is tested and the threat of losing these
good objects is reactivated. Thus, the process of normal
mourning can be viewed from this perspective as involving
the re-building of the individual’s inner world through
which "it's re-instating that object as well as his loved
internal object which he feels he has lost" (Klein cited by
Pedder, 1982, p. 331).

Without the establishment of good internal objects in
the early childhood, depressed individuals and those who do
not mourn successfully are unable to "feel secure in their
inner world when threatened with external loss" (Pedder,
1982, p. 331). It has been suggested that the nature of the
individual’s emotional difficulty is determined by whether
or not he/she has "traversed the divide between the

paranoid-schizoid and the depressive positions" (p. 331) in

46
that "if the depressive position has been reached and, at
least, partially worked through, the difficulties
encountered in the later development of the individual are
not of a psychotic but of a neurotic nature" (Segal, 1964,
p.61).

The Kleinian concept of the depressive position was
discussed and reframed in Winnicott’s (1962) work as the
"capacity for concern" to emphasize the positive aspects of
this developmental phase. He stated that "here, being
depressed is an achievement and implies a high degree of
personal integration and an acceptance of responsibility for
all the destructiveness that is bound up with living, with
instinctual life and with anger at frustration" (p. 176).
Rather than underscoring complete establishment of early
childhood processes, however, he acknowledged that these
processes continued to be strengthened by the experience of
growth in later childhood, adult life, and old age.

It may be said that a general agreement among the
psychodynamic theorists discussed above is their emphasis on
the individual’s early awareness of the primary caregiver as
a separate being and the concern about the effect of his/her
impulses on the caregiver. Potentially important for
conceptualizing the relationship between grief and
depression is the suggestion that vulnerability to the
development of psychopathology in general and depression in
(particular, is associated with unsuccessful attempts at the

establishment of good internal objects which depends upon

47
the availability of "good enough" parenting to help contain
the ambivalent feelings of love and hate. Therefore,
depression is generally considered to be a response to an
early stressful experience which is reactivated by a current
loss (Stricker, 1983).

Application and adaptation of the psychodynamic
perspectives presented above can be found in the literature
both in the conceptualization and treatment of issues
related to grief and depression. In accounting for the
difficulty an individual may experience in relinquishing a
loss object, for example, Lopez (1984) presented clinical
cases of a 39-year-old woman in mourning and an adolescent
with reactive depression to illustrate the relevance of the
Kleinian concepts of libido adhesiveness and the mourning
process as equivalent to the shift of defenses from the
paranoid-schizoid to the depressive position. Smith (1985)
introduced a gestalt therapist’s perspective on grief and
its differences from depression based on Freud's approach to
mourning and melancholia. As an extension of this
psychodynamic position, he introduced a three-dimensional
schemata involving the intensity, duration, and type of loss
and a gestalt therapy of supporting grieving.

Belitsky and Jacobs (1986) used attachment theory as
the conceptual basis of a discussion on grief and the
clinical complications of bereavement. They described the
individual's reactions in terms of separation anxiety and

the activation of intense attachment behavior, which were

48
considered a natural and inevitable response to the loss of
an attachment figure. Complications of the bereavement
process include unresolved grief, clinical depression, and
anxiety disorders. Higher vulnerability to the development
of these pathological grief reactions was suggested for
individuals with early traumatic loss in childhood,
obsessive personality style, a history of depression, or no
prior experience with death.

Although theoretical speculation is generally not
associated with behavioralism, a behavioral perspective on
the relationship between normal and maladaptive response to
loss is suggested by the morbid grief treatment approach of
Lieberman (1978), Mawson, Marks, Ramm, and Stern (1981), and
Ramsay (1977). According to Mawson et al. (1981), the
treatment of unresolved bereavement issues is similar to
that of phobic avoidance, which exposes the individual to
painful memories, ideas, or situations both in imagination
and real life. In other words, this approach of guided.
mourning requires an intensive reliving of avoided painful
memories and feelings related to the loss.

One of the most frequently cited sociological studies
relevant to the relationship between grief and depression is
a study by Brown and Harris (1978), who explored the role of
provoking agents, vulnerability factors, and.symptom
formation factors in the development of depression in 114
‘psychiatric patients and 458 women in the community. The

provoking agents examined in this study included life events

49
such as losing a job, and long-term difficulties such as a
husband's unemployment. The results indicated that almost
all of the community residents who developed depression
during the year of the investigation had experienced a
severe life event or major difficulty; however, only a fifth
of those with such provoking agents actually broke down.

The vulnerability factors found to contribute to
depression included a lack of a confiding relationship with
husband or others, loss of one’s mother before the age of
11, having three or more children under age 14 living at
home, and lack of employment outside the home. In the
presence of a provoking agent, the rates of depression
jumped from 10% in those with a confiding relationship
regardless of their employment status to 63% in those with
no intimate relationships, early loss of mother, and/or
three or more children living at home, to 100% in those with
all four vulnerability factors. Regarding the dimension of
symptom formation factors, Brown and Harris (1978) reported
that while past loss of any kind was found to influence the
severity of depression, loss of mother before age 11 was
found to have a remarkable effect on the form of depression.
They stated that early loss of mother by death predisposed
the individual to psychotic depression whereas loss by
separation to neurotic depression. It should be noted that
‘the dichotomy of psychotic and neurotic depression as
«discussed by Brown and Harris is similar to the conventional

«distinction between endogenous and reactive depression.

50

In interpreting the results of their study, Brown and
Harris (1978) postulated that the provoking agents,
vulnerability factors, and symptoms formation factors relate
in different ways to a central experience of hopelessness,
which then lead to depression. They define loss events as
"the deprivation of sources of value and reward” and believe
that "what is important about such a loss for the genesis of
depression is that it leads to an inability to hold good
thoughts about ourselves, our lives and those close to us"
(p. 233). It was also suggested that "low self-esteem is
the common feature behind all four [vulnerability] factors"
(p. 236). Using a psychodynamic perspective, Pedder (1982)
carried Brown and Harris's interpretation one step further
by defining the concept of self-esteem as

a two-person relationship: the esteem in which

one part of the self is held by another part of

the self--or in other words an internal object

relationship, the sense of esteem or value in

which the self is held by internal objects whether

they are called Freud’s critical agency, super-ego

or internal parental images. (p. 333)

Additional perspectives on the relationship between
grief and depression have been provided by a number of
researchers who suggested the use of the grieving process in
the conceptualization of unresolved issues and intervention
in focused problem areas. Based on the model of Kubler-Ross
(1969), for example, Breen (1985) described the
psychological problems of children of alcoholics in terms of
the repressed grieving process. According to this

jperspective, the child of the alcoholic may stay

51
indefinitely in the numbing and denial stages, anger can be
internalized and expressed as guilt, and the stage of
bargaining often takes the form of a spiritual or religious
expression, which may become spiritual depletion in
adulthood. Depression is manifested in the child's
powerlessness to control the alcoholism of the parent and
usually carries over into interpersonal relationships in
adulthood. Interference with the normal grieving process is
postulated because the psychological death of the alcoholic
parent coupled with his/her physical presence is believed to
result in a "passive nonacceptance" of the fact that the
loss can not be repealed.

Bolton (1984) addressed the importance of applying
common-sense principles of intervention, facilitating the
grief process, and providing health care while survivors
face the basic fears of guilt, loss, depression, shame, and
shock in the aftermath of a family suicide. Factors
believed to influence the healing of the individual include
"basic self-esteem, ability to express feelings, positive or
negative relationship with the suicide, knowledge, spiritual
beliefs, experience with handling stress, and acceptance of
humanness of the self" (p. 39). Bolton identified the
principle of "Knowing something about the bereavement
process" as the imperative of the "postvention" stage. In
his discussion of "chronic pain as a third pathologic

emotion," Swanson (1984) compared acute and chronic pain

with grief and depression.

52

Finally, consensus can also be found in a number of
practice-oriented publications regarding the role of
unsuccessful grief in the development of depression and
other psychological problems. For example, Hagglund (1981)
used a case of a 30-year-old woman to illustrate the
transition from depression to mourning, which was
interpreted to be parallel to the transition from
narcissistic preoccupation and rejection of the objects to
the maturation of the psychic apparatus and communication
with inner and outer objects. Volkan (1985) stated that
complications can occur both in the acute and the chronic
stages of the mourning process. Based on the assumption
that complications in the chronic stages culminate
psychologically in either reactive depression or established
pathological grieving, a form of brief intensive "re-grief
therapy" is recommended.

For the patient with unexplainable depression, chronic
illness behavior or symptoms similar to those of a deceased
relative or friend, Zisook and DeVaul (1985) suggest that
the therapist needs to suspect the possibility of unresolved
grief and explore the individual's loss experience and
his/her feelings about them. In the short-term therapy of
depression, Stricker (1983) suggested a focus on a specific
area of precipitating events such as grief, role transition,
interpersonal disputes, and interpersonal deficits. Eigen
(1983) described his interpretation of a woman's depression

as pseudo self-repair in a case of blocked mourning.

53

In comparison with studies on the symptomatic
similarities and differences between grief and depression,
there appear to be a smaller number of investigations on the
theoretical relationship between the two psychological
phenomena. However, reports of empirical studies available
up to the present time seem to support some of the general
theoretical assumptions discussed above. For example,
O'Neil (1987) studied 744 university students and reported
that 44% of those with both early and recent losses in
comparison with 15% of those with either types of loss
experience showed moderate depression on the Beck Depression
Inventory. Their test of the interactional relationships
between early loss, recent loss, and depression provide
empirical support for the perspective of Freud that a recent
loss can reactivate feelings of depression which is
associated with earlier loss.

Additional support can be found in several recent
studies on grief and depression which involve the use of the
Response to Loss Inventory. Deutsch (1982) administered the
Beck Depression Inventory and the Awareness subscale of the
RTL to 152 individuals experiencing the loss of a I
relationship through death and separation. Three of her
major findings appear relevant to the purpose of the present
study. First, the RTL scores correlated significantly with
the time since the loss for individuals with minimal
experience of depression while no such correlation was found

among the severely depressed subjects. Secondly, severely

54
depressed subjects obtained significantly higher scores on
the physical dimension of the RTL when compared with
minimally depressed individuals. Furthermore, it was found
that the discrepancy between the emotional and the cognitive
dimension scores on the RTL was significantly larger for tpe
bereaved subjects who were considered to be depressed than
for the nondepressed bereaved individuals.

McGovern (1983) studied two groups of alcoholic
patients at a substance abuse treatment facility and
reported an increase of grief scores and a decrease of
depression scores upon completion of a treatment program.
Schneider, Hoogterp, and Picone (1992) conducted a study on
the depression and grief reactions of 23 patients in a
psychiatry clinic at Michigan State University. The Beck
Depression Inventory, the Response to Loss Inventory, and
the Hamilton Depression Rating Scale were administered and
both the interview format and paper-and-pencil measures were
used. They obtained correlation coefficients of .55, .66,
.68, -.28, -.52, -.57 and -.57 between scores on the B01 and
those on the Holding On, Letting Go, Awareness, Perspective,
Integration, Reformulation, and Transformation subscales of
the RTL. Similarly, the coefficients of correlation between
the Hamilton Depression Rating Scale and the 7 subscales of
the RTL were .51, .48, .61, -.35, -.46, -.63 and -.30
respectively. The results of this study appear to be
consistent with those of Schneider's preliminary validation

study on the Response to Loss Inventory (Schneider,

55
McGovern, 8 Deutsch, 1991) and support the impression of
general clusters of reactions in the grieving process--the
coping- and awareness-oriented factor and the healing- and
growth-based factor.
A State Versus Trait Distinction

A significant development in behavioral research has
been the conceptualization of psychological reactions in
terms of the state versus trait distinction. One of the
most widely recognized application of this conceptual
distinction has been Spielberger’s (1971, 1985) theory of
state and trait anxiety. An important result of his
research is the construction of the State-Trait Anxiety
Inventory, which has been used in more than 2000 studies on
a multitude of anxiety-related issues ranging from
physiological and biological processes, learning, and memory
to psychotherapy. In addition to the development of this
highly useful scale of anxiety, perhaps one of Spielberger's
most important contribution is his emphasis on the
importance of distinguishing between transitory emotional
states and individual differences of being prone to certain
psychological reactions such as anxiety as a personality
trait. This conceptual distinction appears to provide an
important insight in our search for converging themes in the
theoretical literature on the relationships between grief
and depression. As opposed to the dynamic reactions of
grief, much of the discussion in the literature appears to

be intended to account for the rigidity or persistence of

56
depressive symptoms, whether the underlying process
considered is associated with the psychodynamic process of
early relationship internalization or the concept of learned
helplessness. As Schneider (1992) has suggested, the state
versus trait distinction can be applied to the conceptual
differentiation between grief and depression.
Acceptance of Disability

A concept frequently discussed in the rehabilitation
literature is "acceptance of disability." Linkowski (1971)
defined acceptance as conscious acknowledgement of
inconveniences associated with a disability while
recognizing many more important characteristics that give
the individual meaning and a purpose in life. Although
several theories of accepting disability have been
delineated, Dembo, Leviton, and Wright (1975) presented the
concept of accepting loss which appeared to have distinct
advantages in that it was sufficiently explicated to lend
itself to operationalization (Linkowski, 1971). Consistent
with other concepts of acceptance is the emphasis that the
theory places on the subjective meaning of disability to the
impaired individual and the associated emotions and values.
Wright (1960) summarized the process of accepting loss as a
series of value changes, which included the enlargement of
scope of values, subordination of physique, containment of
disability effects, and transformation from comparative to
asset values. A number of similarities between this

jperspective and the concept of the grieving process seem

57
readily apparent. For example, Linkowski’s components which
define acceptance such as "conscious acknowledgement of
inconveniences," "recognizing many more important
characteristics," and "meaning and purpose in life" appear
to parallel conceptually the grieving tasks of acknowledging
what has been lost, recognizing what is left, and achieving
resolution and transformation through personal and spiritual
growth (Schneider, 1992). Dembo, Leviton, and Wright (1975)
also equated the acceptance of disability with the
acceptance of loss. Their discussions of the various
changes of values appear to be comparable to Schneider's
concepts of gaining perspective and the transformation of
values.

Additional theoretical support for the relationship
between physical disability and the grief process comes from
a comprehensive model of psychological reaction to loss.
This model was proposed by Katz and Florian (1987) who drew
a conceptual parallel among interpersonal loss, the loss of
a limb or function, and environmental loss or loss of peace
of mind which is frequently experienced by refugees and
those forced to move from their homes. Acceptance of a
physical disability was categorized as a reaction observed
during the resolution phase of grief. An underlying
assumption of this comprehensive model is that the dynamic
processes experienced in one area of loss can be

extrapolated and used in understanding other areas of loss.

58
The growth and transformative aspects of the grief process
is not explicitly addressed by this model.

Influence of Biographical and Demographic Variables

One of the most extensively discussed issues in the
rehabilitation literature relevant to psychological
adjustment is the severity of disability. With a few
notable exceptions, the majority of empirical studies do not
support the hypothesis of relationship between the severity
of the disability and psychological reactions of the
individual. Bracken, Shepard, and Webb (1981) stated that
emotional reactions such as anger and depression which are
seen at the time of discharge from acute care
hospitalization were all positively related to the severity
of motor impairment, and to a lesser extent, the loss of
sensory functions. Rosillo and Fogel (1970) studied 110
rehabilitation inpatients with mixed disabilities and
reported that the discharge ratings of these individuals by
psychiatrists were positively related to the severity of
disability, discomfort, and pain.

Antler, Lee, Zaretsky, Pezenik, and Halberstam (1969)
found that mildly physically disabled individuals rated the
wheelchair more positively when compared with more severely
disabled subjects. Hohmann (1966) also suggested a general
reduction in emotionality among individuals with spinal cord
injury which was greater the higher the lesion.. In
contrast, Hopkins (cited by Woodbury, 1978) reported that
the results of their research did not support the hypothesis

59
that the suicide rate increases as the severity of
disability increases. Meyerson (cited by Woodbury, 1978)
indicated that the degree of disability was not
significantly related to the internal versus external
dimension of locus of control scores. An early study by
Seymour (cited by Woodbury, 1978) showed that no differences
existed between quadraplegics and paraplegics in terms of
personality ratings by psychologists using the Rorschach
diagnostic system.

It is somewhat surprising that a small proportion of
findings available in the literature appear to be counter-
intuitive. For example, Hopkins (cited by Woodbury, 1978)
conducted a review of early research and concluded that the
severity of injury was inversely related to the suicide rate
in the spinal cord injury and the amputation populations.

It has been reported that the level of spinal cord injury is
not significantly related to successful mental adjustment
(Kerr 8 Thompson, 1972), denial (Bracken, Shepard, 8 Webb,
1981), locus of control (Crisp, 1984), scores on the Beck
Depression Inventory three weeks before, three months and
one year after discharge from the hospital (Richards, 1986),
scores on the Mini-Mult and the State-Trait Anxiety
Inventory (Cook, 1979), and productivity among individuals
with significant support (Kemp 8 Vash, 1971). Severity of
disability among individuals with spinal cord injury has
also been reported to be unrelated to the internal-external

dimension of locus of control or satisfaction with life

60
(Swenson, 1976) or self-esteem (Green, Pratt, 8 Grigsby,
1984).

A range of demographic variables have been reported in
the literature as correlates of psychological adjustment.
Demographic factors reported in empirical studies include
age, sex, education, length of time since injury, and the
number of post-injury hospitalizations (e. g., Fitzgerald,
1983). In addition, a variety of criterion variables have
been selected for the operationalization of psychological
adjustment, ranging from the individual’s ego strength to
reports of adequate coping with environmental demands and
life satisfaction. Based on the theoretical perspectives
introduced in the preceding discussions, it may be suggested
that these factors may all be related to the adjustment
factor of disability acceptance, grief, and depression. It
is important to note, however, that although a number of
studies have been reported regarding the relationship
between demographic variables and specific aspects of
adjustment, little research has been attempted regarding the
potential influence of demographic variables on the
relationship between two psychological phenomena such as
grief and depression. The interaction of factors in
determining the psychological reactions and adjustment of
individuals with disabilities appears to be a relatively

unexplored area where further research may prove to be

beneficial.

CHAPTER 3'
DESIGN OF THE STUDY
Described in this chapter are the design of the study,
the sample, the measures used, the research questions and
hypotheses, the research procedures, and the statistical
analyses conducted. Finally, a discussion concerning the
limitations of the study is provided.
Research Design
The present investigation consisted of a cross-
sectional correlational field study. Since the primary
intent of the study was to examine the relationships between
two naturally occurring psychological phenomena in a group
of rehabilitation patients, no experimental treatment was
introduced. The design of the study involved the following
steps:
1. A list of 119 polio survivors were solicited for
participation in the study.
2. 86 of these individuals signed their consent forms
and volunteered to fully participate in the study.
3. Instruments were selected to collect information
for analysis. These instrumented included the
Biographical Data Questionnaire (BDQ), the Beck
Depression Inventory (EDI), and the Response to
Loss Inventory (RTL).

4. The research hypotheses were stated.

61

62

5. The subjects were assigned alternately to two
groups based on the order in which the research
instruments were administered.

6. The inventories were administered and data
collected.

7. The data were entered into format readable by the
microcomputer version of the Statistical Package
for the Social Sciences (SPSS-PC+), and checked
for accuracy.

8. The data were analyzed to test the main research
hypotheses.

9. A series of post-hoc analyses were performed to
investigate the generalizability of relationships
between grief and depression, by exploring the
influence of a number of subject background
variables on these relationships.

Each component of the research design will be described
in detail in the subsequent sections of this chapter.

Subjects

This study involved the use of a convenience sample,
consisting of a group of individuals with post-polio
conditions. With the assistance of researchers at the
University of Michigan Medical Center in Ann Arbor,
Michigan, recruitment of these research subjects was
conducted by mail, using a list of 119 previous research

participants generated from a database maintained at the

63

University of Michigan Medical Center. Respondents to the
written invitation to the study who signed the Consent Form
or the Limited Participation Consent Form were included in
the study and the research questionnaires were administered
to them. All research participants were adults and, based
on an evaluation of available information about the 1989
post-polio study, were presumed to be within the normal
range of intellectual functioning.

Decisions on the types and sources of subjects to be
selected were based on four major considerations. First,
the scope of the present study was limited to an exploration
of reactions to a physical disability as a loss. Post-polio
disability was considered to be one of the debilitating
physical conditions seen in the rehabilitation setting
which, unlike traumatic brain injury or multiple sclerosis,
was uncomplicated by associated impairment of intellectual
and emotional functioning. Second, with the ultimate goal
of facilitating patient adjustment outside rather than
within the hospital environment, it can be argued that
professional accountability in rehabilitation dictates
reliable monitoring of patient adjustment and progress in
the context of their real-life situations. Collecting data
by mail from the subjects in the privacy and familiarity of
their home was believed to be consistent with this
philosophical stance. The University of Michigan Medical

Center is one the largest polio treatment and research

64

facilities in the country that maintain a relatively up-to-
date database on their former patients. To the best
knowledge of the investigator, the vast majority of the
individuals on the polio research database did not have
regular visits to the hospital and could be best contacted
by mail.

Third, some of the background information in the polio
research database consisted of disability ratings by
rehabilitation professionals. It was believed that this use
background information would complement the participant
self-reports solicited by the three research questionnaires.
Finally, after a somewhat deliberate attempt at recruiting
research participants, polio survivors at the University of
Michigan Hospital were one of the few groups of potential
subjects available to the investigator.

The subjects were informed that the investigator was
conducting a study on response to a physical disability.
Although it was indicated that their contribution to this
project as research subjects was expected to help achieve an
enhanced understanding of the disability adjustment process,
it was particularly emphasized that participation in this
study was entirely voluntary. It was also explained that
information regarding individual research participants would
be kept strictly confidential and that the results of the
study would be reported only in nonidentifiable and

aggregate format. The subjects were advised that they could

65

choose to discontinue their participation in this study at
any time and that choosing to participate or not to
participate would not result in any treatment privilege or
affect the services they received at the University of
Michigan Medical Center.

