1
BEREAVED INDIVIDUALS‘ FEELINGS OF ANGER TOWARD DECEASED
FAMILY MEMBERS: A MIXED METHODS APPROACH
by
BRIANA L. ROOT
Submitted in partial fulfillment of the requirements
For the degree of Doctor of Philosophy
Dissertation Advisor: Dr. Julie Exline
Department of Psychology
CASE WESTERN RESERVE UNIVERSITY
August, 2012
2
CASE WESTERN RESERVE UNIVERSITY
SCHOOL OF GRADUATE STUDIES
We hereby approve the thesis/dissertation of
Briana L. Root
candidate for the
(signed)
.
Doctor of Philosophy
degree *.
Julie Juola Exline, Ph.D.
(chair of the committee)
.
Norah Feeny, Ph.D.
.
Aloen L. Townsend, Ph.D.
.
TJ McCallum, Ph.D.
.
Maryjo Prince-Paul, Ph.D.
.
(date) 5/10/11 .
*We also certify that written approval has been obtained for any
proprietary material contained therein.
3
Dedication and Acknowledgments
First, I would like to thank all participants for sharing their stories of love and
loss. I am grateful for their courage and openness, and dedicate this study to them.
I would like to thank my advisor, Julie Exline, for her support, warmth and grace.
I count myself very lucky to have had such a wonderful human being as a mentor and
friend. I thank Maryjo Prince-Paul for kindness and her boundless enthusiasm in
supporting the completion of this study. I would also like to thank the rest of my
committee, Norah Feeny, TJ McCallum, and Aloen Townsend, for their guidance and
insight shared. I would like to thank the wonderful Karen Peereboom for providing
coding support—you were a joy to work with! I am very grateful to the staff of the
Hospice of the Western Reserve and the Elisabeth Severance Prentiss Bereavement
Center for their support of this research.
I want to thank my parents and my sisters, Bethany and Noelle, for their
unwavering support and love. I am happy to have shared each step of my life with you. I
also want to thank the ―family‖ that I have established here in Cleveland and at Case
Western. To Abby Braden, Kelly Christian, and Clare Mitchell—you have been my
graduate school ―sisters‖ and I am so grateful for the compassion and wonderful
friendship you have provided for me. To Erin Lea, Lauren Fisher, and Sarah Spannagel,
I feel the same way, and I thank you for your loyal friendship and for always being there
to listen. I would like to thank Charlie Hughes—I am a better person for having known
you. Finally, I want to thank Ronnie James for being a source of constant comfort and
amusement throughout my graduate studies. I am so grateful to you all and am proud to
share this accomplishment with you.
4
Table of Contents
Abstract …………………………………………………………………………….
Introduction ………………………………………………………………………..
Anger ………………………………………………………………………
Interpersonal Conflict and Forgiveness ……………………………………
Forgiveness-Related Issues at the End of Life …………………….
Hospice and Palliative Care ………………………………..
Quality of Life for Family Members of Hospice Patients …
Unresolved Anger Between the Bereaved and the Deceased .…………….
Source of Anger Toward the Deceased ……………………………
Anger about Past, Pre-Illness Transgression ………………
Anger about Transgression Related to Family Member‘s
Terminal Illness……………………………………..……...
Caregiving-Related Anger ……………………........
Attribution of Blame for Illness ……………………
Death and its Consequences as the Transgression …………
Prevalence and Measurement of Feelings of Anger Experienced in
Bereavement ……………………………………………………………….
The Experience of Anger in Bereavement…………………………
Anger at the Deceased ……………………………………..
The Experience of Anger in Bereavement Following
Terminal Illness ……………………………………………
Conclusions ………………………………………………………..
Conceptual Model: Anger, Adjustment Outcomes, and the Post-death
Relationship ………………………………………………………………..
Ongoing Feelings of Anger and Grief Outcomes ………………………….
Empirical Findings Relating Anger to Post-Loss Adjustment
Outcomes …………………………………………………………..
Complicated Grief …………………………………………
Other Forms of Distress ……………………………………
Posttraumatic Growth………………………………………
Conclusion and Hypotheses ……………………………………….
Unresolved Anger and the Continuing Relationship with the Deceased …..
Review of Continuing Bonds Theoretical and Empirical Literature
Continuing Bonds‘ Link with (Mal)Adjustment …………..
Unresolved Anger and the Continuing Relationship ………………
Conclusion and Hypotheses ………………………………………..
Aims of the Current Study …………………………………………………………
Study Design ……………………………………………………………………….
10
12
12
14
15
16
17
18
18
18
19
20
21
21
23
23
24
25
26
27
28
29
30
32
32
33
33
33
35
38
40
40
42
5
Mixed Method Design……………………………………………………...
Scale Derived from Literature Review …………………………….
Procedures …………………………………………………………………
Participants ………………………………………………………………...
General Recruitment ……………………………………………….
Phase 1: Qualitative Study …………………………………………………………
Qualitative Phase Methods ………………………………………………...
Qualitative Phase Recruitment …………………………………….
Purposive Sampling Procedure …………………………….
Qualitative Phase Participants……………………………………...
Measures for Qualitative Phase ……………………………………………
Background and Demographics Questions ………………………...
Qualitative Interview ………………………………………………
Qualitative Phase Results ………………………………………………….
Initial Qualitative Phase Data Analysis ……………………………
Use of Qualitative Data to Inform the Quantitative Phase ...
In-Depth Qualitative Phase Data Analysis ………………………...
Credibility of Data …………………………………………
Results of In-Depth Qualitative Data Analysis ……………………
Themes Related to Anger Associated with Family
Member‘s Illness or Health Care …………………………..
Family Member Did Not Take Care of Health …….
Anger Related to Caregiving Interactions …………
Themes Related to Anger Associated with the Death of the
Family Member ……………………………………………
Separation-Related Anger ………………………….
Negative Consequences of the Death ……………...
Themes Related to Anger Regarding Interpersonal Conflict
with Family Member……………………………………….
Hurtful Words or Actions ………………………….
Family Member Neglected to do Something That
was Important………………………………………
Betrayal of Trust …………………………………...
Being Put in a Difficult Position……………………
Summary of Qualitative Phase……………………………………..
Phase 2: Quantitative Study ………………………………………………………..
Quantitative Phase Methods ……………………………………………….
Quantitative Phase Recruitment …………………………………...
Quantitative Phase Participants ……………………………………
42
43
44
45
46
46
46
46
47
49
50
50
50
51
51
51
53
53
54
55
55
56
56
56
57
57
57
57
57
58
58
58
58
58
59
6
Measures for Quantitative Phase…………………………………...
Background and Demographic Questions………………….
Measures of Unresolved Conflict and Feelings of Anger
Toward the Deceased ……………………………………...
Closeness and Quality of the Pre-Death
Relationship………………………………………...
Unresolved Issues in Relationship …………………
History of Family Member Offenses ………………
Current Feelings of Anger Toward Deceased ……..
Current Feelings of Anger at Other Entities ……….
Trait Anger ………………………………………………...
Adjustment Measures …………………………...................
Complicated Grief …………………………………
Depression …………………………………………
General Distress ……………………………………
Posttraumatic Growth ……………………………...
Continuing Relationship with the Deceased ……………….
Continuing Relationship: Belief in a Continued
Existence……………………………………………
Continuing Relationship: Communication ………...
Quantitative Results ………………………………………………………..
Prevalence and Intensity of Anger Toward Deceased ……………..
Intercorrelations for Main Study Variables ………………………..
Construct Validity of Anger Scale …………………………
Anger and Adjustment ……………………………………..
Anger and the Continuing Relationship …………………...
Mediation Hypotheses ……………………………………………..
Regression Analyses………………………………………………..
Control Variables…………………………………………...
Anger Subscales as Predictors ……………………………..
Anger Predicting the Belief that the Family Member
Continues to Exist ………………………………………….
Anger Predicting Distress…………………………………..
Anger Predicting Posttraumatic Growth …………………...
Discussion ………………………………………………………………………….
New Anger Scale …………………………………………………………..
Correlates of Ongoing Anger Toward Deceased Family Members………..
Anger and Perceptions of a Continued Relationship ………………
Anger and Indicators of Adjustment……………………………….
60
60
61
61
61
62
62
64
65
65
65
66
66
66
66
67
67
68
68
69
69
70
70
71
72
72
73
73
75
75
76
77
77
78
80
7
Anger and Distress …………………………………………
Anger and Posttraumatic Growth ………………………….
Limitations and Future Directions …………………………………………
Study Design and Methods ………………………………………...
Qualitative Data Analysis ………………………………………….
Study Sample ………………………………………………………
Forgiveness ………………………………………………………...
Conclusions ………………………………………………………………..
Footnotes……………………………………………………………………………
Appendix A ………………………………………………………………………..
Appendix B ……………………………………………………………………….
Appendix C ……………………………………………………………………….
References .………………………………………………………………………...
80
82
84
84
84
85
86
87
89
126
127
130
136
8
Tables
Table 1 Descriptive Statistics for Categorical Variables in the Qualitative Phase
91
Table 2 Demographic Statistics for Continuous Variables in the Qualitative
Phase…………………………………………………………………………………………
92
Table 3 Parallels Between Qualitative and Quantitative Phase Measures
93
Table 4 Refinements to the Proposed Anger Scale Based Upon Qualitative Data
Analysis………………………………………………………………………………………
96
Table 5 Thematic Structure of Qualitative Data with Representative Excerpts……
98
Table 6 Descriptive Statistics for Categorical Variables in the Quantitative Phase
102
Table 7 Demographic Statistics for Continuous Variables in Quantitative Phase
104
Table 8 Component Loadings for Principal Components Analysis With Varimax
Rotation of Anger Subscales………………………………………………………………
105
Table 9 Prevalence and Intensity of Ongoing Feelings of Anger Toward the
Deceased……………………………………………………………………………………..
106
Table 10 Intercorrelations for Main Study Variables………………………………….
107
Table 11 Intercorrelations for Main Study Variables and Demographic /
Background Variables……………………………………………………………………..
108
Table 12 One-way ANOVA with Bonferroni Correction on Distress and
Posttraumatic Growth by Marital Status: Married vs. Widowed……………………
110
Table 13 One-way ANOVA with Bonferroni Correction on Total Anger, DeathSeparation Anger and Distress by Family Member Relationship to Participant…..
111
Table 14 One-way ANOVA with Bonferroni Correction on Distress by Location of
Death…………………………………………………………………………………………. 112
Table 15 Prediction of Criterion Variables by the Anger Subscales………………… 113
Table 16 Prediction of Belief that Family Member Continues to Exist by Total
Anger Scale………………………………………………………………………………….
114
Table 17 Prediction of Belief that Family Member Continues to Exist by
Relationship Conflict Anger ………………………………………………………………
115
Table 18 Prediction of Distress by Total Anger Scale…………………………………
116
Table 19 Prediction of Distress by Death-Separation Anger…………………………
118
Table 20 Prediction of Posttraumatic Growth by Total Anger Scale………………..
120
Table 21 Prediction of Posttraumatic Growth by Death Separation Anger………... 121
9
Figures
Figure 1 Conceptual Model……………………………………………………………….. 123
Figure 2 Mediation Model and Associated Hypotheses……………………………….. 124
Figure 3 Sequential Exploratory Design - Instrument Development Variant………. 125
10
Bereaved Individuals‘ Feelings of Anger Toward Deceased Family Members:
A Mixed Methods Approach
Abstract
by
BRIANA L. ROOT
The purpose of this study was to examine the prevalence and correlates of
ongoing feelings of anger experienced by bereaved individuals toward their deceased
family members, all of whom had received hospice care. Following the death of a close
other, bereaved individuals may be left dealing with ―unfinished business‖ in their
relationship with the deceased, including lingering negative emotions toward the
deceased. It was hypothesized that ongoing feelings of anger toward the deceased would
be linked with poorer adjustment outcomes for the bereaved individual. Furthermore, it
was proposed that this association would be partially mediated by the nature and quality
of the bereaved individual‘s continuing relationship with the deceased. The study
included development of a scale to measure different facets of anger toward the deceased
that may be experienced by bereaved individuals. The study had a sequential exploratory
mixed methods design, with the data collected during the initial qualitative phase used to
inform and enhance the proposed anger scale included in the subsequent quantitative
phase. The cross-sectional sample was comprised of recently bereaved family members
of hospice patients, 6-15 months post-loss. Eight purposively sampled participants
completed an exploratory qualitative interview, followed by 130 participants completing
a quantitative mail questionnaire. Despite some issues with skew, the newly developed
anger scale demonstrated good internal consistency and initial construct validity. Three
11
subscales emerged: Anger related to Relationship Conflict, Anger related to the Death or
Separation, and Anger related to the Family Member‘s Neglect of Health. Results
indicated that although residual feelings of anger toward deceased family members are a
relatively common experience for bereaved individuals, these feelings tend to be (on
average) low in intensity. Contrary to predictions, the participants‘ experience of a
continued relationship with the deceased was not significantly associated with adjustment
outcomes; therefore the mediation hypotheses were not supported. Higher deathseparation anger predicted more distress and was a marginally significant predictor of
greater posttraumatic growth. Ongoing feelings of anger toward the deceased, in
particular anger related to pre-death relationship conflict, also predicted less belief in a
continued existence of the deceased family member.
12
Bereaved Individuals’ Feelings of Anger Toward Deceased Family Members:
A Mixed Methods Approach
When family members die, bereaved individuals may be left dealing with
―unfinished business‖ in their relationship with the deceased, including lingering negative
emotions linked with past offenses committed by the deceased or feelings of
abandonment stemming from the family member‘s death. Although clinical literature has
cited anger as a common component of post-loss reactions (Bowlby, 1973; 1980; Parkes,
1970; Lindemann, 1944; Worden, 2009), sparse attention has been devoted to the
mourner‘s feelings of anger specifically directed toward the deceased individual. The
purpose of this study was to gain a better understanding of the role ongoing feelings of
anger toward the deceased play in coping with the loss of a family member who had been
in hospice care. The study examined the prevalence and intensity of ongoing feelings of
anger toward deceased family members and assessed how such feelings might link with
important adjustment outcomes. An additional focus of the study was on the relationship
between unresolved anger with the family member and the bereaved individuals‘
continued relationship with the deceased.
Introduction
Anger
Merriam-Webster Dictionary defines anger as ―an emotional state induced by
displeasure.‖ The feelings included in this emotional state can vary in intensity, ranging
from mild annoyance to fury (Spielberger, Jacobs, Russell & Crane, 1983). The above
definition implies that anger arises from the experience of displeasure. Emotion theorists
specify that only particular types of displeasure tend to be linked with feelings of anger.
13
Berkowitz (1989) posited that the interruption or frustration of accomplishing a goal that
one expected to achieve elicits anger. Lazarus (1991) argues that in addition to the
experience of goal frustration, to elicit anger the situation needs to be appraised as
demeaning to one‘s ideas of who one is, who one wants to be and how one should be
treated. That is, feelings of anger occur in conjunction with the belief that one has been
unfairly slighted in some way.
Anger occurs within an interpersonal context—other people tend to be viewed as
the cause or source (through their transgressions) and the target of feelings of anger
(Peterson, 1996). Individuals feel angry at others when they appraise another person as
being responsible for the offense and furthermore, as being in control of their offensive
actions (Lazarus, 1991). Moreover, anger has interpersonal consequences. Strong
feelings of anger produce urges to act in ways that would remove or harm the individual
blamed (Fridja, 1988)—that is, avoiding the other person or seeking revenge.
This study focused on feelings of anger directed toward another person. Given
the discussion above, such feelings of anger are likely to occur when an individual
appraised the other person as having acted in a way that 1) disrupts or blocks an
individual‘s goal attainment (Berkowitz, 1989) and/or 2) demeans or disrespects the
individual (Lazarus, 1991). Relationship conflicts and transgressions, which will be
detailed below, are a common precipitant of anger. Feelings of anger toward another
person can also arise, however, in other interpersonal situations such as after separation
and abandonment (Bowlby, 1973; 1980) or when the other person is viewed as inhibiting
the realization of one‘s goals (Berkowitz, 1989).
14
Interpersonal Conflict and Forgiveness
Within any relationship there lies opportunity for interpersonal conflict.
Interpersonal offenses can occur when one person harms, hurts, rejects, offends or
disappoints another person. Following such transgressions, the offended person can
experience an affective response (Barki & Hartwick, 1993), including a variety of
negative emotions such as anger, fear and/or sadness (Worthington, 1998). While other
emotions could be experienced following a transgression, the focus here was specifically
on feelings of anger. Although feelings of anger can be adaptive in the aftermath of the
transgression by encouraging the offended individual to set limits and to seek justice
(Lamb & Murphy, 2002), lingering anger about the offense may, over the long term,
become destructive. The initial emotional responses of anger may persevere, amplify,
and harden into grudge-holding (McCullough, Bellah, Kilpatrick, & Johnson, 2001;
McCullough, Bono, & Root, 2007). Feelings of anger, once vitalizing, can become
burdensome and constricting. The feelings of bitterness, hatred, and resentment involved
in grudge-holding can leave an individual feeling emotionally and physically depleted.
Additionally, the stress of prolonged anger can generate health risks, such as
cardiovascular problems (Berry & Worthington, 2001; Gallo & Matthews, 2003).
Forgiveness is one possible method of reducing anger related to an offense.
Forgiveness entails a transformation of the offended person‘s feelings and attitudes
toward the transgressor, resulting in reduced motivation to avoid or seek revenge against
this individual (McCullough, Worthington, & Rachal, 1997). Broadening one‘s
perception of the offense (e.g., by recalling a time when one has committed a similar
transgression or by empathizing with the transgressor) or warming one‘s view of the
15
transgressor (e.g., by reflecting on past pleasant experiences with the transgressor) are
both effective methods to facilitate the forgiveness process (Exline, Baumeister, Zell,
Kraft, & Witvliet, 2008; Karremans, Van Lange, & Holland, 2005; McCullough,
Worthington & Rachal, 1997; McCullough et al., 1998).
Various benefits at both the individual and interpersonal levels are related to
forgiveness. Higher levels of forgiveness are associated with increased mental health, as
evidenced by higher self-esteem and hope, lower levels of depression and anxiety, and
reduced amounts of negative affect (Al-Mabuk, Enright, & Cardis, 1995; Coyle &
Enright, 1997; Freedman & Enright, 1996; Hargrave & Sells, 1997; Hebl & Enright,
1993; Worthington & Scherer, 2004). Forgiveness is also associated with lower levels of
negative physical health symptoms such as lower physiological stress, and higher selfrated health (Harris & Thoresen, 2005; Witvliet, Ludwig, & van der Laan, 2001; Witvliet
& McCullough, 2005, Toussaint, Williams, Musick & Everson, 2001; Worthington &
Scherer, 2004). Additionally, forgiveness can be instrumental in relational repair
(Fincham, Paleari, & Regalia, 2002; Rusbult, Hannon, Stocker & Finkel, 2005).
Forgiveness-related issues at the end of life. For individuals who are terminally
ill, the desire to achieve resolution and healing of interpersonal wounds may feel
particularly pressing. Therefore, forgiveness-related issues may be especially salient for
this population. The context of terminal illness may create a unique opportunity for the
healing of longstanding relational ruptures (Byock, 1996). Not only does the impending
death potentially heighten an individual‘s awareness of the limited time remaining with
close others, it may also result in perspective changes and reappraisals of conflicts.
Clinical lore and anecdotal reports assert that individuals at the end of life have a strong
16
wish to accomplish a sense of closure in their relationships—so much so, that some
authors propose that such resolution forms a key developmental task in the preparation
for a positive and peaceful death and consequently is an important consideration in the
psychosocial component of end-of-life care (Baker, 2005; Byock, 1996; Institute of
Medicine, 2008). Therefore, the dying person may be encouraged to attend to
―unfinished business‖ in their relationships—which may involve the communication of
important relationship-centered messages such as regret, forgiveness, acceptance,
gratitude, appreciation, and affection (e.g., Byock, 1996; Keeley, 2004; Keeley, 2007;
Keeley & Koenig Kellas, 2005; McQuellon & Cowan, 2000; Prince-Paul, 2008a,
2008b). Empirical research has also indicated that the majority of both patients and
bereaved family members believe that obtaining closure through resolving relationship
issues is important (Steinhauser, Christakis, Clipp, McNeilly, McIntyre, & Tulsky, 2000).
Hospice and palliative care. This emphasis on the dying individual‘s
psychosocial well-being is congruent with the hospice and palliative care philosophies.
Hospice programs provide palliative end-of-life care for patients and support for
caregivers and family members of patients. In hospice care, the focus shifts from curing
the disease to holistic care of the patient. According to the World Health Organization
(WHO), the goal of palliative care is the improvement of terminally ill patients‘ and their
families‘ quality of life through the alleviation of suffering in the physical, psychosocial
and spiritual domains (Sepulveda, Marlin, Yoshida, & Ullrich, 2002). The focus of
palliative care, under this definition, includes not only the wellbeing of the patient but the
wellbeing of the patients‘ family members both during the patient‘s care and in
bereavement (Sepulveda, Marlin, Yoshida, & Ullrich, 2002).
17
Quality of life for family members of hospice patients. The WHO‘s
acknowledgement of the family members‘ wellbeing as an additional focus of palliative
care is noteworthy and highlights an area in need of further examination. Sherman
(1998) argues that there is reciprocity of suffering between terminally ill patients and
their family members—that is, that the experience of suffering is shared by both parties
and that individual suffering is influenced by the other person‘s suffering. Attending to
relational ruptures, accordingly, may be important to address from the family member‘s
perspective as well as from the hospice patient‘s perspective. Of course, dying
individuals are not the only persons who may desire relationship closure within the endof-life context. Family members of the ill individual may feel similar urges to attend to
past and present relational conflicts in hopes of achieving reconciliation and/or resolution
in their remaining time with their loved one; an idea supported by qualitative research
(Gold, 1984, as cited in Keeley, 2004). However, in regards to attending to relationship
ruptures, the experience of the other side of the dyad—the surviving bereaved
individual—during both the time leading up to the death as well as in bereavement, has
received very little attention. Following a loss, bereaved individuals may find
themselves dealing with lingering anger and resentment toward their deceased loved ones
for offenses not resolved prior to the death. The current study examined the experiences
of family members of hospice patients, allowing for a better understanding of how the
relationship to the patient may impact the family member‘s psychosocial wellbeing in the
aftermath of the hospice patient‘s death.
18
Unresolved Anger between the Bereaved and the Deceased
The experience of ongoing feelings of anger by bereaved individuals toward their
deceased family members has received sparse attention in the empirical literature. By
examining the prevalence of residual feelings of anger toward the deceased, this study
will help establish whether forgiveness-related issues constitute a relevant area of inquiry
for bereaved populations. This study examined the form, prevalence, and correlates of
anger directed toward transgressors who are no longer living. For example, do bereaved
individuals continue to experience feelings of anger for past relational conflicts and
frustrations? Do bereaved individuals feel angry at the deceased for the separation
resulting from the loss? What are the adjustment outcomes for mourners with unresolved
anger? Using a sample of recently bereaved family members of hospice patients, the
prevalence, intensity, and correlates of the bereaved person‘s unresolved feelings of
anger toward the deceased was investigated.
Source of anger toward the deceased. Lingering feelings of anger toward the
deceased person may stem from past relationship conflicts, frustrated goals, or feelings of
abandonment. The source of the bereaved individual‘s anger may be a past offense that
occurred prior to the onset of the deceased individual‘s illness, or it may be a
transgression related to the family member‘s illness. Additionally, the unresolved anger
may be tied to the occurrence of the death itself. Each will be briefly elaborated below.
Anger about past, pre-illness transgression. Ongoing anger felt by the bereaved
individual toward the deceased may be due to unresolved past offenses committed by the
deceased person, prior to and unrelated to their terminal illness. The bereaved person
may experience lingering anger toward the deceased for transgressions involving
19
aggression or violence, betrayal, abandonment or neglect, rejection, disappointment,
hurtful words or actions, and violations of trust, for example. Additionally, the bereaved
individual may view the deceased as having disappointed their hopes or expectations
(Field, Bonanno, Williams & Horowitz, 2000). The bereaved individual may feel anger
toward the deceased resulting from long-standing relational patterns, including needs and
wishes left unfulfilled by the deceased (e.g., their loved one did not provide the emotional
support the bereaved individual desired).
Anger about transgression related to family member’s terminal illness.
Alternatively, unresolved anger experienced by the bereaved toward the deceased may be
a result of transgressions occurring during or as a result of the deceased person‘s illness
and end-of-life care. The demands related to the family member‘s health care needs can
place a strain on the family in terms of both psychological and financial resources, which
may lead to heightened tensions among family members. The illness may bring dramatic
changes in the patient‘s behavior, cognitions, and emotions, which in turn may impact his
or her relationships with close others. The family member‘s illness may involve
symptoms that are distressing to witness, aversive or disruptive. The patient‘s behavior
(e.g., being demanding, being critical or ungrateful for care) may elicit strong negative
emotions in close relationship partners. Both family members and their ill relative may
have difficulty accepting the changes in the patient‘s behavior (such as heightened
disruptiveness or dependency) and the terminal prognosis, which could stimulate conflict
(Deimling & Bass, 1986; Kramer, Boelk, & Auer, 2006; Robinson & Thurnher, 1979;
Springer & Brubaker, 1984). For example, in a sample of families with a family member
who died from lung cancer, over a third of participants reported some type of familial
20
conflict at the end of life, including disagreements and arguments, feelings of resentment
and anger, and incidents of yelling and insulting each other (Kramer et al., 2010).
Caregiving-related anger. Many individuals find at least some aspect of the
caregiving as a positive experience (Cohen, Colantonio, & Vernich, 2002) and report
perceived associated benefits such as feelings of increased closeness with the care
recipient (de Vugt et al., 2003), and feelings of importance and competence (Cohen,
Colantonio, & Vernich, 2002). Although some caregivers may find the experience
gratifying or meaningful, caring for a terminally ill family member may also be a source
of strain and conflict. If the survivor acted as a caregiver for the dying individual, they
may have more heightened exposure to distressing changes in behavior as well as feel the
brunt of the increasing demands inherent in his or her loved one‘s care. Relational
tension may result from caregiving interactions (Brody, 1985). For example, there is
some evidence that relationships between caregiver and care-recipients with dementia
tend to deteriorate in levels of intimacy, affection, and communication (see Quinn, Clare,
& Woods, 2009 for a review).
Assuming the caregiver role is often experienced as stressful and burdensome
(Lawton et al., 1989) and it requires individuals to make sacrifices (Zarit & Zarit, 2007),
including such losses as diminished social interactions, loss of previous routines, loss of
flexibility or ability to make plans and loss of self-identity (Pruchno & Resch, 1990).
Such sacrifices may contribute to feelings of resentment in the caregiver (Springer &
Brubaker, 1984).
Additionally, when a loved one is diagnosed with a terminal illness, family
members are often faced with difficult decisions about their care. The patient and family
21
member may disagree on the appropriate treatment steps (Kramer et al., 2006).
Alternatively, caregivers may feel frustrated that care recipients are unable to make these
decisions themselves due to incapacitating illness and communication limitations. Such
limitations may also be linked with less care-recipient cooperation with the caregiver,
which may also increase the caregiver‘s feelings of frustration.
Attribution of blame for illness. Anger or resentment may arise if the surviving
person appraises the illness and death as having been preventable—for example, if the
dying individual had practiced better self-care or behaved in an alternate way. For
instance, the illness that led to death may have been linked with unhealthy yet
controllable behaviors such as poor nutrition, smoking, excessive alcohol or substance
use, or lack of exercise. If the bereaved person blames the dying individual for causing
the death, then he or she is likely to experience anger as a result (Lazarus, 1991). Indeed,
past work has shown that widows of alcoholics reported high levels of anger toward their
deceased husbands; a finding that the authors believe is explained in part by attribution of
blame for the death (Glick, Weiss, & Parkes, 1974).
Death and its consequences as the transgression. Finally, the family member‘s
death itself may represent a source of anger for the bereaved. The surviving individual
may feel abandoned by their loved one (Bowlby, 1973; 1980; Parkes & Prigerson, 2010).
According to attachment theory, feelings of anger are an essential component of a normal
reaction to separation, based on infant-caregiver attachment models (Bowlby, 1973;
1980). When a child is separated from his or her mother, the child tends to react to his or
her intense fears of abandonment by emphatic protest aimed at punishing the mother.
Such demonstrations of anger are adaptive in that the mother is likely to find the
22
experience aversive and thereby become less likely to desert the child again. Attachment
theorists draw parallels between the mourning experience of adults and infant-caregiver
separation responses (Parkes, 2009). Therefore, according to attachment theory, the
yearning and sadness associated with a loved one‘s death are often paired with anger.
There is both the desire to reclaim what was lost (yearning) and the urge to punish the
attachment figure for leaving (anger) (Rando, 1993). It follows then, that the loss and
abandonment inherent in the death may elicit anger toward the deceased in the surviving
individual. Bereaved individuals may angrily question the deceased, ―Why did you leave
me?‖ (Attig, 1996; Parkes & Prigerson, 2010).
Additionally, the bereaved may ask, ―Why did you do this to me?‖ (Parkes &
Prigerson, 2010). The bereaved individual may view the death and the resulting
psychological and physical distress as an ―unjust punishment‖ and ―feel angry with the
presumed author‖ (Parkes & Prigerson, 2010, p.93). Angry feelings may therefore arise
if the bereaved individual blames the deceased for the negative consequences related to
the death. Such consequences could include the pain associated with grief, lossmandated role changes such as being forced to take on foreign responsibilities or roles
(Rubin, 1999; Stroebe & Schut, 1999), or loss of support once provided by the deceased
(e.g., source of advice, companionship, financial contributions, child care, etc.; Cerney &
Buskirk, 1991; Parkes & Prigerson, 2010). The death of the family member may
represent a loss of many different things, depending upon the roles that family member
held in the bereaved individual‘s life. If the surviving individual attributes his or her
current painful or unsatisfactory situation as directly resulting from the death of the
23
family member, he or she may blame the deceased for these negative consequences and
therefore feel resentment and anger (Field, Bonanno, Williams, & Horowitz, 2000).
Prevalence and Measurement of Feelings of Anger Experienced in Bereavement
Although relationships in general, and in the context of the end of life
specifically, hold many opportunities for conflict, transgressions, and resulting feelings of
anger, it remains unclear how common feelings of lingering anger toward the deceased
are for individuals coping with the loss of close others.
The experience of anger in bereavement. Clinical bereavement literature has
long designated anger as a common and expected component of normal grief reactions,
occurring along with feelings of numbness, yearning, sadness, disorganization and
despair (Bowlby, 1973; 1980; Glick, Weiss, & Parkes, 1974; Lindemann, 1944; Worden;
2009). Empirical findings suggest that some bereaved individuals do feel anger, although
the prevalence appears to be relatively low. For example, the Yale Bereavement Study
included 281 individuals whose family members died due to natural causes (including
terminal illness) and who were not experiencing complicated grief. In this sample, levels
of anger related to the death were low and remained consistently low for two years
following the loss (Maciejewski, Zhang, Block, Prigerson, 2007; Prigerson,
Vanderwerker, & Maciejewski, 2008). However, this finding is based only on a single,
general item about anger: ―I can‘t help but feel angry about his or her death.‖ This item
does not specify the source or target of anger experienced by participants (i.e., if the
participant felt anger toward the deceased).
The most common experiences of anger in bereavement cited in the literature are
linked with 1) feelings of fear, 2) feeling the death was unfair, and 3) attributions of
24
blame for the loss. First, clinical writings cite the prevalence of irritability and shortened
tempers following a loss (Worden, 2009). Such tension has been likened to that
experienced with fear: It is thought that the bereaved individual is constantly on guard
from facing the distressing realization that his or her loved one is truly dead (Parkes &
Prigerson, 2010). Feelings of anger in bereavement are also associated in with particular
types of death—in particular those viewed as untimely or unjust (e.g., prenatal deaths,
homicides; Hogan, Greenfield, & Schmidt, 2001; Prigerson et al., 2002; Smith &
Borgers, 1988-1989). These are the types of deaths that often violate people‘s beliefs in a
just and orderly world (Janoff-Bulman, 1993). In attempts to establish a sense of order,
the bereaved may struggle to make sense of the loss by searching for explanations or
seeking someone or something to blame (Field, Bonanno, Williams, & Horowitz, 2000;
Parkes & Prigerson, 2010). Bereaved individuals feel anger at those they see as having
caused or contributed to the death. Therefore, powerful external figures such as health
care professionals and even God may become targets for anger, due to the perception that
these figures have control over life and death (Glick, Parkes, & Weiss, 1974; Parkes &
Prigerson, 2010; Worden, 2009).
Anger at the deceased. Although less commonly addressed in the empirical
literature, there is evidence that bereaved individuals do experience feelings of anger
toward their deceased loved ones as well. In a sample of 49 young widows whose
spouses died from natural causes or an accident, 20% of participants expressed anger
directed toward their deceased husbands for not assuming more proactive care of their
physical well-being or for having otherwise contributed to their own death (Glick, Weiss,
& Parkes, 1974). Another bereavement study revealed that 37% of 244 participants
25
endorsed some current negative feelings toward a deceased loved one (Exline, Park,
Smyth, & Carey, 2011). Bonanno & Keltner (1997) assessed facial expressions of 38
bereaved individuals (mode of death unspecified) while they described their relationship
with their deceased spouse. Six months post loss, 60% of the participants demonstrated
angry facial expressions while talking about their relationship with the deceased
(Bonanno & Keltner, 1997). However, because anger was being assessed via facial
expression, the source or target of the negative feelings cannot be assumed to be the
deceased. Another study examined interpersonal themes within 66 conjugally bereaved
individuals‘ verbal descriptions of their relationship with the deceased. Six months postloss, 42% of participants expressed themes of interpersonal discord when discussing their
relationship with the deceased, with contempt being the most commonly occurring
relational emotion (Bonanno, Mihalecz, & LeJeune, 1999).
The experience of anger in bereavement following terminal illness. Qualitative
research findings suggest that many hospice caregivers experience strong emotions,
including anger and sadness, in their experience caring for the terminally ill patient
(Waldrop, 2007). Although Waldrop (2007) categorizes the anger responses garnered in
their interviews as being directed ―at providers, family, and the situation,‖ the excerpt
used to typify an anger response was a caregiver expressing anger toward the dying
individual. Quantitative data has also indicated that family caregivers of hospice patients
tend to feel more ―easily annoyed or irritated‖ than controls (Chentsova-Dutton et al.,
2000) and some occasionally direct their anger toward the physician or hospital involved
with the patient‘s care (Waldrop, Kramer, Skretny, Milch, & Finn, 2005). In both of
26
these cases, however, the anger captured in the studies was either generalized or directed
at entities other than the patient.
Following the death of a family member in hospice care, bereaved caregivers‘
feelings of anger seem to decrease. Although bereaved hospice caregivers, in one study,
demonstrated significantly higher levels of hostility (measured by feeling easily annoyed
or irritated) than non-bereaved controls, the hostility levels steadily decreased over time
(Chentsova-Dutton et al., 2002). Other research produced similar results, indicating a
dramatic reduction in feelings of anger following the death (Waldrop, 2007). However,
again the findings included here all focus on general feelings of anger, not anger directed
toward the deceased patient. Finally, close family members of patients with cancer in a
palliative care unit were found to have less persisting feelings of anger and irritability
following the loss than bereaved family members of cancer patients in non-palliative care
(Cameron & Parkes, 1983). In this study, the anger experienced by the bereaved was
targeted at the hospital staff. The family member‘s anger was more intense if the
patient‘s pain was considered severe and unrelieved (Cameron & Parkes, 1983). Overall,
feelings of anger toward deceased hospice patients in particular have remained relatively
unexplored.
Conclusions. Feelings of anger do occur among bereaved individuals, although
existing studies suggest that these feelings are not particularly widespread or intense. In
examining the existing empirical literature, it is important to distinguish between 1) anger
as a symptom of grief and 2) the bereaved individual‘s experience of anger toward the
deceased due to interpersonal issues—which may be both a symptom and a mediator of
27
grief. Currently, little empirical attention has been devoted to the bereaved individual‘s
experience with lingering issues of anger and forgiveness involving the deceased person.
Existing assessments of anger in bereavement have tended to be non-specific; that
is, no target for the anger has been specified (e.g., Hogan, Greenfield, & Schmidt, 2001;
Maciejewski, Zhang, Block, Prigerson, 2007), leaving much to learn in regards to
understanding bereaved individuals‘ experience of unresolved anger with deceased loved
