This article was downloaded by: [Gebze Yuksek Teknoloji Enstitïsu ]On: 20 December 2014, At: 21:53Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Social Work in End-Of-Life &Palliative CarePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wswe20

Good Grief: Exploring the Dimensionalityof Grief Experiences and Social WorkSupportTheresa A. Gordon aa Department of Communication Disorders and Social Work ,University of Central Missouri , Warrensburg , Missouri , USAPublished online: 25 Feb 2013.

To cite this article: Theresa A. Gordon (2013) Good Grief: Exploring the Dimensionality of GriefExperiences and Social Work Support, Journal of Social Work in End-Of-Life & Palliative Care, 9:1,27-42, DOI: 10.1080/15524256.2012.758607

To link to this article: http://dx.doi.org/10.1080/15524256.2012.758607

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

27

Good Grief: Exploring the Dimensionality of Grief Experiences and Social Work Support

THERESA A. GORDON Department of Communication Disorders and Social Work, University of

Central Missouri, Warrensburg, Missouri, USA

This study explored the dimensionality of grief with a sample (n = 180) of caregivers of deceased loved ones; utilizing a positive grief scale, additional data were collected about perceptions of social worker practice behaviors in end-of-life care. Results revealed the presence of both positive and negative aspects of grief. Supportive social work practice behaviors at the end of life were present at least 52.2% of the time and specific practices were analyzed as to their association with positive or negative grief reactions. Results from this study suggest that grief is a multidimensional process and that social work practice behaviors can support positive aspects of grief with clients in all fields of practice.

KEYWORDS aging, bereavement, caregivers, caregiving, grief, grief dimensions, loss, older adults

Grief is normal and a natural reaction to loss (Kubler-Ross, 1968; Rando, 1984). Much attention has been given to the negative repercussions of grief. However, little attention has been paid to the positive repercussions (Neimeyer, 2002). Since we know that some form of grief expression occurs at every loss, the goal of social workers with respect to grief is to support people through the grief process and to minimize the debilitating impact of negative grief and maximize the possible positive aspects of grief. In order to accomplish this, a clear understanding of the totality of the grief process (both negative and positive aspects of grief) is necessary. Furthermore, an

Received 22 August 2012; accepted 17 November 2012. Address correspondence to Theresa A. Gordon, Associate Professor, Department of

Communication Disorders and Social Work, 7D Wood, University of Central Missouri, Warrensburg, MO 64093, USA. E-mail: tgordon@ucmo.edu

Journal of Social Work in End-of-Life & Palliative Care, 9:27–42, 2013Copyright © Taylor & Francis Group, LLCISSN: 1552-4256 print/1552-4264 onlineDOI: 10.1080/15524256.2012.758607

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

28 T. A. Gordon

exploration into the positive aspects of grief could lead to more effective methods of support. This study was an exploration of the incidence of “posi-tive grief” and “negative grief” in a sample of persons who provided emo-tional support and physical caregiving of a deceased loved one.

THE IMPACT OF GRIEF

Most people experience sadness and a time of readjustment to the loss of the loved one, but many are able to adjust, adapt, and find resolution with the loss and go on to live their lives. It is estimated that 80–90% of bereaved individuals are able to maneuver through their grief and come to this resolu-tion (Prigerson, 2004). Time from death to this resolution can vary from less than a year to many years. However, regardless of the time frame, bereaved individuals report that they are able to go on with their lives without becom-ing physical ill, clinically depressed, or socially isolated (Prigerson, 2004; Silverman et al., 2000).

The grieving process can manifest itself negatively in psychological ways such as depression, denial, anxiety, and anger; in physical ways such as insomnia, exhaustion, eating disorders and anhedonia; in social ways as isolation and withdrawal; and in spiritual ways such as anger toward a higher power and loss of purpose (Worden, 2003). Unresolved, debilitating grief can require treatment since it has an impact on physical and mental health. This type of grief is referred to as “complicated grief” and is associated with long-term impairments for those who experience it ( Jacobs et  al., 1990; Prigerson, et al., 1995; Rando, 1993; Silverman et al., 2000; Zhang, El-Jawahri, & Prigerson, 2006). Complicated grief has been associated with physical ill-nesses as cancer, hypertension, heart problems, and suicidal ideation and completion (Chen, Bierhals, Prigerson et  al., 1999; Latham & Prigerson, 2004). In addition, increased alcohol consumption, clinical depression, and increased use of anti-depressants have also been correlated with compli-cated grief symptoms (Ott, 2003; Prigerson et al., 1995; Rando, 1993; Silverman et  al., 2000). Social implications for complicated grief include a “sense of disconnect with people,” and a “sense of alienation”; resulting in avoidance of social encounters with friends and family (Prigerson, Vanderwerker, & Maciejewski, 2007, p. 8). Current research has reported that approximately 11% of all bereaved individuals whose loved ones have died from natural causes appear to manifest complicated grief (Barry, Kasl, & Prigerson, 2001; Latham & Prigerson, 2004). With approximately 2.5 million deaths per year (Centers for Disease Control, 2012), the potential for complicated grief reac-tions for hundreds of thousands of surviving loved ones is possible.