The subjects were informed that the study would involve
the utilization of three self-report questionnaires which
would be administered to them by mail and could be completed
in roughly an hour. They were asked to grant permission for
the investigator to access background information about them
through a database at the University of Michigan Medical
Center. It was explained that the first of the three
questionnaires which they were asked to complete would be a
survey of additional information about their general
background, life experience, and their disability history.
One of the other questionnaires would require answering
questions about their current feelings and thoughts. The
third inventory would require the subjects to rate the
accuracy of a series of statements regarding their reactions
to their disabilities. The subjects were then asked to
complete the standard research Consent Form as required by
the Human Subjects Committees at both Michigan State
University and the University of Michigan Medical Center.
They were also informed that those who indicated an interest
in the results of the study on the research consent form

‘would be provided a brief summary of findings at the end of

66

the investigation. As a compensation for their time and
involvement in this study, it was explained to the
participants that a check for $10 would be provided to them
upon receipt of their three completed questionnaires.
Measures Used in The Study

In addition to a biographical data questionnaire, two
other measures were used in the study. The Beck Depression
Inventory was selected as a widely reputable measure of
depression and the Response to Loss Inventory was used to
measure different aspects of the individual’s grief
reactions.
W

Information regarding the background of the subjects
was collected with the use of the Biographical Data
Questionnaire. This is a survey instrument designed by the
investigator specifically for the present study. Self-
report items were included in the questionnaire to determine
biographical variables such as current occupation and
volunteer work activities, age and sex of children, initial
awareness of the disability as a loss, and previous history
of loss experience and depression (see Appendix A). Five-
point rating scales were used to solicit information about
the subjects' perceptions of their own general health status
(excellent, very good, good, fair, or poor), emotional
support from others (extremely dissatisfied, very
dissatisfied, satisfied, very satisfied, or extremely

67

satisfied), the severity of their disabilities (not severe
at all, not very severe, moderately severe, very severe, or
extremely severe), and chance of complete cure from their
physical disabilities (0%, 25%, 50%, 75% or 100% chance).
W

The Beck Depression Inventory is an extensively
researched instrument that has received wide acceptance by
both researchers and clinicians. It is a 21-item, self—
report questionnaire based on cognitive, emotional,
motivational, and physical manifestations of depression.
This measure was selected to operationalize the concept of
depression because of its high reliability and validity, the
short administration time required, and its wide use in both
general behavioral and psychosocial rehabilitation research.
Each of the items on the BDI consists of four evaluative
self-statements in order of increasing severity. The
subject is instructed to circle the statement that best
describes his or her feelings.

The BDI is known to have acceptable levels of both
reliability and validity. A split-half reliability
coefficient of .86 has been reported on a sample of 97
depressed subjects (Beck 8 Beamesderfer, 1974). Item
analysis demonstrated a positive correlation between each
item of the BDI and the total score (Beck 8 Beamesderfer,
1974). In addition to its face validity, the content

validity of the BDI has been rated as high (Stehouwer,

68

1985). It was also found to have a correlation of .65 with
clinicians’ global ratings regarding the depth of depression
(Conoley, 1992). Nussbaum and Michaux (cited by Beck 8
Steer, 1987) reported that initial and final correlation
coefficients between the depression subscale of the
Minnesota Multiphasic Personality Inventory (MMPI D-Scale)
and the BDI were .75 and .69 respectively. Construct
validity of the BDI has been supported by the empirical
validation of seven hypotheses regarding a number of
characteristics of depression, including masochistic dream
content, negative self-concept, identification with the
loser on projective tests, history of deprivation,
disproportional drop in self-esteem as a response to
experimentally induced failure, high correlation between
intensity of depression and suicidal intent, and significant
subjective and objective improvement following a success
experience.
B3EDQn§§_§Q_LQ§§_IDXEDIQI¥

Although the issues of loss and grief have been
recently given an increased amount of attention in the
clinical literature, previous attempts at objective
assessment of grief issues have utilized a very limited
number of grief measures. Most of the available measures
are geared towards particular types of loss experience such
as bereavement. With the exception of Schneider's Response

to Loss Inventory, none of these instruments appears

69

suitable for use with rehabilitation patients with physical
disabilities such as polio and post-polio conditions.

As a result of a 10-year developmental process, the
Response to Loss Inventory is a self-report questionnaire
which includes 517 items in its entire scale. Two shorter
alternative (split-half) forms of the total RTL have been
developed to reduce the amount of time required for
inventory administration and to aid future research efforts
which involve pre-post or longitudinal treatment designs.

Each item on the RTL corresponds to one of the
observable phenomena which have been identified as related
to normal grieving in Schneider's model (Schneider, 1984,
1994). The task of the subject is to indicate on a 5-point
scale if the statement contained in each item definitely,
most of the time, some of the time, occasionally, or does
not accurately describe his or her present feelings or
reactions to a specific loss. The individual is instructed
to skip the item if he/she believes that the statement is
true about him/her but not a reaction to the loss. The
score profile is separated into seven distinct subscales:
Holding On, Letting Go, Awareness, Perspective, Integration,
Self-Empowerment, and Transformation. Each of these scales
correspond to one of Schneider's postulated phases of
grieving.

The Awareness subscale has been of most interest to

researchers and thus there is more information available

70

regarding its reliability and validity. Deutsch (1982)
reported an internal consistency coefficient of .95 for the
scale, and two empirical studies have contributed to the
construct validation of the scale. McGovern (1983) found
that across the time of alcoholism treatment, scores on the
BDI decreased, while scores on an adapted version of the
Awareness subscale of the RTL increased. This finding
suggests not only a difference between the two constructs
but possibly an inverse relationship between the two.
Deutsch (1982) reported empirical confirmation of several
theoretical hypotheses regarding the awareness of the
grieving process, such as the prediction of the RTL
Awareness subscale scores based on the impact of the loss
and time since the loss, the differentiation of grief and
depression based on depressed subjects' defensive system of
separating cognition from emotions, and the association of
depression and significantly higher scores on the Physical
Index on the RTL Awareness subscale.

The most recent and systematic research efforts related
to the reliability and validity of the RTL involved an
investigation of 207 subjects selected from a variety of
loss groups, clinical settings, classes, workshops, and
therapy groups (Schneider, McGovern, 8 Deutsch, 1990, 1991).
These subjects represented a wide range of age groups,
living conditions, types and nature of loss experience,

length of time since the loss, and certain subjective

71

factors such as the individuals’ perceived presence or
absence of choice. Partial results of this validation study
were two sets of reliability coefficients for the different
subscales of the RTL. The Cronbach’s alpha reliability
coefficients for these subscales range from .88 to .97,
while Guttman split-half coefficients ranged from .90 to
.96. Evidence of construct validity of the RTL was provided
by constructing a intercorrelation matrix for the various
subscales. The correlation matrix indicates two strong
clusters of factors, confirming the clinical observations of
Schneider and his colleagues, and lending support to the
hypothesis that a major shift occurs in the grieving process
that allows some people to distance themselves and grow from
their losses. Additional research is needed to explore this
hypothesis. 1

The RTL was selected for the present study for two
primary reasons. First, it represented the most systematic
and comprehensive approach to date to the assessment of
grief experience. Second, the development of this
instrument was based on a thorough review and consideration
of the grief literature (Schneider, 1984), years of clinical
observations (Schneider, McGovern, 8 Deutsch, 1990, 1991), a
coherent theoretical framework (Schneider, 1984, 1994), and

a great deal of effort on the repeated validation of the

inventory items.

72

Research Questions and Hypotheses

The primary research question concerning the
relationships between depression and grief was investigated
in the hypothesis testing phase of this study.

Specifically, attempts were made to address this general
question by testing a total of seven hypotheses regarding
the relationships between depression and each of the seven
phasic components of the grieving process (see page 11 for a
description of these phasic components).

H¥29&h§§i§_l= Scores obtained on the Beck Depression
Inventory are linearly related to scores on the RTL Holding
On subscale. In other words, the subjects’ attempts to beat
their loss and stress experience were expected to be related
to the intensity of their depression.

Hype;heeie_11: Scores obtained on the Beck Depression
Inventory are linearly related to scores on the RTL Letting
Go subscale. In other words, subjects’ reported experiences
of depression were expected to be related to their attempts
to cope by minimizing the significance of their loss and
stress experience.

H!RQ§D§§1§.III= Scores obtained on the Beck Depression
Inventory are linearly related to scores on the RTL
Awareness subscale. In other words, subjects’ conscious
experiences of loss, stress, and grief were expected to be

associated with the intensity of depression.

73

H¥22§h§§i§_ly= Scores obtained on the Beck Depression
Inventory are negatively linearly related to scores on the
Perspective subscale of the Response to Loss Inventory.
High scores obtained on the Beck Depression Inventory were
anticipated to be associated with low scores on the RTL
Perspective subscale. In other words, individuals who
reported a great deal of gain in their insight about the
meaning of their disability were expected to indicate
minimal experience of depression.

Hypefiheeie_y: Scores obtained on the Beck Depression
Inventory are negatively linearly related to scores on the
Integration subscale of the Response to Loss Inventory.
High scores obtained on the Beck Depression Inventory were
anticipated to be associated with low scores on the RTL
Integration subscale. In other words, individuals who
reported active involvement in remembering and finishing
business with their physical disabilities as a loss were
expected to indicate minimal experience of depression.

fiypefiheeie_yl: Scores on the Beck Depression Inventory
are negatively linearly related to scores on the Self-
Empowerment subscale of the Response to Loss Inventory.

High scores obtained on the Beck Depression Inventory were
anticipated to be associated with low scores on the RTL
Self-Empowerment subscale. In other words, individuals who
reported a great increase of resourcefulness, flexibility,

(and responsivity as a reflection of their physical

74

disability were expected to indicate minimal experience of

depression.

Hype;heeie_¥11: Scores on the Beck Depression
Inventory are negatively linearly related to scores on the
Transformation subscale of the Response to Loss Inventory.
High scores obtained on the Beck Depression Inventory were
anticipated to be associated with low scores on the RTL
Transformation subscale. In other words, individuals who
reported a great deal of changes in their world views and
the nature of losses in general as a function of their
physical disability were expected to indicate minimal
experience of depréssion.

The seven corresponding null hypotheses were identical
to the above research hypotheses except for the absence of
any hypothesized linear association between BDI total scores
and scores on the seven subscales of the Response to Loss
Inventory.

In addition to the testing of the seven main research
hypotheses, a series of post-hoc analyses were conducted.
The subject background information collected through the use
of the University of Michigan Medical Center database and
the Biographical Data Questionnaire served as the source of
independent variables in these analyses (see Tables 7-10).
The rationale for including these variables in the analyses
'was that, although they had been discussed in the

:rehabilitation literature as factors influencing

75

psychosocial reactions and disability adjustment per se,
only limited information was available regarding their roles
in the association between two psychological phenomena.
Particularly, virtually no discussion could be found
concerning the impact of background factors such as
demographic, biographical, and disability variables on the
relationships between grief and depression. Since the
existing literature had not provided a sufficiently solid
theoretical or empirical basis for the formulation of a
priori research hypotheses about such interactions, the
primary purpose of the post-hoc analyses in this study was
exploratory and heuristic in nature.
Research Procedures

The present study involved the use of a group of adult
polio survivors as research subjects. With the assistance
of researchers at the University of Michigan Medical Center,
these participants were recruited from a group of 119
individuals who had participated in a previous study on
post-polio adjustment in 1989. The process of obtaining
informed written consent from the research subjects was
implemented in two stages. First, a letter was sent along
with a Consent Form to all of the prospective subjects
soliciting their participation. Both the solicitation
letter and the Consent Form contained a description
regarding the purpose of the study, tasks for the subjects,

‘the voluntary nature of participation in and withdrawal from

76

the study, safeguards for participant confidentiality and
welfare, as well as expected compensation for their
participation (see Appendices E and F). Individuals who
agreed to participate in the study were asked to indicate
their intent to do so by endorsing the appropriate choice
and providing their signature on the Consent Form and
returning it in a pre-addressed postage-paid envelope prior
to the initiation of any formal data collection activities.
Second, in order to understand the life situations of
individuals who expressed a sense of ambivalence or
reluctance about the study, those who indicated their
decision not to participate on the Consent Form were asked
to consider partial participation and the signing of a
Limited Participation Consent Form. It was explained that I
the Limited Participation Consent Form could be used to
indicate their interest in completing only the Biographical
Data Questionnaire and/or grant the investigator access to
background information about them through the University of
Michigan Medical Center database. Both the full and limited
participation consent forms were accompanied by explanations
about the nature of the consent and safeguards for them as
research participants.
Upon receipt of the returned Consent Form, participants
were sent and asked to complete a packet of three
inventories: The Biographical Data Questionnaire, the Beck

Depression Inventory, and the Response to Loss Inventory.

 

 

77

Instructions to the participants were designed to be self-
explanatory so that the inventories could be completed
independently. In order to control for the potential
confounding effects of inventory administration conditions
such as the order of inventory presentation, a counter-
balancing design was employed assigning subjects to two
groups; the first group would receive the BDQ, the BDI, and
lastly the RTL, while the second group would receive the
BDQ, the RTL, and finally the BDI. Assignment to groups was
based on alphabetical listings of batches of returned
questionnaires; every other entry in a list would be
assigned to the same group.

The purpose of administering the BDQ first was to help
the subjects become accustomed to the research task. It was
also hoped that the relatively factual nature of information
solicited would minimize potential response bias introduced
by possible individual differences in the subjects’ rate of
adjustment to the research situation.

Upon completion of the three research inventories, the
last question in the research inventory packet was
introduced to solicit the participants’ overall reactions to
the research task. Each individual was asked to indicate on
a 5-point scale if he/she felt "not positive at all," "not
‘very positive," ”positive," "very positive," or "extremely

positive" about completing the three research

78

questionnaires. The subjects were also encouraged to
provide open-ended explanations for their ratings.

Safeguards for the confidentiality of individual
participant information was implemented in this study at a
number of levels. First, cabinets and a briefcase with
locks were used by the investigator and his assistants in
the storage and transportation of all identifiable
information gathered for this study. Second, individuals
not directly related to this study did not have access to
completed research instruments and other identifiable
subject information. In addition, with the exception of the
Consent Form and the Limited Participation Consent Form, all
research instruments were assigned the subject codes (e. g.,
P-Fl, P-F2, etc.) instead of identifying information such as
the subjects’ names and social security numbers. The list
of subject identification numbers and corresponding names of
individual participants were maintained by the investigator
and his assistants at a separate and locked location.
Finally, the results of this study were discussed only in a
group or aggregate format. No individual subjects were
identified in any research report.

Statistical Analyses

The present study required a one-time administration of
three self-report instruments to all of the research
participants. The collection and manipulation of

information from these instruments yielded four sets of

79

variables: The BDI total scale scores, representing the
intensity of depression; the subject background
characteristics; the product of these two types of variables
as indicators of interaction effects; and the RTL subscale
scores corresponding to the seven phasic components of
grief. The RTL scores were always considered the outcome
variable, and the other scores, predictors.

A set of seven regression models was used to test the
seven main research hypotheses on the relationships between
grief and depression, using only the total score on the Beck
Depression Inventory as the predictor variable in each
model. The generalizability of these findings was also
investigated by searching for evidence that the
relationships between grief and depression differed between
different populations. For instance, perhaps the
relationship between Awareness and depression differed
within male and female populations of post-polio subjects.
Or, perhaps the strength of the relationship between Holding
On and depression increases with subjects’ age. For the
purpose of exploring these possibilities, interaction terms
were created (as described above) and checked for
significance within a regression format.

To address the question of whether the relationships
between depression and the seven phasic components of grief
are generalizable across demographic, health, disability,

and biographical characteristics, a preliminary examination

80

of potential interaction effects was conducted through a
five-step procedure of post-hoc data selection and analysis.
First, a number of subject background variables were
selected for analysis based on a logical judgment regarding
the theoretical and practical significance of their
potential impact on the grief-depression relationships. Due
to statistical limitations associated with the subject
requirements of regression analysis and the sample size of
the study, nominal scale background variables with multiple
categories such as marital status were converted into
dichotomous variables (e.g., 1 - Married and 2 - Not
Married). The categories of each dichotomous variable were
assigned values of O or 1 prior to the creation of the
interaction terms. Second, each of the selected background
variables was multiplied by the BDI total score to create a
corresponding set of interaction variables. For the
variable of gender, for example, all male participants were
assigned a value of 0 and all female subjects, a value of 1
before the product of the gender variable value and the BDI
total scores was obtained. Third, correlation coefficients
were obtained between the newly created interactional effect
variables and the scores on the seven grief scales from the
RTL.

Although coefficients in this correlation matrix could
serve as estimates of interaction effects, there is a

problem if the interaction term is correlated with either

81

the BDI total score or the background variable that is one
of its factors. For instance, in the case where the
interaction term of interest is GenderXBDI score, if Gender
is correlated with the interaction term, or BDI score is
correlated with the interaction term, there is a problem
with multicollinearity. A significance test of the
interaction term may merely indicate that one of the main
effects was in fact related to the outcome. This problem of
multicollinearity is common when interaction terms are
created by multiplying continuous variables (such as BDI
score) by either categorical or continuous variables. And,
as stated above, the BDI score was used in the creation of
every interaction term.

However, it would be poor practice to handle the
problem by automatically including both main effects and the
interaction term in a regression and then testing for the
interaction. When there is high multicollinearity, it
reduces the chance of finding a significant interaction
effect (or main effect). Thus, a hierarchical approach to
deletion of main effects terms was employed.

Before hierarchical procedures began, it was assumed
that 238 regressions (34 main effects X 7 grief subscales)
would be run. Each regression would include a background
‘variable, BDI total score, and a term representing the
interaction between the two main effects. As stated above,

lhowever, if multicollinearity existed, it would lead to a

82

low likelihood of determining a significant interaction
effect. If either main effect were found to be unrelated to
the outcome (not holding the interaction constant), it would
be justified to drop it from the analysis, thus reducing the
effect of multicollinearity on the remaining terms. Thus,
the following procedure was employed:

First, a correlation matrix was generated showing the
correlations between BDI score and the seven grief
subscales, and between the background variables and the
seven grief subscales.

Second, it was determined, for each of the 238
regressions, whether the BDI score was significantly
correlated with the outcome at the .05 level. If it was
not, it was deleted from the interaction analysis.

Third, it was determined, for each of the 238
regressions, whether the background variable was
significantly correlated with the outcome at the .05 level.
If it was not, it was deleted from the interaction analysis.

Using the procedure above protects against finding
significant interactions, when in fact it is the main
effects which are significant; however, it also increases
the power of finding significant interactions if they indeed
exist.

After deletion of the variables, each of the 238
regressions was run, testing for an interaction at the .01

level. Since separate testing of interaction effects for

83

each of the selected background variables for all of the

 

grief components requires a large number of regression
equations, using the commonly recognized probability level
of .05 as the threshold of statistical significance would
probably result in the type 1 error of considering
nonexistent interactional effect to be significant.

However, using a combined a of .05 across all regression
equations might lead to the type 2 error of not finding true
interaction effect. For instance, if the Bonferroni
procedure (e.g., see Hamilton, 1992, p. 132) was used to set
the overall type 1 error rate to .05, the comparison-based
alpha would be set to .05/238 = .00021. Given a two-tailed
test and a full sample size of 77 (although some.
correlations, due to missing data, utilized fewer subjects),
the power to detect a correlation of .30 would be only .18.

.The power to detect a correlation of .40 in such a situation

 

is only .51, and the power to detect a correlation of .5
(considered large by Cohen, 1988) is .88. Considering that
in the social sciences correlations of less that .40 are
most common, use of a comparison-based alpha of only .00021
would likely lead to the retaining of many false null
hypotheses of no correlation. A pragmatic compromise was
the probability level of .01 as an acceptable threshold of
statistical significance for each regression equation. The

personal computer version of the Statistical Package for the

84

Social Sciences software was employed in all of the data
analyses in this study.
Limitations of the Study.

It is important to note a number of limitations in this
study. Many of these limitations are related to the type
and source of the research sample employed. For example,
all of the subjects involved in this study were adults. It
may be argued that the developmental stage, need structure,
cognitive framework, and coping patterns of children and
adolescents may be so different from those of adults that
the results of this study may have limited relevance to the
psychosocial situations of youths. Similarly, the scope of
explorations in the present study is restricted to the
psychological reactions of adult polio survivors, most of
whom experienced minimal intensity of depression. The
generalizability of findings regarding the relationships
between grief and depression to individuals with a different
disability, acute rather than chronic debilitating health
problems, alternative loss issues or greater intensity of
depression needs to be determined through further empirical
investigations.

Moreover, like most other research endeavors in the
social sciences, participation in this study is entirely
voluntary. It is possible that differences exist in terms
of coping styles and the degrees of denial, depression, and

grief between the research subjects and those individuals

85

who were not recruited for or declined to participate in the
study. Investigations of unwilling subjects and
uncooperative patients present the researcher with a great
technical challenge and an ethical dilemma and, at present,
no attempts have been made to apply the research procedures
and findings of the present study to this group of
individuals.

Several comments can be made regarding the limitations
of the study due to the research design used. First, as
with virtually all correlational field research, the results
of this study are intended to be used for making relational
observations rather than causal inferences. Given the
current state of our research technology, no legitimate
causal assertions can be made concerning grief and
depression until further investigation is conducted that
involves longitudinal observation of levels of grief and
depression in various individuals. Furthermore, the primary
focus of the present study is a one-time exploration of
relationships between depression and grief. Any statements
made On the basis of this cross-sectional study with regard
to the process of grief, depression, and variations in the
relationships between the two variables over time is
speculative at best.