ones. Because there is no established technique to assess this construct of interest, one
focal point of the current study was to explore methods of assessing lingering anger
toward the deceased through the development of a measure that specifically addressed
this experience. By assessing whether such anger is linked with adjustment outcomes for
individuals coping with loss, the current study also aimed to understand whether negative
feelings toward the deceased are a relevant and important factor for future research.
Conceptual Model: Anger, Adjustment Outcomes, and the Post-death Relationship
What role might ongoing feelings of anger toward the deceased play in the
bereaved individual‘s adjustment outcomes? It was hypothesized that feelings of anger
toward the deceased would be related to adjustment outcomes in two ways: 1) directly
and 2) partially mediated by the nature and quality of the bereaved individual‘s continued
relationship with the deceased (See conceptual model in Figure 1).
The following is a review of the extant literature that is relevant to the relationship
between unresolved anger at the deceased and post-loss adjustment outcomes. First,
evidence for the direct link between feelings of anger and adjustment outcomes will be
examined. Secondly, the literature pertaining to grief outcomes and continuing bonds, a
proposed marker of grief adaptation that specifically highlights the post-death
28
relationship between the bereaved and the deceased individuals, will be reviewed. A
specific type of continuing bond (a continued relationship) will be discussed in detail.
Finally, empirical data regarding the relationship between feelings of anger toward the
deceased and continuing bonds will be reviewed. Hypotheses regarding the role of
ongoing anger toward the deceased in bereavement outcomes will be derived throughout
the literature review below.
Ongoing Feelings of Anger and Grief Outcomes
The nature and quality of a bereaved individual‘s relationship with their loved one
post loss has been highlighted by bereavement theorists as being an integral component
of adaptation to grief. Classical bereavement theory has proposed that bereaved
individuals‘ feelings of anger toward the deceased may form an obstacle to grief
resolution. This framework suggested that resolution of grief is the result of emotional
detachment from lost loved ones. Beginning with Freud‘s understanding of mourning
(1957 & 1917) and extending to later ―grief work‖ theories, it was believed that the
bereaved needed to withdraw the emotional and psychic energy previously committed to
the deceased in order to have it available to devote to forming new relationships and
pursuing new life endeavors (Stroebe, Gergen, Gergen, & Stroebe 1992). By ―working
through‖ memories, thoughts and feelings related to the deceased, the bereaved were
thought to release ties with the deceased and become available for new relationships
(Stroebe et al., 1992; Stroebe & Schut, 2005). Therefore, through the classical
bereavement model lens, the goal of grief resolution is to decrease one‘s tie with the
deceased.
29
Having unresolved feelings of anger toward the deceased may make emotional
detachment difficult. Anger related to offenses may feed into a strong emotional tie to
the deceased, making it difficult to ―let go‖ of the relationship. The experience of anger
with the deceased is thought to be a contributing factor to more complicated and difficult
grief (Freud, 1957 & 1917; Parkes & Weiss, 1983; Raphael, 1983). Part of the
complication, as viewed through the psychoanalytic framework, is that such negative
feelings toward the deceased are seen as threatening and are often directed elsewhere or
converted by the bereaved individual to safer feelings (e.g., self-reproach; Parkes &
Prigerson, 2010). Therefore, the recognition and expression of negative emotion
(Shuchter & Zisook, 1993; Worden, 2009), in particular the bereaved person's
recognition and expression of anger ( Cerney & Buskirk, 1991; Weissman, Markowitz, &
Klerman, 2000), have long been emphasized as facilitating grief resolution and recovery
from loss.
Empirical findings relating anger to post-loss adjustment outcomes.
Experiences of anger in bereavement have been linked with greater grief severity. Anger
tended to be expressed by bereaved individuals who displayed problematic grief
responses—including sustained intensity of grief levels, emotional instability, and
inability to reorganize their lives by taking on new roles and responsibilities (Glick,
Weiss & Parkes, 1974). Bereaved individuals who included themes of interpersonal
discord as part of an empty-chair monologue addressing the deceased endorsed higher
levels of grief at 6 months, 14 months, and 25 months post loss (Bonanno, Mihalecz, &
LeJeune, 1998). Anger and contempt related to the bereaved individual‘s relationship
with the deceased, as assessed through facial expression at 6 months post loss, was
30
associated with higher grief severity at 14 months and 25 months post loss (Bonanno &
Keltner, 1997). Additionally, self-reported levels of feeling angry when thinking of the
deceased were also positively correlated with grief levels at 14 months (Bonnano &
Keltner, 1997). Participants expressing strong negative emotions during a free-writing
exercise, including anger and blame directed at the deceased, reported higher levels of
grief (Gamino & Sewell, 2004). However, other studies have found no such link between
anger directed at the deceased with either concurrent or prospective grief symptoms
(Field, Bonanno, Williams, & Horowitz, 2000; Field, Gal-Oz, & Bonanno, 2003).
Complicated grief. Abnormal or complicated grief is indicated when a bereaved
individual fails to return to pre-loss levels of functioning. Emotional and behavioral
disturbances prevent the integration of the loss into the bereaved person‘s life, resulting
in a prolonging of normal, acute grief reactions (Prigerson et al., 1995, Shear & Shair,
2005).
Research indicates that anger and unresolved conflict with the deceased are linked
with symptoms of complicated grief. The experience of intrusive thoughts related to the
deceased individual is a key characteristic of complicated grief (Horowitz, Bonanno, &
Holen, 1993). Surviving individuals, at a loss for addressing lingering tensions with the
deceased, may become preoccupied with the offense and the negative emotions
associated with it (Attig, 1996). In attempts to settle this ―unfinished business,‖ the
bereaved person‘s thoughts may constantly be drawn to the deceased, resulting in high
levels of rumination. Because of the negative feelings associated with the transgression,
the bereaved may find such thoughts disturbing. Indeed, Field and colleagues (2000)
found that bereaved individuals who expressed more anger and blame toward the
31
deceased were more likely to experience intrusive and distressing thoughts about the
deceased person in their daily life.
Yearning for the deceased is another indicator of complicated grief (Prigerson et
al., 1995). Those struggling with feelings of anger toward a deceased loved one may find
themselves longing for the return of the deceased, believing that such problems could
only be adequately addressed and resolved if this person is actually present (Attig, 1996).
Empirical findings indicate that the link between lingering feelings of anger toward the
deceased and yearning for the lost person remains unclear. The majority of young,
conjugally bereaved individuals who reported two or more areas of conflict in their
marriage reported strong yearning for their partner (with whom they had had a conflict)
as compared to less than a third of respondents who did not report conflict in their
relationship with the deceased (Glick, Weiss, Parkes, 1974; Parkes & Prigerson, 2010).
However, another study indicated that older bereaved individuals, whose long-term
relationships had been assessed as troubled prior to the death, demonstrated diminished
longing for their lost partner at 6 months post loss (Carr et al., 2000). The timing of the
assessment of grief symptoms may play a role in the discrepant results. Parkes and Weiss
(1983) found that individuals with conflicted marriages initially reported low levels of
grief, but over the long term they demonstrated increasing and enduring levels of distress
paired with longing for their spouse 2-4 years post loss.
Finally, unspecified anger (i.e., not necessarily directed toward the deceased), has
been linked with complicated grief symptoms as well. Generalized anger and irritability
reported by widows was moderately correlated with social withdrawal and difficulty
32
accepting the reality of the loss (Parkes & Prigerson, 2010), congruent with symptoms of
complicated grief (Prigerson et al., 1995).
Other forms of distress. Experiences of general feelings of anger and ongoing
anger at the deceased have also been linked to the general distress indicators of
depression and anxiety. Blaming the deceased and expressions of anger in bereavement
have been linked to symptoms of anxiety and somatic complaints at 6 and 14 months post
loss (Field, Bonanno, Williams, & Horowitz, 2000). Generalized anger has been linked
with feelings of tension, restlessness, and self-perceived ill health (Parkes & Prigerson,
2010). Multiple areas of conflict with one‘s spouse and lack of conflict resolution were
linked with the poorer outcomes for the conjugally bereaved individual, including lasting
tension, anxiety, depression and difficulty coping with one‘s roles and responsibilities 2-4
years post conjugal loss (Glick, Weiss, & Parkes, 1974).
Posttraumatic growth. It is possible that positive outcomes can be experienced in
the wake of traumatic events. There is evidence that bereaved individuals can perceive at
least some good emerging in the form of personal growth and learning important lessons
as a consequence of a loved one‘s death (Davis, Nolen-Hoeksema, & Larson, 1998). As
previously suggested, attributions of responsibility for the consequences of the death are
linked with specific emotional responses (Lazarus, 1991). If people coping with loss
perceive positive consequences resulting from the death, they may feel more positively
toward the deceased if they believe he or she is somewhat responsible for the beneficial
outcome. Finding benefit in one‘s experience of grief is linked with better emotional
adjustment (Davis & Nolen-Hoeksema, 2001). However, individuals who have
unresolved negative feelings regarding their relationship with the deceased may feel that
33
there are primarily negative consequences from the death. There is initial support for this
claim in the empirical literature. Gamino & Sewell (2004) examined a free-writing
exercise about the meaning of the loss written by 85 individuals grieving a significant
other‘s death. Individuals whose writing included themes of anger and blame also tended
to report less personal growth stemming from the loss (Gamino & Sewell, 2004).
Conclusion and hypotheses. In the current study, endorsement of ongoing
feelings of anger toward the deceased was expected to be correlated with higher levels of
grief-related and psychological distress, as well as lower levels of personal growth related
to the loss. If such links were established between lingering feelings of anger and poor
adjustment, it would provide initial validation of the anger measure included in this
study.
Unresolved Anger and the Continuing Relationship with the Deceased
The proposed association between feelings of anger with the deceased and
distress was intuitive and would help demonstrate construct validity for the new measure.
However, the current study also examined the relationship of ongoing anger directed at
the deceased with another facet of grief experience: the continuing connection between
the bereaved and the deceased. The link between ongoing feelings of anger and the nature
and quality of continuing bonds with the deceased represents uncharted territory in the
empirical literature. Therefore, the current study provided an opportunity to enhance
understanding significantly in this area.
Review of continuing bonds theoretical and empirical literature. As
mentioned in the prior review of classical bereavement theory, the state of the attachment
between the bereaved individual and the lost significant other has been viewed in the
34
clinical literature as an important indicator of how an individual is coping with the loss.
In the grief work model, the emphasis is on decreasing the emotional connection.
However, a new divergence in thought is occurring in bereavement theory, one that
involves a shift away from grief work‘s traditional emphasis on detachment and toward
the inclusion of continuing bonds or maintained connections with the deceased. The
continuing bonds model not only proposes that maintaining ties to the deceased is a
natural component of the bereavement (Klass, Silverman, & Nickman, 1996), but an
instrumental factor in grief resolution as well (Silverman & Klass, 1996).
Continuing bonds have been defined as an ongoing, inner relationship with the
deceased (Stroebe & Schut, 2005). There are many examples within the clinical and
empirical literature of manifestations of a continued attachment with the deceased,
including the following: sensing the presence of the deceased (Glick, Weiss & Parkes,
1974; Tyson-Rawson, 1996); telling stories about the deceased (Silverman & Nickman,
1996a); reminiscing about the deceased (Marwit & Klass, 1996); having dreams or
nightmares about the deceased (Silverman & Nickman, 1996; Tyson & Rawson, 1996);
internalizing values and beliefs the deceased espoused (Klass, 1993); taking on
characteristics of the deceased (Russac, Steighner, & Canto, 2002; Tyson-Rawson, 1996);
keeping possessions that once belonged to the deceased (Silverman & Nickman, 1996;
Tyson-Rawson, 1996); viewing the deceased as a role model to guide behavior (Marwit
& Klass, 1996; Tyson-Rawson, 1996); seeking situation-specific guidance from the
deceased (Marwit & Klass, 1996); and direct (and potentially interactive) communication
with the deceased (Normand, Nickman & Silverman, 1996; Silverman & Nickman,
1996).
35
Several models of coping with loss emphasize the continuing bond. According to
Rubin‘s (1999) two-track model of bereavement, in order for the bereaved to effectively
cope with the death, they must develop sufficient comfort and fluidity in relation to their
representation of the deceased. Rubin and colleagues (2008) argue that assessing
biopsychosocial functioning, although important in understanding grief adaptation, is
insufficient. Rather, they assert that a parallel concern must be the bereaved individual‘s
ongoing relationship with the deceased (Rubin, Malkinson, & Witzum, 2008). The dualprocess model of bereavement (Stroebe & Schut, 1999) also includes concurrent foci in
coping with grief. According to this model, people must balance the demands of moving
on in the world without the deceased and the need to negotiate the relationship with the
lost loved one. Continuing bonds may act as grief-specific coping strategies that provide
the bereaved with a link to their loved one, a source of solace and structure that may help
alleviate the pain associated with the death (Conant, 1996; Klass, 1993).
The current study examined a particular type of continuing bond—the perception
of a literal continuing relationship (Benore & Park, 2004). A continuing relationship is
the bereaved individual‘s experience of a literal ongoing relationship with the deceased,
marked by the possibility of exchanges of communication. This type of bond will be
detailed in more depth below. Because there is limited existing empirical data regarding
bereaved individuals‘ experiences of a continuing relationship, a review of general
continuing bonds and their association with adjustment outcomes will be covered first.
Continuing bonds’ link with (mal)adjustment. Research findings demonstrate
that survivors maintain continuing attachments to the deceased (Glick, Weiss, & Parkes,
1974; Marwit & Klass, 1996; Shuchter & Zisook , 1993, Silverman & Nickman, 1996),
36
but it remains unclear under what circumstances such bonds are helpful or hurtful. In
fact, there appear to be contradictory findings across studies. Endorsements of keeping
the deceased‘s possessions has been linked with concurrent but not later distress (Boelen,
Stroebe, Schut, & Zijerveld, 2006) and higher intensity grief over the long term in a
different sample (Field, Nichols, Holen & Horowitz, 1999). Using memories of the
deceased was linked with being judged as better handling the loss (Field et al., 1999) but
also higher grief severity at 16-21 months post loss in another sample (Boelen, Stroebe,
Schut, & Zijerveld, 2006). The use of continuing bonds has also been linked with
increased distress at various time-points post loss—both immediately following the death
(Field & Friedrichs, 2004) and up to five years later (Field, Gal-Oz, & Bonnano, 2003).
On the other hand, some qualitative data seem to indicate that bereaved individuals
perceive continuing bonds as providing comfort and resolution (Nowatzi & Grant
Kalischuck, 2009; Normand, Nickman & Silverman, 1996; Tyson-Rawson, 1996).
Although continuing bonds theory proposes that maintaining an emotional
relationship with the deceased is beneficial for the bereaved, upon reviewing the existing
literature, few conclusions can be made regarding the adaptive quality of continuing bond
use. In some respects the conflicting findings may be because the focus of inquiry is too
broad (Root & Exline, 2011). The current operational definition of a continuing bond—
as an ongoing, inner relationship with the deceased—encompasses a wide gamut of
expressions, varying in the degree of interaction between the bereaved and the deceased,
the degree of proximity to the deceased, the possibility of a direct connection to the
deceased, the agency ascribed to the deceased, and the degree to which the relationship is
placed in the past versus continuing to evolve in the present and future. Because of the
37
diversity in expression, it may be difficult to identify clear implications of empirical
findings or to isolate characteristics of the continuing bond experience that contribute to
specific grief outcomes.
However, it can also be argued that existing research has been too narrow in its
focus. The present conceptualizations and measurements of continuing bond expressions
may obscure the relationship between continuing bonds and grief resolution (Root &
Exline, 2011). Current methods of measuring continuing bonds (i.e., the Continuing
Bonds Scale; CBS; Field et al., 2009) have tended to assume an approach orientation—
that is, assuming that continuing bond experiences are welcomed and desired. These
measures, therefore, do not allow for the possibility that some individuals may perceive
continuing connections with the deceased as intrusive or frightening. Continuing bonds
may also be perceived as unwelcome if they tend to elicit negative affect regarding the
loss, the deceased person or the pre-death relationship (Rubin, 1999; Field & Freidrichs,
2004).
An additional void in the current continuing bond research involves consideration
of the bereaved individual‘s afterlife beliefs (Benore & Park, 2004; Root & Exline,
2011). This lack of acknowledgement within the continuing bonds research is puzzling,
as beliefs in some form of continued existence after death are emphasized in most
religions (Rosenblatt, Walsh, & Jackson, 1976). Such beliefs would seem a crucial
component in assessing the function of continuing bonds (Benore & Park, 2004; Park &
Benore, 2004). In particular, the belief in a continued life after death would suggest
specific forms of continuing bonds available for use—bonds that represent an interactive
and dynamic relationship with the deceased.
38
This particular form of bond, the perception of a literal ongoing relationship after
the death, has been labeled a continued relationship (Benore & Park, 2004). There are
limited empirical findings focused on continued relationships: One study found that
approximately a third of bereaved participants, assessed 2 months to 13 months post loss,
reported communicating with their deceased spouse frequently (Shuchter & Zisook,
1993). Additionally, over half of child participants reported speaking to a deceased
parent at 4 months post loss, with 43% (mostly younger children) believing they received
answers to their communications (Silverman & Worden, 1993). The experience of a
continued relationship with the deceased may be helpful in coping with the loss and
therefore linked with better adjustment. Not only may such a connection reduce feelings
of the irrevocability of the loss (Benore & Park, 2004), but the concept of a continued
relationship with the deceased seems a particularly relevant area of study for those
individuals struggling with lingering feelings of anger toward the deceased (Root &
Exline, 2011). If the relationship is seen as ongoing, there remains a chance that closure
not established prior to the death may still be achieved.
Unresolved anger and the continuing relationship. What role does the predeath relationship play in the adaptiveness of maintaining a post-death tie to the
deceased? Unresolved anger with the deceased may imply difficulties in grief resolution
within the continuing bond framework as well, in that lingering anger and resentment
may limit the bereaved individual‘s ability to feel solace or support from a continued
connection with the deceased. Field and colleagues (2003) found that pre-death
relationship adjustment was not related to the intensity of grief symptoms expressed 5
years post loss but was positively correlated with the use of continuing bonds. Anger and
39
blame expressed toward the deceased during a monologue exercise, however, were
thought to thwart the use of continuing bonds (Field et al., 2003). These findings suggest
that a bereaved individual struggling with lingering anger toward the deceased may be
less likely to experience a continued relationship with the loved one. In summary, use of
continuing bonds seems more likely when pre-death relationships were positive. It is
unclear, however, whether a positive pre-death relationship is a prerequisite for the
existence of continuing bonds (or continuing relationships in particular).
Premorbid and unresolved relational wounds may impact whether: 1) continuing
bonds are experienced by the bereaved individual (as suggested above) and 2) whether
such bonds are adaptive (Root & Exline, 2011). Qualitative research of women‘s
emotional relationships with their deceased fathers indicated that participants who
reported conflict in the pre-death relationship did endorse continued ties with their
fathers; however, these connections were seen as debilitating and intrusive (TysonRawson, 1996). Unresolved feelings of anger may leave the bereaved individual less
receptive to continuing contact with the significant other. Bereaved individuals coping
with unresolved anger may view the task of successfully transforming their bond with
their loved one as more extensive and overwhelming. Not only must their ongoing
relationships transform to incorporate the reality of the death, but they also must
negotiate the ―unfinished business‖ between themselves and the deceased (TysonRawson, 1996). Yet as suggested previously, it is possible that certain continuing bond
expressions (e.g., continued relationships or feeling as if one could communicate with the
deceased) may actually aid the bereaved in coming to terms with unresolved anger with
the deceased.
40
Conclusion and hypotheses. At this point, it is unclear how continuing bonds
with deceased loved ones manifest in relationships with unresolved conflict. Of
particular interest, due to the possibility of relationship change, is the bereaved
individual‘s experience of a literal ongoing relationship with the deceased—the continued
relationship. Although a measure does exist that addresses individuals beliefs in the
possibility for a continued relationship, it leaves the actual experience of continued
relationships in bereavement unexplored. Therefore, bereaved individuals‘ experiences
of continued relationships with the deceased represent another new area lacking an
established measure. The current study provided a unique opportunity to assess not only
the existence of continued relationships in bereavement, but their link with premorbid
relational conflict and ongoing feelings of anger toward the deceased. First, it was
hypothesized that reports that a continued relationship with the deceased was not
experienced, or was perceived as a negative experience, would be linked with higher
levels of maladjustment (higher levels of depression and complicated grief and lower
levels of posttraumatic growth). Secondly, it was hypothesized that ongoing anger at the
deceased would be associated with lower reports of a continued relationship. If
continued relationships were endorsed, then it was expected that individuals experiencing
lingering anger at the deceased would perceive such interactions as more negative than
those individuals who do not report ongoing angry feelings toward the deceased.
Aims of the Current Study
In the context of close relationships, end of life, and death, there are many
possibilities for transgressions to occur, resulting in feelings of anger. Although
commonly referred to in classical bereavement theory (Bowlby, 1973; 1980) and clinical
41
writings (Cerney & Buskirk, 1991), the prevalence, intensity, and correlates of ongoing
feelings of anger toward the deceased have received little empirical attention. In an
attempt to better understand the construct of unresolved anger between the bereaved and
the deceased, the current study attempted to measure different facets of anger toward the
deceased that people might experience in bereavement. It was hypothesized that feelings
of ongoing anger toward the deceased would exist in the sample. Endorsement of
ongoing anger was expected to be correlated with higher levels of complicated grief and
depression and lower levels of posttraumatic growth.
Because of its emphasis on the relationship between the deceased and the
bereaved, it was also important for the current study to examine continuing bonds—in
particular, the study examined continuing relationships with the deceased. This study
provided an exciting opportunity to clarify areas of concern related to continuing bonds
measurement (Root & Exline, 2011) through the examination of several factors: 1) the
existence of a specific type of bond that involves literal continued relationships (Benore
& Park, 2004; Park & Benore, 2004), 2) the bereaved person‘s perceptions of the
continuing relationship as positive or negative (Root & Exline, 2011; Field & Filanosky,
2010), and 3) the association between unresolved anger and the existence and quality of
the post-death relationship (Root & Exline, 2011). Given preliminary empirical findings,
it was expected that individuals experiencing lingering anger toward their deceased
family member would report less experience of continued relationships with this person.
Furthermore, if participants with unresolved feelings of anger toward the deceased did
report a continued relationship, it was expected that they would be more likely to report
such a connection as negatively experienced.
42
The relationship between ongoing anger and adjustment outcomes was expected
to be partially mediated by the existence and quality of the continued relationship with
the deceased. That is, the relationship between ongoing anger and the continuing
relationship variables was expected to partially account for the relationship between
ongoing anger and adjustment outcomes (See Figure 2).
Study Design
Mixed Method Design
The study‘s primary goal was to explore the relationship between ongoing
feelings of anger at the deceased and adjustment outcomes for bereaved individuals.
However, existing measures of anger experienced in bereavement tend to be limited (i.e.,
a single question) or non-specific (e.g., ―I can‘t help but feel angry about his or her
death‖; Maciejewski, Zhang, Block, Prigerson, 2007) and do not discriminate between
different types of anger experienced by the bereaved. Therefore another purpose of the
current study was to develop a scale that assessed bereaved individuals‘ experiences of
ongoing anger toward a deceased family member. A preliminary set of questions were
proposed for the scale, derived from a review of the empirical and theoretical literature
(see Appendix A). These questions aimed at assessing potential sources and reasons for
feelings of anger toward a deceased family member as well as the intensity of these
feelings. As it was a new area of inquiry, it was unclear which questions would be most
effective at capturing the construct of anger toward a deceased loved one. Although an
earnest effort was made to design a questionnaire that would accurately measure the
survivor‘s experience of lingering anger toward the deceased, it was unknown whether all
facets of this construct were adequately captured in this measure based upon the literature
43
review alone. Therefore, to enhance the creation of the proposed measure, the study
followed a sequential exploratory mixed methods design (See Figure 3; Creswell, 2003;
Creswall & Plano Clark, 2011).
Mixed method design incorporates the collection and analysis of both
quantitative and qualitative data. In a sequential exploratory mixed methods approach,
the study is conducted in two phases, beginning with a phase of qualitative data
collection and analysis followed by a phase devoted to quantitative data collection and
analysis (See Figure 3; Creswell, 2003). This design is often employed in the creation of
an instrument (Creswell, 1999). According to Creswell and Plano Clark (2011), in the
instrument-development variant of exploratory mixed methods designs, ―the initial
qualitative phase plays a secondary role, often for the purpose of gathering information
to build a quantitative instrument that is needed for the prioritized quantitative phase‖ (p.
90). In this study, the initial qualitative phase allowed for a deep exploration of the
phenomenon in question, with the goal of suggesting refinements and additions to the
items drafted in the proposed measure. The data garnered from the qualitative phase
added to the likelihood that the proposed measure was an accurate reflection of the
experience of the population of interest—that is, bereaved individuals who feel anger
toward their deceased relatives (Creswell, 1999). The addition of the qualitative phase
also helped to establish content validity for the proposed anger measure.
Scale derived from literature review. Based upon a review of the relevant
theoretical and empirical literature a preliminary scale was drafted (see Appendix A).
There is evidence that bereaved individuals tend to idealize deceased loved ones (Rubin,
1993) and tend to minimize past conflicts when asked to globally assess the relationship
44
(Parkes & Weiss, 1984). Therefore, the scale‘s items were constructed to describe
specific interpersonal transgressions and specific feelings of ongoing anger toward the
deceased family member. In the initial draft of the scale, the prompt asked participants to
rate whether they currently experienced any negative emotions toward the deceased for
offenses covering three domains of conflict: offenses committed by the deceased across
the course of the relationship with the bereaved (e.g., ―for violations of trust that occurred
in your relationship,‖ ―for something hurtful he/she said to you‖), offenses committed by
the deceased during or related to their illness (e.g., ―for not taking better care of his/her
health,‖ ―for the disruption his/her illness created in your life‖), and the death and its
consequences as the transgression (e.g., ―for leaving you by dying,‖ ―for your current
emotional pain due to the loss‖). Each domain in the preliminary draft of the scale
included five questions, for a total of 15 items. The prompts asked participants to rate
current levels of negative emotion on a Likert scale including the following points: 0 (not
at all), 1 (Slightly annoyed), 2 (Annoyed), 3 (Angry), 4 (Very Angry), and 5 (Furious).
Descriptive phrases were attached to each number, rather than having participants simply
rate their anger from ―not at all‖ to ―totally.‖ This decision was made because of concerns
that the word ―angry‖ might seem too harsh or severe to participants, therefore resulting
in denial of any level of negative feelings toward the deceased.
Procedures
Figure 3 outlines the sequential exploratory mixed methods design of the study.
First, the initial qualitative phase was completed. The qualitative phase involved
conducting in-person, exploratory, semi-structured interviews with participants (see
details below). The data collected in the qualitative phase was analyzed and used to
45
refine the proposed anger scale to be included in the quantitative phase of the study. Data
collection in the quantitative phase of the study involved participants completing a
questionnaire (see details below). Upon completion of the interview or the return of the
questionnaire, participants were given or mailed a ten dollar gift card to Target as
compensation for their participation in the study. A research grant from the Fetzer
Institute provided funds for the purchase of these gift cards as well as other study
supplies.
Participants
Participants for both phases of the study were recently bereaved (6-15 months
post loss) family members of patients from the Hospice of the Western Reserve (HWR).
For the purpose of this study, the term family member does not necessarily connote a
blood relative; rather it is meant to indicate a person who has a close relationship with the
deceased (e.g., a spouse, sibling, parent, child, friend, romantic partner or neighbor).
Participants in this study were those designated by the HWR as the ―primary bereaved‖
of the hospice patient. The label of primary bereaved indicates that the hospice patient
had designated this person as playing a significant role in his or her life (e.g., the
bereaved person was the caregiver or otherwise close to the patient).
Six months post loss was thought to be an appropriate time to begin recruitment
for the study. Six months would likely allow enough time for the initial shock of the
death to subside, and persistent, debilitating grief reactions continuing beyond 6 months
post-loss have been suggested as a diagnostic criterion of complicated grief (Prigerson, et
al., 2009). Additionally, participants would presumably be accustomed to receiving
mailings from the Bereavement Center of the HWR at this time point. Thirteen months
46
post loss was selected as the cutoff point for sample recruitment, as it marked the end of
bereavement services provided by the HWR in the majority of cases. Due to the time
elapsed between the recruitment mailings and participant responses, some participants
completed the study 14-15 months post-loss.
General recruitment. Participants were recruited from the Elisabeth Severance
Prentiss Bereavement Center of HWR, Inc., of Cleveland, Ohio. The Bereavement
Center of HWR routinely compiles and updates a database of hospice patients who have
died, pairing these data with the contact information of the primary bereaved individuals
for that patient. This database serves as a mailing list for the Bereavement Center of
HWR, and every designated bereaved individual on this list receives mailings from the
HWR. Participant recruitment contacts lists were created for both study phases using this
mailing list (see details below). The contact lists contained the bereaved individuals‘
names, phone numbers and home addresses.
Phase 1: Qualitative Study
Qualitative Phase Methods
Qualitative phase recruitment. The coordinator of the Bereavement Center of
HWR‘s mailing list database created a recruitment contact list for the qualitative phase of
the study. The initial contact list (n = 2830) included all individuals who were designated
as the primary contact person for a hospice patient who had died between October 1,
2009 and May 1, 2010. The primary contact person was selected (from the primary
bereaved individuals listed for each patient) in attempts to avoid having multiple
participants per patient complete the study. Because the qualitative portion of the study
required meeting with participants in person to complete an interview, a research
47
assistant at the HWR further refined the qualitative study recruitment contact list by
selecting only individuals who resided in zip codes within the HWR service area, thereby
restricting the list of potential participants to individuals who resided in Northeast Ohio
(n = 2616). Next, 200 individuals were randomly selected, using a random number
generator, to create the qualitative study recruitment contact list.
Recruitment for the qualitative phase of the study involved calling potential
participants and completing a short screening interview on the telephone. Prior to
making these recruitment phone calls, however, potential participants were given the
opportunity to opt-out of being contacted for the study. Each of the 200 individuals on
the qualitative study recruitment contact list were mailed both a letter describing the
study and a postage-paid opt-out postcard addressed to a research assistant at HWR.
Those individuals who did not wish to be contacted for the study were instructed to return
the postcard within two weeks upon receipt. Individuals who returned postcards to the
HWR opting out of being contacted for the study (n = 41) were removed from the
qualitative study recruitment contact list by the research assistant. Additionally, two
more individuals were removed due to having invalid addresses and therefore never
receiving the opt-out card mailing. For those individuals who did not reply by 2 weeks of
the mailing, it was assumed that they were passively consenting to be contacted for the
study. The final qualitative study recruitment contact list had 155 individuals total.
Purposive sampling procedure. Purposive sampling was employed for the initial
qualitative phase of the study. Therefore, the sample selected for participation was
comprised of individuals who were thought to be able to best assist in enhancing the
understanding of bereaved individuals‘ experience of feelings of ongoing anger toward
48
the deceased. (In other words, the sample was comprised of people experiencing feelings
of anger toward deceased family members; Creswell, 2003.)
The following screening script was read:
―Hello, my name is Briana Root, and I am a doctoral student in psychology at
Case Western Reserve University. We are doing a research study in partnership
with the Bereavement Center of the Hospice of the Western Reserve. However, I
want to clarify that this study is separate from the Bereavement Program services
that are available to you through the Bereavement Center. The purpose of the
study is to try to better understand the thoughts and feelings of people who have
recently experienced the death of a family member in hospice care. We are
especially interested in learning more about people‘s relationships with the family
member who died. I am calling you today because your name was randomly
selected from the list compiled of bereaved family members of hospice patients.
Are you interested in hearing more about this research study?
―Great, I appreciate your interest. I now need to ask you some more specific
questions to see whether this study is a good fit for you. As I said, the focus of
the research study is on the relationship between bereaved individuals and the
family member who died, and the feelings associated with the relationship. We
would like to understand the feelings people have now when they think about
their family member who died.
―It‘s very common for people to experience a wide variety of feelings about a
deceased family member. It is common for these feelings to be mixed, both good
and bad. For example many people may feel love, relief, guilt, fear or sadness.
In this study we are especially interested in feelings related to annoyance,
frustration, or anger toward the person who died.
―Sometimes people may find these feelings are hard to talk about. But what
we‘re doing in this study is giving people a chance to talk about these difficult
feelings if they are experiencing them.
―I was wondering whether you might want to consider participating in this type of
study. In other words, have you found yourself feeling any annoyance, frustration
or anger toward your family member who died? Would you be interested in
having a conversation sometime about your experiences and these feelings?‖
If the person called met the screening criteria (i.e, endorsed ongoing feelings of
anger, annoyance or frustration toward the deceased family member), and expressed
interest in participating, a brief description of the study procedures was read and the
49
participant was informed of the gift card compensation he or she would receive upon his
or her completion of the study. The participant was also informed that the interview
would be audio taped. Audio taping the interviews was necessary for transcription (a key
component of the thematic analysis of the interviews). Full and elaborated participant
consents (to participate in the study and to be audio taped) were discussed and obtained
in person prior to the start of the qualitative interview.
Location of the interview was
mutually convenient, with the preferences of the participant prioritized. Locations
included the participant‘s home, the public library, and Case Western Reserve
University‘s Psychology Department Psychology Training Clinic rooms.