On the other hand, grief can also have positive aspects. An alternative definition of grief from a strengths perspective is that it involves reconstruct-ing the world and its meaning in light of the challenge of death (Neimeyer,

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 29

2000). Awareness is emerging that grieving may not be just a negative pro-cess but also a time for post-traumatic growth, reassessment of the meaning of life, and an opportunity to evaluate the important elements of life (for example, human relationships, well-being, and spirituality) (Neimeyer, 2002; Singh, 1998). Attig (1996) verbalized his view of this opportunity as a “reor-ganization … as we relearn … we reweave the fabric of our lives and come to a new wholeness” (p. 146). Psychologically, people can experience relief and joy that the person is no longer suffering; increased self-esteem for ful-filling their role with the dying person; greater self efficacy around things that they have learned through the process; and a greater appreciation of life in general (Munn & Zimmerman, 2006; Neimeyer, 2005, Tedeschi, Park, & Calhoun, 1998). Physically, grieving people can begin or resume physical activities, attend to their own health concerns, and resolve to live healthier. Socially, they can appreciate more the old and new friendships, reach out to others, and find mutual support and value relationship in a deeper way. Spiritually, they can experience a greater connection with the mystery of life, appreciate life more, have stronger bonds to spiritual or religious traditions, and be transformed through their grief (Klass, Silverman, & Nickman, 1996; Munn & Zimmerman, 2006; Rando, 1984; Tedeschi, Park, & Calhoun, 1998). Just as caregiving has documented benefits and burdens of caregiving, the grief process itself has stresses and joys.

For this study, the research questions are grounded within this context that grief is a multidimensional concept. Specifically, the research questions are: (a) Do both positive and negative grief aspects exist concurrently within the grieving individual? If so, to what degree?; and (b) Do specific practice behaviors by social workers (and other health care professionals) support positive aspects of grief?

METHODS

This study was predominately a quantitative study and included two open-ended items. The survey instrument included 52 quantitative items (19 items from the Inventory of Complicated Grief-Revised (ICGR); 10 items from the Positive Grief scale; 10 demographic items; 13 items regarding social work practice behaviors) and two qualitative questions regarding what social workers did to support caregivers as they provided care for the dying indi-vidual and after the death helped the respondents through the grieving process.

Sample and Procedures

The study sample consisted of caregivers of persons who had died no less than 6 months and no more than 2 years prior to the beginning of the study.

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

30 T. A. Gordon

The sample was obtained through cooperation with a Midwestern cancer support agency. The caregivers were no longer receiving direct services from the agency. In order to reduce sampling error and decrease confounding variables, eligibility requirements for inclusion in the study were as follows: all the survivors cared for a loved one with cancer; had a close relationship (spouses/partners, siblings, or children) to the deceased; and identified themselves as “caregivers” who provided emotional and/or physical support. A letter of invitation was sent to 1,327 bereaved individuals to participate in the study. One-hundred eighty caregivers agreed to participate in the study. This represents a 13.6% response rate.

Quantitative Items—Scales

Complicated grief was measured by using the Inventory of Complicated Grief-Revised (ICGR). The ICGR has been used in its original or revised form in research studies since 1995 (Prigerson et al., 1995). The current ICGR is a 19-item survey instrument. This scale employs a 5-point Likert scale ranging from always to never). Scores can range from 19 to 95. Scores that are 89 or more indicate “complicated grief.” High internal consistency exists for the 19-item scale (Cronbach’s alpha = .94). Test-retest reliability is .80. The ICGR also is positively correlated highly with the Texas Revised Inventory of Grief (TRIG), with the Grief Measurement Scale, and with the Beck Depression Inventory (Prigerson et al., 2007).