The stimulation of observations and theoretical
conjectures associated with the process of grief,

depression, and their relationships is a major purpose of

86

the post-hoc portion of data analysis. At this time,
however, the validity of any such observations will need to
be tested in future studies, preferably those involving
longitudinal research designs. Finally, the definition of
grief used in this study is primarily based on the
theoretical model of Dr. John Schneider. While it is
assumed that this comprehensive model incorporates various
aspects of the grieving process discussed in the literature,
this assumption does not exclude the possibility that
readers who subscribe to a different theoretical or
conceptual approach may need to re-interpret the results of
the study to fit their particular theoretical framework.
The present study represents an initial step in a long
series of empirical explorations needed to help us better
understand the process of grief, depression, adjustment to
disabilities, and the interrelationship among these
variables. It is hoped that the findings of this study

provide an impetus for the exploration of these issues in

future research efforts.

CHAPTER 4-
RESULTS

This chapter presents the results of the study.
Included in this chapter are a description of subject
characteristics, the outcome of hypothesis testing, and
findings from a series of post-hoc exploratory analyses.

Subject Characteristics
B§§RQD§§_EALQ

A letter of invitation to the study was sent to 119
individuals who had participated in a previous post-polio
study in 1989. This initial mailing was returned for twelve
of these prospective participants by the U.S. Postal Service
because it was considered to be "undeliverable." One
recipient of the invitation letter indicated an interest in
partial involvement with this study by completing only the
Biographical Data Questionnaire and granting research access
to the background information through the University of
Michigan database. Of the 91 respondents who agreed to
participate in the current study, 86 individuals returned
the questionnaire packet and 77 participants completed all
three research instruments.

After receiving the questionnaire packet, one
prospective participant did not fill out the Beck Depression
Inventory, six declined to complete the Response to Loss
Inventory, and two individuals withdrew their involvement
‘with this study. Explanations offered by these individuals

for their decision not to complete the questionnaires

87

88

included the absence of a significant disability or
functional impairment, a sense of irrelevance between the
issues addressed by the research questionnaires and their
perceptions of their post-polio condition as primarily a
physical disability, and a lack of interest in an
exploration of their psychological reactions.
E . F 1°

Data analysis for the study was conducted utilizing a
final sample of 33 men and 44 women whose ages ranged from
38.48 to 80.70 years with a mean age of 53.91 years. As
indicated in Table 1, approximately 49% of the 77
participants were employed, 31% engaged in volunteer work
and 20% reported having received services from Michigan
Rehabilitation Services, the state public vocational
rehabilitation program. Approximately 69% of the
individuals had educational attainment beyond high school
graduation. These subject demographic data appear to be
consistent with a recent report by the National Center for
Health Statistics (1989) which described polio survivors
overall as "middle class, well educated, and employed" with

an age range of 30s to 80s and average age of late 40s to

early 60s.

WM

Selected participant health characteristics are
presented in Table 2. Current general health ratings of

Wgood," "very good," or "excellent" were provided by 63.7%

Selected Participant

89

Table 1

Demographic Characteristics

mime
Age

Marital Status
Married
Widowed
Divorced
Separated
Never married

Number of Children

Living Situation
Alone
In a household

Education
Some high school
Finished high school
Some college
Finished college
Finished grad. school

Frequency of Religious
Service Attendance
More than once a week
Once a week
2-3 times per month
Once a month
A Few times per year
Never

Importance of Religious
Beliefs
Very important
Quite important
Somewhat important
Not Very important
Not At All important

GHGWH
ee eee
UIUUI‘DQ

10.4
89.6

7.8
23.4
28.6
27.3
13.0

46.8
26.0
14.3
6.5
6.5

53.91

Standard
mammal

9.10

77

77

77

77

77

77

77

90

Table 1 (Continued)

Standard
211131211 mmmn
Currently Employed 49.4 77
Hours of Work per Week 40.62 12.15 37
Type of Occupation 77
Professional 23.4
Managerial 5.2
Sales 10.4
Clerical 2.6
Operative 2.6
Other 5.2
Current Job Satisfaction 77
Extremely dissatisfied 2.6
Very dissatisfied 3.9
Satisfied 14.3
Very satisfied 24.7
Extremely satisfied 7.8
Experience of Job
Termination of Denial
Due to Disability 22.1 77
Currently Engaged in
Volunteer Work 31.2 77
Hours of Volunteer Work
per Week 6.51 7.67 21
Volunteer Work
Satisfaction 77
Satisfied 15.6
Very satisfied 13.0
Extremely satisfied 2.6
Personal Income 77
Under $5000 7.8
$5000-9999 9.1
$10,000-l4,999 7.8
$15,000-l9,999 3.9
$20,000-29,999 18.2
$30,000-39,999 13.0
$40,000-59,999 13.0
$60,000-79,999 3.9
$80,000 or more 1.3
Previous Service From
State Vocational Rehab. 19.5 77

91

Table 2

Selected Participant
Health Characteristics

Standard
2311.121: Wanemmh
W
Self-Rating 77
Poor 3.9
Fair 32.5
Good 37.7
Very good 16.9
Excellent 9.1
Number of Co-morbidities 2.78 1.71 77
Diabetes 7.8 77
Respiratory disease 19.5 77
Cancer/Leukemia 2.6 77
High blood pressure 36.4 77
Cardiac problems 13.0 77
Circulatory problems 37.7 77
Gastrointestinal
Diseases 29.9 77
Urinary tract disorders 35.1 77
Stroke or neuromuscular
Problems 9.1 77
Scoliosis 36.4 77
Arthritis/Rheumatism 50.6 77
MW
Life Satisfaction Rating
(on a scale of 1=very
satisfied) to 72
very dissatisfied) 2.68 1.52 77
Satisfaction With Support
(on a Scale of
lsextremely dis-
satisfied) to 52
extremely satisfied)
From doctor(s . 2.91 .95 77
From family 3.44 1.08 77
From friends 3.51 .81 76

In general 3.30 .68 73

92

of the subjects, and 82.2% described themselves as
"satisfied," "very satisfied," or "extremely satisfied" with
the amount of general emotional support from others. This
positive account of their health circumstances is consistent
with data collected approximately four years prior to the
present study in which 74% of the same individuals described
themselves as more satisfied than neutral or dissatisfied
with their life. Of the eleven types of co-morbidity
addressed in the 1989 post-polio study, 54.5% of the
subjects indicated three or more health problems other than
their post-polio conditions. Among the most frequently
reported health problems were arthritis, circulatory
difficulties in the extremities, hypertension, and
scoliosis. Current contact with a psychotherapist was
indicated by 6.5% of the subjects, and participation in a
support group was reported by 24.7%.
st' 5

Selected participant disability characteristics are
presented in Table 3. Approximately 32.5% of the
participants rated their own disability as "not severe at
all" or "not very severe." This proportion is roughly
comparable to the 31.4% who rated the amount of
deterioration from their post-polio period of best physical
functioning in 1989 as "none," "not much," and "a little."

As indicated in Table 4, the participants’ self-ratings

93

Table 3

Selected Participant
Disability Characteristics

Standard
Mable WMWE
Years Since Polio Diagnosis 41.75 2.71 77
Age of Polio Diagnosis 11.99 9.46 77
Years Since End of Best
Physical Functioning 15.64 7.81 73
Type of Polio 77
Bulbar 6.5
Spinal 54.5
Bulbar and spinal 31.2
Expert Rating of
Gait Abnormality 77
Normal 23.4
Equivocal 13.0
Mildly abnormal 18.2
Moderately abnormal 22.1
Severely abnormal 6.5
Expert Rating Regarding
Extent of Disability 77
No significant
disability 37.6
Mild disability 39.0
Moderate disability 16.9
Severe disability 6.5
Self-Rating Regarding
Severity of Disability 77
Not severe at all 13.0
Not very severe 19.5
Moderately severe 50.6
Very severe 15.6
Extremely severe 1.3

Table 3 (Continued)

23:11:21:

94

22IEIESSSQ 3253

Self-Assessed Deterioration

From Physical Best
None
Not much
A little
Some
A fair amount
Quite a bit
A great deal

Self-Rated Increase of
Pain Since Physical Best

None

A little
Some

Quite a bit
A great deal

Pain at Its Worst
Mild
Discomforting
Distressing
Horrible
Excruciating

Self-Assessed Chance of

Complete Cure From
Physical Disability
0 percent
25 percent
50 percent

100 percent

10.4
10.4
10.4
14.3
20.8
18.2
15.6

18.2
14.3
28.6
20.8
18.2

1.3
16.9
36.4
20.8
10.4

UII-‘NO
O...
Mucus

Standard
29.11.23.129

3

77

77

77

77

95

Table 3 (Continued)

Standard
mm: Museum!

Initial Awareness
of Disability 77
As an irreversible
change 74.0
Having specific
memory of when
this occurred 40.3
Number of years
since this occurred 32.28 14.23 31
As a loss 64.9
Number of years
since this occurred 29.70 14.47 32

Feeling of Being Res-
ponsible for Disability 77
Not responsible
at all 81.8
Not very responsible
Moderately
responsible
Very responsible

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97

regarding the severity of their disability were found to
significantly positively correlate with expert ratings of
gait abnormality and extent of disability which were
obtained in 1989.

Polio diagnosis by age 10 was reported by 49.4% of the
subjects, and by age 20 80.5% were diagnosed as having
polio. The number of years between the subjects’ initial
illness and diagnosis of polio and the subsequent onset of
best physical functioning ranged from 0 to 29 with a mean of
7.42 and a standard deviation of 6.15. The average duration
of this period of best physical functioning is 18.85 years
with a standard deviation of 8.77. The end of this period
occurred less than 5 years ago for 12.3% and less than 10
years ago for 21.9% of the participants. Although more than
90% of the subjects believed that the chance of complete
cure from their physical disability was nonexistent, the
recognition of their disability as a loss was acknowledged
in an appreciably smaller proportion of participants, 64% of
whom reported specific memory of when this recognition had
occurred.
11W

Participant biographical characteristics are presented
in Table 5. Experience of their own life-threatening
illness was reported by 61% of the participants; 19.7% of
‘the illness occurred before age 10 and 38.2% before age 20.

While 79.2% of the subjects reported the death of a parent,

Vgi able

Erevi ous .
Particn
Threatei

Age :

 

Death 01
Death 01
Death 01

Death 01
Age 1'

Death 01
Age 1'

Death of
Age 1'

Death 01
Age 1'

LOSS of
Age 1'

LOSS of
Than By

PinanCia

LOSS Of
Than by

Loss Of
Than by

98

Table 5

Selected Participant
Biographical Characteristics

Standard
21m 119.129.3139.! Sean 2911:1129!
Participants’ Own Life-
Threatening Illness 61.0 77
Age it first occurred 18.57 '13.55 47
Death of Partner/Spouse 6.5 77
Death of a Child 7.8 77
Death of a Grandchild 1.3 77
Death of a Parent 79.2 77
Age it first occurred 35.16 14.76 61
Death of a Grandparent 55.8 77
Age it first occurred 20.88 9.74 41
Death of a Friend 37.7 77
Age it first occurred 30.10 16.48 29
Death of a Brother/Sister 23.4 77
Age it first occurred 37.33 18.34 18
Loss of a Job 28.6 77
Age it first occurred 39.18 12.48 22
Loss of Partner Other
Than By Death 14.3 77
Loss of Home/Homeland 3.9 77
Financial Loss 9.1 77
Loss of a Parent Other
Than by Death 6.5 77
Loss of a Child Other
Than by Death 9.1 77

Table 5 (Continued)

99

Standard
Mable We: Bean 931131121131
Loss of Self Due To Trauma 2.6 77
Other Loss 13.0 77
Number of Previous Losses ‘ 3.47 1.83 77
Before Disability 10.4 77
Age it first occurred 30.00 16.77 10
Diagnosis by
A psychiatrist 1.3 77
A counselor 1.3 77
A medical Doctor 5.2 77
Family 5.2 77
Friend(s) 1.3 77
Self 10.4 77
e 5
After Disability 53.2 77
Number of years since
post-polio depression 12.86 12.93 30
Duration in months 12.32 15.52 33
Diagnosis by
A psychiatrist 10.4 77
A psychologist 9.1 77
A counselor 7.8 77
A social Worker 3.9 77
A medical Doctor 13.0 77
A priest 2.6 77
Family 9.1 77
Friend(s) 13.0 77
Self 36.4 77
W
Igeetion and Behavie;
Thoughts of Hurting Self 14.3 77
Years since self-
injurious thoughts 11.53 13.33 9
Actual Act of Hurting Self 5.2 77
Thoughts of Killing Self 22.1 77
Years since suicidal
thoughts 18.36 17.07 14

Table 5

 

variable

Actual
Kill 3

  
 
   
    

Chrrent

Durent
Current
Support
Alcoh
Alano

 

Table 5 (Continued)

2111:1112

Actual Attempts To
Kill Self

§BQ§§ED§§_522§§_EIQDLQE§

Current Alcohol Problems

Current Drug Problems

Current Substance Abuse

Support Group
Alcoholic Anonymous
Alanon

100

22331292112111

5.2

2.6

Hid

Standard
mm

H

77

77

77

77
77

 

 

Previous

in 14.3%

comparisc

 

on their
substance
Pr
In a
Beck Dapr
InVentory
measures
W
Dist
and the 1:
A °°mparj

Ifl‘v/entary

1978) ind

”Simon

101

only 55.8% acknowledged the previous loss of a grandparent
by death. The loss of a partner or spouse due to reasons
other than death (e. g., divorce) was reported by 14.3% of
the subjects, and 53.2% indicated an experience of
depression subsequent to the onset of their disability.
Previous thoughts of hurting themselves reportedly occurred
in 14.3% and suicidal ideation was experienced by 22.1% in
comparison with 5.2% of the participants who actually acted
on their self-destructive impulses. Previous experience of
substance abuse was indicated by 2.6% of the subjects.
Primary Research Instrument Score Distribution

In addition to the Biographical Data Questionnaire, the
Beck Depression Inventory, and the Response to Loss
Inventory were administered by mail to the participants as
measures of primary interest in this study.
BQQE Depression Invegtgry

Distribution of scores on the Beck Depression Inventory
and the Response to Loss Inventory are presented in Table 6.
A comparison with the distribution of Beck Depression
Inventory scores for six normative groups (Beck & Steer,
1978) indicated that the average BDI total score for the
post-polio participants was 1.42 standard deviations below
the mean score of individuals with mixed psychiatric
diagnoses, 1.82 standard deviations below that of
individuals displaying a single episode of major depression,

1.56 standard deviations below that of those with recurrent

102

Table 6

Distribution of Scores on
the Beck Depression Inventory and
the Response to Loss Inventory

De 5' vento
Percent of Mean Standard
mm WWW}!
BDI Total Score 9.10 6.65 77
Severity of Depression 77
Within normal range 59.7
Mild to moderate 28.6
Moderate to severe 11.7
B3EDQD§§_&Q_LQ§§_IDXEDLQI¥
E l I !° t'
Mean
Percentage Standard
W11 mm a
Holding On 22.50 10.77 73
Letting Go 24.53 14.58 70
Awareness 22.43 18.06 69
Perspective 43.21 18.82 62
Integration 41.67 17.99 65
Self-Empowerment 42.79 20.59 63
Transformation 50.76 25.89 57
Total RTL Score 28.28 13.76 75
a = 7
Mean
Percentage Minimum Maximum
RTL Subscale Intensity 899;; 539;;
Holding On 23.0 4 45
Letting Go 15.7 3 40
Awareness 25.0 11 55
Perspective 40.5 17 65
Integration 36.8 11 65
Self-Empowerment 39.0 21 60

 

major de
those vi
that of
deviatic
intensit‘
judged t
depressio
The stand
present 5‘
groups am
dysthymic
mew
Analj
Conducted
to limit .
“fiber of
°f items .
small DUmj
increaSed
A d8cisim
derlOPer
analYSis 1
”Ores o

103

major depression, 1.17 standard deviations below that of
those with dysthymic disorder, .45 standard deviations below
that of those suffering from alcoholism, and .44 standard
deviations below that of heroin addicts. Based on Beck's
intensity rating guidelines, 40.3% of the subjects were
judged to be within the mild to the moderate-severe range of
depression with a maximum individual BDI total score of 29.
The standard deviation of BDI total scores found in the
present study is less than those of all of Beck’s normative

groups and most similar to that of individuals with

dysthymic disorder.
W

Analysis of the Response to Loss Inventory data was
conducted after a score adjustment procedure was implemented
to limit the biasing effect of outliers. However, a small
number of participants failed to respond to a large number
of items on the Response to Loss Inventory, resulting in a
small number of extremely low subscale scores and an
increased chance of distorted group average on these scales.
.A decision was made upon consultation with the primary
developer of the RTL, Dr. John Schneider, to eliminate from
analysis the Holding On, Letting Go, and Awareness subscale
.scnres of less than 5% intensity, if at least 75% of the
subscale items were omitted by the subject. Also, among the
Perspective, Integration, Self-Empowerment, and

Enransformation subscales, scores of less than 10% intensity

which i
were al
The
selectio
average
polio di
best pos
particip
higher 1e
phases th
experienc
Subjects \
with high.
tOthis e;
Omission ;
half of t]
Counts of
RTL allow:
believed .
to his/ he:
Were base:

UPOn

104

which involved at least 50% of the subscale items omitted
were also deleted from the analysis.

The main rationale for the use of two different sets of
selection criteria for score deletion was that given the
average temporal distance of more than 41 years from their
polio diagnosis and more than 15 years from the end of their
best post-polio physical functioning, the research
participants were expected to be currently investing a much
higher level of energy in the healing- and growth-oriented
phases than the initial phases of coping with and
experiencing their disability as a loss. Therefore, the
subjects were anticipated to endorse a large number of items
with higher ratings in the second half of the RTL. Contrary
to this expectation, however, it was noted that response
omission appeared to occur more frequently in the second
half of the RTL than in the first half. Precise frequency
counts of response omission could not be obtained, since the
RTL allows the subject to skip items containing statements
believed to be true about the individual but not a reaction
to his/her disability. Impressions of response omission
were based on observations of a large number or even an
entire section of consecutively skipped items.

Upon the implementation of the score adjustment
procedure described above, a comparison of the resulting
data set with the RTL normative group statistics (Schneider,

McGovern, & Deutsch, 1991) indicated that the mean scores of

105

the post-polio subjects appeared to be comparable to the
normative average of 23.0 on the Holding On subscale,
appreciably higher than the normative average of 15.7 on the
Letting Go subscale, slightly lower than the normative
average of 25.0 on the Awareness subscale, slightly higher
than the normative average of 40.5 on the Perspective
subscale, slightly higher than the normative average of 36.8
on the Integration subscale and slightly higher than the
normative average of 39.0 on the Self-Empowerment subscale.
Normative data on the Transformation subscale was not
available.

Note that after a much longer period of years since the
onset of their loss experience, the mean of the post-polio
subjects’ scores on the Letting Go subscale is appreciably
higher than those of the normative group. The implications
of this observation are discussed in the next chapter.

Table 7 presents a matrix of correlations among the 7
phasic subscales of the Response to Loss Inventory. Data in
this table indicate two clusters of subscale scores. The
RTL subscales of Holding On, Letting Go, and Awareness were
found to significantly positively correlate with one another
at significance level of less than .001. A similar pattern
of relationships were found among the RTL subscales of
Perspective, Integration, Self-Empowerment, and

Transformation.

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106

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research

represen‘

 

questionr
deviatior
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between C
the 91‘ let
individua
equations
in Table

Rase
the Beck
with SCor
the Subje
and Stres.

thfiir dep

the restlh

107

Upon the completion of the three questionnaires, the
participants were asked to indicate their reactions to these
research instruments. On a 5-point scale with 5
representing extremely positive feelings toward the research
questionnaires, the average rating was 3.20 with a standard
deviation of 1.05. The subjects were also encouraged to
provide open-ended explanations for the ratings they had
provided. A desire to be helpful to the investigator or
other individuals with a disability was expressed in the
open-ended explanations by 20.8 of the participants without
any specific prompt for doing so.

Hypothesis Testing

A total of seven research hypotheses were proposed for
the present study, each concerned with the relationship
between depression and one of the seven phasic components of
the grieving process. These research hypotheses were
individually tested using seven linear regression analysis
equations. The results of hypothesis testing are presented
in Table 8.

Research Hypothesis I stated that scores obtained on
the Beck Depression Inventory would be linearly associated
with scores on the RTL Holding On subscale. In other words,
the subjects' attempts to overcome their experience of loss
and stress was expected to be related to the intensity of
their depression. This research hypothesis was supported by

the results of data analysis (1 - .35288, beta 3 .570774,

: UEOVEOQOQ IOQ§§
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MI -Hneoh

108

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the Beck

109

p - .002, two-tailed). The significant positive correlation
between the BDI total score and the Holding on subscale
score suggested that individuals acknowledging a more
intense experience of depression tend to exhibit stronger
attempts to cope with their post-polio condition by
conquering the issues of loss and stress associated with
their physical disability.

Research Hypothesis II stated that scores obtained on
the Beck Depression Inventory would be linearly associated
with scores on the RTL Letting Go subscale. In other words,
subjects’ reported experience of depression was expected to
be related to their attempts to cope by minimizing the
significance of their disability as a loss. As with the
preceding hypothesis, this research hypothesis was supported
by the results of data analysis (; a .54367, beta 8
1.178533, p < .0001, two-tailed). At a higher level of
statistical significance relative to research Hypothesis I,
the positive correlation between the BDI total score and the
Letting Go subscale score on the Response to Loss Inventory
suggested that individuals acknowledging a more intense
experience of depression tended to exhibit stronger attempts
to cope with their post-polio condition by minimizing the
significance of disability based experience of stress and
loss.

Research Hypothesis III stated that scores obtained on

the Beck Depression Inventory would be linearly associated

 

 

Response

acknowled
to report
Stress is
RESe
negatiVe
Beck Depr-

SUbscale

110

with scores on the RTL Awareness subscale. In other words,
subjects’ conscious experience of loss, stress, and grief
was expected to be associated with the intensity of their
depression. 0f the seven research hypotheses proposed in
this study, statistical testing of Hypothesis III yielded
the most significant results (I - .69923, pee; - 1.877378, 2
< .0001, two-tailed). The positive correlation between the
BDI total scores and scores on the Awareness subscale of the
Response to Loss Inventory suggested that individuals
acknowledging a more intense experience of depression tended
to report more intense consciousness of their loss and
stress issues.