Qualitative phase participants. Of the 155 individuals on the qualitative study
recruitment contact list, 20 numbers were disconnected or wrong numbers. Seventy-three
individuals were not reached after at least 2 attempts (i.e., when called the line was busy,
or an answering machine or voicemail message was encountered). Of the 62 individuals
who completed the phone screen, 29 were not interested in participating in a research
study and 23 denied feeling angry, frustrated, or annoyed at their deceased family
member. Two individuals did report some feelings of anger, but were either not
interested or unable to participate in the study at that time. Overall, 8 individuals (7
women, 1 man) endorsed feelings of anger, frustration and/or annoyance at their deceased
family member and expressed interest in participating in the study. This number falls
within the 7-10 recommended sample size range when conducting a qualitative semistructured interview (Creswell, 2003). Of these participants, one individual had
contacted the researcher upon receiving the study description with the opt-out card and
requested to participate—the rest were recruited by calling individuals on the qualitative
50
study recruitment contact list. Because of significant delays in scheduling the meeting
with the eighth participant, this final interview was conducted after the quantitative phase
had begun and therefore did not contribute to the refinement of the proposed anger scale.
Seven participants in the qualitative phase were Caucasian and one participant
was African American/Black. The mean age of the participants was 57.30 years
(SD=12.24). See tables 1 and 2 for descriptive information on the demographic and
background variables for the qualitative phase participants.
Measures for qualitative phase.
Background and demographics questions. The participants first completed a
short questionnaire including basic questions assessing factors such as age, gender,
ethnicity, and socioeconomic status. Additional questions focused on patient-related
factors including the diagnosis of the patient, how long the patient had been ill, what type
of hospice care the patient received, when the patient died and how sudden the loss felt.
The exact same demographics and background questionnaire was used in the quantitative
phase of the study. See tables 1 and 2 for the descriptive information on these variables.
Qualitative interview. The qualitative interview was semi-structured, allowing
the interviewer to guide the material presented with questions but also allowing for
participant expansion of ideas (see Appendix B for qualitative interview script). The
interview focused on the experience of feelings of anger, frustration and/or annoyance
toward the deceased family member.1 The interview included questions related to the predeath relationship both prior to and during the family member‘s illness and the presence
of lingering anger regarding unresolved conflict or other issues with the deceased.
However, broad interview questions were also included to complement that coverage of
51
the quantitative questionnaire (see Table 3) and to not prematurely restrict the
participant‘s responses. Interview questions were included that were potentially relevant
to the experience of feelings of anger toward the deceased for some participants and not
for others. (For example, for some participants, changes occurring because of the loss or
troubling grief symptoms could be sources of anger if the participant blamed the
deceased family member for these negative experiences.) The qualitative interview also
included questions that addressed the existence and quality of a current continued
relationship with the deceased.
Qualitative Phase Results
Initial qualitative phase data analysis. All interviews were transcribed verbatim
from digital recording files. Initial analysis was performed by the author after conducting
the first seven interviews. As noted above, delays in scheduling the eighth participant‘s
interview prevented that participant‘s information from being included in the data used to
refine the proposed anger scale. The interviews were reviewed and excerpts clearly
relevant to the description of sources and/or reasons for feelings of anger toward the
deceased family member were identified. These excerpts were then compared to the
preliminary draft of the proposed anger scale to assess whether existing items adequately
captured the sources/reasons for anger described in the qualitative interviews.
Use of qualitative data to inform the quantitative phase. The qualitative phase
served two purposes. First, because participants were identified that were experiencing
feelings of anger toward their deceased family members, rationale was provided to
further examine anger via a quantitative questionnaire. Second, the qualitative data were
used to enhance the quantitative questionnaire—in particular, the proposed anger scale.
52
A preliminary draft of the anger scale was created based upon a review of the theoretical
and empirical literature (see Appendix A). Based upon the initial qualitative data
analysis performed, several additional aspects of feelings of ongoing anger toward the
deceased were identified and led to alterations in the quantitative scale (see Table 4).
Three themes were identified from the qualitative interview data that were not
adequately addressed in the preliminary draft of the anger scale. First, participants in the
qualitative interviews expressed feelings of anger related to feeling unappreciated by
their family members for the participants‘ efforts to care for them. Second, some
participants in the qualitative phase expressed anger related to the perception that their
family members had given up on life. Third, some participants expressed strong feelings
of anger at their deceased family members for not addressing important legal matters
prior to his or her death (e.g., not leaving a will). Therefore, three items were added to
the scale to capture these areas for potential feelings of anger toward the deceased: ―For
failing to appreciate attempts that were made to care for him/her,‖ ―For giving up‖, and
―For not having legal affairs in order (issues with the will, insurance, belongings/assets).‖
Four items on the preliminary draft of the anger scale were combined to create the
following two items (see Table 4): ―For your current emotional pain or loneliness,‖ and
―for disagreements about care or not cooperating with attempts to care for him/her while
ill.‖
Based upon consultation with an expert in the field of interpersonal offenses and
forgiveness, additional adjustments were also made to the relationship conflict portion of
the proposed scale, including adding this item: ―For hurting or failing to help someone
else that you care about.‖ See Table 4 for details on all edits made to the proposed anger
53
scale. After the proposed draft of the anger scale was revised based on the preliminary
qualitative data analysis results described above, the quantitative phase was initiated (see
details below).
In-depth qualitative phase data analysis. In-depth data analysis was performed
upon the 8 completed qualitative interviews. In-depth data analysis followed the
guidelines of Moustaka‘s (1994) modification of the van Kaam method of analysis of
phenomenological data. Each transcribed interview was reviewed closely and useful
excerpts describing the participant‘s experience of anger in bereavement were identified.
Each excerpt that was potentially significant to the experience of feeling angry with a
deceased family member was identified and listed. The initial list was broad, and
included any description of feelings of anger experienced by the bereaved. This list was
then narrowed and focused in several manners: 1) excerpts that were not considered clear
(and unambiguous) descriptions of the experience of feelings of anger toward the
deceased were removed, 2) excerpts that were repetitive were removed, leaving the
clearest description of the experience, and 3) excerpts that described dimensions of anger
that were not related to sources/reasons for anger were removed. The final list of
excerpts was then assigned codes that described or summarized the essence of the
excerpt‘s content. Theme structures, including major and minor themes, were created
from these codes.
Credibility of data. The researcher is the primary instrument in qualitative
research (Creswell, 2003). Therefore, steps were made to ensure that the results obtained
were credible and accurate representations of the participants‘ phenomenological
experience. First, the author examined her own relevant experiences (e.g., caregiving
54
experiences, experiences with family members with serious illness, relationship loss, and
related research experiences) in order to clarify her potential biases related to the
construct of interest (Creswell, 2003). Second, an individual external to the study was
enrolled as a peer reviewer. Peer review can enhance the credibility of qualitative results
by exposing the researcher‘s decision-making process involved in the coding and
thematic analysis to an external check, similar to interrater reliability in quantitative
research (Creswell, 1998). By acting as a ―devil‘s advocate,‖ the peer reviewer helps
keep the researcher honest and aware of the bases for his or her interpretation of the
results (Lincoln & Guba, 1985). The peer reviewer in this study was a registered nurse
and graduate student enrolled in the Adult Oncology and Palliative Care Nurse
Practitioner Program at Case Western Reserve University. The peer reviewer has 21
years of experience as a nurse in oncology and palliative care units. The peer reviewer
examined (and challenged as needed) the researcher‘s decision making process regarding
the selection of relevant excerpts from the transcribed interviews as well as the
researcher‘s creation of meaning units or themes from the excerpts. Another method in
enhancing the credibility of the qualitative data analysis was the creation of an audit trail
(Lincoln & Guba, 1985). The researcher created records detailing the different stages of
analysis and her rationales for decisions made in coding and creation of themes. The peer
reviewer also wrote summaries of the meetings with the researcher and the decision
making process.
Results of in-depth qualitative data analysis. Table 5 depicts the major and
minor theme structure that emerged from the qualitative data analysis and includes
representative excerpts from the interviews. The thematic analysis of the participant‘s
55
interviews generated three major themes. The first major theme described anger related
to issues regarding the family member‘s illness or healthcare and included two minor
themes. In particular, participants described anger related to perceptions that their family
member neglected to take care of their health (Minor theme 1). Participants also
described anger related to caregiving interactions with the family member (Minor theme
2). The second major theme involved anger related to the death of the family member
and included two minor themes. Participants described anger at their family members
associated with the separation resulting from the death (Minor theme 3). Participants also
reported anger at the deceased, blaming them for perceived negative consequences of
their death (Minor theme 4).
The third major theme described anger related to
relationship conflict between the participant and the family member and included four
minor themes. Participants reported anger related to hurtful words or actions performed
by the deceased family member (Minor theme 5). Another source of anger described by
participants was the perception that the family member neglected to do something that
was important to the participant (Minor theme 6). Participants also described angry
feelings related to betrayals of trust committed by the family member (Minor theme 7).
Finally, participants reported anger related to perceptions that the family member had
placed them in a difficult position (Minor them 8).
Themes related to anger associated with family member’s illness or healthcare.
Family member did not take care of health. Participants expressed anger,
frustration and annoyance related to perceptions that their family member neglected to
take care of his or her health. Some participants described anger that their family
member did not seek treatment when the participant believed treatment was indicated.
56
Other participants described feeling angry because the family member‘s unhealthy
behavior had contributed to their illness or that their family member had continued to
engage in unhealthy behaviors despite being ill. A related experience was the perception
that the family member ―gave up‖ on life or attempts to get better.
Anger related to caregiving interactions. Participants described caregiving duties
as being very stressful and overwhelming, as well as requiring them to shoulder great
responsibility and to face unique challenges. A particular source of anger was the
experience that the family member was very demanding and insisted that the participant
be readily available. Often participants reported that their family member specifically
requested assistance from the participant and denied others‘ attempts to care for them. In
addition, another source of anger was the perception that efforts to care and/or the
sacrifices made by the participant to care for their family member were not appreciated or
recognized by their family member.
Additionally, participants described anger related to disagreements with their
family member regarding their care. Feelings of anger stemmed from family members
disagreeing with the participant regarding the next steps in care or otherwise not
cooperating with the participant‘s efforts to care for them. A related disagreement, and
source of anger, was conflict regarding arrangements following the family member‘s
death (e.g., the family member‘s wish to be cremated, funeral arrangements, etc.).
Themes related to anger associated with the death of the family member.
Separation-related anger. Participants described feelings of anger related to their
separation (by death) from their family member. Participants reported feeling angry at
57
their family member for leaving them. Additionally, participants described feeling angry
that the family member was no longer there to support them or to witness milestones.
Negative consequences of the death. Participants described anger related to
negative consequences brought on by the death. For example, participants reported anger
associated with blaming the deceased for their current distress or disturbing grief
symptoms. Finally, a major source of anger for participants stemmed from financial or
legal matters left unsettled or unresolved by the family member. Participants expressed
anger related to the family member leaving either no will or an ambiguous will, or
leaving life insurance unsettled. Also related to this theme was anger related to having to
deal with the family member‘s belongings following the death.
Themes related to anger regarding interpersonal conflict with family member.
Hurtful words or actions. Participants described feeling angry at the deceased
family member for verbal abuse or inconsiderate words or behaviors that the family
member committed.
Family member neglected to do something that was important. Participants also
described feeling angry that their family members failed to do something that was
important to the participant. Often participants‘ anger was related to the perception that
their family member was not supportive of them or seriously disagreed with them.
Betrayal of trust. Another source of anger related to relational conflict was the
betrayal of trust committed by the participants‘ family members. Participants described
anger related to family members misleading them or lying to them in some way. Also,
participants described feeling betrayed by their family member when they perceived their
family member as siding with or valuing other people over the participant.
58
Being put in a difficult position. Finally, participants reported anger at their
family members because they perceived their family members as placing them in an
unwanted or difficult position. The participants reported that their family member‘s
actions had either placed the participants at odds with other people or were otherwise
detrimental to the participant‘s wellbeing.
Summary of Qualitative Phase
The completion of the qualitative phase provided an enriched understanding of
the potential sources for feelings of anger toward a deceased family member. The indepth interviews with bereaved individuals struggling with lingering tensions in their
relationships with the deceased allowed for important refinements of the new anger scale.
The qualitative analyses also established that angry feelings are indeed experienced by
some in bereavement and therefore constitute a relevant area of inquiry. The next step
was to examine the utility of the new anger scale and to explore the associations between
ongoing anger toward the deceased, post-loss adjustment and the perception of a
continued relationship with the deceased.
Phase 2: Quantitative Study
Quantitative Phase Methods
Quantitative phase recruitment. The coordinator of the Bereavement Center of
HWR‘s mailing list database created a second recruitment contact list for the quantitative
phase of the study. The initial contact list (n = 2847) included all individuals who were
designated as the primary contact person for a hospice patient who had died between
December 1st, 2009 and July 1st, 2010. Again, the primary contact person was selected
in attempts to avoid having multiple participants per patient participate in the study. A
59
research assistant at the HWR further refined the quantitative study recruitment contact
list by selecting only individuals who had complete address information (n = 2721) and
who had not been on the qualitative study recruitment contact list (n = 2578). Next, 500
individuals were randomly selected, using a random number generator, to create the
quantitative study recruitment contact list. Over the course of one month, 500 study
packets were sent out to individuals on this contact list. Study packets included an
introductory letter, two consent forms (one for the participant to keep and one for the
participant to sign and return), the study questionnaire, a contact information sheet (to use
to send the participants their gift card compensation), and a postage paid, return envelope
addressed to the author.
Quantitative phase participants. Out of the 500 study packets, 138 participants
responded. Six participants were excluded due to not meeting the entry criteria related to
the time elapsed since the death (5 participants were excluded because it had been less
than 6 months since the death of their family member, 1 participant was excluded
because it had been 2 years since the loss). One participant was excluded because the
hospice patient family member was an infant. One participant completed the
questionnaire twice; therefore only one response was included in the final dataset.
The final number of participants was 130 (100 women; 30 men). The mean age
was 59.30 years (SD=11.44). The sample was 84% Caucasian, 15% African American or
Black, 2% Native American, and less than 1% other ethnicity. (Percentages exceed
100% because some participants endorsed multiple options. There were no participants
who endorsed being Latino or Hispanic, Asian, or Middle Eastern.)
60
Measures for quantitative phase. In the designing of the questionnaire, wellvalidated scales were used whenever possible. See Appendix C for specific questionnaire
items. Established measures were more available for the mental health and grief domains
than for the domains of ongoing feelings of anger toward the deceased and continued
relationships. For the latter domains, new scales were developed for use in the study.
Additionally, some items were borrowed from another ongoing study with the hospice
population (Exline, Prince-Paul, Root, & Peereboom, 2010).
Background and demographic questions. The questionnaire began with basic
questions assessing factors such as age, gender, ethnicity, and socioeconomic status.
Additional questions examined patient-related factors including the diagnosis of the
patient, how long the patient had been ill, what type of hospice care the patient received,
when the patient died and how sudden the loss seemed to the participant (See Appendix
C for specific items described here). Tables 6 and 7 summarize the descriptive
information for the background and demographic variables in the quantitative phase.
Due to problems with skew, certain background and demographic variables (to be
specified below) were transformed. Specific skew levels representing a significant
deviation from normality remain unclear in the methods literature. However, Curran,
West & Finch (1996) suggested that skew levels approaching the absolute value of 2.00
are problematic. In this study, a more conservative cutoff was adopted, and variables
with skew values over the absolute value of 1.00 were transformed. Raw variables are
reported in the descriptive tables for ease of interpretation; however, the transformed
variables were used in correlational analyses. Specifically, positive skew in both illness
duration (2.82) and hospice care duration variables (4.28) were corrected or reduced by a
61
cube root transformation (0.47) and log transformation2, respectively (1.28).
Additionally, the participant‘s family member‘s age at death was negatively skewed (1.21) and was corrected using a square root transformation (-0.40).
Measures of unresolved conflict and feelings of anger toward the deceased.
Closeness and quality of the pre-death relationship. As shown in Appendix C,
participants were asked to gauge the general quality of their pre-death relationship with
their family member. Participants rated their relationship on a Likert scale ranging from
0 (not at all) to 5 (extremely) as close, unhappy, distant, loving and difficult, following
techniques used in an ongoing study of family members of hospice patients (Exline,
Prince-Paul, Root & Peereboom, 2010). Skew in the positive relationship quality items,
―close‖ (-2.16) and ―loving‖ (-1.72), was corrected or reduced by log transformation
(skew=-1.09 and -0.95, respectively). The transformed positive relationship items were
then averaged (α=.87). The majority of the negative relationship items—―unhappy‖
(1.50), ―distant‖ (1.61), and ―difficult‖ (0.62) — were positively skewed. Skew was
corrected for or reduced by log transformations (skew =0.90, 1.06, and 0.15 respectively).
The transformed negative relationship items were averaged (α=.77).3 Once again, raw
variables are reported in Table 7, whereas transformed variables were used in
correlational analyses.
Unresolved issues in relationship. Participants were asked to rate from 0 (not at
all) to 5 (totally) the extent they currently felt that there were unresolved issues in their
relationship with family member who died (M=0.86, SD=1.46). Because 63% of
participants reported no unresolved issues in their relationship with their deceased family
member, the distribution of this item was skewed (1.54). This item was transformed into
62
a dichotomous variable, separating participants who endorsed no unresolved issues from
those who acknowledged some degree of unresolved issues (see Table 6 for descriptive
information).
History of family member offenses. Participants read a short introduction: ―People
in close relationships often do things that hurt each other. Sometimes these things are
accidents, and sometimes they are done on purpose. They can range from small
misunderstandings to major fights.‖ Participants were then asked, ―Can you think of
things your family member did (or failed to do) that caused some problems or hurt
feelings between you and your family member?‖ Participants circled a number from 0
(no, none) to 5 (yes, many). This item mirrors techniques in an ongoing study of family
members of hospice patients (Exline, Prince-Paul, Root & Peereboom, 2010). See Table
7 for descriptive information on this variable.
Current feelings of anger toward deceased. As shown in Appendix C,
participants were asked to rate whether they currently had any negative emotions toward
the deceased for various offenses. Based upon the qualitative phase data analysis, there
were 16 items total on this scale. Participants rated current levels of negative emotion on
a Likert scale including the following points: 0 (Not at all), 1 (Slightly annoyed), 2
(Annoyed), 3 (Angry), 4 (Very Angry), and 5 (Furious).
The 16 items of the anger scale were subjected to principal components analysis
(PCA). Tabachnick and Fidell (1996) suggest that transformation of substantially skewed
variables should be considered prior to completing PCA. Because the majority of
participants did not report intense feelings of anger toward their deceased family
members, the items on the anger scale were significantly skewed (skewness for the scale
63
items ranged from 1.32 to 4.00). Skew was reduced somewhat (skewness on transformed
items ranged from 0.73 to 2.92) using a log transformation. The transformed variables
were used in the PCA.
Additionally, the factorability of the data was assessed prior to completing the
PCA. Inspection of the correlation matrix demonstrated that many coefficients were .30
and above. The Kaiser-Meyer-Oklin value was .80, exceeding the recommended value of
.60 and Bartlett‘s Test of Sphericity reached statistical significance, supporting the
appropriateness of the data for factor analysis (Pallant, 2007).
Principal components analysis revealed the presence of four components with
eigenvalues exceeding 1. Catell‘s scree test determined that three components be
retained for further investigation (Pallant, 2007). The results of Parallel Analysis further
supported the use of three components. Parallel analysis demonstrated only three
components with eigenvalues exceeding the corresponding criterion values for a
randomly generated data matrix of the same size.
To determine the adequacy of the rotation, the analysis was completed using an
oblique rotation (oblimen) and the correlations among components were examined. The
factor correlation matrix did not reveal correlations above .32, indicating that there was
less than a 10% overlap in variance among factors, therefore justifying the use of an
orthogonal rotation (Tabachnick & Fidell, 1996). Varimax rotation was performed to
enhance the interpretation of the three components. The rotation revealed a somewhat
complex structure: While all three components showed a number of strong loadings,
several variables loaded on multiple components (see Table 8 for component loadings).
To clarify components, only the highest loading variables were included (i.e., loadings
64
.50 or above, or the highest loading if the variable loaded on two components at .50 or
above). Finally, one item (―for hurting or failing to help someone else that you care
about‖) was removed from the anger scale due to having a low communality value (.33).
The first component, Relationship Conflict Anger, contained eight items: ―acting
in an insensitive or inconsiderate way,‖ ―violations of trust that occurred,‖ ―something
hurtful he/she did or said to you,‖ ―neglecting to do or say something that was important
to you,‖ ―treating you poorly during his/her illness (for example, being critical,
demanding or aggressive),‖ ―failing to appreciate attempts that were made to care for
him/her,‖ ―the stress his/her illness created in your life,‖ and ―not having legal affairs in
order (issues with the will, insurance, belongings/assets)‖ (M=0.12, SD=0.16, α=.87,
Eigenvalue=5.66, 37.7% of variance). The second component, Death-Separation Anger,
contained four items: ―no longer being here to support you,‖ ―your current emotional pain
or loneliness,‖ ―leaving you (by dying),‖ and ―problems in your life since the loss or due
to the loss (problems in finances, relationships, etc.)‖ (M=0.14, SD=0.18, α=.81,
Eigenvalue=2.60, 17.3% of variance). The third component, Neglect of Health Anger,
contained three items: ―not taking better care of his/her health,‖ ―giving up,‖ and
―disagreements about care or not cooperating with attempts to care for him/her while ill‖
(M=0.12, SD=0.17, α=.71, Eigenvalue=1.39, 9.3% of variance). Finally, the log
transformed anger scale items were averaged to create a total anger score (M=0.12,
SD=0.13). The total anger scale demonstrated good internal consistency (α=.87).
Current feelings of anger at other entities. For exploratory purposes, participants
also rated, from 0 (not at all) to 5 (totally), the extent to which they felt negative emotions
toward God or a Higher Power, toward doctors or medical professionals, toward hospice
65
and toward themselves, for issues related to their relationship with the deceased, the
family member‘s illness, and the family member‘s death (See Appendix C for specific
wording of items). For ease of interpretation (in comparing levels on anger across
different targets of anger), participants‘ ratings of anger related to the relationship with
the deceased, the family member‘s illness, and the family member‘s death were averaged
to create total anger scores for each separate entity (themselves, other family members,
doctors or medical professionals, etc.; see Table 7 for descriptive information).
Trait Anger. The 10 trait anger questions of the State-Trait Anger Scale (STAS;
Spielberger, Jacobs, Russell & Crane, 1983) were used to assess individual differences in
the frequency of angry feelings experienced. The majority of items on the STAS were
positively skewed (0.48-3.67). Skew was reduced or corrected by log transformations (0.18-2.94). The transformed items were summed to create a total trait anger score
(α=.82). Descriptive statistics summarizing the raw trait anger scale are reported in Table
7; however, the transformed scale was used in correlational analyses.
Grief and adjustment related measures.
Complicated grief. The Inventory of Complicated Grief – Screen version (IGCS)
was selected to assess grief severity (Prigerson & Jacobs, 2001). This measure was
selected because it is brief (9 items) and does not include items that could overlap with
continuing bond expressions (e.g., ―I hear the voice of the person who died speak to me‖)
that are included in the full version of this measure. The IGCS has demonstrated good
internal consistency reliability (α=.90; Field & Filanosky, 2010). The items of the IGCS
were summed to create a total complicated grief score (see table 7 for descriptive
information on this scale).
66
Depression. Depression was assessed using the Center for Epidemiologic Studies
Depression Scale 10 item screen (CES-D 10). The short form has demonstrated good
predictive accuracy in predicting depression in older adults (kappa=.97; Andresen,
Malmgren, Carter, & Patrick, 1994). Two positively worded items (for which higher
scores indicated lower depression) were reversed and a total CES-D 10 score created by
summing the items (see table 7 for descriptive information on this scale).
General distress. Total scores for both the IGCS and the CES-D 10 were highly
positively correlated (r=.73, n=120, p < .001). Therefore, these scales were combined by
averaging the standardized total scores of the IGCS and the CES-D 10 to create a general
distress variable (M=-0.003, SD=0.92, α=.84).
Posttraumatic growth. The short form of the Posttraumatic Growth Inventory
(PTGI-S; Calhoun & Tedeschi, 1999) was used to assess participant‘s perception of
positive changes or personal growth stemming from the loss. The measure included 13
items related to perceptions of positive changes in five areas: relating to others, new
possibilities, personal strength, spiritual change, and appreciation of life. The short form
has demonstrated good internal consistency (α=.91; Val & Linley, 2006). The items were
summed to create a total score (see table 7 for descriptive information on this scale).
Only the total score was examined in this study and not the subscales, as there is evidence
that posttraumatic growth can be understood as a single construct (Joseph, Linley, &
Harris, 2005).
Continuing relationship with the deceased. There is no existing measure of
bereaved individuals‘ experience of a continuing relationship with a deceased other.
Therefore, a short measure was created to suit the purpose of this study. This measure
67
was preferable to other existing continuing bond measures for multiple reasons. First, the
continuing relationship measure assessed the belief in the possibility of having a literal
ongoing relationship with the deceased family member and the actual experience of the
continuing relationship, whereas other continuing bond measures focus on a wide variety
of expressions, including more indirect or distal connections with the deceased.
Additionally, existing continuing bond measures tend to focus solely on positive ties to
the deceased (e.g., including items such as ―think of good memories‖). Because the goal
of this study was to examine ongoing feelings of anger, it was important to include a
measure that allowed for negative ties with the deceased as well as positive. Questions
were included to address participants‘ specific beliefs and communication experiences in
regards to their deceased family member. In particular, both the existence of continued
communication and the quality of the continued communication with their loved one
were assessed.
Continuing relationship: Belief in a continued existence. First the participant was
asked to rate the degree, from 0 (strongly disagree) to 5 (strongly agree), which they
believe that the deceased family member ―continues to exist (or live on) in some form‖
(See table 7 for descriptive data). Problems with skew (-1.26) were corrected by log
transformations (skew=-0.83). The transformed variable was used in correlational
analyses.
Continuing relationship: Communication. Next participants were asked about
their beliefs in the possibility of having a literal ongoing relationship with the deceased
family member (as represented by the ability to directly communicate with the deceased).
Participants rated the degree, from 0 (strongly disagree) to 5 (strongly agree), to which
68
they believed that it was ―possible for me to communicate with my family member‖
(M=2.13, SD=1.91) and ―possible for my family member to communicate with me‖
(M=2.10, SD=1.86). They also rated the degree, from 0 (strongly disagree) to 5 (strongly
agree), to which they believed that ―there has already been some communication between
my family member and myself‖ (M=1.74, SD=1.96). These three continued relationship
communication items were averaged. Participants that endorsed the belief that
communication had occurred between themselves and their deceased family member
(N=66) were asked to rate, from 0 (strongly disagree) to 5 (strongly agree), whether this
communication had been perceived as a positive experience and as a negative experience.
Problems with skew for the ―positive‖ communication variable (-1.85) were reduced by
log transformations (-1.06). The transformed variable was used in correlational analyses.
As virtually every participant who had endorsed the belief that communication had
occurred between themselves and their deceased family member reported strongly
disagreeing that the experience was negative, there was very little variability for this
item; thus it was not included in the correlational analyses.
Quantitative Results
Prevalence and intensity of anger toward deceased. At least some degree of
ongoing feelings of anger toward the deceased family member was reported by 75% of
the participants (See Table 9). On a scale ranging from 0 (not at all) to 5 (furious), the
average level of total anger endorsed by participants was 0.55 (SD=0.67). This indicates
that although the experience of feeling anger toward the deceased was somewhat
common, these feelings tended to have low intensity on average (ranging from less than
slightly annoyed to annoyed).
69
For exploratory purposes, a one-way repeated measures ANOVA was conducted
to compare participant‘s level of ongoing anger toward different entities (the deceased,
the participant, other family members, doctors and medical professionals, hospice, and
God). There was a significant effect for entity on the intensity of anger reported, Wilks‘
Lambda = .62, F (5, 124) = 14.62, p<.001, partial η2 = .37. Post-hoc comparisons using
the Bonferroni correction indicated that participants reported significantly less anger
toward hospice (M=0.18, SD=0.58, p<.001) and God (M=0.18, SD=0.55, p<.001) than
toward their deceased family members (M=0.54, SD=0.65). Additionally, at trend level
significance, participants reported more anger toward doctors or other medical
professionals than toward their deceased family member (M=0.88, SD= 1.36, p=.08).
Intercorrelations for main study variables. The relationships between main
study variables were investigated using Pearson product-moment correlation coefficients
(see Table 10). Intercorrelations between demographic variables and main study
variables will be discussed further when detailing the selection of control variables for
regression analyses below.
Construct validity of anger scale. Having performed initial psychometric
analyses on the new anger scale, the next step was to examine construct validity. The
total anger score was positively correlated with perceiving the pre-death relationship as
having negative qualities (such as being distant, unhappy, or difficult), with endorsements
that the family member had hurt the participant in some way during their relationship,
and with a sense of having unresolved issues with the family member. The anger scale
created for this study was comprised of a list of potential sources of anger related to the
bereaved individual‘s relationship with the deceased. It would be expected that
70
participants‘ scores on the anger scale would be associated with higher levels of difficulty
in the relationship, higher levels of past offenses by the family member and higher levels
of unsettled business in the relationship. Therefore, these associations help demonstrate
the anger scale‘s construct validity.
Anger and adjustment. It was hypothesized that feelings of ongoing anger
toward the deceased would be associated with higher levels of distress and lower levels
of posttraumatic growth. The correlations depicted in Table 10 indicate some support of
this hypothesis. Total anger scores were positively correlated with distress.
Unexpectedly, however, total anger was positively correlated with posttraumatic growth
as well. Looking at the individual anger subscales, anger related to relationship conflict
was not significantly correlated with distress or posttraumatic growth. However, both of
the other subscales (Death-Separation Anger and Neglect of Health Anger) were
positively related to distress and posttraumatic growth. While ongoing anger was related
to higher levels of distress, as predicted, its relationship with posttraumatic growth was
contrary to hypotheses. Posttraumatic growth, in turn, was highly positively correlated
with distress.
Anger and the continuing relationship. It is noteworthy that endorsement of a
continued relationship with the deceased family member was not significantly correlated
with any of the anger or adjustment-related variables (see Table 10). For those
participants who endorsed at least some level of a continued relationship,
intercorrelations between the positivity of the perceived relationship and the main study
variables were examined. At trend level significance, positive continued relationship
experiences were negatively correlated with death and separation-related anger. In other
71
words, those who endorsed some sense of a continued relationship, along with anger that
the family member was no longer alive and present, tended to perceive their continued
relationship with the deceased as less positive. Even though the association between a
positive continued relationship experience and Death-Separation Anger was in the
expected direction, there was low power available for that correlation because only 60
people answered the positive continued relationship item; therefore it was not included in
regression analyses. (When it was included, the ability of death-separation anger to
predict a positive continued relationship was not significant (R2=.05, β=-.22, p=.097).)
Another component of the continued relationship scale did demonstrate
significant associations with anger variables: the participant‘s belief that the family
member continued to exist in some form. Participants were less likely to endorse beliefs
that their family member continued to exist if they reported higher levels of anger overall,
and higher levels of anger about premorbid relationship conflict with the deceased (see
Table 10). At trend level significance, higher reports of anger related to family members‘
neglect of health was also associated with less belief that the family member continued to
exist. It was hypothesized that ongoing feelings of anger toward the deceased would be
associated with less of a continued relationship; however, no such relationship was found.
The correlations indicated instead that ongoing feelings of anger were associated with
less belief that the family member continued to exist (a prerequisite for the literal ongoing
nature of a continued relationship).
Mediation hypotheses. It was hypothesized that not only would anger toward
the deceased be associated with lower levels of adjustment, but that the existence and