Positive grief was assessed through a measure created specifically for this study. The 10 items are as follows:

• My life has more meaning now than it ever had. • I believe that I learned more about myself after caring for the person who

died. • I feel that I have gotten the important things I want in life. • Since the person’s death, I find that material goods don’t mean a lot to me. • I feel that I am a better person for having provided care for the person

who died. • Since the person’s death, I am more spiritually aware. • I have good memories when I think of the person who died. • Since the person’s death, I value each day. • I believe that if I could live my life over, I would change almost nothing.• Since the person’s death, I don’t fear my own death.

These 10 items reflect what other researchers have reported to be posi-tive aspects of grief: continuing bonds with the deceased that reflect that these bonds give the griever comfort (Calhoun & Tedeschi, 2002; Neimeyer, 2002); positive growth in spirituality (Attig, 1996; Milo, 1997; Neimeyer, 2002); self-awareness and self-esteem (Janoff-Bulman & Berger, 2000;

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 31

Neimeyer, 2005); value reconstruction and meaning-making (Frantz, Farrell, & Trolley, 2001; Janoff-Bulman & Berger, 2000; Milo, 1997; Neimeyer, 2005). The potential scoring range was 10–50. Since this scale was untested, no cut-off score for positive grief was hypothesized. However, scores closer to 10 indicated less positive grief; scores closer to 50 more positive grief.

Scale face validity was confirmed through feedback from a pilot study with 15 individuals including 5 bereaved individuals; 5 social work profes-sionals in the bereavement field, and 5 academic experts. Suggestions from the pilot study were incorporated into the 10 items before dissemination of the questionnaire. A Likert format was used that mirrored the format used in the ICGR from always to never.

Initially, the positive grief scale had 10 items and with these items the potential scale range was from 10–50. A factor analysis was performed on all 10 items. Factor analysis statistically determines the validation a scale or index by demonstrating that its constituent items load on the same factor, and it is also use to make determinations to drop proposed scale items which cross-load on more than one factor (Kim & Mueller, 1978). Employing a maximum likelihood factor analysis method, it took three iterations to result in a two-solution factor analysis. However, three items loaded poorly on either factor (had loadings less than .4). They were “material goods don’t mean a lot to me”; “don’t fear death”; and “change almost nothing.” In con-ducting a reliability analysis for the 10-item scale, the Cronbach’s alpha was .69.

Consequently, item-total statistics were calculated and examined to determine if deleting these items would improve the reliability analysis of the scale. These items were deleted in a step-wise fashion beginning with “don’t fear death” (Cronbach’s alpha = .75); then “change almost nothing” (Cronbach’s alpha = .76); and “material goods” (Cronbach’s alpha = .79). Consequently the subsequent analyses regarding the positive grief scale use this seven-item scale Thus the amended range of score is 7–35. A score closer to 7 indicated less positive grief and a score closer to 35 more positive grief.

Quantitative Items—Practice Behaviors

Practice behavior questions were adapted from the Standards for End of Life Care for Social Workers developed in 2004 by the National Association of Social Workers (NASW, 2004). Specifically, these questions asked first if the person had experienced the practice behavior that corresponded to the NASW standards for care—i.e., social workers provided community referrals; were easily available; supplied information on treatment and/or disease pro-cess; listened to their concerns; respected their culture; discussed the dying process itself; discussed the loss and grief process; gave information about loss and grief; supported them emotionally and supported them spiritually.

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

32 T. A. Gordon

In addition, a follow-up question inquired as to the degree of the helpfulness of the practice behavior.

Qualitative Item Development

Two open-ended questions were asked. One question asked specifically about social workers they encountered in either a hospital, hospice, or pal-liative care setting and the other question asked the respondents to identify anything that social workers in any setting did that was helpful to them as they dealt with their loss and grief. Space on the page and back of question-naire was available for their responses.

Data Analysis

The quantitative questions were analyzed using SPSS 18.0 (SPSS, Inc., Chicago, IL, USA). Demographic questions were examined with percentages for nomi-nal variables and means for ratio variables computed. Mean scores for both the ICGR and the Positive Grief Scale were also totaled. A confirmatory factor analysis test was performed on the ICGR Scale and factor analysis, means, and chi-square tests were performed on the both scales. For the practice behaviors, percentages were calculated regarding the presence of the behavior and mean scores for the helpfulness of the behavior were obtained. Bivariate correlations were performed to analyze the relationship between the practice behavior and the scores on both the ICGR and the Positive Grief Scales. The qualitative questions were open-ended. They were coded and grouped into themes.