Research Hypothesis IV stated that there would be a
negative linear association between subjects’ scores on the
Beck Depression Inventory and scores on the Perspective
subscale of the Response to Loss Inventory. High scores
obtained on the Beck Depression Inventory were anticipated
to be associated with low scores on the RTL Perspective
subscale. In other words, individuals who reported a great
deal of gain in their insight about the meaning of their
disability were expected to indicate minimal experience of
depression. This research hypothesis was not supported by
the results of data analysis (3 a .15148, beg; - .465315, 2
- .8800, one-tailed indicating a lack of evidence for the
existence of a systematic relationship between depression

and the gaining of insight in the process of grieving.

Re

 

associa
Invento
Response

Beck Deg

 

with low
words, i;
remember
disabili'
experiem
failed t.
'.516118
is some .
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finding <
depress 1‘

Res:

111

Research Hypothesis V proposed a negative linear
association between subjects’ scores on the Beck Depression
Inventory and scores on the Integration subscale of the
Response to Loss Inventory. High scores obtained on the
Beck Depression Inventory were anticipated to be associated
with low scores on the RTL Integration subscale. In other
words, individuals who reported active involvement in
remembering and finishing business with their physical
disabilities as a loss were expected to indicate minimal
experience of depression. The results of data analysis also
failed to support this hypothesis (1 = -.17665, egg; 2
-.516118, 9 = .0796, one-tailed), although certainly there
is some evidence that such a relationship might exist.
Further analysis with a larger sample may result in a
finding of significant negative relationship between
depression and the grief component of Integration.

Research Hypothesis VI proposed a negative linear
association between subjects’ scores on the Beck Depression
Inventory and their scores on the Self-Empowerment subscale
of the Response to Loss Inventory. High scores obtained on
the Beck Depression Inventory were anticipated to be
associated with low scores on the RTL Self-Empowerment
subscale. In other words, individuals who reported a great
increase of resourcefulness, flexibility, and responsivity
.as.a result of their experience with physical disability

were expected to indicate minimal experience of depression.

 

Again,

researc
between
grieving

one-tail

 

Res
associat
Inventor
Response
Beck Dep
with low
Other V10
in their
losses i
were eXp
Statisti
yield an
g~20253

Tlvc>
the cum
come fro;

mile th!
growth 3‘

lain reSE

112

Again, the results of data analysis failed to support this
research hypothesis and no systematic relationship was found
between depression and the self-empowerment phase of the
grieving process (; a .05378, QQEQ = .179626, 9 = .6622,
one-tailed).

Research Hypothesis VII proposed a negative linear
association between subjects’ scores on the Beck Depression
Inventory and scores on the Transformation subscale of the
Response to Loss Inventory. High scores obtained on the
Beck Depression Inventory were anticipated to be associated
with low scores on the RTL Transformation subscale. In
other words, individuals who reported a great deal of change
in their world views and perceptions regarding the nature of
losses in general as a function of their physical disability
were expected to indicate minimal experience of depression.
Statistical testing of this research hypothesis failed to
yield any finding of systematic relationship as proposed (;
a .20253, beg; - .862757, 2 a .9346, one-tailed).

Two distinct groups of findings can be delineated from
the outcome of hypothesis testing; the positive findings all
come from scales associated with coping and experiencing,
while the null findings are associated with healing and
growth scales.

Post-Hoc Analyses
In addition to the statistical testing of the seven

:main research hypotheses described above, a series of post-

hoc da‘

the ger

 

 

the sev
interac
by mult
demogra
issues,
analysi
practic
depress
(Table
effects
correla
associa
scores .
Mltico.
°°rrela‘
time Si]
COz'z-ela1
inVGStig
outlinec

Po]

tOtal SC

113

hoc data analyses were performed in an attempt to explore
the generalizability of relationships between depression and
the seven phasic components of grief. A total of 34
interaction effect variables were created for this purpose,
by multiplying the BDI total score with each of the 6
demographic variables, 8 health factors, 8 biographical
issues, and 12 disability characteristics selected for
analysis based on judgments regarding the theoretical and
practical significance of their potential impact on grief-
depression relationships. A correlation matrix was obtained
(Table 9) as a set of preliminary estimates of interaction
effects. However, as discussed in chapter 3, significant
correlations in this matrix could merely reflect
associations of the seven grief components with the BDI
scores and/or subject background variables, due to
multicollinearity. For example, the BDI total score had a
correlation of .99 with the interaction term associated with
time since polio diagnosis and BDI score. Table 9 shows the
correlations between BDI score and the interaction terms
investigated in this study). Thus, the three-step procedure
outlined in chapter 3 was implemented.

Following this procedure, it was found that the BDI
total score was correlated with the first three subscales
(Holding On, Letting Go, and Awareness), and uncorrelated
'with the remaining four (Perspective, Integration, Self-

Empowerment, and Transformation) (Table 10). Thus,

114

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115

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116

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117

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118

regressions with the first three grief variables as outcomes
included a main effect of BDI score, and regressions with
one of the last four grief variables as an outcome did not
include BDI score as a main effect. Also, there were only
ten significant correlations (p<.01) between background
variables and the seven grief subscales (Table 11). Thus,
for the 10 regressions using these background variables with
these outcomes, the background variable in question was kept
in the regression. For the other 228 regressions, the
background variables were omitted. This procedure thus
provided

1. Ten regressions using the BDI score, a background
variable main effect, and the interaction term.

2. 92 regressions using only the BDI score and an
interaction variable

3. 136 regressions using only an interaction term

Table 11 provides the e-values for the interaction
terms in these regressions, and Table 12 provides the p-
.values. Positive g-values indicate a change of the grief-
depression relationships in the positive direction as a
function of associated subject background characteristics,
suggesting that individuals who acknowledged stronger grief
reactions also tended to report a more intense experience of
depression if they possessed or scored higher on associated
background characteristics. Conversely, negative g-values

indicate a change of grief-depression relationships in the

119

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120

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121

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122

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123

negative direction as a function of background variables,
suggesting that, in comparison with the other research
participants, individuals with associated background
characteristics tended to report a lower intensity of
depression while acknowledging greater involvement with the
process of grief or vice versa.

Specifically, the significant findings were as follows:

1. The relationship between depression and the grief
component of Letting Go was stronger in subjects who
manifested lower satisfaction ratings of emotional support
from their doctors . i

2. The relationship between depression and the grief
component of Awareness was stronger in subjects giving a
positive appraisal of emotional support from their support
groups

3. The relationship between depression and the grief
component of Awareness was stronger in those who felt less
satisfied with the amount of emotional support from their
friends

4. The relationship between depression and the grief
component of Transformation was stronger in those who felt
more satisfied with the amount of emotional support from
their friends

5. The relationship between depression and the grief
component of Holding On was stronger in people in the sample

who were younger

124

6. The relationship between depression and the grief
component of Letting Go was stronger in people in the sample
who were younger

7. The relationship between depression and the grief
component of Letting Go was stronger for those subjects who
were closest in time from the period of their best physical
functioning

A general review of the results presented in Tables 9
and 10 reveals two findings. First, the relationship
between depression and the seven phasic components of grief
appear to be generalizable across subject background
characteristics, as suggested by the fact that only 7 or
2.9% of the 238 interaction effect tests yielded significant
results. One must guard against thinking that this implies
strong evidence of generalizability, however. There are
three problems: First, for 102 of the regressions run, main
effect variables that were sometimes highly collinear with
the interaction terms were used, due to the significant
correlations between these main effects and the outcome.
When collinear terms are in the same regression together,
the chance of finding a significant effect decreases
sharply.

Second, there may be some interaction between two
background variables that results in different relationships
between grief and depression. For instance, perhaps among

older females, the relationship between depression and

125

Letting Go is very high, while it is not so high for males
and younger females. However, the number of background
variables of interest and the small sample size precluded
any investigation relating combinations of background
variables to grief-depression relationships. Third, there
is a power issue; 238 regressions were run, each at an a a
.01. Within the 136 regressions with only the interaction
term and a grief outcome, the power for finding a
correlation of .30 or greater was only .65, given a sample
size of 75 and this alpha. Unfortunately, a larger sample
'size was not available, and increasing this alpha would
greatly increase the type 1 error rate.

The second finding regarding the interaction effects
was that six of the seven observations of significant
interaction were associated with the grief components of
Holding On, Letting Go, and Awareness, suggesting that the
relationship between depression and the healing and growth
aspects of the grieving process may be less susceptible to
the influence of background considerations, compared to the
coping- and experience-oriented components. This
differentiated pattern of the grief-depression relationship
generalizability appears to parallel the two groups of
hypothesis testing findings discussed previously and further
supports the conceptual distinction of coping- and

experience-based reactions from the healing- and growth-

126

oriented grief reactions in the process of adjusting to
post-polio conditions.

Care needs to be exercised so as not to overinterpret
these findings of specific interaction effects, as a very
small percentage of post-hoc analyses yield significant
results. The relatively small research sample used, in
combination with the use of a very large number of tests in
this phase of data analysis increases the risk of rejecting
a true null hypothesis. In general, the results of post-hoe
data analysis support the generalizability of relationships
between depression and the seven phasic components of grief
across a large number of background variables, with a
possibility of a few exceptions after taking into
consideration (and attempting to minimize)
multicollinearity.

Summary of Findings

The results of hypothesis testing yielded findings of
significant positive relationships of depression with the
coping- and experience-based grief components of Holding On,
Letting Go, and Awareness, as well as a lack of significant
relationships with the healing- and growth-oriented grief
components of Perspective, Integration, Self-Empowerment,
and Transformation. Post-hoc analyses suggested that
depression interacted with few (five) subject background
considerations in its relationship with the coping- and

experience-based components of Holding On, Letting Go, and

127

Awareness, and even fewer (one) with the healing- and
growth-oriented components of Perspective, Integration,
Self—Empowerment, and Transformation. With less than 3% of
its 238 regression analysis equations yielding results of
significant interaction effects (a a .01), and the increased
chance of type 1 error due to the large number of analyses,
the post-hoc data analysis generally supports a hypothesis
of generalizability of the relationships between depression
and the seven phasic components of the grieving process.

Of the seven regression equations resulting in findings
of significant interaction effects, two were associated with
the background factor of age and four with self-reported
satisfaction with the amount of emotional support from
friends and support groups, suggesting a potentially salient
mediational role played by these background considerations
in the relationships between grief and depression. Specific
results of post-hoc analysis prompt several interesting
observations regarding the potential mediational role of
background variables. Due to an increased chance of type 1
error associated with the large number of interaction effect
analyses performed and the relatively small research sample
employed in this study, however, these specific results need

to be interpreted with extreme caution.

CHAPTER 5
DISCUSSION

This chapter presents a discussion of the results of
the study and its implications. Included in this discussion
are the general theoretical basis of the study, an
interpretation of the hypothesis testing and post-hoc
findings, what these results suggest concerning the
differentiation between grief and depression, and
implications for clinical practice. The chapter concludes
with a number of recommendations for future research.

A Summary of the Theoretical Rationale

The purpose of the present study was to explore the
relationships between depression as a pathological mental
health condition, and the normal process of grieving, as
represented by Schneider's (1984, 1994) seven phases of
grief. This operationalization of grief, as a nonunitary
construct, goes beyond the traditional view of grief found
in the literature, where it is seen as a global phenomenon.
Two unique elements of the current investigation were the
selection of individuals with post-polio conditions as
research subjects for an exploration of long-term adjustment
issues and the incorporation of Schneider's comprehensive
model of reactions to loss in the conceptualization of
grief. Using the Beck Depression Inventory to
operationalize the amount of depression and the Response to
Loss Inventory to operationalize the amount of involvement

in the seven phasic components of grief, seven research

128

129

hypotheses were developed to examine the relationships
between depression and grief. These research hypotheses
stemmed from a critical review of the literature, which
appeared to support three general themes. I
First, while to some professionals grief and depression
appear to have similar symptomatic manifestations, important
differences between the two exist. At a deeper level,
professionals often believe that depression stems from
blocked or complicated grieving, associated with a lack of
internal capacity for dealing effectively with traumatic
change or inadequate resolution of loss issues in the
individual’s psychosocial history. Finally, a conceptual
parallel seems to exist between the concept of disability
acceptance in the rehabilitation literature and the healing-
and growth-oriented aspects of the grieving process, as
illustrated by the final four phasic components of
Schneider's grief model. These three themes combined to
suggest an investigation of the relationship of depression
with more specific measures of grief, as measured by the

RTL»

Interpretation of Results
W
The hypothesis testing supported the existence of
positive relationships between depression and the Holding
On, Letting Go, and Awareness components of the grieving

process. In other words, individuals with post-polio

130

conditions who acknowledged a strong attempts to cope with
their disability by conquering it or minimizing its
significance also tended to report a more intense experience
of depression. Similarly, those who acknowledged strong
experience of loss associated with their disability tended
to report a more intense experience of depression. These
findings yield a number of particularly significant
interpretations when the time since the participants'
initial polio diagnosis and the end of their best physical
functioning was taken into account.

In a typical case of normal grieving, one may expect to
see a relatively high degree of involvement with attempts to
cope with and awareness of loss issues during the first
year, but a lower level of involvement with these coping-
and awareness-based experiences approximately two to five
years after the loss event. However, subjects in this
sample had scores on the Holding On, Letting Go, and
Awareness subscales either basically equivalent to or higher
than the sample of 207 individuals used in Schneider,
McGovern, and Deutsch (1991); these 207 individuals were, on
the average, less than five years from their loss event.

The fact that the subjects in this study showed relatively
high degrees of involvement with coping- and awareness-
oriented experiences more than 41 years after their initial
polio diagnosis and 15 years after the end of their best
physical functioning, combined with the finding of positive

131

correlations between depression and the three grief
subscales mentioned above, tends to support the state-
versus-trait theory of grief-depression differentiation. In
other words, individuals who display relatively significant
amounts of what appear to be early grief reactions, without
an appreciable reduction in their intensity over a long
period of years, may actually be exhibiting persistent
symptoms of depression.

Furthermore, the finding of significant positive
relationships between depression and the coping-oriented
components of grief also lends support to clinicians'
prevalent working definition of depression as an outcome of
blocked or complicated grief. Although attempts to conquer
problems associated with a physical disability may serve an
important function of modulating the extent of loss
awareness as an adaptive initial reaction to disability, the
finding of a significant positive relationship between
depression and the grief component of Holding On indicates
that excessive use of this fighting response over an
extended period of years may interfere with the normal
progression of the grieving process and lead to the
formation of depressive symptoms. The significant positive
relationship between depression and the grief component of
Letting Go validates the clinical observation of Schneider
(1995), regarding the pertinent role of the avoidance or

flight coping response in the development of depression. It

132

may be suggested that premature attempts at detachment from
the experience of loss, by minimizing the significance of
disability, may contribute to the symptoms of denial, self-
reports of feeling immobilized, and fixed emotional states,
which have been discussed as among the unique features of
depression (Schneider & Deutsch, 1992a & b).

As the phasic component whose manifest characteristics
have been most frequently discussed in the literature as
symptoms of the grief response, awareness of loss was found
to have a strong positive relationship with depression.
This finding supports the idea that the considerable
similarity between grief and depression may explain the lack
of consistency in the literature regarding the role and
treatment of depression in the process of disability
adjustment. Consistent with the preceding discussions, one
way of resolving this confusion regarding the psychological
reactions of the post-polio subjects is to consider the
coping- and experience-based components of grief to be
indicators of depression as a mental health problem.
Clearly, this is a pathologically oriented approach to data
interpretation, for which indirect support can be found from
several subject characteristics.

For example, the absence of a severe physical
disability was indicated for nearly three-fourths of the
subjects based on expert judgment and one-third of the

subjects according to their self-appraisal. In the absence

133

of severe physical disability, considering the participants'
self-reported negative psychological reactions to be
indicators of depression is consistent with the clinical
belief and theoretical postulate that grief is a normal
reaction to an objectively significant loss while depression
is related to a distress source of an internal and
unrealistic nature or the lack of an adequate internalized
coping structure. In summary, pathologically focused
interpretations concerning the positive relationships
between depression and the coping-oriented grief components
of Holding On and Letting Go, as well as the experience-
based grief component of Awareness, argue that signs that a
subject is in a coping or experience-oriented phase of the
grieving process may actually indicate a pathological
phenomenon of depression, especially when there is an
absence of a severe disability, a history of blocked or
complicated grief, and an inadequate internal structure for
dealing with change and stress.

The interpretations of results provided above are
largely based on the predominant views of the nature of
grief and depression in the clinical psychological
literature. It is important to note that, although
rationales exist for considering early signs of grief as
indicators of depression, support can be found for treating
what appear to be depressive symptoms as a part of normal

grieving. A careful consideration of the phenomenology of

134

post-polio conditions as a chronic illness and the life
development context of disability adjustment in general
suggests several alternative (and perhaps more benign)
explanations for the significant positive relationships
between depression and the grief components of Holding On,
Letting Go, and Awareness.

Unlike acute and yet relatively stable disabling
conditions such as traumatic amputation, for example, one of
the unique aspects of the post-polio experience is a sense
of lacking closure regarding the ultimate extent and impact
of the resulting disability. It is possible that the
unpredictability of polio symptom relapse and concerns over
the possible occurrence of a "second disability" (Frick,
1985) can generate such a significant amount of distress
that a heightened awareness of disability-related loss
issues and a strong need for coping become a salient part of
the ongoing life experience for these polio survivors. If
this perspective on the nature of post-polio adjustment is
valid, than a logical interpretation of the significant
positive relationships between depression and the grief
components of Holding On, Letting Go, and Awareness is that,
given the remarkable similarities between depression and
initial signs of grief, the BDI scores of the subjects may
actually reflect nothing more than a somewhat higher
intensity of loss awareness and coping needs. These higher

intensities of loss awareness and coping needs may very well

135

be necessary, adaptive, and a perfectly normal part of long-
term adjustment to post-polio conditions as a chronic
illness with an uncertain future.

Evidence of support for seeing the subjects’
psychological reactions as normal come from a number of
characteristics found in most of the participants, including
positive perceptions of their own general health; emotional
support from others, and their lives in general despite
three or more health problems in addition to their post-
polio conditions; a self-reported history of post-disability
depression, possibly indicating some openness to the working
through of disability-related loss issues; a realistic self-
appraisal regarding the chance of complete cure from their
physical disability as nonexistent; BDI total scores within
the normal range of depression; the absence of ongoing
reliance on the service of a psychotherapist or emotional
support from a support group; and the willingness to engage
in an exploration of their psychological reactions as the
primary task in their participation in this study.

An alternative interpretation supporting the premise of
the subjects’ normal psychological reactions resulted from
speculations on the potential impact of life span
development issues as a context for disability adjustment.
Traditional views in the rehabilitation literature such as
stage theory consider disability adjustment as a process of

linear progression toward an end point of resolution or

136

disability acceptance. In contrast, it would appear to be
consistent with clinical intuition to entertain the
possibility that individuals who have lived with a physical
disability for a significant portion of their lives may have
once felt concerned about their social desirability as
teenagers due to their unusual physique, their employability
as young adults due to unfavorable social attitudes toward
people with disabling conditions, their ability to assume
certain child care responsibilities as new parents due to
realistic limitations associated with demands for strenuous
physical activities, and their capacity for day-to-day
functional independence due to the compounding effect of
their disability and diminishing physical strength and
mental competence as a part of the aging process. The
potential interference of physical disability with the
accomplishment of normal developmental tasks across the life
span leads to speculations on the emergence, processing and
resolution of new loss issues at different stages of adult
development, providing a plausible explanation for the
results of the study as discussed above.

Given the fact that the majority of the subjects were
above the age of 50 at the time of their research
participation, it is possible that their relatively high
scores on the coping and loss awareness aspects of grief
actually reflect normal reactions to a new set of polio-

related loss issues, as they enter and attempt to adapt to

137

the late stages of their lives. Issues of life span
development have been discussed by Schneider (1989) as a
salient context of the loss and grief process, and the
ongoing nature of life span development appears to have
important implications for our conceptualization of
disability adjustment. It can be suggested from this
perspective that the meaning of physically disabling
conditions may vary over time for people with disability as
a function of their changing developmental priorities across
the life span. Instead of a task to be accomplished with an
end stage of disability acceptance as suggested by such
traditional views in the rehabilitation literature as stage
theory, disability adjustment may be considered to be a
lifelong and cyclical process of initial awareness, coping,
conscious experiencing, healing, and growing from
continually emerging loss issues at different stages of
change and development.

Statistical testing of research hypotheses 4 through 7
failed to yield significant relationships between depression
and the healing-oriented grief components of Perspective and
Integration, as well as the growth-oriented grief components
of Self-Empowerment and Transformation. This outcome on the
surface contradicts previous findings of Schneider,
Hoogterp, and Picone (1992) regarding the existence of
negative relationships between depression and the grief

components of Perspective, Integration, Self-Empowerment,

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138

and Transformation among psychiatric patients; however, note
that the population of interest in their study (psychiatric
patients) differs from those in the present investigation.
The null results for hypotheses 4 through 7 are also
inconsistent with the theoretical premise that depression is
a result of blocked or complicated grieving and that it can
be differentiated from normal grief by a consistent absence
of healing- and growth-oriented reactions, such as the
ability to see meaning for the disability as a loss. A
number of explanations can be proposed for this surprising
outcome.