quality of the continued relationship would mediate this association. However, given that
72
none of the continued relationship variables were significantly correlated with the
outcome measures (i.e., in Figure 2, Path b was not established), mediational analyses
were not appropriate. Instead, multiple regression analyses were performed to learn more
about the relationships between feelings of ongoing anger toward the deceased with both
adjustment outcomes and beliefs in the family member‘s continued existence (Paths c and
a respectively on Figure 2).
Regression analyses.
Control variables. In order to determine control variables for the regression
analyses, the relationships between main study variables (the anger total score and
subscales, distress, posttraumatic growth and belief in the continued existence of the
family member) and the demographic / background variables were investigated using
Pearson product-moment correlation coefficients (see Table 11).
Three demographic / background questions (participant‘s marital status, the
hospice patient‘s relationship to the participant, and the location of the family member‘s
death) were non-dichotomous categorical variables. One-way analysis of variance was
performed to explore the impact of different categories of these variables on levels of
anger, distress, posttraumatic growth and belief in the continued existence of the
deceased family member. There was a statistically significant difference in distress (F
(3,120) =5.71, p =.001) and posttraumatic growth scores (F (3,114) =3.21, p =.026) for
marital status. Post-hoc comparisons using the Bonferroni correction indicated the mean
distress score and posttraumatic growth score for married participants was significantly
less than for widowed participants (see Table 12). Therefore two dichotomous variables
73
were created for marital status married and marital status widowed. These dichotomous
variables were entered into the correlational analyses.
There was a statistically significant difference in overall anger scale scores (F
(7,121) =2.81, p =.010), death-separation anger (F (7,121) =2.60, p =.016), and distress
(F (7,121) =4.42, p <.001) depending on the relationship of the family member to the
participant.4 Again, post-hoc comparisons were made using the Bonferroni correction.
Given the significant differences between means for different family member
relationships (as demonstrated in Table 13), four dichotomized variables were created to
designate family members who were romantic partners, spouses, fathers or mothers.5
Finally, there was a statistically significant difference in levels of distress depending on
the location of the family member‘s death (F (3,120) =7.30, p < .001). Post-hoc
comparisons using the Bonferroni correction indicated significant differences in mean
levels of distress for participants whose family members died at home, died at a nursing
home, or died at the hospital (see Table 14). Three dichotomous variables were created
accordingly to use in the correlational analyses.
Anger subscales as predictors. Multiple regression was used to assess the ability
of the three anger subscales (Relationship Conflict Anger, Death-Separation Anger, and
Neglect of Health Anger) to predict the three criterion variables (belief in family
member‘s continued existence, distress, and posttraumatic growth) (See Table 15). In
predicting continued existence beliefs, only relationship conflict anger was significant,
whereas only death-separation anger was significant in predicting distress and
posttraumatic growth.
74
Anger predicting the belief that the family member continues to exist. It was
hypothesized that higher levels of ongoing anger toward the deceased would predict less
belief that the deceased family member continued to exist in some form (path a on Figure
2). Multiple regression was performed to test this hypothesis. Participants‘ overall level
of ongoing anger toward the deceased explained 4.4% of the variance in continued
existence beliefs. Specifically, higher levels of ongoing anger predicted less belief in the
family member‘s continued existence (β=-.21, p=.016). Hierarchical multiple regression
was conducted to assess whether overall feelings of lingering anger toward the deceased
continued to predict continued existence beliefs even after controlling for demographic
variables and trait anger. As summarized in Table 16, the demographic variables (those
significantly correlated with the criterion variable as demonstrated in Table 11) were
entered at Step 1, trait anger was entered in Step 2, and the participant‘s total anger score
was entered at Step 3. After controlling for demographic variables and trait anger,
overall feelings of lingering anger toward the deceased continued to be a significant
predictor of continued existence beliefs. As a conservative measure, participants‘ belief
in an afterlife (e.g., Heaven, Hell, reincarnation, etc.) was entered as a final step in the
regression analyses. By controlling for afterlife beliefs, it was demonstrated that the
association between anger and continued existence beliefs was not entirely explained by
whether the participant believed that an afterlife was possible. Rather, higher levels of
lingering anger toward the deceased predicted significantly lower levels of belief that the
family member continued to exist in some form, even after controlling for general
afterlife beliefs (see Table 16).
75
As presented in Table 15, the subscale Relationship Conflict Anger was a
significant predictor of belief in a continued existence for one‘s deceased family member.
Again, hierarchical multiple regression was conducted to assess whether having lingering
feelings of anger toward the deceased related to relationship conflict continued to predict
continued existence beliefs even after controlling for demographic variables and total
trait anger. As summarized in Table 17, after controlling for demographics and trait
anger, relationship conflict anger continued to be a significant predictor of participants‘
beliefs in a continued existence for their family member. Again, afterlife beliefs were
entered as a final step. After controlling for afterlife beliefs, relationship conflict anger‘s
contribution to the explanation of the variance in continued existence beliefs was
marginally significant.
Anger predicting distress. Multiple regression was used to assess whether overall
levels of anger toward the deceased predicted distress, as hypothesized. Participants‘
total levels of anger toward the deceased explained 10.4% of the variance in distress.
Specifically, higher levels of anger predicted higher levels of distress (β=.32, p<.001).
However, after controlling for demographics (those significantly correlated with the
criterion variable as demonstrated in Table 11) and trait anger, total ongoing anger did
not contribute significantly to explaining the variance in distress and was not a significant
predictor (see Table 18). Next, death-separation anger was evaluated as a predictor of
distress. As indicated in Table 15, death-separation anger was a significant predictor of
distress. After controlling for demographics and trait anger, death-separation anger
explained an additional 11% of the variance in distress levels. Higher death-separation
76
anger was predictive of higher distress, a finding which supports the hypothesis (see table
19).
Anger predicting posttraumatic growth. Multiple regression was conducted to
assess the ability of overall ongoing anger toward the deceased to predict posttraumatic
growth. It was expected that higher levels of anger would predict lower levels of growth
following the death. Participants‘ total levels of anger toward the deceased explained
3.4% of the variance in posttraumatic growth. Contrary to predictions, however, higher
levels of anger predicted higher levels of posttraumatic growth (β=.19, p=.039). Overall
levels of anger toward the deceased did not explain significant variance in posttraumatic
growth after controlling for demographics (those significantly correlated with the
criterion variable as demonstrated in table 11) and trait anger (see table 20). Again,
death-separation anger was also assessed as a predictor of greater posttraumatic growth.
Once demographics and trait anger were controlled for, death-separation anger did not
contribute significantly to explaining the variance of posttraumatic growth and was
significant only at the trend level as a predictor of posttraumatic growth (see Table 21).
As an exploratory step, distress was also entered as a predictor of posttraumatic growth.
After controlling for distress, the link between death-separation anger and posttraumatic
growth was no longer significant. In other words, the reason that death-separation anger
seemed to predict greater growth was apparently because anger was associated with
greater distress, which in turn was associated with greater perceived growth.
Discussion
After the death of a family member, bereaved individuals may be left dealing with
unresolved issues in their relationship with the deceased, including ongoing feelings of
77
anger linked with past interpersonal offenses committed by the family member or
feelings of abandonment generated from the family member‘s death. This study explored
the prevalence, intensity and correlates of feelings of ongoing anger toward deceased
family members by bereaved individuals. Specifically, all participants in this study were
individuals who had a family member in hospice care die within the past 6-15 months.
New Anger Scale
Based upon a literature review as well as the results of in-depth qualitative
interviews conducted in the initial phase of the study, a new anger scale was created that
was designed to specifically address potential sources of anger toward the deceased
(offenses) and the intensity of anger experienced. The anger scale developed for this
study contained three subscales: Anger related to Relationship Conflict, Anger related to
the Death or Separation, and Anger related to the Family Member‘s Neglect of Health.
Overall, the majority of participants reported at least some degree of current feelings of
anger toward the deceased; however these feelings tended to have low intensity on
average. Although this scale had significant positive skew, it demonstrated good internal
consistency and initial construct validity. Therefore, the newly developed anger scale
may be a helpful contribution to understanding lingering negative emotions experienced
by bereaved individuals toward deceased family members.
Correlates of Ongoing Anger toward Deceased Family Members
The mediation model originally proposed (see Figure 2) was not supported. In
particular, there was no significant association between the participant‘s perception of a
continued relationship with the deceased and the participant‘s post-loss adjustment (path
b in Figure 2). Therefore, contrary to hypotheses, the existence and/or quality of the
78
participant‘s continued relationship with the deceased did not mediate the association
between ongoing anger and adjustment because there was no relationship between the
extent and quality of the continued relationship and adjustment. However, ongoing
feelings of anger toward the deceased were significant predictors of both adjustment and
a particular facet of the participant‘s post-death relationship with the deceased, the belief
that the family member continued to exist (paths a and c on Figure 2). These significant
correlates of anger will be explored in detail below.
Anger and perceptions of a continued relationship. It was hypothesized that
individuals who experienced lingering feelings of anger toward the deceased would be
less likely to endorse a continued relationship with this person, and if they did, it was
expected that the continued relationship would be perceived as a negative experience.
Study results indicated that participants‘ experience of a continued relationship—a literal
ongoing relationship with the deceased—was not significantly associated with levels of
ongoing anger. That is, contrary to expectations, the perception that one could and had
communicated with the deceased family member was not associated with levels of anger
toward the family member. Not enough participants endorsed a continued relationship
for there to be sufficient power to detect significant associations between the perceived
quality of the continued relationship and feelings of ongoing anger. An interesting
relationship emerged, however, between lingering anger toward the deceased and what
could be considered a prerequisite for a continued relationship—the participant‘s belief
that the deceased family member continued to exist in some form. Specifically, higher
levels of anger related to pre-death relationship conflict were predictive of less belief in a
continued existence for the deceased family member.
79
It is important to clarify that this association was not fully explained by the
participants‘ general beliefs in life after death (e.g. Heaven, Hell, reincarnation). That is,
it was not simply that participants with ongoing anger toward the deceased did not
believe in life after death. As demonstrated in Table 10, ongoing feelings of anger were
not significantly associated with beliefs in an afterlife in general, only in beliefs in an
afterlife for the family member in question. Participants‘ total anger score continued to
predict less belief in a continued existence after controlling for the participants‘ beliefs in
an afterlife. The Relationship Conflict Anger subscale was a marginally significant
predictor of less belief in an a continued existence after controlling for afterlife beliefs.
Therefore, regardless of the extent to which participants believed in an afterlife, being
angry with one‘s deceased family member was associated with less belief that the family
member continued to exist in some form.
It was expected that anger toward the family member would predict if and how
the post-death relationship with the deceased manifested. Instead, it appears that anger
predicted whether the family member was believed to continue to exist after death, not
whether a post-death relationship existed. It could be that participants‘ responses
regarding their belief in a continued existence for their family member were based upon
to what extent they had perceived or experienced evidence for the family member‘s
continued existence (e.g., whether they had perceived the family member had
communicated with them, had dreams, seen ―signs‖, etc.). If this were true, the continued
existence question could actually be assessing by proxy the extent to which a continued
connection with the deceased was experienced.
80
However, perhaps the association between anger and continued existence beliefs
reflects avoidance employed by the bereaved as a self-protective coping strategy to deal
with the negative feelings associated with the interpersonal transgression committed by
the family member. Following an interpersonal offense, individuals may feel motivated
to avoid the transgressor (McCullough & Hoyt, 2002). Although the death itself makes
physical proximity with the offending family member impossible, perhaps denying the
continued existence of the deceased reflects an effort to create psychological distance
between the bereaved and the offending family member. Unlike other grief measures
(e.g., the full version of the Inventory of Complicated Grief; Prigerson et al., 1995) the
complicated grief scale used in this study did not include questions addressing avoidance
of reminders or thoughts about the deceased; therefore it was not possible to assess the
role of avoidance of the deceased in understanding the link between anger and belief in a
continued existence.
Anger and indicators of adjustment.
Anger and distress. It was expected that ongoing feelings of anger toward the
deceased would predict distress for the bereaved participants. This hypothesis was
partially supported. The Death-Separation Anger subscale was closely associated with
distress. Given that separation distress is a component of the conceptualization of
complicated grief (e.g., Prigerson et al., 2009), it is not surprising that anger related to the
absence of the deceased would be associated with higher levels of distress in this sample.
Within the attachment framework, as noted in the literature review above, it is suggested
that separation from an attachment figure often elicits both strong yearning for the return
of that person but also feelings of anger associated with perceptions of being abandoned.
81
However, it should be noted that the attribution of causality for distress is not implied
here. Death-separation anger does not necessarily cause more distress. In fact, it could
be that the direction of the prediction is the reverse, with higher levels of post-loss
distress predicting increased feelings of anger about the absence of the deceased.
It is interesting to note that of the three subscales assessing anger toward the
deceased, only the Death-Separation Anger subscale was predictive of distress.
Lingering feelings of anger toward the deceased stemming from offenses in the pre-death
relationship were not linked with adjustment outcomes. This lack of association may be
explained by the fact that participants‘ levels of ongoing anger were not particularly
intense. Perhaps the anger experienced by participants related to pre-death transgressions
was not disruptive enough to be related to distress.
There are several possible reasons why the anger reported in this study tended to
have low intensity. It is possible that anger related to relationship conflict may not be
commonly experienced in bereavement. Perhaps the death of the transgressor nullifies or
diminishes feelings of anger related to pre-death offenses in some way. For example, the
absence of the offending family member may result in reductions in the intensity of these
feelings. Additionally, the death and removal of the deceased from ―worldly concerns‖
may have made it easier for the bereaved to resolve negative feelings toward the deceased
by providing a shift in perspective (Hussein & Oyebode, 2009). Witnessing the
deterioration and vulnerability of the family member as the illness progressed may have
also led to shifts in the surviving individual‘s perspective of the transgressor and a
resulting reduction of anger. Alternatively, beliefs regarding the morality of harboring
82
feelings of anger toward a deceased person may have led to suppression of feelings or
underreporting of feelings by participants.
Finally, the fact that study participants were recruited from a hospice organization
may have influenced the intensity of anger reported as well. Hospice services emphasize
the active preparation (both emotionally and logistically) for the death of the family
member, which may include attending to relationship wounds and the related negative
feelings experienced by both the dying and surviving individuals prior to the death
(Sepulveda, Marlin, Yoshida, & Ullrich, 2002). Additionally, HWR provides follow-up
services for the bereaved, offering further opportunity to receive support regarding
unresolved feelings of anger related to the relationship with the deceased family member
or to the separation from the family member due to the death. Future studies exploring
the experience of feelings of anger toward the deceased in bereavement would benefit
from following participants longitudinally to assess how the above factors may influence
levels of anger reported. Additionally, as indicated above, it will be important to assess
participants outside the hospice system and those whose family members were not
involved in hospice care.
Anger and posttraumatic growth. Both overall anger and death-separation anger
were only marginally significant predictors of posttraumatic growth, and the association
was in the opposite direction than what had been hypothesized. That is, higher levels of
anger toward the deceased were correlated with higher levels of posttraumatic growth.
The potential role of rumination or cognitive processing in both grappling with
unresolved relationship issues as well as in coping with the loss may provide a possible
explanation for the positive association between ongoing feelings of anger and
83
posttraumatic growth. Individuals struggling with lingering tensions with the deceased
may become preoccupied with the offense and the feelings of anger associated with it
(Attig, 1996). Because physical proximity to the deceased family member is no longer
possible, the bereaved individual‘s attempts to resolve feelings of anger are necessarily
one-sided, without the benefit of increased clarification from hearing the transgressor‘s
perspective or perhaps apology. Efforts to work out these unsettled relationship concerns
may result in high levels of cognitive processing and/or rumination for the bereaved
individual. Tedeschi & Calhoun‘s (2004) model of posttraumatic growth incorporates
both intrusive and deliberate rumination about the traumatic event. They argue that it is
through such continuous examination and cognitive processing of the event that growth is
possible (Tedeschi & Calhoun, 2004).
The finding that posttraumatic growth was positively associated with distress
brings into question what exactly was assessed by participants‘ self-reported post-loss
growth. On one hand, persistent distress may stimulate the experience of growth, and
therefore the positive association makes sense. On the other hand, the concurrent
experience of distress and posttraumatic growth questions whether posttraumatic growth
should be considered an indicator of adjustment (Nolen-Hoeksema & Davis, 2004).
There are also some concerns with the measure employed to assess posttraumatic
growth in this study. Some participants indicated that they answered the growth-related
questions in terms of how well these items described their general approach to life and
not how these domains had changed for them due to experiencing the death of their
family member. It is unclear how many participants answered in this manner, and
whether the resulting data reflects actual changes experienced due to the loss or
84
participants‘ efforts to describe their character. Additionally, as all of the items reflected
positive developments stemming from the loss, the participant might have felt the desire
to present themselves in a favorable light, therefore amplifying the level of growth
reported. It is important to recognize that the storyline of suffering and subsequent
growth has become a fixture in popular culture (e.g., it is the basis for countless
memoirs). Perhaps participants felt that posttraumatic growth was an expected or even
required component of their bereavement experience, again leading to over-reporting. In
the future, it might be worthwhile to include a measure of changes experienced due to the
loss that also includes items that reflect negative consequences stemming from the loss as
well as positive. This may allow for a more nuanced description of both the positive and
negative aftereffects of the death of a family member.
Limitations and Future Directions
Study design and methods. One limitation of this study was that it was
correlational and cross sectional in design, therefore limiting the conclusions that could
be drawn regarding the relationships between anger, adjustment and the post-death
continued relationship. It would be extremely informative and beneficial to examine the
construct of ongoing feelings of anger toward the deceased within a longitudinal
framework, allowing for greater understanding of the evolution and timing of these
feelings from pre-loss to post-loss.
As mentioned above, future studies may also benefit from including additional
measures. In particular, to clarify the link between anger and beliefs in a continued
existence, it would be helpful to assess the bereaved individuals‘ level of avoidance of
thinking about or being reminded of the deceased family member. Additionally,
85
including a measure that assessed both positive and negative changes stemming from the
loss could help clarify the relationships between anger, distress and posttraumatic growth
found in this study.
Qualitative data analysis. The qualitative phase generated many facets of anger
experienced by the bereaved regarding their deceased family members. Due to time
constraints associated with the study, only the first phase of qualitative data analysis was
completed before the quantitative phase was begun. Overall, the initial analysis
performed by the author uncovered several major themes related to the experience of
ongoing anger toward a deceased family member that were not addressed in the
preliminary draft of the anger scale: perceptions that caregiving efforts and sacrifice were
unappreciated by the family member, unsettled legal or financial matters, and perceptions
that the deceased family member ―gave up‖ on life. However, it is noted that the second,
more in-depth phase of qualitative data analysis provided a much richer description of
facets of anger experienced by the bereaved. The results of this second phase of analysis
suggest possible additional refinements to the anger scale. In particular, if the scale were
to be revised in the future, it might be worth adding specific items to more directly
address several additional sources of anger: funeral arrangements, perceptions that the
family member did not support or agree with the participant, and being placed in a
difficult position by the family member. These three aspects of anger experienced by the
bereaved participants loosely fit into existing categories represented by the revised anger
scale (disagreements in care, the family member failing to do something that was
important to the participant, and inconsiderate or hurtful actions committed by the family
86
member, respectively). However, if the scale were to be revised, it might be worth
refining the items to more directly address these domains.
An additional limitation of the qualitative phase was that formal memberchecking was not employed as a method to assess credibility. That is, the author did not
re-contact the participants in the qualitative phase to present the themes generated in data
analysis. During each interview, however, the author did present a summary of the
sources of anger reported by the participant, presenting an opportunity for the participant
to verify or amend the initial themes identified by the author.
Study sample. As mentioned above, an important next step for this line of
research will be to assess the prevalence, intensity and correlates of anger in other
bereaved samples. Given the importance and care hospice services devote to the
psychosocial wellbeing of dying patients as well as their family members, it is possible
that participants in the present study had already attended to and reduced feelings of
anger related to relationship wounds between themselves and dying family members
prior to their participation. Therefore it will be important to assess levels of anger in
bereaved populations who may not have as much support and guidance in addressing
these concerns as those who receive hospice care.
Forgiveness. As demonstrated by the current study, residual feelings of anger
toward deceased family members do exist within bereaved individuals, therefore
indicating that forgiveness-related issues may be relevant for some people post-loss. A
key next step will be to examine bereaved individuals‘ efforts to resolve these lingering
feelings of anger toward the deceased. Again, the use of a longitudinal study design
would be particularly helpful in enhancing understanding of the evolution of forgiveness-
87
related issues with family members at the end of life and in bereavement. In particular, a
longitudinal study would allow for examination of the impact of the death of the
transgressor on how the surviving individual feels and thinks about a pre-death
transgression. Understanding individuals‘ efforts and degree of success at navigating the
resolution of interpersonal transgressions after the offending person has died will help
inform forgiveness interventions for bereaved populations.
In order to assess for potential obstacles faced in efforts to resolve anger, it would
be helpful to clarify bereaved individuals‘ beliefs regarding the possibility of forgiveness
and relationship repair following the death of the offending person. Perhaps some
bereaved individuals feel ―stuck‖ in regards to resolving a pre-death transgression or
negative feelings stemming from the death because the family member is no longer
physically present or accessible. Individuals who are grappling with anger toward the
deceased might think, ―There‘s nothing I can do about this now.‖ Therefore, for
bereaved individuals‘ who believe in an afterlife, the continued relationship with the
deceased could provide a possible avenue for relationship issue resolution and would
represent an important factor to explore further. It is also unclear whether the belief in
the possibility of literal communication between the deceased and bereaved is necessary
or whether ―virtual‖ forgiveness communication (i.e., imagining receiving or sending
communication) could be just as effective. This is an especially relevant and potentially
fruitful area of exploration for bereaved populations and warrants further study.
Conclusions
How bereaved individuals navigate their relationship with the deceased has been
the cornerstone of various grief theories. It has been argued that grief adaptation involves
88
a transformation of the relationship. How the relationship is transformed depends upon
the grief theory, and ranges from withdrawing and ―letting go‖ of the relationship to
cultivating a continuing bond with the deceased. One important factor that may impact
how the bereaved relates to the deceased (in whatever manner) is the existence of
lingering feelings of anger related to past interpersonal offenses committed by the family
member or feelings of abandonment generated from the family member‘s death. In
dealing with the death of a family member, bereaved individuals may also be struggling
to resolve relationship issues with the deceased and the associated feelings of anger.
Furthermore, these feelings of anger may be associated with adjustment post-loss.
This study established that many bereaved individuals do experience some
unresolved feelings of anger toward deceased family members. Furthermore, such anger
is related to distress as well as perceptions of the family member‘s continued existence.
The results of this study indicate that lingering feelings of anger toward the deceased are
indeed relevant to understanding individuals‘ post-loss experiences. As indicated above,
there is still much to learn in this area, but this study represents an important start to our
understanding of ongoing feelings of anger toward deceased family members and has
contributed an important tool for future research by creating a scale that specifically
addresses bereaved individuals‘ experiences of unresolved relational anger. Finally, this
study has provided directions for further research with the ultimate goal of developing
specific forgiveness interventions for bereaved individuals struggling with ongoing
feelings of anger following the death of a family member.
89
Footnotes
1
The qualitative method used was based upon a phenomenological approach. The goal
of a phenomenological approach is to understand the phenomenon in question—in this
case, bereaved individuals‘ feelings of anger toward a deceased family member—through
the ―living experience‖ of the participants (Creswell, 1998, p.15). However, it is noted
that because of the secondary role of the qualitative phase in the current study, and its
specific function to refine the proposed scale already drafted by the researcher, the
resulting degree of focus in the analysis of the qualitative interviews was likely more
restricted than is typical for phenomenological studies. Corresponding to the
phenomenological approach, the interviews generated extensive information regarding
various dimensions of the experience of feeling anger toward deceased family members.
However, not all aspects of this phenomenon uncovered in the interviews were relevant
to the purpose of this phase of the study (i.e., to gather information to refine the proposed
measure). Therefore, because themes related to sources and reasons for lingering feelings
of anger toward the deceased were prioritized/attended to over other aspects of the
experience of anger toward the deceased (as these themes directly applied to the content
and structure of the proposed anger measure), the qualitative phase perhaps cannot be
considered purely phenomenological.
2
As the log of zero is undefined, a constant was added during the log transformation of
variables, as needed, to move the minimum value from zero to one.
90
3
Seemingly due to the structural presentation in the questionnaire of the negative
relationship quality questions, 16 participants did not complete any of the negative
relationship quality items. There was not a significant difference between those who did
not complete the negative relationship questions and those who did on the anger scale
total score, posttraumatic growth, and distress. Those who left the negative relationship
items unanswered expressed significantly less anger regarding relationship conflict (M =
0.07 , SD=0.07) than those who completed the negative relationship quality items (M =
0.12, SD= 0.17 , t(43.48) = -2.14 , p = .038). Those who left the negative relationship
items unanswered also reported significantly more anger regarding patient neglect of
health (M = 0.26, SD= 0.23) than those who completed the negative relationship quality
items (M = 0.12, SD= 0.16, t(17.15) = 2.23, p = .039).
4
There was also a significant difference in neglect of health anger (F (7,121) =2.2, p
=.039) depending on the relationship of the family member to the participant. However,
this difference was no longer significant after Bonferroni corrections.
5
A dichotomous variable was created for family members who were aunts or uncles and
entered into the correlation analysis as well. As it was not significantly correlated with
any of the main study variables it was not included in Table 11.
91
Table 1
Descriptive Statistics for Categorical Variables in the Qualitative Phase
n
%
1
7
88
12
1
7
12
88
1
2
4
1
12
25
50
13
1
1
3
1
1
1
12
13
38
12
13
12
7
1
88
12
5
1
2
63
12
25
5
2
1
1
2
63
25
12
12
21
5
1
2
63
12
25
Gender
Female
Male
Ethnicity
African American
Caucasian
Marital Status
Single
Married
Widowed
Living with romantic
partner
Family Member
Husband
Wife
Mother
Romantic Partner
Friend
Other (Brother-in-law)
Primary Caregiver
Yes
No
Type of Hospice Care
Home care
Nursing Home
Hospital
Disease
Cancer
Heart Disease
HIV/AIDs
Stroke
Other
Location of Death
Home
Nursing Home
Hospital
Note. Some percentages exceed 100% because participants were allowed to endorse multiple options.
92
Table 2
Demographic Statistics for Continuous Variables in the Qualitative Phase a
M
SD
Range
Participant Age (years)
57.25
12.24
39-77
Illness Duration (months)
81.88
85.80
1-240
Duration of Hospice Care (months)
0.58
0.76
0-2.30
Death seemed Sudden
2.88
1.81
0-5
Months post-loss
11.75
2.38
8-15
Age of family member at death
76.38
12.67
53-97
a
n=8.
93
Table 3
Parallels Between Qualitative and Quantitative Phase Measures
Domain of Interest
Patient and Illness
Descriptives
Qualitative
Participant will fill out
quantitative questions regarding
demographics and illness related
questions
Quantitative
First page of
questionnaire
Grief Response
How have you been feeling about
the loss? How has coping with
the loss been for you?
ICG-S
Relationship quality
Can you describe your
relationship with this person for
me? How did you get along?
Relationship Quality
questions
-
During different
times
Before the illness?
Can you describe your
relationship with ________
during the illness.‖
-
Relationship
conflicts
Every relationship has its ups and
downs and here we are especially
interested in exploring the
tougher times or the unresolved
issues that you may have had with
________. What sorts of
conflicts did you have in your
relationship with _____, if any?
Were these problems resolved?
How do they impact your feelings
about _______ today?
Questions regarding
unresolved issues, past
offenses by the family
member
Illness Experience
What was your experience during
______‘s illness?
What, if any, was the nature of
your participation in _______‘s
care during the illness?
Some overlap with first
page of questionnaire.
What were the hardest parts for
you in __________‘s illness?
Do you have any unfinished
business or unresolved conflicts
about anything that happened or
didn‘t happen during
____________‘s illness? If so,
Potential overlap with
new anger scale; may also
overlap with questions
regarding anger toward
other entities including
hospital and hospice staff.
-
Conflict related to
illness
94
please explain.
What, if anything, do you feel
good about regarding your
interaction with _____ during
his/her illness? Annoyed about?
Frustrated about? Angry about?
Guilty about? Do you have any
regrets about how things went?
Feelings toward the
deceased
- Ongoing feelings
-
What emotions do you feel
Potential overlap with the
toward your family member when new anger scale
you think about him/her today?
On the phone you mentioned
having feelings of anger,
frustration or annoyance toward
_______. Can you please tell me
more about these feelings?
New anger scale
Unresolved Conflict /
Unfinished Business
Do you have any unfinished
business with _________? Is
there anything you wanted to say
or do that would have made you
feel more comfortable ending the
relationship? Is there anything
you lack closure on?
Unresolved issues
question
Continued Relationship
How would you describe
Continued relationship
________‘s role, if any, in your
questions
life at this time? In other words,
do you have an ongoing sense of
connection to ________ or does
______ play an active part in your
ongoing life?
How do you relate to ______ at
this time, if you do?
**ask belief in afterlife if not
addressed by participant:
Do you think ______ continues to
exist in some way? How so?
(Distinguish between existing in
memories versus literal ongoing
existence)
Ongoing feelings
of anger
95
-
-
Communication
Quality
People often feel like they can
still talk or communicate with
their lost family member or that
their family member still
communicates with them.
Do you talk to ______?
Do you communicate in any way
to _______? If so, how?
Do you ever sense that ______ is
still trying to communicate with
you?
Continued relationship –
Communication questions
What is it like for you to have this Continued relationship
type of relationship or sense of
questions
connection with _____?
Did you view it as positive (as
comforting or something that
made you feel good) or was it
more negative (something
frightening that you would not
want to have happen again)?
Changes due to the loss
How has your life changed since
the ______‘s death?
Posttraumatic growth;
potential overlap with
new anger scale items.
Posttraumatic Growth
(if not addressed in previous
Posttraumatic growth
question): Although the death of a
family member can be a very
difficult, some people also report
feeling a sense of personal growth
following the experience of loss.
Have you experienced any
positive personal changes due to
the loss?
Concluding Question:
Are there any important aspects
of your relationship or the story
surrounding the loss and your
attempts to cope with it that I
didn‘t ask about and you would
like to share with me?
96
Table 4
Refinements to the Proposed Anger Scale Based Upon Qualitative Data Analysis
Preliminary Draft Version
Final Version
Description of Edits
N/A.
For failing to appreciate
attempts that were made to
care for him/her
New item added based
upon qualitative interview
information
N/A.
For giving up
New item added based
upon qualitative interview
information
N/A.
For not having legal affairs
in order (issues with the
will, insurance,
belongings/assets)
New item added based
upon qualitative interview
information
For your current emotional
pain due to the loss?
For your current emotional
pain or loneliness.
Two similar items were
combined.
For disagreements about
care or not cooperating with
attempts to care for him/her
while ill?
Two similar items were
combined.
For the disruption his/her
illness created in your life?
For the stress his/her illness
created in your life?
Edited item.
For leaving you by dying?
For leaving you (by dying)?
Edited item.
For your current loneliness?
For not cooperating with
your attempts to care for
him/her while ill?
For disagreements with
him/her about his/her care?
For negative changes in
For problems in your life
your life since the loss
since the loss or due to the
(example: financial, social)? loss (problems in finances,
relationships, etc.)?
Edited item.
97
Table 4 Continued
Preliminary Draft Version
Final Version
Description of Edits
For violations of trust that
occurred in your
relationship?
For violations of trust that
occurred?
Edited item.
For something hurtful
he/she said to you?
For something hurtful
he/she did or said to you?
Expanded item.
For behaving selfishly or
inconsiderately toward you?
For acting in an insensitive
or inconsiderate way?
Edited item.
For betraying you?
N/A.
Deleted item.
N/A.
For hurting or failing to help
someone else that you care
about?
New item based upon
consultation with expert.
98
Table 5
Thematic Structure of Qualitative Data with Representative Excerpts
Major Theme 1: Anger related to family member‘s illness or healthcare
Minor Theme 1: Family member did not take care of his or her health