FINDINGS

Study Demographics

The average age of the participants was 61.9 (median age of 62.8 years). The youngest participant was 20 years and the oldest was 88. Participants were generally women (70%), Caucasian (87.2%) with 6.7% African-American and 3.3% First Nations; and spouses/partners (68.9%) with 15% children and 16.1% other loved ones. Ninety-six percent of the participants stated that they had provided both emotional and physical support to the dying loved one. Finally, data were collected about the length of the caregiving experi-ence by the participants. The mean length for caregiving was 4.1 years and the median length was 4 years (n = 180).

ICGR Scale Scores

With regard to complicated grief, none of these caregivers’ scores on the ICGR indicated complicated grief. The overall mean score was 45.2 far below

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 33

the cut-off score determined by the scale developers. Table 1 lists the means and standard deviations for the ICGR scale.

Finally, further validation of the ICGR was conducted to analyze the results of a factor analysis and two-factor solution, the goodness of fit, and the Cronbach’s alpha. A maximum likelihood factor analysis was performed and all 19 items loaded on two factors. The goodness-of-fit test resulted in a chi-square analysis whose results were significant, χ2 (135, n = 180) = 209.79, p = .000. The Cronbach’s alpha of .76 was determined. The amount of vari-ance explained by this solution was 59.6%.

Positive Grief Scale Scores

The overall scores for the Positive Grief Scale were 25.72 (mean), 26 (median), and 7–35 (range). Table 2 summarizes the mean scores of the seven-item Positive Grief Scale and the standard deviations.

As stated earlier, the factor analysis resulted in all seven items loading on two factors and the goodness-of-fit test resulted in a chi-square analysis. The results of the test were significant, χ2 (8, n = 180) = 17.044, p = .03. As stated earlier, the Cronbach alpha for this scale was .79. The amount of vari-ance explained by this solution was 46.6%.

TABLE 1 ICGR Item Means (n = 173)

Item Mean* Standard deviation

Pain in body 1.32 0.78621See the person 1.41 0.85980Hear the voice 1.71 1.00209Feel unfair 1.82 1.13730Avoid reminders 1.86 2.56705Lost ability to care 1.90 1.00946Hard to trust 1.99 1.94587Feel angry 2.19 1.14253Envious of others 2.24 1.40669Cannot accept death 2.28 1.05236Bitter over death 2.35 1.99731Memories upset 2.39 1.12958Feel stunned 2.52 1.19802Disbelief over happening 2.79 1.12365Hard to do normal things 2.98 1.27621Life is empty 3.09 1.15442Drawn to places 3.20 1.11280Lonely 3.46 3.16102Long for person 3.64 1.09583

Note. ICGR = Inventory of Complicated Grief-Revised.*Likert scale: 1 = “never”; 2 = “rarely”; 3 = “sometimes”; 4 = “often”; 5 = “always.”

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

34 T. A. Gordon

Practice Behavior Scores

Social work practice behaviors associated with the NASW practice standards for end-of-life care were also examined with regard to whether the respon-dent reported experiencing the practice behavior and their helpfulness to the participant in coping with the loss. Two behaviors, listening to the clients and respecting their culture/ethnicity, were present at least 90% of the time. Conversely, two behaviors, spiritual support and information on bereave-ment, were delivered less than 60% of the time. Table 3 reviews all the behaviors and summarizes this data.

An analysis of the bivariate correlations between a high positive grief score and the practice behaviors was conducted. High positive grief was defined as those individuals that reported “often” or “always” to the positive grief items (n = 75). With regard to the presence of the behaviors, “information on the dying process” (p = .04); “emotional support” (p = .01); “spiritual support” (p = .006); and “listened to” (p = .017) were positively and significantly

TABLE 2 Means and Standard Deviation Scores for the Seven-Item Positive Grief Scale (n = 179)

Item Mean* Standard deviation

Life has more meaning 3.03 1.23731Learned about myself 3.59 1.02028Important things in life 3.62 1.04975Am a better person 3.84 1.26297More spiritually aware 3.47 1.14671Have good memories 4.41 0.85050Value each day 3.88 1.08599

*Likert scale: 1 = “never”; 2 = “rarely”; 3 = “sometimes”; 4 = “often”; 5 = “always.”

TABLE 3 Practice Behaviors and Helpfulness Ratings (n = 180)

Practice behaviors Presence

(% of “Yes” replies) Helpfulness

mean* Standard deviation

Listened to 92.8% 1.31 .61767Respected culture/ethnicity 90.6% 1.51 .83919Availability of providers 86.7% 1.27 .55019Information on disease 86.7% 1.15 .53253Inclusion in plans of care 85.5% 1.20 .53014Discussed treatment option 79.4% 1.24 .63185Emotional support 76.6% 1.38 .65427Information on dying process 71.7% 1.21 .59774Referrals to resources 71.1% 1.47 .89013Information on bereavement 57.8% 1.46 .70095Spiritual support 52.2% 1.49 .89824

*All ratings fall between very helpful (1) and somewhat helpful (2).