One of the more parsimonious explanations is that the
post-polio sample may be inadequate for the study of grief
and depression. Emphasized by this interpretation are the
limitations of the subject group employed in the study. It
can be argued that a possible outcome of these limitations
is that scores on the Beck Depression Inventory and the
Response to Loss Inventory could have reflected
characteristics of the participants other than depression or
grief reactions. Since the Beck Depression Inventory
includes a number of items on the physical symptoms of
depression, for example, the BDI total score as a measure of
depression could have been inflated due to the individuals’
endorsement of such items as complaints of physical aches
and pain, inability to work, and fatigue, which may be a
very realistic and understandable part of their post-polio

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139

condition. It is also possible that after an extended
period of years since their polio diagnosis and the end of
their best physical functioning, the participants may have
long resolved their loss issues, and scores on the coping-
oriented RTL subscales of Holding On and Letting Go may have
merely reflected their long-standing style of solving
problems or coping with stress in general rather than their
reactions of grief to their disability.

Another possibility is that despite the participants’
attempts to focus their attention on issues relevant to
their disability, their responses to the research
questionnaires might have included reactions to a range of
unrelated issues in their lives as a potential source of
data contamination. There are at least two reasons for a
serious consideration of this possibility with the post-
polio population. As the vast majority of polio survivors
is over the age of 30, the focus of these individuals’
consciousness may be on a variety of middle and late
adulthood issues unrelated to their post-polio conditions,
such as issues of their children’s separation and
individuation from them, the deterioration of cognitive
capabilities, nagging minor health problems and related
physical pain, as well as the health problems or even recent
death of their friends and relatives.

In addition, the extended period of years since their

polio diagnosis and the end of their best physical

 

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140

functioning could mean that issues of disability were far
less relevant to them than the day-to-day stress of living
with various types of frustration and irritation in our
complex society. The multitude of problems unrelated to
their disability could affect their thoughts and feelings
and cloud their consciousness of disability-related issues.
Therefore, in spite of the participants’ best effort to
restrict their responses to the research questionnaires to
reactions to their disability, it is conceivable that the
information they provided on the BDI and the second half of
the relatively long RTL may have, at times, included
reactions to the intruding issues of their immediate life
situations.

Other interpretations can be proposed for the lack of
significant relationships between depression and the
healing/growth-oriented grief components of Perspective,
Integration, Self-Empowerment, and Transformation. Although
more conservative explanations may be preferred by
empirically inclined researchers, a decision has been made
by the investigator to include these interpretations as
conceivable underlying phenomena in the current discussion
in the hope of stimulating further theoretical speculations
and investigative efforts. At present, much is still
'unknown about the process of psychological adjustment to
disability as well as the relationship between grief and

depression. In attempting to explore this uncharted

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territory, an openness to all possible explanations is an
important part of scientific inquiry, as much as is careful
empirical verification and rigorous scrutiny.

Perhaps one of the most intriguing alternative
explanations for the finding of null relationships
associated with research hypotheses 4 through 7 is that a
substantial proportion of the post-polio subjects may have
been highly oriented toward coping with or defending against
their awareness of disability based loss issues and, as a
result, minimally or inconsistently invested in accurately
responding to the healing- and growth-based items in the
second half of the Response to Loss Inventory. What has
prompted this speculation are several observations.

In reflecting on the participants’ attitudes toward the
research task in this study, it was noted that more than 75%
of those solicited to participate in this study expressed an
interest to do so, suggesting an high response rate. This
combined with the fact that these individuals had been
involved in previous research in 1989 shows a relatively
strong interest in research participation. This research
interest may have an altruistic motivational base, as
suggested by more than 20% who expressed their desire to be
helpful to the investigator and other individuals with a
disability without any specific prompt. Instead of hoping
to gain psychological benefit for their own disability

adjustment, this altruistic interest could conceivably serve

142

to maintain an external rather than internal focus of the
participants’ focus of consciousness and reflect a coping
rather than growth orientation. The possibility of the
participants’ limited or inconsistent investment in
responding accurately to items in the second half of the
Response to Loss Inventory corresponds to the observation
that response omission appeared to occur more frequently for
inventory items in the second half of the RTL than those in
the first half. This is consistent with the observation of
Scott (1992) that lupus patients in his study appeared to
systematically skip questions in their response which were
related to the issues of death and dying.

The heuristic value of this interpretation is further
suggested by its agreement with a couple of clinical
observations regarding the group dynamics of persons with
chronic debilitating conditions. It has been observed that
many support groups for individuals with chronic health
problems tend to normalize and encourage a strong caping
orientation (Schneider, 1995) and that many individuals with
multiple sclerosis who experience intense reactions of anger
and sadness tend to leave their multiple sclerosis support
groups prematurely due to a sense of incompatibility with
the strong group focus on overcoming, managing, and coping
with their disability (Plavnick, 1995). In fact, some of
these support groups may discourage reactions of grief and

even harbor resentment toward members who decide to leave -

143

with a sense of resolution, healing, and growth beyond their
loss issues.

As with these individuals, the possibility that the
post-polio participants in the present study as a group
exhibited a predominantly coping rather than growth
orientation even after an extended period of years since
their diagnosis and end of best physical functioning not
only provides an account for the lack of relationships
pertaining to research hypotheses 4 through 7, but it may
have significant implications regarding the existence of
unique human psychological response to chronic health
problems compared to other types of loss experiences and
acute disabling conditions.

Another interpretation of nonsignificant results
pertaining to research hypotheses 4 to 7 is that rather than
an absence of relationships, there might be a combination of
two distinct counterbalancing patterns of positive and
negative relationships. In other words, the failure to find
significant relationships does not negate the possibility
that the results contain two relationships of opposite
directions in two sub-groups of the research participants.
For‘example, negative relationships may exist between
depression and the healing- and growth-oriented components
of grief for participants who are relatively aware of and
have worked through loss issues associated with their

disability, while positive relationships can be found

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144

between the same set of variables for those who persistently
invest a major proportion of their energy into the
restriction of their loss awareness through excessive
attempts to cope with their disability. Based on this
concept of defense against loss awareness, the tendency of
individuals in the latter sub-group to indicate positive
changes of healing and growth despite their relatively high
intensity of depression may be considered a sign of pseudo-
healing, pseudo-growth, and pseudo-adjustment to their
disability.

An additional alternative interpretation is based on
the fact that a small number of participants omitted
response to a large number of items on the Response to Loss
Inventory and that the healing- and growth-oriented RTL
subscales of Perspective, Integration, Self-Empowerment, and
Transformation consist of the last 43% of the 259-item
questionnaire. This points to the potential cumulative
effects of such factors as subject inattention, fatigue, or
other similar difficulties in responding to the RTL items as
potential sources of erratic response bias and,
consequently, contributors of non-significant findings.
Another potential source of subject response bias may be a
diminished sense of involvement with the healing and growth
aspects of the grieving process due to the remarkable length
of time since the onset of their disability. Stated

differently, a flip-side of the old saying that time heals

145

all wounds is that time can sometimes make us forget and
fail to appreciate how much change and growth we have gone
through. Whether feeling depressed or not, most of us tend
to look into the future for further experience of success
rather than stopping to count the blessings in our past, and
problems in helping people sustain the benefits of positive
changes in their past such as therapeutic gain are familiar
challenges for mental health practitioners.

In reflecting on additional alternative
interpretations, it is important to point out that an
optimal characteristic of data distribution in the
investigation of relationships is an adequate amount of
variability in both the independent and dependent variables.
The variability of data in the present study is less
desirable than that found in the study by Schneider,
Hoogterp, and Picone (1992); for instance, the variance of
the BDI scores in their study was 86.1, while most
participants in the present study were in the normal range
of depression (with a variance of 44.22). It might be
possible for significant relationships to be found between
depression and the healing- and growth-oriented components
of grief if this study was replicated on a group with a
greater variability and intensity of both grief and
depressive reactions; however, considering that only one of

the correlations found (for depression and Integration) was

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146

negative, it is unlikely that increasing variation would
lead to findings of significant negative correlations.

Finally, there certainly exists the possibility that
there truly is no relationship between these four phases of
grief and amount of depression within the population
studied. Given that this population is somewhat unique
(with the majority over 50, all with one specific
disability) it may be that earlier findings in the
literature do not generalize to this group.
EQEI:HQQ.AD§1¥§§§

general_finging§; As an exploration of
generalizability regarding the relationships between
depression and the seven phasic components of the grieving
process, a series of post-hoc analyses of interaction
effects were conducted. These set interactions incorporated
a total of six demographic variables, eight health factors,
eight biographical issues, and twelve disability
characteristics. More than 97% of the 238 tests failed to
yield significant findings (a=.01) of an interaction effect,
a general pattern consistent with the premise that
regardless of whether one prefers to emphasize the
similarities or differences between grief and depression,
the relationships between these two intrapersonal
psychological phenomena overall appear to be relatively

'independent from external life circumstances.

147

A second general finding from post-hoc analysis is that
upon a review of the seven statistically significant
findings, there appeared to be a slight difference in the
number of interaction effects between the coping/experience-
oriented and healing/growth-oriented phasic components.

This observation tends to reinforce the conceptualization of
the seven phasic components of grief as comprising two
global factors, and further suggests that the two global
factors of grief may be qualitatively different from each
other. This two-factor conceptualization of grief is
supported by the correlations presented in Table 7. While
eight of the background variables were significantly
correlated with the coping/experience-oriented components of
grief, only one correlated with the healing/growth-based
components of grief (see Table 8). A plausible
interpretation of this pattern of main and interaction
effects is that, in terms of the nature of the subjects’
responses to their disability as a loss, the healing- and
growth-based aspects appear to be more impervious to changes
in life and environmental circumstances than the coping- and
experience-oriented phasic components. A possible
theoretical explanation for these findings may be that while
coping responses and experience of loss are susceptible to
the influence of ongoing changes in the individual’s
relatively immediate life circumstances, a characteristic of

transition to healing and growth in the grieving process is

148

a shift from an external to an internal focus of attention
and energy investment (Schneider, 1995). This speculation
is consistent with the finding that adjusted patients in
cancer remission reportedly considered the issue of how long
they would be able to live as no longer personally relevant
to them (Werner, Schwartz, Lezotte, & Chojnacki, 1985).

The line of reasoning presented above prompts a number
of questions regarding the assessment and facilitation of
disability adjustment. Do interventional efforts directed
at changes in the individual’s external environment truly
facilitate disability adjustment beyond the perpetuation of
coping responses? How do we know if the individual is truly
adjusted? Why are some individuals more adjusted than
others when there is no significant differences in
rehabilitation services provided for them? How do the
"hardiness factors" mentioned in the initial sections of
this report relate to internal versus external focus of
attention? How should we facilitate the individual’s shift
to an internal focus as a strategy of helping them change,
heal, and grow from the disability experience?

An emerging argument from the present discussion seems
to be the use of attentional shift from an external to an
internal focus as a viable sign of adjustment to disability
as a loss. This premise appears to have important
implications both in the areas of clinical practice and

disability research, given the emphasis of most

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149

rehabilitation services today on encouraging coping
responses of the individual and limiting the negative impact
of disability through medical and environmental
manipulation. There seems to be a need for increased
attention to the internal psychological processes and
phenomenological aspects of the individual in addition to
such interventions as physical and occupational therapy,
provision of assistive devices and vocational placement,
removal of architectural barriers, active schedules of
social activities, and equal opportunity legislation or
social policies against discrimination.

A third observation considers the importance of the few
findings of interaction effects on interpreting the
difference between grief and depression in selected sub-
samples. For instance, the number of years subjects were
from the end of their best physical functioning has been
found to have a negative interaction effect on the
relationship between scores on the BDI and scores on the
grief subscale of Letting Go. Thus, while the mean
correlation between BDI scores and scores on Letting Go was
.54, lending confusion to differentiating between grief and
depression for most subjects, because of the negative
interaction term, among the subjects furthest away from
their best physical functioning, there is in fact almost no
relationship whatsoever between scores on the BDI and scores

on Letting Go. One might hypothesize, then, that among

150

subjects who are farthest away from the end of their best
physical functioning, we can best differentiate between
grief and depression. When these subjects score high on the
BDI, it seems more likely that they are truly suffering from
depression, rather than simply grieving normally for their
loss. If the present study can be replicated on a different
group of polio survivors with the same seven findings of
interaction effect, then it would suggest the advisability
of considering the six associated background characteristics
in the differential evaluation of grief and depression.
Obviously, further research is needed to confirm the utility
of this assessment approach.

The observed mediational role of age in the
relationships between depression and the coping-oriented
aspects of grief is understandable given the salience of
life-span development issues (Schneider, 1989) and the
concept of growth over life experiences. After nearly a
lifetime of collecting pearls of wisdom about how to deal
with and grow from change, loss, and other traumatic events
in life, there seem to be good reasons to suggest that
compared with younger individuals, older people may tend to
exhibit healthier or more normal grieving responses as they
attempt to cepe with their disability and other life stress
with a lower intensity of depression. Those displaying
significant signs of depression despite the benefit of their

lifetime learning experiences may be truly depressed, have

 

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151

long-term susceptibility to stress, and need special
attention and possible treatment. The point is that among
this population and with this outcome (the coping-oriented
phasic components of grief) we may expect there to be
considerably less of a relationship between grief and

depression.

W In comparison with the task

of accounting for the four general findings discussed above,
interpretation of specific results of post-hoc analysis
appears to be more difficult and problematic. In addition
to the absence of repeated observations and the resulting
sense of reinforced confidence in the observations, several
of these findings appeared to be inconsistent with intuitive
judgment and present a challenge for creative data
interpretation. As indicated by the change of relationship
between depression and the coping-oriented grief component
of Letting Go in the negative direction, for example, the
interactional effect of self-reported predisability
depression appears to be inconsistent with the state-versus-
trait perspective in differentiating between grief and
depression. Perhaps one of the most parsimonious
alternative interpretation is that given the common mistake
of describing normal grief reactions as depression, self-
reported predisability depression was, in fact, a
successfully negotiated experience of normal grieving, which

may have enhanced the participants’ ability to deal with

152

loss and stress and reduced their susceptibility to
depression. Based on this explanation, individuals who
reported high intensity of depression with low coping
responses were probably suffering from an earlier experience
of unsuccessful grieving, which increased their
vulnerability to depression. A second possible explanation
is that perhaps a significant change of therapeutic nature
occurred after the predisability experience of depression,
which resulted in an increase of resilience and provide
protection against the development of depression. It is
possible that their experience of dealing with and
transforming the loss of their disability was responsible
for this therapeutic change.

A second potentially perplexing finding was that the
relationship between depression and the grief component of
awareness changed in a positive direction as a function of
the participants’ self-reported satisfaction with the amount
of emotional support from their support groups. In other
words, the more satisfied the individuals with the emotional
support of their support groups, the stronger the positive
association between depression and awareness of loss. This
finding is not consistent with the belief that emotional
support would lead to successful negotiation of the grief
process and, therefore, a more differentiated response
pattern of grief versus depression instead of increased

symptomatic overlap between the two psychological phenomena.

153

In searching for a plausible explanation for this unexpected
finding, it may be helpful to consider the meaning and
'function of support groups. As suggested by the term,
support groups appear to address the need of individuals who
need some form of practical or emotional support, and
speaking positively about the help that they have received
from the group along with complaints of depression and
feelings of loss and grief seems to constitute a most
favorable interpersonal posture for receiving more support
from others. In other words, instead of only reporting
their experience of loss awareness and depression, there is
a possibility that subjects who had a relatively strong need
to seek support from others might have unwittingly let their
responses to the research questionnaires include certain
aspects of their typically pleasing interpersonal style.

A third somewhat surprising finding of specific
interactional effect was that the relationship between
depression and the grief component of Transformation changed
in the positive direction as a function of self-reported
satisfaction with the amount of emotional support from
friends. In other words, the more satisfied with support
from friends, the stronger the positive association between
depression and Transformation of loss. Given the supposedly
grief-facilitating role of emotional support, one might have
expected a change of this relationships between depression

and Transformation in the negative direction toward a

154

response pattern of differentiation. The reasoning of an
alternative view is similar to the interpretations discussed
above. Again, the assumption is that a report of depression
on the Beck Depression Inventory along with satisfaction
with support of others suggests an inability to utilize
interpersonal resources for coping, a potentially
significant sign of depression. High degrees of self-
reported involvement with loss Transformation in the context
of depression suggests a possible inner struggle for
movement toward the positive and may be a reflection of
pseudo-growth and pseudo-Transformation.
ngngignifiggnt_finging§, In addition to a review of
significant results, considerations of nonsignificant
findings also lead to some interesting and important
discoveries. Given the traditional emphasis of
rehabilitation services on returning the individual to full-
time employment and the focus of social work interventions
on the marital and family relationships, for example, the
nonsignificant effect of both marital and employment status
appear to have some treatment implications. As indicated in
Tables 8 and 9, neither marital nor current employment
status was found to have any interactional effect on the
grief-depression relationships or relate to these
psychological factors in any significant way. Obviously,
these observations suggest a need to focus more diagnostic,

treatment, and service attention on the internal processes

155

and phenomenological world of our clients if we believe that
their feelings matter to us and that psychological
adjustment is as important as adaptation to the external
environment. Clearly, there is a need for us to evaluate
our working assumption that environmental interventions can

lead to psychological adjustment.
A_ggzg_gfi_§ag§igg. It should be emphasized that

without the benefit of a priori prediction based on sound
theoretical foundation, the results of post-hoe analysis
should be interpreted very conservatively. Interpretations
for the four general post-hoc observations were presented
with a sense of confidence as hypotheses pending further
research verification because all of them were based on
patterns of observations rather than a particular finding
alone. Without the confirmation of repeated observations,
however, single findings of significant interaction effects
should be interpreted with care. Furthermore, considering
the relatively small sample of this study for the purpose of
large-scale systematic explorations and the large number of
interactional effect tests used in the post-hoc analysis of
data, the relevance of this word of caution cannot be
overemphasized. Until thorough scrutiny and a systematic
verification through further research efforts, the primary
value of the specific results of post-hoc analysis and

interpretation is primarily heuristic in nature.

156

Differentiation Between Grief and Depression

As stated earlier, a major impetus for the present
investigation has been a lack of semantic precision and
consistent empirical evidence in the identification and
differentiation of depression from grief, which is believed
to be responsible for much of the confusion concerning the
role of depression in the process of psychological
adjustment to disability. Through the testing of seven
research hypotheses on the relationships between depression
and the seven phasic components of grief, it was hoped that
the results of this study would lead to patterns of
observations that would facilitate an empirically
substantiated differentiation between grief and depression.
The reasoning underlying the design of this correlational
field study was relatively straightforward. It was expected
that significant findings of positive relationships would
serve to define the similarities and significantly negative
relationships would highlight the differences between grief
and depression. Based on a critical review of relevant
literature, the prediction was made that although grief and
depression could be similar in the early phases of
disability adjustment, significant negative relationships
should be found between depression and the healing-oriented
components of Perspective and Integration and the growth-

based components of Self-Empowerment and Transformation.

157

The results of hypothesis testing confirmed a great
deal of symptomatic overlap between depression and the first
three phasic components of grief, but failed to yield any
findings of a negative relationship; in fact, three of the
four correlations that were "supposed" to be negative were
actually positive in nature, although generally very small.
Thus, while not all hypotheses were met, and the lack of
negative relationships for the last four grief subscales
challenges some of observations of Schneider and Deutsch
(1992a), there is some indication that for the latter stages
of grief, grief and depression tend to be fairly
independent. Thus, one of the basic premises of the present
research, namely that grief is not a singular construct, has
been supported. The use of seven subscales of the grief
measure can be seen as an step towards the
conceptualization, operationalization, and exploration of
this multifaceted process.

However, a closer review of previous discussions in the
literature suggests that this effort was probably
insufficient for at least two reasons. First, it appears
that practitioners and researchers in general and developers
of both the Beck Depression Inventory as well as the
Response to Loss Inventory did not include systematic
considerations of differential diagnosis in their
instruments at the time of their construction. It is quite

understandable that a natural first attempt at the

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158

development of a new instrument is to try to capture the
primary characteristics of the concept or phenomenon the
instrument purports to measure. Considerations of
differential diagnosis seems to become important only after
this initial task of defining characteristics is
successfully accomplished, which is a rather ambitious and
frequently long—term goal in social science research.
Therefore, although the use of the seven subscales of grief
instead of a global measure appears to be a meaningful
improvement, the subscales used seem to still address the
characteristic features of grief rather than its differences
from depression. In this case, the dramatic overlap of
typical symptoms between grief and depression appeared to
interfere with the delineation of differences. An
implication of this observation seems to be the inclusion of
criteria for differential diagnosis as a reasonable next
step in the refinement of both the grief and the depression
measures.

Toward this systematic exploration of empirically
verifiable criteria for differential diagnosis, a review of
suggested differences between grief and depression in the
literature seems to point to three general directions.
First, much of the discussion on the differences between
grief and depression appears to be at the level of specific
behavior rather than any particular scale or general

concept. For example, a characteristic which distinguishes

159

grief from depression in the transition from loss awareness
to healing is a sense of looking better though not feeling
better; depressed individuals frequently cannot even manage
to look better (Schneider, 1995). Although a systematic
compilation of these diagnostically relevant behaviors into
a single scale would be conceivable some time in the future,
most of the current discussions in the literature and
clinicians’ attention appear to center on a micro-analysis
of the individual’s behavioral presentations. Second,
differentiation of grief from depression appears often to
involve considerations of process dynamics or changes of
behavior over time rather than merely the tabulation of
current symptoms, which seems to be a common strategy of the
paper-and-pencil approach of evaluation. An example of such
process considerations is the inability to consider pleasure
which seems to change over time in normal grief but remain
somewhat constant in depression.

A third observation on the issue of differentiation
between grief and depression is that theoretically driven
perspectives on the differentiation of grief and depression
often include considerations of the individual’s
developmental experiences and psychosocial history. Not
surprisingly, this is probably most apparent in
psychodynamically based approaches. Finally, there still
seems to be a great deal that we do not know about

differentiating grief from depression. At times, one can

160

not help getting the impression that conceptual distinction
between these two phenomena is assumed without any clear
stipulation of what exactly constitute the difference.
Clearly, there is still a great deal that we need to learn
from our clients and there may be much merit to the idea of
soliciting their involvement in our search for answers. In
the absence of a set of clear guidelines, there is a need
for a thoughtful evaluation and careful application of view
points and available empirical findings in one’s formulation
of an approach to grief-depression differentiation.