Code: Family member did not seek treatment when the participant thought
they should have
“I‟m mad, still a little bit because I think had she went to the doctor
earlier knowing that she had HIV, like because when you get sick you just
can‟t ignore that. So I was very angry. I never voiced that to her. But
I….I was….mad that she didn‟t take care of herself for that reason. Like
we‟ve done all these things for all these years, went to Cleveland, and did
all these things to get the HIV in check. So why would you allow yourself
to get to stage 4 lung cancer?”

Code: Family member engaged in unhealthy behaviors (either causing the
current illness or continuing unhealthy behaviors despite being ill)
“I‟m angry the most because I think everything was preventable from his
point of view. He didn‟t have to smoke.”

Code: Family member ―gave up‖ on life or attempts to get better
“I was kinda mad that he…it seemed to me like he…give up. Um…I could
always see him bounce back from everything else. He worked real hard to
get better. And this time, it‟s just like….I wasn‟t enough [getting teary] to
make him want to get better. So…because he fought for 12 years [crying],
you know, why couldn‟t he fight for a little longer? Or a little harder?”
Minor Theme 2: Caregiving interactions

Code: Caregiving was challenging and frustrating
“I was just irritated and I couldn‟t—there‟s nothing I could do for her! I
kept saying, “I just gave you your medicine [patient]” “I just…I just” you
know…and her legs would hurt so bad and I‟d rub and rub her feet. And
a…another friend of ours would come and he would help. And she just
kept making those noises and I got so irritated. …….I just saw, I just got
mad that day! I called her sister and I was bawling my eyes out and I
said, „I‟m sorry, I love your sister but I can‟t stand her today.‟”