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 35

correlated. No behavior had a significant negative correlation. With regard to the helpfulness of the behavior, “the information on dying process” (p = .002); “emotional support” (p = .020); “listened to” (p = .013); “respectfulness” (p = .006); and “availability of worker” (p = .001) were positively and significantly corre-lated. No significant negative correlations on helpfulness were found.

Likewise, bivariate correlations were computed with regard to high negative grief scores and the practice behaviors. A high negative grief score was defined as reporting “sometimes” or “often” to the negative grief items (n = 36). None of the practice behaviors was significantly correlated either positively or negatively with this high negative grief score.

Qualitative Findings

Themes emerged from the data and are grouped according to their associa-tion with positive grief, complicated grief, and service delivery. Of the 180 respondents, 159 entered responses to at least one of the two qualitative questions.

Statements attesting to positive grief were a central theme that emerged from these responses. Forty-nine respondents (31% of the qualitative responses for this item) wrote comments that were coded as positive grief. The responses reflected continuing positive bonds with the deceased loved one; enhanced self-awareness or self-esteem; meaning-making of the death or of continuing life; and value stances that appear to be more important in the light of the death. The responses were identified as positive grief if they contained statements about meaning, enhanced self-esteem and self-aware-ness, spiritual awareness, and reconstruction of values. Also, comments that reported memories or persistent attachment to the deceased that were identi-fied as good things in the life of the surviving loved one were also coded as “positive grief.” Examples of positive grief responses are as follows:

• “I choose to take each day as happy and thankful that I’m still about to get up each day and go on with my life.”

• “I visited a medium—although skeptical, it surprisingly helped me. I felt reassured my husband was happy and in a good place with other loved ones and that he is still with me.”

• “I think about mom quite often but it does not keep me from living life to the fullest … I miss her dearly. She was an important part of my life, but my life is not empty.”

• “I do feel like I’m a better person because of the example he gave to us with the way he handled his cancer—all I can say is I’ve been so blessed.”

• “I fear death even less than I did before mom died.”

Grief statements that supported the negative aspects of loss were also evident. In reviewing the qualitative comments, many individuals voiced

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

36 T. A. Gordon

particularly the sadness and loneliness of loss. Twenty-seven respondents (17% of the qualitative responses for this item) made comments that were coded as negative grief. Examples of these are as follows:

• “It’s been a year and a half since losing my husband and each day is a struggle. The question is how do I go on? I can’t find an answer.”

• “I lost my mom and I still feel there was still so much I should’ve talked to her about.”

• “I just turned 44. I’ve lost two husbands to cancer in less than 5 years. I’ve tried counseling and meds—neither helped.”

• “I wasn’t able to give my mom a proper death and I’ll regret it forever.”

Comments about practice behaviors were frequent with approximately 53% of the respondents pointing out the benefits. The most often mentioned practice behaviors that were appreciated by the respondents were support (emotional or spiritual), listening, normalizing the physical signs of the dying process, respect, and availability. Typical responses were:

• “We were guided through a stressful time with compassion and a lot of support.”

• “Explained everything in detail—answered my questions—listened well to my complaints and concerns.”

• “Created a personal connection with Dad and Me. I/we really felt they were our partners on this path; talking candidly about their perspective, especially about the spiritual aspect of death/dying and cancer in general.”

DISCUSSION

Scale Development

Development of the Positive Grief Scale is a beginning attempt to quantify grief responses that are life-enhancing. The process of developing the scale and its further refinement will provide a tool for researchers and practitio-ners to use to further the discussion of the multidimensionality of grief. At present, grief is seen as a negative process that is painful and a threat to the well-being of the person. Certainly, grief can become complicated. However, grief also invites personal growth and a greater appreciation of life and the people in our lives. Acknowledging this potential for positive aspects of grief presents social workers with a more holistic and useful way to conceptualize the grief process.