An important step in the empirical exploration of grief
and depression has been the advent of the Response to Loss
Inventory as a reliable and comprehensive measure of grief
reactions. Using this measure as a basis for systematic
comparison and the accumulation of knowledge, the present
study can be seen as part of a series of investigative
efforts toward the delineation of similarities and
differences between grief and depression. Based on a study
of college students with relationship loss and bereavement
experiences, Deutsch (1982) reported that individuals with
high intensity of depression tended to invest the majority
of their energy in only physical, cognitive, emotional or
behavioral dimension of the grieving process, suggesting a
split or lack of integrated response to loss as a
characteristic of depression. McGovern (1983) indicated a

decrease in depression scores and an increase in grief

161

awareness scores as a result of an alcoholism treatment
program, suggesting that increased access to grief seemed to
be associated with diminished depression and that depression
could be conceptualized as an inability to tolerate loss
awareness and an inability to grieve.

Schneider, Hoogterp, and Picone (1992) found that
depression correlated positively with the grief components
of Holding On, Letting Go, and Awareness and negatively with
the healing- and growth-oriented grief components of
Perspective, Integration, Self-Empowerment, and
Transformation. This study on a combined group of depressed
and grieving individuals suggested that depression might be
defined as the inability to consider the healing and growth
aspects of loss. Results of the present investigation
confirm the symptomatic overlap between depression and the
coping/experience aspects of grief, support the
generalizability of grief/depression relationships, and
point to interaction effects related to several important
issues. This study suggests that inclusion of pertinent
background considerations such as self-reported satisfaction
with emotional support from others and the age factor could
facilitate the differential diagnosis of depression. In
other words, symptoms of depression may be especially
meaningful for diagnostic purposes when the psychosocial
context of the individual is taken into consideration. It

is suggested that these empirically supported findings from

162

this series of inquiry can be incorporated into the
diagnostic and conceptual framework of clinicians and
researchers in the rehabilitation as well as the mental
health professions.

Finally, the current discussion on the differentiation
between grief and depression would not be complete without a
consideration of the nature of reactive depression.
Although not a focus of the present study, the relevance of
this issue needs to be acknowledged because the
differentiation between grief and depression appears to
parallel and may very well be identical to the distinction
between reactive and endogenous depression (Nelson &
Charney, 1980). The reasoning behind this view is that,
from a strictly trait-versus-state perspective, reactive
depression can be distinguished from its endogenous
counterpart based on the relatively short duration of
symptoms and, therefore, should be considered to be the same
as the phenomenon of normal grief. In other words,
depression can be differentiated from grief based on the
persistence of symptoms rather than the presence or absence
of specific symptoms. Although this argument is consistent
with the finding of positive relationships between
depression and the grief components of Holding On, Letting
Go, and Awareness, it does not provide a specific
explanation for the negative relationships in the study of
Schneider, Hoogterp, and Picone (1992) and the lack of

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relationships in the present investigation between
depression and the grief components of Perspective,
Integration, Self-Empowerment, and Transformation.

In addition, it appears to contradict discussions of
symptoms such as self-reproach (Freud, 1917), unmodulated
physical response, a lack of shifting emotional states
within the same day, a lack of favorable response to
interpersonal warmth, and negative fantasies or imageries
.(Schneider & Deutsch, 1992b) which are believed to
differentiate depression from normal grieving. Before
definitive evidence becomes available, the nature of
reactive depression is clearly an area in need of further
investigation as we attempt to achieve a more refined
differentiation between grief and depression.

Implications for Clinical Practice

Certainly, one of the most significant findings of this
study was the symptomatic overlap between the early stages
of grief and depression, and, in contrast, the lack of
overlap between depression and the later stages of grief.
Of the seven phasic components of grief, awareness has been
most commonly referred to as a depressive symptom and the
fact that it was found to have the highest positive
correlation with depression in this study appears to convey
a message of mixed blessing for mental health and
rehabilitation practitioners. Given the empirically

verified similarities of symptoms between these two types of

 

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psychological reactions, identifying intense conscious
experience of loss issues as depression or vice versa based
on typical manifest symptoms is not entirely unreasonable
and, in fact, reflects some accurate perceptions of primary
problem characteristics. In an era where credibility and
professional prestige for health care providers tends to be
associated with the concrete demonstratability of their
diagnostic reasoning and interventional efficacy and the
basis of psychologically oriented services is often
considered to be little more than intuitive manipulation of
abstract theoretical constructs, it is encouraging for
rehabilitation and mental health practitioners to see clear
support of empirical reality for some of their diagnostic
impressions.

If past clinical wisdom and the converging themes of
time-tested psychological theories demands the
conceptualization of grief and depression as two
qualitatively different phenomena, however, the significant
symptomatic overlap presents a remarkable challenge for the
practitioner in the area of differential diagnosis and
treatment. Toward the resolution of this problem, it is
important to point out that adequate differential diagnosis
of any condition or disorder should be the result of a
careful consideration of both inclusion and exclusion
criteria. As with the diagnosis of any condition involving

overlapping symptoms, it may be suggested that inaccurate

 

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identification of the awareness component of grief as
depression or vice versa probably results from an excessive
reliance on the inclusion criteria of diagnosis. While it
is logical to emphasize the importance of considering the
exclusion criteria of diagnosis, a major problem pertaining
to the differential diagnosis of depression and the grief
component of awareness is that even with the use of
depression and grief measures of empirically tested
reliability, the present study failed to yield any
significant finding of negative relationships between the
two constructs. With a very limited number of empirically
verified differences from other studies at present,
rehabilitation and mental health practitioners will have to
continue relying mostly on criteria for differential
diagnosis that have yielded clinical rather than scientific
validity.

Certain amounts of unfounded theoretical bias and
personal preference may be inevitable in the selection and
use of these diagnostic criteria, and it would be important
for clinicians to be extremely open to the possibility of
error and scrutinize their judgment on a regular basis
regarding the differential diagnosis of grief and
depression. If realistically possible, it may be advisable
to seek routine consultation with a colleague. If the
clinician subscribes to a trait-versus-state distinction

between depression and grief, it would be helpful to review

166

client progress, his/her diagnostic judgment, and treatment
plan at regular intervals on a longitudinal basis. However,
he/she must also be sensitive to the client’s changing life
span developmental needs, how the satisfaction of these
needs may be interfered by the disability, and how
interventions should be adjusted, modified or redesigned as
a result.

The finding of positive association between depression
and the grief component of Holding On has provided an
impetus for several intriguing speculations regarding the
role of rehabilitation services and the personal growth
issues of helping professionals. It appears that much of
medical treatment and rehabilitation services is intended to
help enhance clients’ coping ability through the
encouragement of the fight response. To the extent
possible, many primary treatment components such as physical
and occupational therapy, instructions on activities of
daily living, scheduling of recreational and socialization
activities, vocational rehabilitation services, and the
emphasis on "I can" rather than "I no longer can" are all
directed to the return of the individual to the premorbid
level of functioning despite the negative impact of the
disability, which may be considered a type of "Holding On"
response. Although there have been many published reports
on the facilitative impact of these service activities in

the process of disability adjustment, the effect of the

167

fight response over an extended period of years is not very
clear.

An interpretation of the results of the present
investigation based on the trait-versus-state perspective of
depression-grief differentiation appears to suggest that
fixation on the coping response may be related to a failure
to grieve and, consequently, the development of depressive
symptoms.

It is conceivable that some rehabilitation
professionals may attempt to justify their activity
orientation and coping emphasis by arguing that the learned
helplessness theory would refute the preceding
interpretation unless the emphasis on the "I can" is futile.
However, it appears that this justification is based on an
inappropriate application of Seligman’s (1975) theory and an
inadequate understanding of the grieving process rather than
true client treatment needs for at least five reasons.
First, a pervasive emphasis on coping based on a theory of
depression rather than a model of normal grieving and
adjustment implies that rehabilitation clients are more
susceptible to depression than the general population, an
assumption which contradicts a preponderance of evidence in
the empirical literature. Second, introducing interventions
on a large scale to counteract learned helplessness without
consistent and specific evidence of depressive symptoms in

each individual client constitutes a violation of the

168

concept of individualized treatment and questionable
clinical judgment. Third, as Trieschmann (1988) has pointed
out, what is important in Seligman’s theory is the belief
helplessness rather than a seemingly helpless external
circumstance. An adequate understanding regarding this
aspect of Seligman’s theory suggests a primary focus on the
phenomenological world of the individual rather than his/her
day-to-day activities.

The fourth reason is that a salient therapeutic
principle in mental health practice is to play to the
strength of rather than assume weakness in our clients.
Given the observation that people differ from one another in
their susceptibility to the belief of helplessness
(Trieschmann, 1988), a reasonable goal in rehabilitation
should be to understand better the process of developing
resilience and help our clients learn from their more
adaptive peers rather than to provide interventions on a
large scale based on the psychopathological susceptibility
of a small number of highly vulnerable individuals in our
client population. The pervasive activity and "I can"
orientation seen in many rehabilitation settings today
appears to be based on the overprotective assumption that
our clients would suffer from learned helplessness and
depression without such an emphasis. Finally,
indiscriminate emphasis on the "I can" is not only less than

sophisticated but may be counterproductive if the helping

169

professional does not have a thorough understanding of the
psychodynamics of individual clients and a theoretical
framework for ongoing appraisal of their treatment needs.

This last reason is in need of elaboration. The
emphasis on "I can" has been discussed in the literature as
a desirable practice and the concept of "ability rather than
disability" is frequently introduced by direct service
programs for individuals with disability and disability
support groups. It is the observation of the investigator,
however, that although usually with the intention of helping
encourage positive attitudes and facilitating post-
disability adjustment, these concepts are often introduced
as catch phrases with little attention to or
conceptualization of how they may be interpreted and what
psychological reactions are generated as a result.

According to Schneider (1994), the process of normal
grieving essentially involves the reactions of discovering
and acknowledging what is loss, what is left, and what is
possible. Relative to the concept of "I can", these phasic
reactions can be translated to the statements of "I no
longer can", "but I still can," and "as a result of learning
to change and grow from my disability, now I can." For
individuals in the process of developing the second and
third types of phasic reactions discussed here, the concept
of ”I can" may be, indeed, facilitative of psychological
adjustment to disability. For those in the initial phase of

 

 

 

 

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the grieving process and in need of developing a healthy
degree of loss awareness, however, prematurely and
persistently encouraging the belief of "I can" may actually
prompt the individual to employ and fixate on the mechanism
of denial at the expense of successfully negotiating the
grieving process and ultimate post-disability psychological
adjustment.

The primary purpose of discussing the "I can" concept
here is not to challenge fundamentally its potential utility
and the activity orientation; rather, it is hoped that such
a discussion can effectively highlight the importance of
providing interventions based on a thorough understanding of
our clients’ internal world, careful ongoing appraisal of
their treatment needs, and an adequate theoretical framework
for conceptualizing client reactions. It is the belief of
the investigator that the activity orientation, the "I can"
concept, and Seligman’s theory of learned helplessness may
be the conceptual and interventional strategies of choice in
the treatment of depression. Since the occurrence of
depression is more the exception than the rule in the
general population and in the absence of consistent evidence
for significantly higher incidence and prevalence of
depression among individuals with disability, however, one
cannot overlook the possibility that the pervasive activity

and coping orientation in many rehabilitation settings today

171

may be a response to the needs of the helping professionals
instead of the true treatment priorities of their clients.
In an open-ended search for potential contributors on
the part of the helper for the activity emphasis, it is
worthwhile to note a parallel between the large proportion
of coping-oriented treatment components in a typical
rehabilitation setting and the observation that a
significant proportion of helping professionals rely on the
strategy of "Holding On" in their personal as well as
professional lives (Schneider, 1995). It is a commonly
accepted assumption among those directly involved in the
training of mental health service providers that their
trainees often enter into the helping profession with
unresolved personal problems of a psychological nature and
that attempts to resolve or avoid these problems at a sub-
conscious level which impedes their sensitivity to the
treatment needs of their clients is often associated with_
the phenomenon of progress-interfering countertransference.
Considering the possibility that professional helpers often
live vicariously through their clients’ problems and that
these problems often interact with their own psychological
needs, the importance for practitioners to have a thorough
understanding of their own unresolved psychological issues
and needs, an accurate or undistorted perception of their

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boundaries between their clients and themselves can not be
overemphasized.

Beyond the obvious rationale of anticipated and the
empirically verified treatment efficacy hoped for, the
helping professional needs to consider the possibility of
any personal motivation that he/she may have for the
selection and use of particular treatment strategies. To do
so, he/she needs to have a fairly high level of self-
awareness and practiced commitment to authentic living and
personal growth. To the extent possible, administrative
policies and supervisory relationships in the rehabilitation
setting should also incorporate strategies for supporting
practitioners’ self-reflections on an ongoing basis. For
example, time should be made available for such self-
reflections, and practitioners should be encouraged to
participate in personal growth workshops with special
continuing professional development credit provided.
Particular attention should be directed toward the review of
cases involving the use of holding on coping strategies for
individuals who have been disabled for an extended period of
years with limited recent deterioration of functioning. If
the provision of such services is justified on the ground of
recent changes in the individual’s life circumstances or
developmental needs, the clinician needs to have specific
knowledge of the change and the time that it occurred. For
clients with a chronic disability such as post-polio

173

conditions, the suitability of using holding on oriented
indicators of disability adjustment such as the frequency of
recreational activities in the local community, level of
physical activities, and employment status may need to be
carefully reevaluated.

As with the phasic components of Awareness and Holding
On, the finding of a positive relationship between
depression and the grief component of Letting Go also seems
to pose a special challenge for rehabilitation practitioners
in the area of differential diagnosis. Consistent with
predominant views in the traditional psychological
literature, the results of the study point to excessive use
of the flight or avoidance response to disability over an
extended period of years as a correlate of depression.
Although this finding is highly compatible with the trait-
versus-state and the failure-to-grieve perspectives on
depression, actual diagnosis of this persistent maladaptive
flight response to disability may be more difficult, the
reason being that minimization of the significance of
disability as a core feature of Letting Go appears to bear
some resemblance to the subordination of physique which has
been described as a characteristic of disability acceptance
(Dembo, Leviton, & Wright 1975). Again, research evidence
to date does not provide specific guidelines for
differential diagnosis in this area.

174

Given the need to rely on clinical judgment, three
logical strategies can be proposed to facilitate the
differentiation of depression and the grief components of
Letting Go. First, individuals excessively employing the
Letting Go response may exhibit subtle signs of tension,
anxiety or avoidance when they are asked to consider the
extent of their loss whereas disability acceptance may be
characterized by a sense of openness or resolution.
Secondly, Letting Go may be characterized by a sense of
pessimism or negativism while subordination of physique may
convey a positive message of growth and change. Thirdly,
the other characteristics of disability acceptance can be
incorporated into the assessment process along with the
subordination of physique, including an enlargement of scope
of values, containment of disability effects, and
Transformation from comparative to asset values. The
principles of comparing clients’ self-report with their
behavior and exercising careful clinical judgment is
especially relevant when considering the failure of the
study to yield any significant linear association between
depression and the healing-based grief components of
Perspective and Integration as well as the growth-oriented
components of Self-Empowerment and Transformation.

Since individuals who acknowledged an equivalent extent
of experience with the healing- and growth-oriented aspects

of the grieving process have been observed to report various

175

intensity of depression, self-reports of change, and growth
should not be assumed to indicate favorable psychological
adjustment to disability until ample collaborating evidence
of adequate reliability and validity can be obtained and
carefully considered. As a logical extension of validity
concerns regarding self-reported aspects of grief as
indicators of adequate adjustment, it may also be important
to have a healthy sense of skepticism concerning the
clinical validity and utility of widely presumed signs of
adjustment such as full employment status; mastery of
activities of daily living; high frequency of active
physical and social activities; and self-reports of
emotional coping, adaptation, and life satisfaction in the
assessment of disability adjustment and psychological
adjustment in particular.

The results of post-hoc analysis appear to be highly
relevant to clinical practice. The practitioner can
incorporate into the diagnostic process background
considerations associated with the more differentiated
response patterns of grief versus depression, as indicated
by significant t-values in Tables 9 and 10. For instance,
among older polio survivors, it may be easier to
differentiate between grief and depression than for younger
survivors. Among younger survivors, scores on the two
measures are highly related, and it will be difficult for a

practitioner to diagnose a younger person coming in with

176

both high scores on depression and grief as definitely being
depressed or definitely grieving. However, for the older
person, differentiation between depression and grief will be
easier, given that in that population, there seems to be
little relationship between the two constructs. Because the
results of the present study do not rule out the factor of
age as a covariate of and merely a reflection of other
variables such as the length of time since the end of best
physical functioning, a healthy sense of skepticism is
recommended for clinicians in their day-to-day work with
individual polio survivors.

Since external life circumstances such as marital and
employment status were not found to be related to
involvement with the grieving process in general and the
aspects of healing and growth in particular, adequate
psychological adjustment can not be assumed on the basis of
such progress indicators as successful vocational placement,
increased levels of physical activity, and heightened
involvement with social and recreational activities.
Diagnosis, monitoring, and treatment of psychological
concerns should be considered to be an ongoing and essential
part of the rehabilitation process.

Finally, since the reliability of specific post-hoe
findings is pending further research verification, the

exercise of thoughtful clinical judgment is crucial.

177

Suggestions for Further Research

A range of alternatives can be suggested in terms of
directions for further research. Given the fact that the
results of the present study are somewhat inconsistent with
the report of Schneider, Hoogterp, and Picone (1992)
regarding the existence of negative relationships between
depression and the healing/growth-oriented grief components
of Perspective, Integration, Self-Empowerment, and_
Transformation, it is recommended that this study be
replicated on a different group of adult polio survivors.
Verification of results through a replication of the study
is also needed because the depression and grief data used in
the present investigation included a number of extremely low
scores. If the results of the study can be empirically
verified, the generalizability of these findings can be
explored through similar studies on individuals with other
chronic disabling conditions and comparisons made with
individuals with other loss issues such as acute forms of
disability, bereavement and relationship loss.

A major limitation of the study appears to be the
favorable socioeconomic status of the subjects and their
willingness to participate in psychological research. Since
the concepts of defense against loss awareness, tolerance of
unpleasant affect, and openness to external influences such
as emotional support from others are highly relevant in the

.study of depression and grief, the use of responses from

178

subjects who are ambivalent about the exploration of their
psychological reactions may result in an increased range of
depressive symptoms and intensity. Given the fact that much
of social science research tends to involve correlational
field studies, this expanded range of participant reactions
would conceivably enhance the probability of finding
significant and relevant results and the quality of future
research. Although technically desirable, the recruitment
of depressed individuals and those who feel ambivalent about
the explorations for psychological research would
understandably present an ethical dilemma and a great
logistical challenge for researchers.

Considering the diagnostic and possibly treatment value
of the Beck Depression Inventory and the Response to Loss
Inventory and pertinence of sensitivity to reactions of
grief and depression in the rehabilitation setting, one
suggested solution to this problem would be the
incorporation of both of these instruments into the ongoing
process of assessment, monitoring, and treatment evaluation.
Using assessment tools with empirically tested reliability
and validity for clinical purposes would help clients gain a
sense of reciprocity and concrete benefit for their
investment in the research, and the incorporation of
research data gathering with clinical practice may help
prevent a compartmentalization of the helping profession

into academic versus clinical sectors as well as an

179

accompanying sense of isolation and even hostility between
them, which seems to be such a common part of our
professional reality.

Our current difficulties in the empirical
differentiation between grief and depression also suggest a
few directions for future research. As a focus of
discussion in much of the relevant literature to date
(e. g., Schneider & Deutsch, 1992b), a logical next step
should be an empirical verification of diagnostic utility
for each of the specific discriminating symptoms of
depression such as fixed mood of despair and withdrawal
rather than a range of emotions; negative fantasies and
imageries rather than vivid, clear, and sometimes comforting
dreams; persistent rather than variable restriction of
pleasure; responsiveness to promises, pressure, or urging
rather than interpersonal warmth and reassurance; a loss of
connection with the self and others rather than a sense of
reassurance by the presence of close friends; and
unmodulated physical response which tends to increase one’s
vulnerability to illness.

Given the very limited amount of systematic and
comprehensive research today on the nature of the grieving
process, its relationships with and differentiation from
depression, and.the change of these reactions across an
textended period of time, the use of both the Beck Depression

jInventory and the Response to Loss Inventory with subjects

180

with different disabilities and those with other loss issues
in a series of longitudinal studies with repeated measure

designs should result in a body of knowledge that would be

invaluable in both general clinical and rehabilitation

psychology. As a follow-up to the post-hoc findings of this
study, the sensitivity of researchers to the potential

influence of early and life span development issues, family
relationships as well as psychiatric history may greatly
enhance our understanding regarding the roles of these
salient contextual considerations in the process of

adjustment to disability and traumatic life events in

general. Since our knowledge on the differentiation and

relationships between grief and depression is very sketchy
at present and much can be learned from open-ended
explorations of research participants’ reactions, it may be
helpful to incorporate into future studies the use of

unstructured or semistructured interviews.

As stated earlier, a major stimulus for the present
study has been a discrepancy of perspectives on the role and

proper treatment of depression in the process of adjustment
to disability.

It is expected that a refined and

empirically based definition of depression as differentiated
from grief through the use of both a grief and a depression
measure of established reliability and validity would

eventually result in the resolution of this discrepancy.

With the limitations of research technology and our current

181

knowledge in this area, the present study is merely a

beginning step in a series of needed investigative efforts

toward this goal. It is further believed that adequate

delineation of similarities, differences, and relationships
between grief and depression through rigorous research
verification would not only contribute to this resolution of
discrepancy in rehabilitation but also have broader

implications for the mental health profession. One of the
questions frequently challenging our observational ability

is the issue of why some individuals seem to be more capable
or robust than others in the area of dealing with stress and
traumatic life events such as a physical disability. In an

era of somewhat limited mental health resources, this

question about the individual difference of resilience

should be highly relevant to the day-to-day clinical and

administrative decisions of who should receive more

therapeutic attention and environmental support than others.