Code: Family member was demanding
“And I just wouldn‟t leave—like she didn‟t want me to leave like either.
That‟s probably where a lot of my frustration is, because sometimes I just
needed…even if I—even if it was an hour…and as soon as I would leave,
she would call. Because she was scared [tearing up] and she trusted me.
99
Like she trusted me more than anybody. And she has a lot of brothers and
sisters and nieces and nephews and…she did not want anybody there—she
didn‟t care if they came when I was there, but she did not want anyone
there but me. And so that was—that was a lot of responsibility on me.”

Code: Family member did not appreciate or recognize caregiving
efforts/sacrifices
“And you know I‟d resent the fact that…[sigh] I mean for the past 20
years I was the one doing her shopping, cutting her grass, cleaning her
house, taking her to doctors appointments, dragging my kids along. You
know I did it without complaining. And my sister who would breeze in
maybe [sigh] once in 8 weeks, you know she was a….she spoke nothing
about—you know, praise for her, how she worked, this that and the other
thing….So anyway, all she did—it seemed like she just put me down. And
here I am I‟m cleaning up after her, um, and I did—I never complained.
Just, you know. So…yeah I just reached a boiling point.”

Code: Disagreements about care of family member
“So the team always questioned whether they should talk in front of me or
whether they shouldn‟t. I‟d say yes they could and he‟d say no they
couldn‟t! So then I‟d call the nurse and if he found out I called the nurse
he would get upset so it was always a very frustrating and confusing
trying to decide what is the best care for him.”

Code: Disagreements about after-death arrangements
“That‟s another thing I was really mad about. She donated her body to
science. And um….not that it‟s any of my business what she did with her
body but I just didn‟t want her to do that. …… I am still extremely pissed
off about her donating her body to science. Because she never told me
that! Never! Because she knew I‟d probably throw a fit [laughs] so that
is something I‟m absolutely mad about that. And I—it‟s not my business
to be angry. I should be allowed to pick how I want to die, and where I
want to die, and where I want to be buried. Same as you should be
allowed to make it right? But boy when she made it, whew. I was angry.”
Major Theme 2: Anger related to family member‘s death
Minor Theme 3: Separation-related anger

Code: Family member left (by dying)
“Like I said I just get angry because she left!... I just wish she wasn‟t
gone!...I do get angry with her that she left.”

Code: Family member is no longer here to offer support
“Sometimes I get angry…because she isn‟t there. You know, “Why aren‟t
you here when I really need you?!” You know because sometimes it feels
100
like I have no one to talk to. I could always pick up the phone and talk
with her no matter what. And she understood anything I was talking about
[sniffs]. I don‟t have anyone else to fill that void [sniffs]. ….So…that‟s
why, that‟s why I get angry because she‟s not there. Sometimes I‟m angry
and be like, “why can‟t you be here? I need you so much.”
Minor Theme 4: Negative consequences of the death

Code: Blame family member for current distress / disturbing grief
symptoms
“Sometimes I can‟t sleep, and then I get angry at her, because I‟m
thinking—it seems like right after she died I had a hard time sleeping.”

Code: Financial and legal matters left unsettled
“I‟m really angry—I am really angry that he didn‟t write a will out. I‟m
really upset about that.”
Major Theme 3: Anger related to interpersonal conflict with family member
Minor Theme 5: Hurtful words / actions

Code: Verbal abuse
“I‟m angry about the way he put me down. I look back at pictures of
myself when I was younger, and I was cute…you know [small laugh] I
mean I‟m not bragging, but I never—I never—I never realized. When I
look back at some of these pictures I‟m like wow, but when someone is
putting you down all the time it‟s like—for instance, you know, it‟s like
“when you lose weight, I‟ll marry you.” I lost weight, he didn‟t marry me.
“When you get your teeth fixed, I‟ll marry you.” But I‟m angry at the way
he used to put me down.”

Code: Inconsiderate behavior
“And it just makes me angry that [partner] sabotaged himself after his
divorce. He started his own business, he had a great job, so he didn‟t
want his ex wife to have any more money. So the man was kind of
sabotaging himself along the way. And I‟ve paid the price for it all.”
Minor Theme 6: Family member neglected to do or say something that was
important
“And in some ways I‟m angry at him for having children like he did. You
know? They‟re just not…they‟re just—I….They‟re just not nice people. …
I‟m just angry that, you know, he….he would make excuses especially for
that one son [son]. You know, he‟s never been any good his whole life,
he‟s 41 years old. He‟s still in trouble. And I….I‟m angry that he didn‟t
see that! He wouldn‟t, you know, step up to the plate and, you know,
say—write him off!”
101