In looking at the ICGR Scale developed by Prigerson and her colleagues (1995), the items have strong validity and reliability scores. This study further

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 37

confirmed this data. However, the theoretical grounding for the ICGR is interesting to examine in light of concepts embracing positive grief. From a positive grief perspective, persistent memories and feeling of closeness with the deceased is not seen as pathology, but as a natural normal experience in which persons stay connected to the person in a spiritual or psychological way (Klass et al., 1996; Munn & Zimmerman, 2006; Rando, 1984; Tedeschi et al., 1998). Consequently, some of the items in the scale could be called into question as to their validity. Items like, “I hear the voice of the person who died speak to me”; “I see the person who died stand before me”; “I feel drawn to places and things associated with the person who died; and “I feel myself longing for the person that died” from a negative grief standpoint assess rumination and yearning that lead to a bereaved person’s inability to go on with their lives in a normal way (Barry et al., 2001; Latham & Prigerson, 2004; Prigerson et al., 2007). However, from a positive grief perspective, this is healthy and validates the continuing bonds and relationships of loved ones (Klass et al., 1996; Munn & Zimmerman, 2006; Rando, 1984; Tedeschi et al., 1998). As the items stand now, it is impossible to delineate whether these experiences are troubling and indicators of complicated grief or whether they are supportive and life affirming. Interestingly, in this study two of the above items (drawn to places and longing for the person) were reported most frequently by the participants. Not knowing whether these were identified negative experiences that caused them pain or sadness or whether they were positive experiences that gave them comfort is problem-atic. Further explorations into this lack of clarity are definitely warranted.

Multidimensionality of Grief

This study appears to confirm that in this population of bereaved individuals elements of both positive and negative grief occur simultaneously and at levels that are not pathological (none of the respondents scored in the com-plicated grief range). Mixed messages of the grieving process were evident in every returned questionnaire for this study. The mean score for all the respondents on the ICGR was 45 (range from 19–95). This represents that “sometimes” to “often” the respondent felt elements of negative grief. The mean score for the Positive Grief Scale was 26 (range from 7–35). This rep-resents that “sometimes” to “often” the respondents felt elements of positive grief. The qualitative findings also support mixed messages in the grieving process for all but two of the respondents.

If grief is multidimensional, does having both perceptions create within the bereaved cognitive dissonance? And if so, does the theory of cognitive dissonance point toward more effective ways of helping people grieve well? Festinger (1957) proposed that if a person has conflicting perceptions and if holding those conflicting beliefs create discomfort within the individual, the  individual would work to resolve the conflict and find consonance.

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

38 T. A. Gordon

This corresponds to Festinger’s (1957) belief that cognitive consistency is an internal cognitive goal. One of the ways in which a person could resolve the dissonance would be to increase the importance of one perspective and thus outweigh the other. If this theory is accepted, then maximizing positive grief aspects could lead to a lessening of negative grief reactions and subse-quently help prevent or reduce the incidence of complicated grief reactions. Some research studies have alluded to this. For example, expressions by the bereaved of positive appraisals such as evidence of self-growth, awareness of personal strengths, and quality of the relationship appear to be associated with less complicated grief (Bonanno, Moskowitz, Papa, & Folkman, 2005). Those who have “protective factors” such as an “acceptance of death,” “a belief in a just world,” and “instrumental support” appear to grieve well (Bonanno et al., 2005, p. 830). Spirituality and its connections to positive grief have also been found (Michael, Crowther, Schmid, & Allen, 2003; Walsh, King, Jones, Tookman, & Blizard, 2002). Finally, support prior to the loss significantly reduces bereavement stress even more than support during bereavement (Bass, Bowman, & Nelker, 1991). More targeted research is needed to further explore whether positive grief experiences have a moder-ating or mitigating impact on the development of complicated grief experiences.

Implications for Social Workers

The second research question explores whether the practice behaviors for social workers working in end-of-life care are correlated positively or nega-tively with grief response. Social workers, in a variety of health and mental health settings, serve people who are dying and their families/friends who care for them and who must cope with losing them to death. NASW (2004) has identified that competency in end-of-life care is not just applicable to a specific field of practice but applicable to all social work practitioners:

All social workers, regardless of practice setting, will inevitably work with clients facing acute or long-term situations involving life-limiting illness, dying, death, grief and bereavement. Using their expertise in working with (varying) populations … social workers … must be prepared to assess needs and intervene appropriately. (p. 7)

This mandate compels social workers to be aware of the standards of practice and to gain competency in delivering those practice behaviors that promote healthy grieving. In this study, the presence of the practice behavior and its degree of helpfulness were assessed. From the data, for this sample some practice behaviors were infrequently addressed. The presence of the behaviors ranged from 52.2% (spiritual support) to 92.8% (listened to). Since the standards for optimal end-of-life care support the need for all of these

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 39

practice behaviors, theoretically all the behaviors should be present for all clients at the 100% level.