Given our widespread perception of grief as a normal

adjustment process and depression as a potentially

pathological condition, it appears that once adequately

differentiated, the individual’s grief and depression scores

can be used as a criterion for treatment and support
resource allocation. The diagnostic utility of grief and
depression can be explored by correlating them with other

indicators of adjustment. Correlations of grief and

depression with subsequent progress and adjustment can also

182

be used for predicting success and identifying at-risk

individuals for more intensive treatment. The use of grief

and depression measures before and after certain treatment

procedures also provides a method of treatment and progress

evaluation. Studies exploring the relationships of grief

and depression with other psychological variables such as

external versus internal locus of control and type A
personality can also stimulate further insight into the

inner world of people with disability and the process of

adapting to change in general.
A Concluding Statement

When life fits our expectations, we think of it as
an opportunity; when it does not, we think the
world failed us--not our expectations. ... There
are many diseases and disabilities of the body,
but there is only one plague of the mind. It is
to believe that one’s life is not enough.
What became new and exciting was this idea that
perhaps the power to determine how I look upon
life was within me. ... To accept, gracefully,
something that is awful seems impossible and a
contradiction in terms. But once you get the hang
of experiencing things from the inside, anything
becomes possible. ... When you try to explain
the unexplainable, you can not. Then you are
forced.to give up your narrow and literal beliefs.
Out of the confusion can emerge a truth beyond
words and stories-"one that casts the individual
into a higher plane of consciousness (Beisser,

1989).
Exploring the relationships between grief and depression

represents an attempt at addressing a much broader question:
How can we help our clients benefit from the growth and
transformative experience of their adjusted peers? Seeking

answers to this question is not only professionally

 

183

important but personally relevant. As Arnold Beisser so

eloquently pointed out, "it is better to be a doctor than a

patient, and not only because it is more blessed to give

than to receive." For those of us who have a clear

awareness of our own inner dynamics, it probably should not

be a surprise that our career decisions as helping

professionals are not entirely altruistic. Scholars in the

field of animal science believe that learning about the

behavior of other animals is a way of learning about

ourselves.
It is the personal conviction of the investigator that

one of the greatest benefits of living and working with
people from a different culture is that the discovery of
differences provides a mirror on our own behavior; an

excellent opportunity for gaining insight into our own

needs, motivation, and conflicts; a repetitive reminder of
such salient issues of change such as choice, personal

responsibility, and consequences; and a new horizon of

Similarly, the potential

alternati for personal growth .

growth-promoting utility of countertransference reactions

and the patient as the therapist of the professional helper

are not new concepts in the psychological literature. In

some ways, witnessing and experiencing the trials and

tribulations of adjustment to a physical disability is a

privilege. For Beisser, the adjustment to disability is a

process of learning about the "grace to accept with serenity

 

 

184

the things that can not be changed, courage to change the

things which should be changed, and the wisdom to

distinguish the one from the other" (Niebuhr cited by

Host of us can-readily see the relevance of

Beisser, 1989).
It is this

these personal growth issues in our own lives.
recognition of universality of experiences and the resulting

commitment to the ongoing process of self-exploration that
helps us develop a healthy sense of respect for our clients,
appreciate the psychological dimension and the
phenomenological aspects of the disability adjustment
process and guard against our acting on our feelings of

undesirable countertransference to the detriment of people
It is with this sense of humility and

we intend to help.
authenticity that we can most effectively uncover with our

clients the secrets of changing, growing and, in the words

of Beisser, "flying without wings."

 

APPENDICES

APPENDICES

BIOGRAPHICAL DATA QUESTIONNAIRE

RESPONSE TO LOSS INVENTORY

BECK DEPRESSION INVENTORY

SUBJECT OVERALL RATING SHEET

LETTER OF INVITATION TO PROSPECTIVE PARTICIPANTS
CONSENT FORM

FOLLOW-UP LETTERS

 

 

 

APPENDIX A

BIOGRAPHICAL DATA QUESTIONNAIRE

W

W

1.

2.

\

Today’s Date: 1
(Month) (Day) (Year)

Do you have any children? ___Yes __Ho
- (If no, please skip to question 3 below.)
- If yes, please indicate below the sex and age of each
child and whether he/she is currently living with you.

Sex Ass W
a. _Hale _Female __ _Yes _Ho
b. ___Hale ,___Female ______ ___¥es ___No
c . _Hale _Fema le __ _Yes _No
d. ___Hale ___Female ______ ___¥es ___No
a. ___Hale ___Female _______ ___!es ___No
f . _Hale _Female __ _Yes __Ho
9. __Hale ___Female __ __Yes __Ho
h. _Hale __Female __ _‘tes _Ho

Are you currently employed? __Yes __No
- (If no, please skip to question 4 below.)
- If yes:

 

a) How many hours per week do you work?

b) Your current occupation:

 

c) How satisfied do you feel about your current. job
situation? (Please check gnly one)

1. Extremely dissatisfied.

2. Very dissatisfied.

____ 3. Satisfied.

4. Very satisfied.

5. Extremely satisfied.

 

Are you currently doing any mm; work? __Yes __No
- (If no, please skip to question 5 on the next page.)

- If yes:

a) How many hours per week do you work?

 

 

b) Type of volunteer activity:

185

 

186

c) How satisfied do you feel about your current volunteer
work situation? (Please check only one)

1. Extremely dissatisfied.

2. Very dissatisfied.

3. Satisfied.

4. very satisfied.

5. Extremely satisfied.

 

5. Currently, how would you rate your general health? (Please
check only one)

1. Poor.

2. Pair.

3. Good.

4. very good.

5. Excellent.

6. How severe do you believe your physical disability is?
(Please check only one):

1. Not severe at all.

2. Not very severe.

3. Moderately severe.

4. very severe.

5. Extremely severe.

 

‘7. ‘What.do you believe is your chance of complete cure from your
physical disability? (Please check only one)

1. 0 percent chance.

2. 25 percent chance.

3. so percent chance.

4. 75 percent chance.

5. 100 percent chance.

8. How satisfied do you feel about the amount of emotional
support that you have received from (Please check only one for

each of the following):

a) Your doctor(s)
1. Extremely dissatisfied.

2. Very dissatisfied.
3. Satisfied.

4. very satisfied.

5. Extremely satisfied.

 

9.

187

in Your family
1. Extremely dissatisfied.

2. Very dissatisfied.
3. Satisfied.

4. Very satisfied.

5. Extremely satisfied.

 

c) Your friends
1. Extremely dissatisfied.

2. Very dissatisfied.
3. Satisfied.

4. Very satisfied.

5. Extremely satisfied.

 

d) Your counselor or psychotherapist

** I do not have a counselor or psychotherapist.
1. Extremely dissatisfied.

2. Very dissatisfied.

3. Satisfied.

4. Very satisfied.

5. Extremely satisfied.

 

0) Support group(s)
** I do not participate in a support group.

1. Extremely dissatisfied.
2. Very dissatisfied.

3. Satisfied.

4. Very satisfied.

5. Extremely satisfied.

W
a) How responsible do you feel you were for how your
physical disability occurred? (Please check only one)
1. Not responsible at all.
2. Not very responsible.
3. Moderately responsible.
4. Very responsible.
5. Extremely responsible.

 

 

1b) Has there ever been a time when you realized that you
‘were not going to be the same physically as you.had been
before your disability? ___Yes ___No
- If yes, do you have a specific memory of when this
realization first happened? ___Yes ___No
I

- If yes, when was that? I
(Month) (Day) (Year)

 

c)

188

Have you thought of your disability as a loss (absence of
something valuable or meaningful for you)? _Yes _No
- If yes, when did this first occur?
1

(Month)

I
(Day) (Year)

10. 23W - Please check (It) below all that you

have experienced and indicate at what age each loss happened.

 

 

 

 

 

 

 

W W
‘___ my own life threatening illness.

death of a partner/spouse.

death of a child.

death of a grandchild.

death of a parent.

death of a grandparent.

death of a friend.

death of a brother/sister.

loss of job.

loss of partner/spouse other

by death.

loss of home, homeland, culture.
financial loss (e. 9., bankruptcy).
loss of
loss of
through
loss of
through
loss of

 

 

 

 

 

freedom (e. g., arrest).
parents other than
death.

children other than
death.

self due to traumatic

 

 

 

 

experience (e. 9., crime, rape,
incest, war, other disasters, etc.)

Other:

 

 

11. .2:io:_to your disability:

Did you ever suffer from depression? ___Yes ___flo
If yes, how old were you when it happened for the first

a)

b)

3)

time?

How long did your depression last?

years old.

 

Was the depression diagnosed by a (Check all that apply) :
_ psychiatrist _ psychologist __ counselor
.___ social worker .___ medical doctor .____priest

____family
other (Please specify):

_ friend ( 8) __ yourself

 

 

189

12. anon your disability:

a) Have you suffered from depression? _Yes _No

b) If yes, approximately when? 1 1
month (Day) (Year)

b) How long did your depression last?

c) Was the depression diagnosed by a (Check all that apply):

psychiatrist psychologist _ counselor
social worker __ medical doctor _ priest

family _ friend (s) _ yourself
other (Please specify):

 

 

13. Have you mg:

a) Thought of hurting yourself? _Yes No
- If yes, when? (Please fill in appropriate numbers)

 

 

years months ago.
b) Tried to W hurt yourself? _Yes No
- If yes, when? (Please fill in appropriate numbers)
years months ago.

 

c) Thought of killing yourself? _Yes _No
- If yes, when? (Please fill in appropriate ntmbers)

 

 

_ years months ago.
d) Tried to W kill yourself? _Yes _No
- If yes, when? (Please fill in appropriate numbers)
years months ago.

14. W3

a) Are you currently experiencing any alcohol problems?
_Yes _No

b) Are you currently experiencing any drug problems?

_Yes _No
- If yes, what substance are you using now? (Please

list)

o) Are you currently participating in a substance abuse
treatment program? _Yes _No

 

 

190

d) Are you currently participating in a substance abuse

support group e. g., LL)? _Yes _No
- If yes, please provide the name of the support
group:

 

15 . Are you filling out this questionnaire by yourself or with the
help of another person? (Please check ono)
_ Dy myself .
__ with the help of another person
Relationship of your assistant to you (Hy helper is my) :

 

 

 

 

APPENDIX B

RESPONSE TO LOSS INVENTORY

 

O 1992 RTL-ODD

Jam 25. 1993

RESPONSE TO LOSS:

ODD

 

o 1992-3

191

 

192

RESPONSE TO 1358 (RTL)
Questionnaire Instruction
copyright Schneider-Deutsch

This is an inventory of ways people respond to losses in
their lives. All of the questions reflect the noun], process of
grieving, although, of course, none of us reacts in All of these
ways to any given loss. Responding to this Inventory may help you
identify your current reactions to significant changes in your
life, particularly losses. You may find responding to this
questionnaire difficult because some questions may bring up
memories or feelings which are painful. w

W. You are not required to do so.

For the purpose of the present study, you are asked to
indicate your reactions which are strictly related to your physical
disability. Therefore, when responding to items in this
questionnaire, please keep in mind that the word "loss” refers onlx
to your physical disability.

__ Since this inventory asks you only W
219113—1191: you may find that you have changed from how you would
have responded even a few days or a few months ago.

It might be helpful to discuss your reactions with
someone. You are invited to record your thoughts about taking the
inventory at the and of your answer sheets.

As you read each question, ask yourself if the statement
18 truo about You W- You
can indicate the degree to which you are having these responses
according to the following scheme:

this isn't true about my current response to this loss
occasionally this is true about my responses to this loss.
some of the time this is true about my responses to this loss.
most of the time this is true about my responses to this loss.
this definitely is true at>out my current responses to this
loss.

ueuuH
IIIII

NOTE: If a statement is true about you, but is not a response
to the loss, leave it blank.

Please respond to All questions, even if you leave some of
them blank. You may find it helpful to take one or more breaks
while you are filling out the questionnaire. It does not need to
be filled out in one day, but within a few days. If the loss has
occurred recently, or if filling out these items provokes strong
feelings, you may postpone filling out this questionnaire.

W

when responding to items in this questionnaire, please keep
in mind that the word l'loss“ refers to your physical disability.

 

193

01992RTL

1 -thisisn'taccwateaboutmyamtresponsetodisloss

Z-occasionalbrdiisistrueaboutmyrespmsestods'slass.

3-someofdietimediisistmeabwtmyresponsestodlisloss.

4-mostofdiedrnedfisisdueaboutmyrespmsestodlisloss.
is fini i rat at '

EMINDER: lfastatementistrueaboutyou. butisnogaresponsetodieloss. leave itblank.

Since the time of this loss,
1. Keeping active and busy helps me feel less anxious about dis loss.
2. I am smoking more.
3. Taking care of others distracts me from thinking about my loss.
4. I want/need to tell others what happened
5. If I tried hard enough, I can bring back what I lost.
6. I'm looking for who made this loss happen.
7. I avoid being alone.
8.1Iookjustasgoodaslalwaysdid.
9. I've found someone or something to replace what/who I've lost.
I n’ li v i I re Il h
1 1. I keep thinking something could be done to bring back what I lost.
12. I try to figureouthowitcould have beendifferent.
13. I tryto figureoutwhy thislosshappenedtome.
Since this loss, I think
14. If I don't concentrate on remembering what has happened. I'll forget it.
15. If I'm good enough, nobody I love will ever de.
16. It will all work out in the long mn.
17. Every cloud has a silver lining.
18. People get the respect they deserve in this world.
19. The show must go on.
I I han r d il'
21. lfIamgoodenoughor'perfectenmgltwlmtwaslostwilcomeback
22. I think I am responsible for this loss.
23. I wish things were the way they were before this loss occurred.
24. I'm scared to share what I've been thinking. feeling and doing.
25. I feel guilty or disloyal when I forget this loss.
26. I don’t remember what I cfid and/or didn't do just before the loss happened.
27. Being in control helps me feel less overwhelmed.
28. I can't control my feelings when I'm with those who share my loss.
29. I want someone punished for this loss.
'm i I'll f I if I in ' '
31. l'm not ready tolet goofmy feelingsaboutwhathappen.
32. I ignore the physical pain just to keep going.
33. I keep myself from having sex.
34. I don't eat as much
35. I am sleeping less.
In light of this loss,
36.Idream thatsometlinghasl'lappenedtoreversemyloss.
37. Life seems unfair.
38. I believe someding goodwill come outofthis.
39. I can outlast any intruder

 

41. IIawlwIIInotbetestedbeyondmycapacitytoerme.
42.lwonderiflreallydeservewlmtlhave.
43.llmowlwon'tgiveup.
44.Iwillmakethoserespormiblepayfortlis.
4S.Thislossmstbecimnged

 

 

01 992 RTL
1 — thisisn'taccuateabwtmycurentreqaameto
2 - occasionallydiisistrueaboutrmrrespmsesto
3-someofthetimediisistrueaboutmy disloss.
4-mostofdieu'mediisisaueaboutmy thisloss
Since this loss.
46. I avoid people who remind me of this loss.
47. I refuse to discuss this loss.
48. I don't spend as much time with my family.
49. I act as though thisdoesn't really mattertome.
I 'nk f r I
51. I lose or misplace things that relate to this loss.
52. I avoid reminders of this loss.
53. I can be physically abusive when others remind me of the In
54. I am not interested in getting involved.
Since the time of this loss, I have thoudit
55. Somethingelseisgoingtogowrmg.
56. I cannot imagine how anything pos'tive could come out oftla’s loss.
57. If I don't look out for myself, no one else will.
58. Very fewpeopleareworthmytimeandenergynow.
59. Noonecenchangewlmt‘salreedyhappened.
WM
61. It'sbestnottodwellontI-iepast.
62. Nobody rullymderstandshowthislossaffectsme.
63. My thinking has been critical and judgmental.
64. I've focused on the present.
In considering this loss, I believe:
65. Why get involved? You just get but
66. It‘s God's will. Learn to accept it.
67. Why try? It won't make any difference.
68. There's no such ding as a free ride.
69. Out of sight. out of mind.
29 I : ! . f . I! ! i I | .
71. Do your own thing.
72. Fate is against me.
73. To succeed is to de.
When I am reminded of this loss,
74. I feel ovemhelmed.
75. I try not to let anything affect me.
76.lfeeldetachedandseparatefromod1ers.
77. I feel bored with life.
78. People irritate me easily.
79. I feel frustrated
If II If I I '

81.lgetupsetwithmyselfforthewayllmvebehaved.

82. lamrevoltedbydiewaypeoplehaveresponded.
As a result of this loss

83.ldon'twanttobetouched.

84. I'm more clunsy and accident prone.
85.lhave felts’cktomystomach.

86. l exercise less

87.Isleepmore.

88.Iwishlco:.nldbesavedfromlmvingtodealwidldisexp¢ience.
89. Iwonderwhatpomtthereismgoungon.

loss
loss.

ii

i;

   
 

 

 

As a result of this loss
91. My life doesn't seem to have a purpose.
92. Nobody careshowlamdoing.
93. There's no sense thinking or worrying about what happened.
94. I've lost respect for myself.
95. If people important to me knew mycontributiontodl'sloss. dieywouldbeshocked.
96. I've had fantasies of being dead.
97. It wasn't my fault this happened.
98. I can't be expected to be responsible at times like dis.
Since the time of this loss.
99. It's been hard to concentrate.
Wm
101. It's hard for me to make decisions.
102. I am less confident.
103. I talk abouthowit'sbeenformesincethetimeofdisloss.
104. I avoid being in new situations.
105. I avoid getting close to others.
106. My friends have been avoiding me.
107. My friends avoid talking about my loss.
When I think about this loss,
108. I lose trackofwhat'sgoingon.
109. I can't imagine how things will get better.
I'm trivial Iif
111. lam overwhelmed athowrealandinescapabletll'slossseems.
112. Itseemshopeless totryto understandwhatreallyhappened.
113.1d1inkabouthowmylifehasbeenchanged.
114. l'm reminded how little I really control.
115.lthinkaboutthedreamsthatwillnevercometrue.
116. My feelings just come.
117. I really miss it/him/her.
118. I miss expressing my love.
119. Joy is missing in my life.
W
121. I feel emmy, like a shell, like I amjust existing.
122. Music can stir up my feelings.
123. Looking at old photos stirs up painful feelings.
Since the time of this loss,
124. I feel restless.
125.luseuprmchmoreenergythanldidbefore.
126. lam exhausted by any effort.
127. I feel pangs.
128. I cry.

129.Iwakeupfeelingstiffandachy.asifl'dbeentensedridit
I30! ! I' I 'l

131.Mydreen'sremindmeofmyloss.
132.Ilackasexlife.

133Wsomeonetwchesmemyfeehgscometotheslfaoe.
134.lfeelsick.

135.Mystomachrealycluns.

 

 

 

196

01992RTL
1 -thisisn'taccuateaboutrnycurrentresponseto
Z-occasionallydu‘sistrue
3-someofdietimedrisistrue
4-mostofdietimethisisdue

a

Since the time of this loss,
136. l have achesandpainswhich remindmeofmyloss.
137. I would rather die than go on experiencing this.
138. No amount of money could ever replace it.
139. The finite seems empty.

Wh I valu m in life ha n
141. I question the existence of the God I used to believe in.
142 I cannot continue life the same way as before.
143. I realize my life will never be totally free from pain and suffering.
144. I know I will lose things and people important to me.
145. There are parts of me that are missing.
146. I am not the loving. caring. trusting person I was.
147. When I'm convinced things can 't get any worse, they do.
148. It seems like I have lost my desire to live.

 

In the time since this loss,
149. Hearing about other's experiences with similar losses helps.
Th i I I
151. Being by myself has been healing.
152. I take long walks andjust daydream.
153. Activities like getting a massage, painting or mus‘c are sending.
154. Talking or writing about it gives me relief and release.
155. I can let thingstum out thewaytheywill.
156. I realize that I've lost a lot. but I haven't lost everyth’ng.
157. I think about howl have changed. what is dfferent.
1S8. l'mnotasresponsibleaslthoughtlwasforwhathappened.
159. I have already passed the lowest point.
f a i Ie
161. lam able to express my feelings about the loss.
162. My feelings still catch me by surprise. but they don't last as long.
163. My guilt has lessened.
164. I'm not so sad.
165. My disgustoverwhathappenedhaslessened.
166. I realize that sadness and peacefulness can co-exist
167. I can enjoy simple pleasures of life again.
In considering this loss,
168. The achesand pairslusedtohavewithtlislosshavelessened.
169. I enjoy being touched and held once aga'n.
WM
171. I notice how things smell and taste again.
172. I have Ieernedtoacceptthatlossesandchangesareapartoflife.
173. My life will continue.
174. Wdreansseemtohelpmemderstandmdaoceptwhatlmpet
175. My faithorspiritual mderstandinghelpedmewithdisexperience.
176. Mylifedoesseemtohavenieenii'ig.
177. Whateverlcontributedtothisloss.lddnotwmtittohappen.
178. Lifeseemsmorefragileandprecious.

179. Mypastwillalwaysbeapartofme.

 

 

 

3
E

01992RTL

l-disisn'taccrnteabout responsetodislms
noccasionallydisisaueaboutmyresponsestodisloss.

3- someofthetimedisistrueaboutmyresponsestodislos.

4-mostofdiedmedisisdueaboutmyresponsestodisloss.
is fini i t 'I

As a result of this loss.
181 l'vefoundwaystogetbackmyintegrity.

182: I don't depend as much on odiers.
183 I've remembered what I really want to remember about it.

184. I’ve finished things related to my loss as completely as I can.

185: I've taken steps to forgive those involved.
186 I am making restitution for my contributions to this loss.

187: I like being with people again.

In light of this loss.
188. Putting my thoughts into words has helped me recover.
189. It's important to have times of celebration and remembrance before it's too late.