Code: Family member disagreed or did not support participant
“There were times when she didn‟t always agree with me. Like if I got
mad at my daughter, she‟d go, “Oh you‟re too hard on her, leave her
alone, she‟s ok.” You know, blah blah blah. We had conflicts about that.
About how I raised her. Or even when she was an adult. She‟d get mad at
me because I was too hard on her. Or just…”lay off her, give her a
break.” So………. I try to remember those things that she told me. I get
mad at her because she did tell me those things and now… it‟s coming
back—I hear her voice saying, “Just give her a break” you know, “lay off
her, you‟re too hard on her.” I get mad at her because I think she needs
to be somebody---somebody needs to be hard on her sometimes!”
Minor Theme 7: Betrayal of trust
“She betrayed me in such a major way that the rest of our lives together
was affected by it and it wasn‟t the only time she‟d done it but it was so
major that, I still can‟t think about it without wondering how in God‟s
name she could have believed that I did what these family members said I
did. Um. And took their side…..So that overarched everything we did,
you know. …..Well, the sense of why would you listen to your sister
instead of your daughter? You know…..How could they come first? So…I
think that will always, well not only hurt but…anger, anger me.”
Minor Theme 8: Being put in a difficult position
“And then I‟m—I‟m angry at him too because he kind of put me in a
situation. He had me cosign for the youngest son‟s motorcycle. We never
really got along. We were together for 27 years and this kid, he never
really liked me and we were never close. And now I‟m in this situation,
and I‟m—and he said that when I did it, he said, well you know it‟ll make
you and [son] closer. Well that hasn‟t worked! So now I‟m like facing
maybe possibly paying for a motorcycle that I‟ll never have. So—and I‟m
angry at him about that! For putting me in that situation.”
102
Table 6
Descriptive Statistics for Categorical Variables in the Quantitative Phase
n
%
100
30
77
23
19
109
2
1
15
84
2
1
18
62
38
6
3
3
14
48
29
5
2
2
22
9
36
26
5
6
7
3
2
1
5
3
5
17
7
28
20
4
5
5
2
1
1
4
2
4
104
22
83
17
58
51
30
19
45
40
23
15
61
23
9
47
18
7
Gender
Female
Male
Ethnicity
African American
Caucasian
Native American
Other
Marital Status
Single
Married
Widowed
Divorced/Separated
Living with romantic partner
Other
Family Member
Husband
Wife
Mother
Father
Romantic Partner
Brother
Sister
Daughter
Son
Friend
Aunt
Uncle
Other
Primary Caregiver
Yes
No
Type of Hospice Care
Home care
Nursing Home
Hospice House
Hospital
Disease
Cancer
Heart Disease
Lung Disease
Table continues on next page
103
Table 6 Continued
HIV/AIDs
Kidney Disease
Dementia/Alzheimer‘s
Diabetes
Stroke
Other
Location of Death
Home
Nursing Home
Hospice House
Hospital
Unresolved Issues
Yes
No
n
1
13
32
5
5
27
%
1
10
25
4
4
21
44
41
14
25
36
33
11
20
48
82
37
63
Note. Some percentages exceed 100% because participants were allowed to endorse multiple options.
104
Table 7
Demographic Statistics for Continuous Variables in Quantitative Phase
M
SD
α
Range
n
Participant Age (years)
59.30
11.44
--
30-88
125
Illness Duration (months)
29.54
40.21
--
.10-240
123
Duration of Hospice Care (months)
3.86
8.30
--
0-60
125
Death seemed Sudden
1.79
1.84
--
0-5
126
Months post-loss
10.53
2.11
--
6-14
130
Age of family member at death
76.50
15.36
--
18-99
129
Positive Quality Relationship
4.28
1.07
.87
0-5
127
Negative Quality Relationship
1.09
1.20
.75
0-5
114
Past Offenses by Family Member
1.28
1.59
--
0-5
108
Total Anger Scale
0.54
0.65
.87
0-5
130
Participant
0.55
0.96
--
0-5
129
Other Family
0.61
1.00
--
0-5
129
Doctors / Medical Professionals
0.88
1.36
--
0-5
129
Hospice
0.18
0.58
--
0-5
129
God
0.18
0.55
--
0-5
129
Trait Anger
15.64
4.31
.83
10-40
122
Complicated Grief
13.01
11.66
.93
0-45
125
Depression
9.18
6.77
.88
0-30
125
Posttraumatic Growth
29.90
16.12
.92
0-65
124
Continued Relationship
1.99
1.75
.90
0-5
126
Positive Communication
4.18
1.32
--
0-5
60
Negative Communication
0.05
0.23
--
0-5
57
Belief in Continued Existence of Family 3.82
Member
1.76
--
0-5
130
Anger at Other Entities
Positive Continued Existence
4.66
0.79
--
0-5
113
Negative Continued Existence
0.10
0.43
--
0-5
108
4.04
1.63
--
0-5
129
Belief in Afterlife
105
Table 8
Component Loadings for Principal Components Analysis With Varimax Rotation of
Anger Subscales
Anger Scale Item
Acting in an insensitive or
inconsiderate waya
Something hurtful he/she did or
saida
Violations of trusta
Neglecting to do or say
something that was importanta
Treating you poorly during
his/her illness (for example,
being critical, demanding or
aggressive) a
Failing to appreciate attempts
that were made to care for
him/hera
The stress his/her illness created
Not having legal affairs in order
(issues with the will, insurance,
belongings/assets)
No longer being here to support
youa
Current emotional pain or
lonelinessb
Leaving you (by dying)
Problems in your life since the
loss or due to the loss (problems
in finances, relationships, etc.) a
Not taking better care of his/her
health
Giving up
Disagreements about care or not
cooperating with attempts to
care for him/her while ill
Component 1:
Relationship
Conflict Anger
.871
Component 2:
Death-Separation
Anger
.070
Component 3:
Neglect of
Health Anger
.117
.858
.019
-.067
.775
.729
.029
.277
-.052
.130
.675
-.054
.408
.623
.047
.520
.579
.569
.015
.187
.471
.317
.078
.832
.092
.143
.825
.198
-.221
.300
.788
.650
.253
.052
.025
.146
.755
.007
.419
.271
.182
.739
.693
Note. Item loadings for each component are bolded. Only the highest loading items were included (i.e.,
loadings 0.5 or above, or the highest loading if the variable loaded on two components at 0.5 or above).
a
n=129. bn=128. If not otherwise noted, n=130.
106
Table 9
Prevalence and Intensity of Ongoing Feelings of Anger Toward the Deceased
Frequency (%)
Mean (SD)
For violations of trust that occurred? b
19.2
0.41 (0.10)
For something hurtful he/she did or said to you? b
30.0
0.60 (1.14)
For neglecting to do or say something that was
important to you? b
33.8
0.68 (1.20)
For acting in an insensitive or inconsiderate way? b
33.1
0.58 (1.09)
For hurting or failing to help someone else that you
care about? a, b
21.5
0.39 (0.91)
For not taking better care of his/her health?
43.1
0.98 (1.39)
For disagreements about care or not cooperating
with attempts to care for him/her while ill?
30.8
0.67 (1.26)
For the stress his/her illness created in your life?
30.0
0.51 (0.94)
For failing to appreciate attempts that were made to
care for him/her? b
23.1
0.41 (0.98)
For treating you poorly during his/her illness (for
example, being critical, demanding or aggressive)? b
18.5
0.33 (0.91)
For giving up?
13.1
0.26 (0.83)
For leaving you (by dying)?
25.4
0.62 (1.28)
For your current emotional pain or loneliness? c
23.8
0.47 (1.02)
For problems in your life since the loss or due to the
loss (problems in finances, relationships, etc.)? b
25.4
0.47 (0.98)
For not having legal affairs in order (issues with the
will, insurance, belongings/assets)?
26.9
0.65 (1.35)
For no longer being here to support you? b
31.5
0.59 (1.07)
Total Anger Score
75.4
0.55 (0.65)
a
b
This item was not included in the final scale and was not included in the Total Anger Score.
n=129. c n=128. If not otherwise noted, n=130.
107
Table 10
Intercorrelations for Main Study Variables
1. Total Anger Scale
2. Relationship
Conflict Anger
3. Death Separation
Anger
n
130
130
1.
2.
1
.87*** 1
3.
130
.62*** .22*
1
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
107
4. Neglect of Health 130
.73*** .46*** .39*** 1
Anger
5. Distress
130
.32*** .07
.58*** .23** 1
6. Posttraumatic Growth 124
.19*
.03
.29*** .21* .43*** 1
7. Belief in Continued
130
-.21*
-.24** -.02
-.15† .09
.12
1
Existence of Family
Member
8. Continued
126
-.02
-.01
.05
.01
.02
.07
.27** 1
Relationshipa
9. Positive
60
-.19
-.17
-.22†
-.06
-.11
-.03
.27*
.59*** 1
Communicationb
10. Belief in Afterlife
129
-.08
-.17
.11
-.04
.12
.12
.67*** .14
.02 1
11. Unresolved Issues
130
.45*** .45*** .24** .25** .27** .05
-.15† .08
-.07 -.11
1
12. Hurt by Family
108
.53*** .68*** .02
.27** -.01 -.09 -.32*** .19† -.10 -.24* .34*** 1
Member
13. Positive Quality
127
-.09
-.27** .21*
.01
.31*** .42*** .29*** .13
.13 .29*** -.14 -.25** 1
Relationship
14. Negative Quality
114
.42*** .49*** .09
.21* -.04 -.23* -.37*** .02
-.10 -.32*** .38*** .54*** -.60***
Relationship
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
a
After selecting for participants who endorsed some level of belief in a continued existence for their family member (did not answer
0), n=112.
b
After selecting for participants who endorsed some level of a continued relationship with the deceased (did not answer 0; n=66).
108
Table 11
Intercorrelations for Main Study Variables and Demographic / Background Variables
n
100
125
Total
Anger
Scale
.11
.00
Female
Participant Age
Ethnicity
African American
19
.14
Caucasian
109
-.13
Incomea
123
-.16†
Marital Status
Widowed
38
-.00
Married
62
-.10
Family Member
Spouse
31
-.01
Romantic Partner
5
.31***
Mother
36
-.10
Father
26
-.09
Illness Duration
123
.11
Duration in Hospice Care 125
.01
Primary Caregiver
104
.08
Type of Hospice
Homecare
58
.06
Nursing Home
51
-.06
Hospital
19
.07
Hospice House
30
.05
Disease
Cancer
61
.14
Table continues on next page
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
Relationship
Conflict
Anger
.02
.05
Death
Separation
Anger
.15†
-.08
Health
Neglect
Anger
.15†
.00
Distress Posttraumatic Belief in Continued
Growth
Existence of Family
Member
.18*
.04
-.01
-.11
-.13
-.14
.09
-.07
-.04
.05
-.06
-.31***
.22*
-.21*
-.07
-.05
.01
-.36***
.12
-.15
-.31***
-.22*
.22*
-.02
-.03
-.05
.17
-.13
-.07
-.07
.31***
-.30***
.20*
-.24**
-.02
.03
-.05
.22*
-.02
-.06
.09
.05
-.01
.15†
.30***
-.13
-.10
.12
-.02
.18*
-.10
.22*
-.13
-.04
.04
-.05
.08
.27**
.25**
-.04
-.25**
.02
-.09
.19*
.18*
.04
.04
-.25**
.06
.07
.03
.02
.02
-.12
.15†
.03
.02
-.03
.04
.02
.05
.00
.07
-.13
.02
.08
.03
-.11
.10
.07
.27**
-.29***
.03
-.03
.01
.01
.06
.06
.14
-.07
.06
-.09
.10
.14
.10
.30***
.20*
.02
108
109
Table 11 Continued
n
Total
Anger
Scale
Disease
Heart Disease
23
-.08
Lung Disease
9
.08
Kidney Disease
13
.04
Dementia/
32
-.03
Alzheimer‘s
Diabetes
5
-.02
Stroke
5
-.02
Location of Death
Home
44
.03
Nursing Home
41
-.11
Hospital
14
-.05
Death seemed Sudden
126
.04
Age at Death
129
-.17†
Months Post-loss
130
-.11
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
Relationship
Conflict
Anger
Death
Health
Separation Neglect
Anger
Anger
Distress Posttraumatic Belief in Continued
Growth
Existence of Family
Member
-.06
.04
.04
-.04
-.02
.08
-.02
-.07
-.10
.08
.05
.07
-.04
-.06
-.01
-.18*
-.01
-.08
-.03
-.03
-.08
-.06
-.07
.01
.00
-.01
-.05
-.01
.00
-.03
.06
-.02
-.09
-.17†
-.23**
.06
.00
.00
-.10
-.05
-.08
-.04
.08
-.19*
.03
.12
-.21*
-.14
.02
-.15†
.01
.10
-.15†
-.10
.31***
-.35***
.07
.12
-.34***
-.13
.02
-.15†
.15†
-.06
-.24**
.02
.08
-.07
.16†
.06
-.12
-.17†
a
Because the categories included in the household income question do not have equivalent intervals (see Appendix C), it was technically an ordinal variable.
The Pearson correlation coefficients for this variable are reported here because household income was entered as a control variable in the regression analyses.
Spearman rank order correlation was also performed and indicated similar significant relationships for household income: Death-Separation Anger (r=-.29, p=
.001), Distress (r=-.34, p < .001), Posttraumatic Growth (r=-.26, p = .005).
109
110
Table 12
One-way ANOVA with Bonferroni Correction on Distress and Posttraumatic Growth by Marital Status: Married vs. Widowed
Marital Status: Married (n=62)
M
SD
Marital Status: Widowed (n=38)
M
SD
Distress
-.30
.77
.44
.99
.000
Posttraumatic Growth
25.90
16.44
34.94
13.29
.043
a
pa
Post-hoc test multiple comparisons did not provide a test statistic. The p-value reported here reflects the significance of the mean difference between groups.
110
111
Table 13
One-way ANOVA with Bonferroni Correction on Total Anger, Death-Separation Anger and Distress by Family Member Relationship
to Participant
M
Family Member b:
Total Anger Score
Death-Separation
Anger
Distress
a
b
Romantic Partner
Romantic Partner
Father
M
SD
pa
Spouse
0.12
0.11
.029
Father
0.10
0.12
.010
Mother
0.10
0.11
.008
Aunt/Uncle
0.09
0.13
.042
Father
0.08
0.14
.013
Mother
0.08
0.12
.010
Aunt/Uncle
0.07
0.20
.048
Spouse
0.44
1.04
.003
Romantic Partner
1.16
0.92
.004
SD
Family Member b:
0.32
0.37
-0.47
0.14
0.20
0.61
Post-hoc test multiple comparisons did not provide a test statistic. The p-value reported here reflects the significance of the mean difference between groups.
Romantic partner n=5, spouse n=31, father n=26, mother n=36, aunt/uncle n=8.
111
112
Table 14
One-way ANOVA with Bonferroni Correction on Distress by Location of Death
M
Location of Death: b
Distress
a
b
Nursing Home
M
SD
pa
Home
0.39
0.99
.000
Hospital
0.19
0.96
.092
SD
Location of Death: b
-0.48
0.66
Post-hoc test multiple comparisons did not provide a test statistic. The p-value reported here reflects the significance of the mean difference between groups.
Nursing home n=41, home n=44, hospital n=14.
112
113
Table 15
Prediction of Criterion Variables by the Anger Subscales
Belief that Family Member
β
Continues to Exist
Distress
Posttraumatic Growth
(n=130)
(n=130)
(n=124)
R2=.06*
β
R2=.34***
β
Relationship Conflict Anger
-.22 *
-.07
-.11
Death Separation Anger
.06
.58***
.25**
Neglect of Health Anger
.17
.04
.17
R2=.10**
*** p ≤ .001, ** p ≤ .01, * p ≤ .05
113
114
Table 16
Prediction of Belief that Family Member Continues to Exist by Total Anger Scale
n
β
19
109
26
5
14
130
.10
.27
.13
-.19*
.16†
-.15†
Step 1
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
Step 2
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
Trait Anger
19
109
26
5
14
130
122
19
109
26
5
14
130
122
130
.15
.001
.19
.036*
.56
.375***
.13
.28
.11
-.20*
.15†
-.17†
.00
-.20*
Step 4
African American
19
Caucasian
109
Family Member: Father
26
Disease: Diabetes
5
Location of Death: Hospital
14
Months Post-loss
130
Trait Anger
122
Total Anger Scale
130
Belief in Afterlife
129
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
R2 Change
--
.09
.26
.12
-.19*
.16†
-.14
-.04
Step 3
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
Trait Anger
Total Anger Scale
R2
.15**
.25
.41*
.08
-.05
.13†
-.16*
.01
-.15*
.64***
115
Table 17
Prediction of Belief that Family Member Continues to Exist by Relationship Conflict Anger
n
β
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
19
109
26
5
14
130
.08
.27
.13
-.19*
.16†
-.15†
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
Trait Anger
19
109
26
5
14
130
122
.09
.26
.12
-.19*
.16†
-.14
-.04
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
Trait Anger
Relationship Conflict Anger
19
109
26
5
14
130
122
.14
.29
.11
-.20*
.14
-.16†
-.01
-.22*
African American
Caucasian
Family Member: Father
Disease: Diabetes
Location of Death: Hospital
Months Post-loss
Trait Anger
Relationship Conflict Anger
Belief in an Afterlife
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
19
109
26
5
14
130
122
130
129
.24
.42*
.09
-..05
.12†
-.15*
-.002
-.12†
.63***
Step 1
Step 2
Step 3
Step 4
R2
.15**
R2 Change
--
.15
.001
.20
.046*
.56
.358***
116
Table 18
Prediction of Distress by Total Anger Scale
n
β
Female
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Romantic Partner
Family Member: Father
Primary Caregiver
Type of Hospice Care: Homecare
Type of Hospice Care: Nursing
Home
Disease: Cancer
Disease: Dementia
Location of Death: Home
Location of Death: Nursing Home
Age at Death
100
123
38
62
31
5
26
104
58
51
.15†
-.25*
.04
.03
.05
.13
-.07
.08
.04
.16
61
32
44
41
129
.03
.02
.20
-.31*
-.15
Female
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Romantic Partner
Family Member: Father
Primary Caregiver
Type of Hospice Care: Homecare
Type of Hospice Care: Nursing
Home
Disease: Cancer
Disease: Dementia
Location of Death: Home
Location of Death: Nursing Home
Age at Death
Trait Anger
100
123
38
62
31
5
26
104
58
51
.18*
-.18†
.06
.02
.12
.11
-.04
.11
-.09
.10
61
32
44
41
129
122
.07
.03
.16
-.28*
-.13
.27**
Step 1
Step 2
Table continues on next page
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
R2
.37***
R2 Change
--
.43
.06**
117
Table 18 Continued
n
β
100
123
38
62
31
5
26
104
58
51
.17*
-.18†
.09
.03
.11
.07
-.04
.10
-.08
.08
61
32
44
41
129
122
130
.05
.03
.17
-.26*
-.12
.25**
.15*
Step 3
Female
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Romantic Partner
Family Member: Father
Primary Caregiver
Type of Hospice Care: Homecare
Type of Hospice Care: Nursing
Home
Disease: Cancer
Disease: Dementia
Location of Death: Home
Location of Death: Nursing Home
Age at Death
Trait Anger
Total Anger Scale
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
R2
.44
R2 Change
.02†
118
Table 19
Prediction of Distress by Death-Separation Anger
n
β
100
123
38
62
31
5
26
104
58
51
.15†
-.25*
.04
.03
.05
.13
-.07
.08
.04
.16
61
32
44
41
129
.03
.02
.20
-.31*
-.15
100
123
38
62
31
5
26
104
58
51
.18*
-.18†
.06
.02
.12
.11
-.04
.11
-.09
.10
61
32
44
41
129
122
.07
.03
.16
-.28*
-.13
.27**
Step 1
Female
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Romantic Partner
Family Member: Father
Primary Caregiver
Type of Hospice Care: Homecare
Type of Hospice Care: Nursing
Home
Disease: Cancer
Disease: Dementia
Location of Death: Home
Location of Death: Nursing Home
Age at Death
Step 2
Female
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Romantic Partner
Family Member: Father
Primary Caregiver
Type of Hospice Care: Homecare
Type of Hospice Care: Nursing
Home
Disease: Cancer
Disease: Dementia
Location of Death: Home
Location of Death: Nursing Home
Age at Death
Trait Anger
Table continues on next page.
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
R2
.37***
R2 Change
--
.43
.06**
119
Table 19 Continued
n
β
100
123
38
62
31
5
26
104
58
51
.13†
-.09
.11
-.03
.02
.01
-.07
.05
-.03
.11
61
32
44
41
129
122
130
.04
.01
.17
-.20†
-.11
.18*
.40***
Step 3
Female
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Romantic Partner
Family Member: Father
Primary Caregiver
Type of Hospice Care: Homecare
Type of Hospice Care: Nursing
Home
Disease: Cancer
Disease: Dementia
Location of Death: Home
Location of Death: Nursing Home
Age at Death
Trait Anger
Death Separation Anger
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
R2
.54
R2 Change
.11***
120
Table 20
Prediction of Posttraumatic Growth by Total Anger Scale
n
β
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Father
Disease: Cancer
Disease: Stroke
Location of Death: Nursing Home
Location of Death: Hospital
Age at Death
123
38
62
31
26
61
5
41
14
129
-.20†
.00
-.06
.02
-.07
.07
-.11
-.05
.17†
-.05
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Father
Disease: Cancer
Disease: Stroke
Location of Death: Nursing Home
Location of Death: Hospital
Age at Death
Total Trait Anger
123
38
62
31
26
61
5
41
14
129
122
-.15
.01
-.07
.08
-.05
.08
-.11
-.03
.19†
-.05
.21*
Step 1
Step 2
Step 3
Income
123
Marital Status: Widowed
38
Marital Status: Married
62
Family Member: Spouse
31
Family Member: Father
26
Disease: Cancer
61
Disease: Stroke
5
Location of Death: Nursing Home 41
Location of Death: Hospital
14
Age at Death
129
Total Trait Anger
122
Total Anger Scale
130
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
-.14
.02
-.06
.08
-.04
.08
-.12
.02
.20*
-.04
.19*
.10
R2
.18*
R2 Change
--
.21
.04*
.22
.01
121
Table 21
Prediction of Posttraumatic Growth by Death Separation Anger
n
β
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Father
Disease: Cancer
Disease: Stroke
Location of Death: Nursing Home
Location of Death: Hospital
Age at Death
123
38
62
31
26
61
5
41
14
129
-.20†
.00
-.06
.02
-.07
.07
-.11
-.05
.17†
-.05
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Father
Disease: Cancer
Disease: Stroke
Location of Death: Nursing Home
Location of Death: Hospital
Age at Death
Total Trait Anger
123
38
62
31
26
61
5
41
14
129
122
-.15
.01
-.07
.08
-.05
.08
-.11
-.03
.19†
-.05
.21*
Step 1
Step 2
Step 3
Income
Marital Status: Widowed
Marital Status: Married
Family Member: Spouse
Family Member: Father
Disease: Cancer
Disease: Stroke
Location of Death: Nursing Home
Location of Death: Hospital
Age at Death
Total Trait Anger
Death Separation Anger
123
38
62
31
26
61
5
41
14
129
122
130
Table continues on next page.
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
-.09
.02
-.09
.06
-.05
.09
-.12
.00
.19*
-.04
.18†
.17†
R2
.18*
R2 Change
--
.21
.04*
.24
.02†
122
Table 21 Continued
n
β
Step 4
Income
123
Marital Status: Widowed
38
Marital Status: Married
62
Family Member: Spouse
31
Family Member: Father
26
Disease: Cancer
61
Disease: Stroke
5
Location of Death: Nursing
41
Home
Location of Death: Hospital
14
Age at Death
129
Total Trait Anger
122
Death Separation Anger
130
Distress
130
*** p ≤ .001, ** p ≤ .01, * p ≤ .05, † p ≤ .10
-.07
-.01
-.08
.05
-.02
.07
-.15
.06
.09*
-.02
.12
.05
.29*
R2
.28
R2 Change
.04*
123
Existence of a
Continuing
Relationship
Perceived
Quality of
Relationship
Continuing Relationship
+
-
Anger toward Deceased
Adjustment
Distress
Posttraumatic
Growth
123
Figure 1. Conceptual model representing hypothesized relationships between residual feelings of anger toward the deceased family
member, adjustment, and the continued relationship with the family member.
124
Ongoing Feelings of Anger
toward Deceased
Grief and Adjustment
Outcomes: 1) Distress,
2) Posttraumatic Growth
c
Continued Relationship
with Deceased:
1) Existence, 2) Quality
b
a
Ongoing Feelings of Anger
toward Deceased
c’
Grief and Adjustment
Outcomes: 1) Distress,
2) Posttraumatic Growth
Figure 2. Mediation Model and Associated Hypotheses
Path a. Endorsement of ongoing feelings of anger toward the deceased will be associated with fewer
reports of a continued relationship with the deceased and more negatively experienced continued
relationships with the deceased.
Path b. The lack of a continued relationship or the presence of a negatively experienced continued
relationship will be associated with poorer adjustment outcomes (higher levels of distress and lower levels
of posttraumatic growth) while controlling for ongoing feelings of anger. Note. This pathway is dashed
to indicate that this association was not established.
Path c (direct effect). Endorsement of ongoing feelings of anger toward the deceased will be associated
adjustment outcomes (higher levels of distress and lower levels of posttraumatic growth).
Path c‘(indirect effect through mediation). The effect of ongoing anger on adjustment outcomes after
controlling for the mediator of continuing relationships: The link between feelings of ongoing anger and
poorer adjustment outcomes will be partially mediated by the existence and quality of continued
relationships with the deceased.
125
Qualitative
Initial Draft of
Instrument
(Anger Scale)
based on
literature review
Qualitative
Data
Collection
Qualitative
Data
Analysis
Refine
Instrument
Refine
Instrument
(Anger Scale)
Quantitative
Quantitative
Data
Collection
Quantitative
Data
Analysis
Interpretation of
the Entire
Analysis
Figure 3. Sequential Exploratory Design - Instrument Development Variant (figure adapted from Creswall & Plano Clark, 2011, p.
134).
125
126
Appendix A
Initial Draft of the New Anger Scale
Not
at all
Slightly
Annoyed
0
1
2
3
4
5
For something hurtful he/she said to
you?
0
1
2
3
4
5
For neglecting to do or say something
that was important to you?
0
1
2
3
4
5
For behaving selfishly or
inconsiderately toward you?
0
1
2
3
4
5
For betraying you?
0
1
2
3
4
5
For not taking better care of his/her
health?
0
1
2
3
4
5
For not cooperating with your
attempts to care for him/her while ill?
0
1
2
3
4
5
For the disruption his/her illness
created in your life?
0
1
2
3
4
5
For disagreements with him/her about
his/her care?
0
1
2
3
4
5
For treating you poorly during his/her
illness (for example being critical,
demanding or aggressive)?
0
1
2
3
4
5
For leaving you by dying?
0
1
2
3
4
5
For your current emotional pain due
to the loss?
0
1
2
3
4
5
For negative changes in your life
since the loss (example: financial,
social)?
0
1
2
3
4
5
For your current loneliness?
0
1
2
3
4
5
For no longer being here to support
you?
0
1
2
3
4
5
Do you currently have any negative
emotions at your deceased family
member….
For violations of trust that occurred in
your relationship?
Annoyed Angry
Very Furious
Angry
127
Appendix B
Qualitative Interview Script
I‘m going to now ask you a series of questions about your relationship with _______ and the
feelings associated with your relationship. First I‘ll focus on the time of _____‘s illness.
What was your experience during ______‘s illness?
What, if any, was the nature of your participation in _______‘s care during the illness?
Can you describe your relationship with _________ during the illness.
What, if anything, do you feel good about regarding your interaction with _____ during his/her
illness? Annoyed about? Frustrated about? Angry about? Guilty about? Do you have any
regrets about how things went?
What were the hardest parts for you in __________‘s illness?
Do you have any unfinished business or unresolved conflicts about anything that happened or
didn‘t happen during ____________‘s illness? If so, please explain.
(if describe past problem – do you feel that it got resolved?)
How have you been feeling about the loss? How has coping with the loss been for you?
128
How has your life changed since the ______‘s death? (ask for the emotions that accompany the
changes)
(if not addressed in previous question): Although the death of a family member can be a very
difficult, some people also report feeling a sense of personal growth following the experience of
loss. Have you experienced any positive personal changes due to the loss?
How would you describe ________‘s role, if any, in your life at this time? In other words, do
you have an ongoing sense of connection to ________ or does ______ play an active part in your
ongoing life?
How do you relate to ______ at this time, if you do?
**ask belief in afterlife if not addressed by participant:
Do you think ______ continues to exist in some way? How so?
People often feel like they can still talk or communicate with their lost family member or that
their family member still communicates with them.
Do you talk to ______?
Do you communicate in any way to _______? If so, how?
Do you ever sense that ______ is still trying to communicate with you?
What is it like for you to have this type of relationship or sense of connection with _____?
Did you view it as positive (as comforting or something that made you feel good) or was it more
negative (something frightening that you would not want to have happen again)?
129
Now I‘d like to step back to look at the bigger picture of your relationship with ________.
Can you describe your relationship with ______ before the illness? How did you get along?
Every relationship has its ups and downs and here we are especially interested in exploring the
tougher times or the unresolved issues that you may have had with ________.
What sorts of
conflicts did you have in your relationship with _____, if any?
(were these problems resolved? How do they impact your feelings about _______ today?)
What emotions do you feel toward _____________ when you think about him/her today?
On the phone you mentioned having feelings of anger, frustration or annoyance toward _______.
Can you please tell me more about these feelings?
Do you have any unfinished business with _________? Is there anything you lack closure on?
Is there anything you wanted to say or do that would have made you more comfortable ending
the relationship?
Are there any important aspects of your relationship or story surrounding the loss and your
attempts to cope with it that I didn‘t ask you about and that you would like to share with me?
130
Appendix C
Questionnaire Items
DEMOGRAPHIC AND BACKGROUND QUESTIONS:
Please fill in the following blanks:
What is your gender? ____ Male ____ Female
What is your age? ____
What is your ethnic background? Please check all that apply. ___ African-American or Black
___ Latino or Hispanic
___ Asian or Pacific Islander
___ Middle Eastern ___ Native American
___ White or Caucasian ___ Other
Which best describes your marital status? ___Single ___Married ___Widowed