The findings of this study imply that good social work practice behav-iors appear to support normal grief and enhance their coping with their loss. Regardless of the fields of practice, social workers are taught the importance of listening to clients, providing education, providing emotional and spiritual support, and being available and respectful. Consequently, social workers do not need to learn a new skill set but need to be faithful to delivering what they already know well as competently as possible within the constraints of their practice setting.

This study also points out the need for social workers to be aware of the multidimensional nature of the grieving process. Both negative and posi-tive aspects of grief appear to exist simultaneously. This study supported that this existence of both aspects may be a normal and expected manifestation of grief. Reassuring loved ones that they are grieving as expected even if they are profoundly sad on one hand and feeling positive on another is indicated. Also supporting the strengths of positive grief can assist loved ones in iden-tifying their own growth through the grieving process. As with other ele-ments of a strengths perspective, persons may not be aware of their resil-iency until it is spotlighted and acknowledged. Being aware of the elements of positive grief (growth in meaning-making, self-awareness, self-esteem, spirituality, and reconstruction of values) social workers can then address these when providing counseling to support healthy grieving. Conversely, social workers also need to be aware of the warning signs of a more compli-cated grief experience so that they can intervene early and help the person access timely therapeutic support.

Limitations and Future Research

Limitations of this study include the low response rate, the use of the Positive Grief Scale (an untested measure), and the lack of ethnic and gender diver-sity within the sample. Another key concern with response rate is that the respondents may have failed to represent a full range of people who experi-ence grief as those with complicated grief may have chosen not to partici-pate in the study. Therefore, this study likely only represents those people who are grieving well. Another limitation is the cross-sectional nature of the study. Since grief is also embedded within time, the reliability of these find-ings is also limited because this is only a snapshot of the grief process and is not generalizable.

Further research is needed to explore the dimensionality of positive grief and further refining its definition and implications. A longitudinal study of bereaved persons at 6-month intervals from the death to study the progres-sion of time and its influence on both positive and complicated grief may be able to provide a more accurate conceptualization of the grief process and

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

40 T. A. Gordon

the possible interplay between positive and negative grief experiences. This might also shed light as to whether cognitive dissonance appears to be a factor in grieving processes. Further research on the Positive Grief Scale needs to occur to reinforce validity and reliability data to support its use. Specifically, refinement of the items themselves; testing with diverse groups and testing within diverse settings would be next steps. However, this is a beginning attempt to look at grief responses in a more holistic way and initial validity and reliability measurements are promising. In addition, further research as to which social work practice behaviors help to support positive grief and decrease negative grief is needed to provide evidence-based practices that moderate the impact of negative grief and support healthy coping with loss.

CONCLUSION

Social workers in all fields of practice and especially other health care profes-sionals have an important role in supporting a good dying experience for the ill person and further supporting those loved ones that grieve. By recognizing the multidimensionality of grief, social workers can more fully understand normal grieving processes and differentiate them from complicated grief, thus leading to more effective social work practice. In addition, basic social work practice behaviors appear to support positive grief experiences.

REFERENCES

Attig, T. (1996). How we grieve: Relearning the world. New York, NY: Oxford Press.Barry, L., Kasl, S., & Prigerson, H. (2001). Psychiatric disorders among bereaved per-

sons: The role of perceived circumstances of death and preparedness for death. American Journal of Geriatric Psychiatry, 10, 447–457.

Bass, D., Bowman, K., & Nelker, L. (1991). The influence of caregiving and bereave-ment support at death. The Gerontologist, 31, 32–43.

Bonanno, G., Moskowitz, J., Papa, A., & Folkman, S. (2005). Resilience to loss in bereaved spouses, bereaved parents, and bereaved gay men. Journal of Personality and Social Psychology, 88(5), 827–843.

Calhoun, L., & Tedeschi, R. (2002). Positive aspects of critical life problems: Recollection of grief. Omega, 20, 265–272.

Centers for Disease Control (2012). Deaths: Preliminary data for 2010. National Vital Statistics Report, 60(4), 1–52.

Chen, J., Bierhals, A., Prigerson, H., Reynolds, C., Shear, M., Day, N., … Jacobs, S. (1999). Gender differences in the effects of bereavement related psychological distress in health outcome. Psychological Medicine, 29, 367–380.

Festinger, L. (1957). A theory of cognitive dissonance. Palo Alto, CA: Stanford University Press.

Frantz, T. T., Farrell, M., & Trolley, B. (2001). Positive outcomes of losing a loved one. In R. Neimeyer (Ed.), Meaning reconstruction and the experience of loss (pp. 191–209). Washington, DC: American Psychological Association.