Whamm
191 I've felt all I can feel about this loss.

192. I've found effective ways to expres my feelings.
193. I've experienced this loss in ways that were healing.
194. I've let go of the guilt

195. I've let go of the anger.
196.leenmakesenseoutofthenmgesfrommybody.
197.ldon'tpushmybodybeyondlinits.

198. I relax.

199. I sleep well.

What.
201lcanbesexuallyorromanticallyinterested.

202. I know my life is important
203. My dreams are restful. playful and helpfu.
204. I've restored or regained part of what I had lost.
205 I feel the presence of what/who I lost.

206. l have forgiven myself for what happened.

207: I have forgiven others for what happened.
208 lwould notwantmylossreversedifitmeantgivingupallmygrowthfromit

209:lfeel confidentenoughinmyselftomoveontoodiertl'mgs. .
' - l-r‘fli'dr.’ ° 'lr 0r). t-{I -

'4 IND 'lf1. ‘ n i -. -°.°.I L... all

L”

As a result of this loss,
WM
21 1. I enjoy being alone.

212. I'm nicer to myself.

213. I'm not as seriousa person.

214. I'm able to take risksagain.
215. I'm more self-disciplined.

216. I don't place limits in frontofmyselfasreadlyaslddbeforetlisloss.
Z17. Iarnmoreabletogivetoothers.

218.Ihave time formyfamilyandfriendsandtimeforme.

219. lcanexpressmyselfinmanyways.

221.1f:el moreconfident.
222.I'vegrown.

223. I see tl'lepastasjustas'lmortmtaswlmtislmermlgnmv.
224. Past. presentandflmreareeqdyinportant.
225.1feelchalengedtokeepmp‘ng.

 

 

198

01992RTL
l-disisn'taccuateaboutmycurrentresponsetodisloss
Z-occasionallydiisistme '

3-someofthetime'

As a result of this less.
226. I trust my ways of thinking.
227. I don't avoid my feelings.
228. I've found new ways to expres my feelings.
229. I feel loving and affectionate.
231. lam curious about many things.
232. I listen to what my body tells me.
233. I enjoy making love.
234. I feel strong.
235. I am active in caring for myself physically.
236. What I eat is healthy.
When I think of dis loss
237. I feel warm all over.
238. I have what is meaningful witl‘l'n me.
239. I've learned to respect myself.
mm
241. l'vediscovered diattl‘iereismoretometlmnwlmtmeetsdieeye.
242. My dreams make sense.
243. I live as fully as I can.
244. Whatisimportanttomehascl'mged.
245. I have fewer conditions on my love.
246. I realize I can do destructive things.
247. I feel lovable.
248. I've challengedmdfltuedsoneofmynmstduisledmdlmgstarxiigassmpdue

andbeliefs.
EMINDER:lfastatementistrueaboutyou.butisnmarewonsetodielossJeeveitblank.

249. I know I want other people in my Ife.

l ar wi
251. What I own isn't as important
252. I know the qcles of life have times of birth and death.
253. I am sometimessurprised bywhatllmowandsay.
254. I feel connected to the world and to nature
255. I lmowthatthingsinmylifecanchangeandifecanstill bemeaningfu.
256. I am curious about what will happen after I die.
257. I realize that I can't live without loving myself.
258. ldiscoveredsomeessentialpartsofme.
259. My life has times of joy.

W

no

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APPENDIX C

BECK DEPRESSION INVENTORY

 

BEELINVENTORY

Name

Date

On this questionnaire are groups of statements. Please read each group of
statements carefully. Then pick out the one statement in each group which best
describes the way you have been feeling the PAST week, INCLUDING TODAY!
Circle the number beside statement you picked. If several statements in the group
seem to apply equally well, circle each one. Be sure to read all the statements in
each group before making your choice.

1 0
1
2
3
2 0
l
2
3
3 0
l
2
3
4 0
1
2
3
5 0
l
2
3
6 0
l
2
3

I do not feel sad.

I feel sad.

I am sad all the time and I can’t snap out of it.
I am so sad or unhappy that I can’t stand it.

I am not particularly discouraged about the future.

I feel discouraged about the future.

I feel I have nothing to look forward to.

I feel that the future is hopeless and that things cannot improve.

I do not feel like a failure.

I feel I have failed more than the average person.

As I look back on my life, all I can see is a lot of failures.
I feel I am a complete failure as a person.

I get as much satisfaction out of things as I used to.
I don’t enjoy things the way I used to.

I don’t get real satisfaction out of anything anymore.
I am dissatisfied or bored with everything.

I don’t feel particularly guilty.

I feel guilty a good part of the time.
I feel quite guilty most of the time.
I feel guilty all of the time.

I don’t feel I am being punished.
I feel I may be punished.

I expect to be punished.

I feel I am being punished.

201

10

11

12

13

14

15

U NHO UNHO WNHO LAND-*0 “Nb-'0 WNHO WNHO WNHO

UNHC

202

I don’t feel disappointed in myself.
I am disappointed in myself.

I am disgusted with myself.

I hate myself.

I don’t feel I am any worst than anybody else.

I am critical of myself for my weaknesses or mistakes.
I blame myself all the time for my faults.

I blame myself for everything bad that happens.

I don’t have any thoughts of killing myself.

I have thoughts of killing myself, but I would not carry them out.
I would like to kill myself.

I would kill myself if I had the chance.

I don’t cry any more than usual.

I cry more now than I used to.

I cry all the time now.

I used to be able to cry, but now I can’t cry even though I want to.

I am no more irritated now than I ever am.
I get annoyed or irritated more easily than I used to.

I feel irritated all the time now.
I don’t get irritated at all by the things that used to irritate me.

I have not lost interest in other people.

I am less interested in other people than I used to be.
I have lost most of my interest in other people.

I have lost all of my interest in other people.

I make decisions about as well as I ever could.

I put off making decisions more than I used to.

I have greater difficulty in making decisions than before.
I can’t make decisions at all anymore.

I don’t feel I look any worse than I used to.

I am worried that I am looking old or unattractive.

I feel that there are permanent changes in my appearance that make me
look unattractive.

I believe that I look ugly.

I can work about as well as before.

It takes an extra effort to get started at doing something.
I have to push myself very hard to do anything.

I ean’t do any work at all.

16

17

l8

19

2O

21

H

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203

I can sleep as well as usual.

I don’t sleep as well as I used to.

I wake up 1-2 hours earlier than usual and find it hard to get back to
sleep.

I wake up several hours earlier than I used to and cannot get back to
sleep.

I don’t get more tired than usual.

I get tired more easily than I used to.
I get tired from doing almost anything.
I am too tired to do anything.

My appetite is no worse than usual.

My appetite is not as good as it used to be.
My appetite is much worse now.

I have no appetite at all anymore.

I haven’t lost much weight, if any, lately.
I have lost more than 5 pounds.

I have lost more than 10 pounds.

I have lost more than 15 pounds.

I am purposely trying to lose weight by eating less. Yes_ No_

I am no more worried about my health than usual.

I am worried about physical problems such as aches and pains; or
upset stomach; or constipation.

I am very worried about physical problems and it’s hard to think of
much else.

I am so worried about my physical problems that I cannot think about

anything else.

I have not noticed any recent change in my interest in sex.
I am less interested in sex than I used to be.

I am much less interested in sex now.

I have lost interest in sex completely.

APPENDIX D

SUBJECT OVERALL RATING SHEET

W

How positive do you feel about completing the three questionnaires?
(Please check one.)

1. Not positive at all
2. Not very positive
3. Positive

4. Very positive

5. Extremely positive

 

 

Please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please use the reverse side it lore space is needed.)

... m YOU m 1003 3131131211103 1' ms mm em! ***

204

APPENDIX E

LETTER OF INVITATION TO PROSPECTIVE PARTICIPANTS

 

 

erersatv at Micnngen Doom d m
Mectean Center W and W
museum or‘ Michigan sosoataos

l
l
i

i

ill
{3

1500 East more: Canter Crzve
Ans Amer. 'Jicmgan 3828943342
1113) 936-7135

Theooore H. Case. MD.
’rotessor we Che-men

Warren
aecroneurcmvograaw
Ocaaoanona: Thereby

Canon: and P'osmeec Seances

m Thereby

Phys-can 3 Guam Gin-c

Renae-manor! Sam

Watson PM and Neuoosycnouogy
W Pane-ow

Deer Prospective Participant:

Two years ago you may have participated in a research project
about the secondary characteristics of polio conducted by Dr.
Maynard, Sunny Roller and myself at the University of Michigan
Hedical Center. We are currently in the process of writing the
findings of that study. While every day we are learning about
the late effects of polio, we would like to ask you to consider
being a participant in another new study that looks at reactions

to loss and disability.

Your input in this study will be especially valuable in helping
us better understand the human potential for adaptation and the
process of response to physically debilitating conditions. We
strongly believe that the results of this study will help
heighten our sensitivity to the treatment needs of different
individuals and upgrade the quality of our services. The
intonation you provide about your own experience may also be
very helpful for people confronted with a similar experience of
physical disability in the future. We would very much appreciate

your participation in this study.

Your role in this study will be to complete by mail, a
biographical data questionnaire, a Response to Loss Inventory and
the Beck Inventory, which asks you to rate your current level of
distress. This activity will probably take you about an hour.
Information you give us for the purpose of this study will be
treated in strict confidence, and you are not personally

identified in any reports.

As a token of compensation for your time and involvement in this
study, a check for $10.00 will be sent to you upon our receipt of
your three completed research questionnaires.

Your participation is completely voluntary. You can withdraw
your participation at any time. Choosing to participate or not
to participate will not affect your receiving services at the
Universityofhichiganltedicaltenterinanywaynoworinthe

future.

205

206

We would appreciate your response if you can take a moment to
fill out, sign and return to us the "Consent ton“. Thank yo

advance for your cooperation and support.
Sincerely,
e ”
W 1%
Denise 6. rate, Ph.D.
Assistant Professor

uin

APPENDIX F

CONSENT FORM

5.

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raeuehwinbekeptmnfidendflandlfluabemflyidendfiedhuynputdthhndy.

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tobasenttoueuponeompletionofthestudy.

Please check mm of the following:

__... Iasreewuamnnatsinthissmdv-
__ I prefer not to participate in this study.

Check here ifpatient is unable to

 

 

 

 

 

 

 

__ sign and verbal authorization is
(Signature of Patient) fives. Wad.)
(Please Print Your Name) (Signaurre of First Witness)
Date: Time:
(Signature of Second Witness)
Your Mailing Address:

 

Wmddyouliketohaveaone-pagemmryofthegeuenlgrouprenuusenttoyou
upon completion of the study? _Yes __No

207

APPENDIX G

FOLLOW-UP LETTERS

 

UmverptvolM-cnogae mum
--'1f— MedicarCenrer WNW-traumatic:

=——' '_... =_F-"= Umvemtv or maa.m m

2..." " —_ 1500 East Men-a0 Canter DIM
Ann Arbor. Macaroon «roams:
I173) 936-7185

Theodore H. Cole. M 0.
Professor and Charmer!

El

Many
Orton: and Presmene Sew-ear
Phys-cat Thereby
Macao s Outoauem CHI-c
Moon Engineering
Walton Psychology and Neuronsycnorogy
Sousa-UM! PM

Dear Participant:

Thank you for your recent decision to participate in our study on reactions to a physical
disability as a response to loss. This study is a joint effort of the University of Michigan and
Michigan State University, and it is our strong belief that the information you provide as a
research participant will be very helpful for individuals connouted with a similar experience
of physical disability and the professionals who work with them.

Enclosedarethethreequestiounaireswhichyoahaveagudtoeomplete. ‘l'hefollowingsteps
arerecom-eaded inyourprocessingoftheseresearch materials:

I. Find a comfortable place away flora distraction.

2. Completethethneqnestiomairesmjnlyintheorderinwhichthsyappearin

yourpacltet,respondingtoalloftheiternsineachquestionnaire. Toensure

adequate validity ofour data, pleasetakenomorethauseveraldaystocomplete
allthreequestionnaires.

3. Return all research materials together in the enclosed self-addressed postage
paid envelope.

We would appreciate your filling out the three questionnaires and returning them to us at your
earliest convenience. A: a token of compensation for your precious time and involvement in
our study, we will send you a check for $10 upon our receipt of your three completed
questionnaires. Upon the completion of this study, a onepage summary of the general group
results will be made available to you at your request.

Agaimletusthanltyou foryourparticipationinthisstudy. Wearelooklngforwardto
receiving your completed questionnaires soon.

Sincerely,

W mot

Denise G. Tate, m.
Assistant Professor

208

209

 

 

; 2a Unmw oi Micmgan Department at Fina-eel
—= Ef" Medical Center Medicine and Rehabilitation
:_= University of Michigan Reactions
= - = 1500 E88! MOO“ CU?!" Che.
Am- Arno' Michigan #8109003:
.313: 936.7135
Theodora M Cate. M O.
firotessov an: Chairmen
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Elscnoneuromvocraony
Ocmmanonaa Therapy
Omar-c and onsmeuc Sconces
Phys-cat Therapy

W s Comma! Cline
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fictional-tattoo Psychology and Neuoosycnonogy

WW Pwoqy

”Respective Participant:

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Check hereifpatient is unable to
__ sign and verbal authorization is

 

 

 

 

 

 

(Signature of Patient) given. MW)
(Please Print Your Name) (Signamre of First Witness)
Date: Time:
(Signature of Second Wimess)
Address:

 

Phone:( 1

 

211

 

UHIWSDW cl M-cmgan Department at Physical

 

-— . . . .
g — =1 r— Meoicai Center Medicine and Rehabilitation
E _—//= unwersatv oi Micmgan actuate-s
= - —-— 2500 East Mao-cat Center Ome
Arm A'ao'. M-chigai' “10943032
:33: 936-7335
’neocore M Cote M n
P'oiesso' arc Cos-man
Wench

Electronecromvcg'asw
Occuoaiucnas Three-,-
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Phys-ca: Therapy
Physio” s Ouisaneni Came

Henson-tainon Engnnmng
Renae-manor! asycriciow and Neurons-money

South-Language Painomgy

Dear Participant:

1 packet of three questionnaires was sent to you about ttio weeks ago
in response to your agraenant to participate in a research study at
the University or itichigan itedical Center. As you nay recall, the
purpose or the study is to explore reactions to a physical

disability as a response to loss.

In a follow-up to your agreement to participate in this study, I are
writing to verity that you have received the packet of
questionnaires and to ask that you return the conpleted
questionnaires at your earliest convenience. tour proapt coapletion
and return or these questionnaires will greatly enhance the validity

or our study.

It you have not received the packet of questionnaires for this
study, I would appreciate your completing the enclosed "Request tor
Inventory Packet" torn and returning it in the salt-addressed
postage-paid envelope. It you have already completed and returned
all three questionnaires, please disregard this letter. As a token
of compensation tor your precious tine and involve-ant in this
study, a check for $10 will he sent to you upon our receipt or your
three completed questionnaires.

'i'hank you very nuch tor your participation in this study. I an
looking forward to hearing tron you soon.

sincerely,

I .T—a...

Denise 0. rate, Ph.D.
Assistant Professor

Mttc

212

W

Please complete this form and return it in the self-addressed postage-paid envelope
ifyou have oat received a packet of three questionnaires for our study on reactions to a
physicaldisabilityasaresponsetoloss. Ifyouhavealreadycompletedandrennncdallthree
questionnaires. please disregard this form.

 

Ihave not received apackct ofthree research questionnaires foryourstudy. Please
send me the packet as soon as possible.

Your Name:

Mailing Address:

 

 

 

 

213

 

‘ —___.__‘ UHIVC'S'N of M-cmgan Department at mysieal
== =1 r: Medical Center Medina and Rehabilitation
=2 =2: Umw oi Mocmgan ecsoctais
= ' = 3500 East Meoocai Center Owe

Ana boot, Michigan 88129-0342
1313-5367185

'Hecuove ti Coca. 9.1 :1
Protease! arc Caesrman

Wurst-:6
QWOJOF‘VOQMSHI
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Physical -"'-eraov

Physician s Ouzca:.em can»:

Renacmiaion E‘glnecflfiq

Rehab-matter! Psvcnoaogy ano NOutOOSVC-“Oiogy

Stream-Language Paimcgy

DearPai-tidpant:

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Slacerely.

I . _r—
Menuhin.“
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214

 

 

55:1; mwumw “rim-"W.
—— — _- icai center Medicine and W
5:: University of Michigan Wists
= "’ 1500 East Medina Center O'NQ
Ann Amos. Mocmgan tales-con
i313! 936-7385
'heooore *5 Cone. M D.
P'oiasso' or: Cowman
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Elecumeurortvocraany

Phys-can s Outpatient Clinic

WMIIIOI‘! Engineering
Ration-«canon 994.900” and Neuronsycnoiogy

Spam-Language Patnatogy

Dui- Prospective Participant:

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aphysiealdisahilityasarespoasetalesa. Slaawahaveaotreceivedyoarrespansatediislnvltatiaadam
uidagmhfmyoathuwemldappredanyourcoaddaadoudparddpaflaghthhsady.

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brim npoauurieceiptofyourthreecomplaedquadoanhesasatohenofcumpasadea foryearpreriens
haandiavolvementinourstudy. Upeathecoinpledoaofthcstndynoaa-"seuryofthapenlgeup
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asp—afloaaadsapport.

215

 

 

a _ Universotv of Michigan W oi m

_-= E};- Medical Comer We ... Rehabilitation

:11: .../.1: University at Michigan mamas

7: " = ism East Medical Center DINO
Ann Arbor. Michigan 18109-0042
0733 935-7335
We M Cone. MD.
Protease! arc Chairman

mutation

lecuonearogwograorv

an “every

Oman: and Prosthetic Seances

Physical Thereby

Physician s Outpatient Clair

Relish-interim Engineering

Renae-amen Psycnoogy and Neuroosvmoiogy

Spam-Language PM

Dear Participant:

As a token ct compensation tor your precious time and in
appreciation for your participation in our study on reactions to a
physical disability as a response to loss, please accept our
gratitude for your contribution and a check tor 310. we are glad to
inrorm you that the three research questionnaires which you have

completed for the study are currently being processed.

You have provided some very valuable intonation and assistance
toward the completion or our study. It is our strong belief that the
results or this study will be ct help tor individuals confronted
with an experience or physical disability and the protessionals who
work with them.

Upon the completion or the study, a one-page summary or the general

group results will be made available to you at your request. Please
feel tree to contact us it you have any turther questions about this

study.
Again, thank you for your participation in this study.
sincerely,
Denise 6. rate, Ph.D.
Assistant Professor

Mitts

REFERENCES

Re e e es

Akiskal, H.S., & Lemmi, H. (1983). Clinical,
neuroendocrine, and sleep EEG diagnosis of "unusual"
affective presentations: A practical review.

WW 5. 69- 83.

Albrecht G., & Higgins, P. (1977). Rehabilitation success:
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oc'a ehav'o , 1g, 36-45.

American Psychiatric Association (1994). Qiagngg;ig_gng
'st'ca anua men a is (4th ed.).

Washington, DC: Author.

Anderson, T. P., & Andberg, M. M. (1979). Psychosocial
factors associated with pressure sores. Argnigg_gj

WW i9. 341-346-
Anderson, S.V., & Bauwens, E. E. (1981). Qh;gnig_nga1§h
em : o e ts a d ' ' . St. Louis:
Mosby.

Antler, L., Lee M., Zaretsky, 3., Pezenik, D., 8 Halberstam,
J. (1969). Attitudes of rehabilitation patients
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Beck A.T., & Beamesderfer, A. (1974). Assessment of
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Beck, A.T., Rush, A., Shaw, 8., & Emery, G. (1979).

he e ess' . New York: Guilford.
Beck, A.T., & Steer, R.A. (1987). ec ess o
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Beisser, A.R. (1989). ’ w' w .
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Belitsky, R., & Jacobs, S. (1986). Bereavement, attachment

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Blanchard, C.G., Blanchard, E. 8., Becker, J. V. (1976). The
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Bolton, I. (1984). Families coping with suicide. family
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217

Bowlby, J. (1980). - v 3.
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Bracken, M. B., Shepard, M. J. & Webb, S. B. (1981).
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Breen, J. (1985). Children of alcoholics: The subterranean

grieving process. anghotnarapy Pagie E- ;(1), 85-94.
Brown, G.W., & Harris, T. (1978). gagial_g;igin§_gf

gepgesaig . London: Tavistock.

Bruno, R. L., & Frick, N. M. (1987). Stress and type A
behavior as precipitants of post polio sequelae. In L.

S. Halstead, & D. O. Wiechers (Eds. L Baaaazgn_aag
' ' s c e . White

Plains, NY: March of Dimes.

Carey, R.G. (1977). The widowed: A year later. agaznal_a§
qunéellng_£§Y2h2129Y- 21(2). 125-131-

Cashdan, S. (1988). ' l ' ° U '
Iglatigngnip. New York: Norton.

Clayton, P., Desmarais, L., & Winokur, G. (1968). A study

of normal bereavement. Amazigag Jougna; of ancniagny,
lZQ, 168-178.

Clayton, P., Herjanic, M., Murphy, 6., & Woodruff, R.
(1974). Mourning and depression: Their similarities

and differences. a i n s t c so

19.911131, l2! 309'312 .

Codd, M.B., Mulder, D W., Kurland, L.T., Beard, D.M., 8
O'Fallon, W. M. (1985). Poliomyelitis in Rochester,
Minnesota, 1935-1955: Epidemiology and long term
sequelae: A preliminary report. In L. s. Halstead, &

D- 0- Wiechers (Eds-). Late_effects_of_noliomxelitis
(pp. 11-31). Miami, FL: Symposia Foundation.

Cohen, J. (1988). '
,aaiang_§. Hillsdale, NJ: Lawrence Erlbaum.

Conoley, C. W. (1992L Review of the Beck Depression
Inventory (Revised EditionL In J.J. Kramer & J.C.

Conoley (Eds. ), v
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