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

Good Grief 41

Jacobs, S., Hanson, G., Kasl, S., Ostfeld, A., Berkman, L., Kosten, T., & Kim, K. (1990). Anxiety disorders during acute bereavement risk and risk factors. The Hospice Journal, 2, 21–26.

Janoff-Bulman, R., & Berger, A. (2000). The other side of trauma: Towards a psychol-ogy of appreciation. In J. H. Harvey & E. D. Miller (Eds.), Loss and trauma: General and close relationship perspectives (pp. 29–44). Philadelphia, PA: Brunner-Routledge.

Kim, J., & Mueller, C. (1978). Factor analysis: Statistical methods and practical issues (Quantitative Applications in the Social Sciences Series, No. 14). Thousand Oaks, CA: Sage.

Klass, D., Silverman, P., & Nickman, S. (1996). Continuing bonds: New understand-ings of grief. London, United Kingdom: Taylor and Francis.

Kubler-Ross, E. (1968). On death and dying. New York, NY: Macmillan.Latham, A., & Prigerson, H. (2004). Suicidality and bereavement: Complicated grief

as psychiatric disorder presenting greatest risk for suicidality. Suicide and Life-Threatening Behavior, 34, 350–362.

Michael, S., Crowther, M., Schmid, B., & Allen, R. (2003). Widowhood and spirituality: Coping responses to bereavement. Journal of Women & Aging, 15(2–3), 145–166.

Milo, E. (1997). Maternal responses to the life and death of a child with developmen-tal disability. Death Studies, 21, 443–476.

Munn, J., & Zimmerman, S. (2006). A good death for residents of long-term care: Family members speak. Journal of Social Work in End-Of-Life and Palliative Care, 2(3), 45–59.

National Association of Social Workers. (2004). NASW standards for palliative and end-of-life care. Washington, DC: Author.

Neimeyer, R. (2002). Meaning reconstruction and loss. In R. Neimeyer (Ed.), Meaning reconstruction and the experience of loss (pp. 1–9). Washington, DC: American Psychological Association.

Neimeyer, R. (2005). From death anxiety to meaning making at the end of life: Recommendations for psychological assessment. Clinical Psychology: Science and Practice, 12(3), 354–357.

Ott, C. (2003). Impact of complicated grief on mental and physical health at various points in the bereavement process. Death Studies, 27, 249–272.

Prigerson, H. (2004). Complicated grief: When the path of adjustment leads to a dead-end. Bereavement Care, 23, 38–40.

Prigerson, H., Maciejewski, R., Reynolds, C., Bierhals, A., Newsom, J., Frasiczka, A., … Miller, M. (1995). Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65–79.

Prigerson, H., Vanderwerker, L., & Maciejewski, P. (2007). Complicated grief as a mental disorder: Inclusion in the DSM. In M. Stroebe, R. Hansson, H. Schut, & W. Stroebe (Eds.), Handbook of bereavement research and practice in the 21st century. New York, NY: American Psychological Press.

Rando, T. (1984). Grief, dying and death: Clinical interventions for caregivers. Chicago, IL: Research Press.

Rando, T. (1993). Treatment of complicated mourning. Chicago, IL: Research Press.Silverman, C., Jacobs, S., Kasl, S., Shear, M., Jaciejewshi, P., Noaghuil, F., & Prigerson,

H. (2000). Quality of life impairments associated with diagnostic criteria for traumatic grief. Psychological Medicine, 30(2), 857–862.

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14

42 T. A. Gordon

Singh, K. (1998). The grace in dying: How we are transformed spiritually as we die. San Francisco, CA: HarperCollins.

Tedeschi, R., Park, C., & Calhoun, L. (1998). Posttraumatic growth: Conceptual issues. In R. Tedeschi, C. Park, & L. Calhoun (Eds.), Posttraumatic growth. London, United Kingdom: Erlbaum.

Walsh, K., King, M., Jones, L., Tookman, A., & Blizard, R. (2002). Spiritual beliefs may affect outcome of bereavement: Prospective study. British Medical Journal, 324(353), 1551–1555.

Worden, W. (2003). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed). Boston, MA: Psychology Press.

Zhang, B., El-Jawahri, A., & Prigerson, H. (2006). Update of bereavement research: Evidence- based guidelines for the diagnosis and treatment of complicated bereavement. Journal of Palliative Medicine, 9(5), 1188–2003.

Dow

nloa

ded

by [

Geb

ze Y

ukse

k T

ekno

loji

Ens

titïs

u ]

at 2

1:53

20

Dec

embe

r 20

14