___Divorced or separated ____ Living with a romantic partner ____Other (please describe:) ________________
What is your annual household income? ___under $15,000 ___$15,000-$24,999 ___$25,000-$49,999
__$50,000-$74,999 ___$75,000-$99,999 ___$100,000-$149,999 ___$150,000-$199,999 ___$200,000 and up
You are receiving this questionnaire because you had a family member in hospice care.
Please check a response below to complete this statement: ―The person in hospice care was my __________.‖
___ husband ___ wife ___ mother ___ father ___ romantic partner ___ brother ___ sister
___ daughter ___ son ___ friend
___ other (If other, please list here: ________________)
To the best of your knowledge, how long was your family member ill? ____________________
How long was your family member in hospice care? ___________________________________
What type of hospice care did your family member receive? ___ home care ___ nursing home
___ Hospice house ____ in hospital
Were you the primary caregiver for your family member? ___ yes
___ no
What type of illness did your family member have? __cancer __heart disease __lung disease __HIV/AIDS
__kidney disease __dementia/Alzheimer‘s disease __other (If other, what type? ______________________)
Where did your family member die? ___________________________________________________________
Below, please circle a number from 0 (not at all) to 5 (totally): Did your family member‘s death seem sudden or
unexpected?
Not at all
Totally
0
1
2
3
4
5
How long ago did your family member die? ________________________________________
What was the approximate age of your family member at the time of his or her death?_______
Are you currently a participant in a bereavement support group? ___ yes
___ no
131
RELATIONSHIP QUALITY QUESTIONS:
Your Relationship with Your Family Member who Died. Looking back over your entire
relationship, would you describe your relationship with this family member as…
Not at all
Extremely
Not at all
Extremely
close
0 1 2 3 4 5
loving
0 1 2 3 4 5
unhappy
0 1 2 3 4 5
difficult
0 1 2 3 4 5
distant
0 1 2 3 4 5
STATE-TRAIT ANGER SCALE (STAS):
Please rate how you generally feel:
Almost Never Sometimes Often Almost Always
I have a fiery temper …………………………………………………
I am quick tempered …………………………………………………
I am a hotheaded person ……………………………………………..
It makes me furious when I am criticized in front of others …………
I get angry when I‘m slowed down by others‘ mistakes …………….
I feel infuriated when I do a good job & get a poor evaluation ……..
I fly off the handle …………………………………………………...
I feel annoyed when I am not given recognition for doing good work
When I get mad, I say nasty things …………………………………..
When I get frustrated, I feel like hitting someone …………………...
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
INVENTORY OF COMPLICATED GRIEF – SCREEN (ICGS):
Below, please circle a number between 0-5 to indicate how often you have felt in each of these ways during
the past month. In the questions below, “deceased” refers to your family member who died.
Never
Always
In the past month:
I think about the deceased so much that it can be hard for me to do the
things I normally do ………….…………………………………………
0
1
2
3
4
5
I feel myself longing and yearning for the deceased …..………………….
0
1
2
3
4
5
I feel disbelief over the deceased‘s death …………………………………..
0
1
2
3
4
5
Ever since the deceased died, I feel like I have lost the ability to care about
other people or I feel distant from people I care about …………………….
0
1
2
3
4
5
I am bitter about the deceased‘s death ……………………………………..
0
1
2
3
4
5
I feel lonely ever since the deceased died ………………………………….
0
1
2
3
4
5
It‘s hard for me to imagine life being fulfilled without the deceased ……..
0
1
2
3
4
5
I feel part of myself died along with the deceased …………………………
0
1
2
3
4
5
I have lost my sense of security or safety since the death of the deceased ...
0
1
2
3
4
5
132
POSTTRAUMATIC GROWTH INVENTORY (PTGI-S):
Below, please circle a number between 0-5 to indicate the degree to which this change occurred in your life
Not
Small Moderate
Very great
as a result of your loss.
Changes experienced as a result of my loss:
experienced degree
degree
degree
My priorities about what is important in life……………………
0
1
2
3
4
5
Trying to change things that need changing…………………...
0
1
2
3
4
5
A feeling of self-reliance………………………........................
0
1
2
3
4
5
A better understanding of spiritual matters……………………...
0
1
2
3
4
5
Knowing that I can count on people in times of trouble.............
0
1
2
3
4
5
A willingness to express my emotions………………………..
0
1
2
3
4
5
Being able to accept the way things work out…………………..
0
1
2
3
4
5
Having compassion for others ………………………………….
0
1
2
3
4
5
Seeing new opportunities that would not have been available otherwise
0
1
2
3
4
5
Putting more effort into my relationships ………………………
0
1
2
3
4
5
Developing a stronger religious faith …………………………..
0
1
2
3
4
5
Developing new interests ……………………………………….
0
1
2
3
4
5
Accepting needing others ……………………………………….
0
1
2
3
4
5
CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE 10
(CESD-10):
Below, please circle a number between 0-3 to indicate how often you have felt in each of these ways during
Rarely or none Some or a little Occasionally or a Most or all
the past week.
of the time (less of the time
moderate amount of the time
than 1 day)
(1-2 days)
of time (3-4 days) (5-7 days)
In the past week…………..
You were bothered by things that usually don‘t bother you
0
1
2
3
You had trouble keeping your mind on what you were doing 0
1
2
3
You felt depressed ……………………………………….
0
1
2
3
You felt that everything you did was an effort …………….
0
1
2
3
You felt hopeful about the future ………………………..
0
1
2
3
You felt fearful …………………………………………..
0
1
2
3
Your sleep was restless …………………………………..
0
1
2
3
You were happy ………………………………………….
0
1
2
3
You felt lonely …………………………………………...
0
1
2
3
You could not get ―going‖ ……………………………….
0
1
2
3
UNRESOLVED ISSUES IN RELATIONSHIP:
Below, please circle a number from 0 (not at all) to 5 (totally): Do you currently feel that there are unresolved
issues in your relationship with family member who died?
Not at all
0
Totally
1
2
3
4
5
If so, please describe: _________________________________________________________________________
133
PAST OFFENSES OF FAMILY MEMBER:
People in close relationships often do things that hurt each other. Sometimes these things are accidents, and
sometimes they are done on purpose. They can range from small misunderstandings to major fights.
Can you think of things your family member did (or failed to do) that caused No, none
Yes, many
some problems or hurt feelings between you and your family member?
0 1 2 3 4 5
ANGER SCALE:
In the questions below please circle a number from 0 (not at all) to 5 (furious):
Not Slightly
Annoyed
Do you currently have any negative emotions at
at all Annoyed
your deceased family member….
For violations of trust that occurred?
0
1
2
Angry
3
Very
Angry
4
Furious
For something hurtful he/she did or said to you?
0
1
2
3
4
5
For neglecting to do or say something that was
important to you?
0
1
2
3
4
5
For acting in an insensitive or inconsiderate way?
0
1
2
3
4
5
For hurting or failing to help someone else that you
care about?
0
1
2
3
4
5
For not taking better care of his/her health?
0
1
2
3
4
5
For disagreements about care or not cooperating with
attempts to care for him/her while ill?
0
1
2
3
4
5
For the stress his/her illness created in your life?
0
1
2
3
4
5
For failing to appreciate attempts that were made to
care for him/her?
0
1
2
3
4
5
For treating you poorly during his/her illness (for
example, being critical, demanding or aggressive)?
0
1
2
3
4
5
For leaving you (by dying)?
0
1
2
3
4
5
For your current emotional pain or loneliness?
0
1
2
3
4
5
For problems in your life since the loss or due to the
loss (problems in finances, relationships, etc.)?
0
1
2
3
4
5
For not having legal affairs in order (issues with the
will, insurance, belongings/assets)?
0
1
2
3
4
5
For no longer being here to support you?
0
1
2
3
4
5
5
For giving up?
134
ANGER AT OTHER ENTITIES:
Below, please circle a number from 0 (not at all) to 5 (totally). Please complete all three columns.
How much do you
currently have negative
feelings (e.g., annoyance,
frustration, anger)
toward…
Yourself
Other Family Members
Doctors/Medical
Professionals
Hospice
God/Higher Power
No one/Nothing
For problems in your
relationship with your
family member…
For problems related to
your family member’s
illness…
For the death of your
family member….
Not at all
0 1 2
0 1 2
0 1 2
3
3
3
Totally
4 5
4 5
4 5
Not at all
0 1 2
0 1 2
0 1 2
3
3
3
Totally
4 5
4 5
4 5
Not at all
0 1 2
0 1 2
0 1 2
3
3
3
Totally
4 5
4 5
4 5
0
0
0
3
3
3
4 5
4 5
4 5
0
0
0
3
3
3
4 5
4 5
4 5
0
0
0
3
3
3
4 5
4 5
4 5
1
1
1
2
2
2
1
1
1
2
2
2
1
1
1
2
2
2
CONTINUED RELATIONSHIP- CONTINUED EXISTENCE QUESTIONS:
Now please think specifically of your family member who recently passed away: Below, please circle a
number between 0-5 to indicate how much you agree with each of the following statements.
Strongly
Strongly
Disagree
Agree
Do you believe that your family member continues to exist
0
1
2
3
4
5
(or live on) in some form?
-- If so, do you believe that your family member‘s
0
1
2
3
4
5
current existence is positive (for example, he/she is happy,
at peace or in a good place)?
-- If so, do you believe that your family member‘s
0
1
2
3
4
5
current existence is negative (for example, he/she is
unhappy, not at peace, or in a bad place)?
When you envision your family member‘s current existence, what do you see? _____________________________
_____________________________________________________________________________________________
CONTINUED RELATIONSHIP - COMMUNICATION QUESTIONS:
Strongly
Strongly
Disagree
Agree
I believe that it is possible for me to communicate with my
0
1
2
3
4
5
family member.
I believe that it is possible for my family member to
0
1
2
3
4
5
communicate with me.
I believe that there has already been some communication
0
1
2
3
4
5
between my family member and myself.
-- If so, the experience of communicating with my
0
1
2
3
4
5
family member has been positive.
-- If so, the experience of communicating with my
0
1
2
3
4
5
family member has been negative.
Please describe your experience of communication with your family member: ______________________________
_____________________________________________________________________________________________
135
BELIEF IN AN AFTERLIFE:
Please rate your agreement with the following statements.
Strongly
disagree
When people die, there is an afterlife (e.g., Heaven, Hell, reincarnation)……………….
0
Strongly
agree
1
2
3
4
136
References
Al-Mabuk, R.H., Enright, R.D., & Cardis, P.A. (1995). Forgiveness education with parentally
love-deprived late adolescents. Journal of Moral Education, 24, 427-444.
Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older
adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies
Depression Scale). American Journal of Preventative Medicine, 10, 1994, pp.77-84.
Anger. (n.d.). In Merriam-Webster‟s online dictionary. Retrieved from http://www.merriamwebster.com/dictionary/anger
Attig, T. (1996). How we grieve: Relearning the world. New York: Oxford University Press.
Baker, M. (2005). Facilitating forgiveness and peaceful closure: The therapeutic value of
psychosocial intervention in end-of-life care. Journal of Social Work in End-of-Life &
Palliative Care, 1(4), 83-96.
Barki, H., & Hartwick, J. (1993). Conceptualizing the construct of interpersonal conflict.
International Journal of Conflict Management, 15(3), 216-244.
Benore, E.R., & Park, C.L. (2004). Death-specific religious beliefs and bereavement: Belief in
an afterlife and continued attachment. The International Journal for the Psychology of
Religion, 14, 1-22.
Berry, J.W., & Worthington, E.L. (2001). Forgiveness, relationship quality, stress while
imagining relationship events, and physical and mental health. Journal of Counseling
Psychology, 48, 447-455.
Berkowitz, L. (1989). Frustration-aggression hypothesis: Examination and reformulation.
Psychological Bulletin, 106 (1), 59-73.
137
Boelen, P.A., Stroebe, M.S., Schut, H.A.W., & Zijerveld, A.M. (2006). Continuing bonds and
grief: A prospective analysis. Death Studies, 30, 767-776.
Bonanno, G.A., & Keltner, D. (1997). Facial expressions of emotion and the course of conjugal
bereavement. Journal of Abnormal Psychology, 106 (1), 126-137.
Bonanno, G.A., Mihalecz, M.C., & LeJeune, J.T. (1999). The core emotion themes of conjugal
loss. Motivation and Emotion, 23(3), 175-201.
Bowlby, J. (1973). Separation: Anxiety and anger. Basic Books.
Bowlby, J. (1980). Loss: Sadness and depression. Basic Books.
Brody, E.M. (1985). Parent care as normative family stress. The Gerontologist, 25(1), 19-29.
Byock, I.R. (1996). The nature of suffering and the nature of opportunity at the end of life.
Clinics in Geriatric Medicine, 12, 237-252.
Cameron, J., & Parkes, C.M. (1983). Terminal care: Evaluation of effects on surviving family
of care before and after bereavement. Postgraduate Medical Journal, 59, 73-78.
Calhoun, L.G., & Tedeschi, R.G. (1999). Facilitating posttraumatic growth: A clinician‟s
guide. Matwah, NJ: Lawrence Erlbaum Associates.
Carr, D., House, J.S., Kessler, R.C., Nesse, R.M., Sonnega, J., & Wortman, C. (2000). Marital
quality and psychological adjustment to widowhood among older adults: A longitudinal
analysis. Journals of Gerontology: Social Sciences, 56B, S237-S248.
Cerney, M.S., & Buskirk, J.R. (1991). Anger: The hidden part of grief. Bulletin of the
Menninger Clinic, 55(2), 228-237.
Chentsova-Dutton, Y., Shuchter, S., Hutchin, S., Strause, L., Burns, K., & Zisook, S. (2000).
The psychological and physical health of hospice caregivers. Annals of Clinical
Psychiatry, 12, 19-27.
138
Chentsova-Dutton, Y., Shuchter, S., Hutchin, S., Strause, L., Burns, K., Dunn, L., Miller, M., &
Zisook, S. (2002). Depression and grief reactions in hospice caregivers: From pre-death
to 1 year afterwards. Journal of Affective Disorders, 69, 53-60.
Cohen, C.A., Colantonio, A., & Vernich, I. (2002). Positive aspects of caregiving: Rounding
out the caregiver experience. International Journal of Geriatric Psychiatry, 17, 184-188.
Conant, R.D. (1996). Memories of the death and life of a spouse: The role of images and sense
of presence in grief. In D. Klass, P.R. Silverman, S.L. Nickman (Eds.), Continuing
bonds: New understandings of grief (pp. 179-196). Washington, DC: Taylor & Francis.
Coyle, C.T., & Enright, R.D. (1997). Forgiveness intervention with postabortion men. Journal
of Consulting and Clinical Psychology, 65(6),1042-1046.
Creswell, J.W. (1998). Qualitative inquiry and research design: Choosing among five
traditions. Thousand Oaks: Sage Publications.
Creswell, J.W. (1999). Mixed-method research: Introduction and application. In G.J. Cizek
(Ed.), Handbook of educational policy (pp. 455-472). San Diego: Academic Press.
Creswell, J.W. (2003). Research design: Qualitative, quantitative, and mixed methods
approaches. Thousand Oaks: Sage Publications.
Creswell, J.W., & Plano Clark, V.L. (2011). Designing and conducting mixed methods research.
Los Angeles: Sage Publications.
Curran, P.J., West, S.G., & Finch, J.F. (1996), The robustness of test statistics to nonnormality
and specification error in confirmatory factor analysis. Psychological Methods, 1(1), 1629.
Davis, C.G., & Nolen-Hoeksema, S. (2001). Loss and meaning: How do people make sense of
loss? The American Behavioral Scientist, 44(5), 726-741.
139
Davis, C.G., Nolen-Hoeksema, S., & Larson, S. (1998). Making sense of loss and benefiting
from the experience: Two construals of meaning. Journal of Personality and Social
Psychology, 75(2), 561-574.
de Vugt, M.E., Stevens, F., Aalten, P., Lousberg, R., Jaspers, N., Winkens, I., Jolles, J., &
Verhey, F.R.J. (2003). Behavioural disturbances in dementia patients and quality of the
marital relationship. International Journal of Geriatric Psychiatry, 18, 149-154.
Exline, J. J., Baumeister, R. F., Zell, A. L., Kraft, A., & Witvliet, C. V. O. (2008). Not so
innocent: Does seeing one‘s own capability for wrongdoing predict forgiveness? Journal
of Personality and Social Psychology. 94: 495-515,
Exline, J. J., Park, C. L., Smyth, J. M., & Carey, M. P. (2011). Anger toward God: Socialcognitive predictors, prevalence, and links with adjustment to bereavement and cancer.
Journal of Personality and Social Psychology, 100, 129-148.
Exline, J.J., Prince-Paul, M., Root, B.L., & Peereboom, K. (2010). Communication between
family members of hospice patients. [Unpublished raw data, Case Western Reserve
University]
Deimling, G. & Bass, D. (1986). Mental status among the aged: Effects on spouse and adultchild caregivers. Journal of Gerontology, 41. 778-784.
Field, N.P., Bonanno, G.A., Williams, P., & Horowitz, M.J. (2000). Appraisals of blame in
adjustment in conjugal bereavement. Cognitive Therapy and Research, 24(5), 551-569.
Field, N.P., & Filanosky, C. (2010). Continuing bonds, risk factors for complicated grief, and
adjustment to bereavement. Death Studies, 34(1), 1-29.
Field, N.P., & Friedrichs, M. (2004). Continuing bonds in coping with the death of a husband.
Death Studies, 28, 597-620.
140
Field, N.P., Gal-Oz, E., & Bonanno, G.A. (2003). Continuing bonds and adjustment at 5 years
after the death of a spouse. Journal of Consulting and Clinical Psychology, 71, 110-117.
Field, N.P., Nichols, C., Holen, A., & Horowitz, M.J. (1999). The relation of continuing
attachment to adjustment in conjugal bereavement. Journal of Consulting and Clinical
Psychology, 67, 212-218.
Fincham, F. D., Paleari, F. G., & Regalia, C. (2002). Forgiveness in marriage: The role of
relationship quality, attributions and empathy. Personal Relationships, 9, 27-37.
Freedman, S.R., & Enright, R.D. (1996). Forgiveness as an intervention goal with incest
survivors. Journal of Consulting and Clinical Psychology, 64(5), 983-992.
Freud, S. (1957). Mourning and melancholia. In J. Stachey (Ed.), The standard edition of
complete psychological works of Sigmund Freud (Vol. 14, (pp. 152-170). London:
Hogarth Press. (Original work published in 1917).
Fridja, N.H. (1988). The laws of emotion. American Psychologist, 43, 349-358.
Gallo, L.C., & Matthews, K.A. (2003). Understanding the association between socioeconomic
status and physical health: do negative emotions play a role? Psychological Bulletin,
129, 10-51.
Gamino, L.A., & Sewell, K.W. (2004). Meaning constructs as predictors of bereavement
adjustment: A report from the Scott &White grief study. Death Studies, 28(5), 397-421.
Glick, I.O., Weiss, R.S., & Parkes, C.M. (1974). The first year of bereavement. New York:
John Wiley & Sons.
Gold, M. (1984). When someone dies in a hospital. Aging, 345, 18-22.
Hargrave, T.D., & Sells, J.N. (1997). The development of a forgiveness scale. Journal of
Marital and Family Therapy, 23(1), 41-62.
141
Hebl, J.H., & Enright, R.D. (1993). Forgiveness as a psychotherapeutic goal with elderly
females. Psychotherapy, 30, 658-667.
Hogan, N.S., Greenfield, D.B., & Schmidt, L.A. (2001). Development and validation of the
Hogan Grief Reaction Checklist. Death Studies, 25, 1-32.
Horowitz, M.J., Bonanno, G.A., & Holen, A. (1993). Pathological grief: diagnosis and
explanation. Psychosomatic Medicine, 55(3), 260-273.
Hussein, H., & Oyebode, J.R. (2009). Influences of religion and culture on continuing bonds in a
sample of British Muslims of Pakistani origin. Death Studies, 33, 900-912.
Institute of Medicine. (2008). Cancer care for the whole patient: Meeting psychosocial health
needs. Washington, DC: National Academies Press.
Janoff-Bulman, R. (1993). Shattered assumptions: Towards a new psychology of trauma. New
York: Free Press.
Joseph, S., Linley, P. A., & Harris, G. (2005). Understanding positive change following trauma
and adversity: Structural clarification. Journal of Loss and Trauma, 10, 83–96.
Karremans, J.C., Van Lange, P.A.M., & Holland, R.W. (2005). Forgiveness and its associations
with prosocial thinking, feeling, and doing beyond the relationship with the offender.
Personality and Social Psychology Bulletin, 31(10), 1315-1326.
Keeley, M.P. (2004). Final conversations: Messages of love. Qualitative Research Reports in
Communication, 5, 48-57.
Keeley, M.P. (2007). ‗Turning towards death together‘: The functions of messages during final
conversations in close relationships. Journal of Social and Personal Relationships, 24,
225-253.
142
Keeley, M.P., & Koenig Kellas, J. (2005). Constructing life and death through final
conversation narrative. In L.M. Harter, P.M. Japp, & C.S. Beck (Eds.) Narratives,
health, and healing: Communication theory, research, and practice (pp. 365-390).
Mahwah, NJ: Lawrence Erlbaum Associates.
Klass, D. (1993). Solace and immortality: Bereaved parents‘ continuing bond with their
children. Death Studies, 17, 343-368.
Klass, D., Silverman, P.R., & Nickman, S.L. (1996). Continuing bonds: New understandings of
grief. Washington, DC: Taylor & Francis.
Kramer, B.J., Boelk, A., & Auer, C. (2006). Family conflict at the end-of-life: Lessons learned
in a model program for vulnerable older adults. Journal of Palliative Care Medicine, 9,
791-801.
Kramer, B.J., Kavanaugh, M., Trentham-Dietz, A., Walsh, M., & Yonker, J.A. (2010).
Predictors of family conflict at the end of life: The experiences of spouses and adult
children of persons with lung cancer. The Gerontologist, 50(2), 215-225.
Lamb, S., & Murphy, J. G. (Eds.). (2002). Before forgiving: Cautionary views of forgiveness in
psychotherapy. New York: Oxford University Press.
Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University Press.
Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills: Sage Publications.
Lindemann, E. (1944). The symptomatology and management of acute grief. American Journal
of Psychiatry, 101, 141-148.
Maciejewski, P.K., Zhang, B., Block, S.D., & Prigerson, H.G. (2007). An empirical testing of
the stage theory of grief resolution. Journal of the American Medical Association, 297,
716-723.
143
Marwit, S.J., & Klass, D. (1996). Grief and the role of inner representation of the deceased. In
D. Klass, P.R. Silverman, S.L. Nickman (Eds.), Continuing bonds: New understandings
of grief (pp. 297-308). Washington, DC: Taylor & Francis.
McCullough, M.E., Bellah, C.G., Kilpatrick, S.D., & Johnson, J.L. (2001). Vengefulness:
Relationships with forgiveness, rumination, well-being, and the Big Five. Personality
and Social Psychology Bulletin, 27(5), 601-610.
McCullough, M.E., Bono, G., & Root, L.M. (2007). Rumination, emotion, and forgiveness:
Three longitudinal studies. Journal of Personality and Social Psychology, 92(3), 490505.
McCullough, M.E., & Hoyt, W.T. (2002). Transgression-related motivational dispositions:
Personality substrates of forgiveness and their links to the Big Five. Personality and
Social Psychology Bulletin, 28, 1556-1573.
McCullough, M.E., Rachal, K.C., Sandage, S.J., Worthington, E.L., Brown, S.W., & Hight, T.L.
(1998). Interpersonal forgiving in close relationships, II: Theoretical elaboration and
measurement. Journal of Personality and Social Psychology, 75, 1586-1603.
McCullough, M.E., Worthington, E.L., & Rachal, K.C. (1997). Interpersonal forgiving in close
relationships. Journal of Personality and Social Psychology, 73, 321-336.
McQuellon, R.P., & Cowan, M.A. (2000). Turning toward death together: Conversation in
mortal time. American Journal of Hospice & Palliative Care, 17 (5), 312-318.
Moustaka, C. (1994). Phenomenological research methods. Thousand Oaks: Sage
Publications.
144
Nolen-Hoeksema, S., & Davis, C.G. (2004). Theoretical and methodological issues in the
assessment and interpretation of posttraumatic growth. Psychological Inquiry, 15(1), 6064.
Normand, C.L., Nickman, S.L., & Silverman, P.R. (1996). Bereaved children‘s changing
relationships with the deceased. In D. Klass, P.R. Silverman, S.L. Nickman (Eds.),
Continuing bonds: New understandings of grief (pp. 87-111). Washington, DC: Taylor &
Francis.
Nowatzi, N.R., & Grant Kalischuk, R. (2009). Post-death encounters: Grieving, mourning, and
healing. Omega: Journal of Death and Dying, 59(2), 91-111.
Pallant, J. (2007). SPSS Survival Manual (3rd ed.). Berkshire: McGraw Hill.
Park, C.L., & Benore, E.R. (2004). ―You‘re still there‖: Beliefs in continued relationships with
the deceased as unique religious beliefs that may influence coping adjustment. The
International Journal for the Psychology of Religion, 14, 37-46.
Parkes, C. M. (1970) The first year of bereavement: A longitudinal study of the reaction of
London widows to the deaths of their husbands. Psychiatry, 33, 442-467.
Parkes, C.M. (2009). Love and loss: The roots of grief and its complications. London:
Routledge.
Parkes, C.M. & Prigerson, H. G. (2010). Bereavement: Studies of grief in adult life (4th ed.).
London: Routledge.
Parkes, C.M., & Weiss, R.S. (1984). Recovery from Bereavement. New York: Basic Books,
Inc.
Peterson, C. (1996). Deception in intimate relationships. International Journal of Psychology,
31, 279-288.
145
Prigerson, H.G., Ahmed, I., Silverman, G.K., Saxena, A.K., Maciejewski, P.K., Jacobs, S.C.,
Kasl, S.V., Aqeel, N., & Hamirani, M. (2002). Rates and risks of complicated grief
among psychiatric clinic patients in Karachi, Pakistan. Death Studies, 26, 781-792.
Prigerson, H.G., & Jacobs, S.C. (2001). Traumatic grief as a distinct disorder: A rational,
consensus criteria, and a preliminary empirical test. In M.S. Stroebe, R.O., Hansson, W.
Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping,
and care (pp. 613-645). Washington, DC: American Psychological Association.
Prigerson, H.G., Horowitz, M.J., Jacobs, S.C., Parkes, C.M., Aslan, M., Goodkin, K., Raphael,
B., Marwit, S.J., Wortman, C., Neimeyer, R.A., Bonanno, G., Block, S.D., Kissane, D.,
Boelen, P., Maercker, A., Litz, B.T., Johnson, J.G., First, M.B., & Maciejewski, P.K.
(2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSMV and ICD-11. PLoS Med 6(8): e1000121. doi:10.1371/journal.pmed.1000121.
Prigerson, H.G., Maciejewski, P.K., Reynolds III, C.F., Bierhals, A.J., Newsom, J.T., Fasiczka,
A., Frank, E., Doman, J., & Miller, M. (1995). Inventory of complicated grief: A scale to
measure maladaptive symptoms of loss. Psychiatric Research, 59, 65-79.
Prigerson, H.G., Vanderwerker, L.C., & Maciejewski, P.K. (2008). A case for the inclusion of
prolonged grief disorder in DSM-V. In M.S. Stroebe, R.O. Hansson, H. Schut, & W.
Stroebe (Eds.) Handbook of bereavement research and practice: Advances in theory and
intervention (pp. 165-186). Washington, DC: American Psychological Association.
Prince-Paul, M. (2008a). Understanding the meaning of social well-being at the end of life.
Oncology Nursing Forum, 35, 365-371.
146
Prince-Paul, M. (2008b). Relationships among communicative acts, social well-being, and
spiritual well-being on the quality of life at the end of life in patients with cancer enrolled
in Hospice. Journal of Palliative Medicine, 11, 20-25.
Pruchno, R.A., & Resch, N.L. (1989). Mental health of caregiving spouses: Coping as mediator,
moderator, or main effect? Psychology and Aging, 4, 454-463.
Quinn, C., Clare, L, & Woods, B. The impact of the quality of relationship on the experiences
and wellbeing of caregivers of people with dementia: A systematic review. Aging &
Mental Health, 13(2), 143-154.
Rando, T. A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press.
Raphael, B. (1983). The anatomy of bereavement. New York: Basic Books.
Rosenblatt, P.C., Walsh, R.P., & Jackson, D.A. (1976). Grief and mourning in cross-cultural
perspective. New Haven, CT: Human Relations Area Files Press.
Robinson, B., & Thurnher, M. (1979). Taking care of aged parents: A family cycle transition.
The Gerontologist, 19(6), 586-593.
Root, B.L., & Exline, J.J. (2011). The role of continuing bonds in coping with grief: Review and
future directions. Unpublished manuscript, Department of Psychology, Case Western
Reserve University, Cleveland, OH.
Rubin, S.S. (1993). The death of a child is forever: The life course impact of child loss. In M.S.
Stroebe, W. Stroebe, & R.O. Hansson (Eds.) Handbook of bereavement: Theory,
research, and intervention (pp. 285-299).
Rubin, S.S. (1999). The two-track model of bereavement: Overview, retrospect, and prospect.
Death Studies, 23, 681-714.
147
Rubin, S.S., Malkinson, R., & Witztum, E. (2008). Clinical aspects of DSM complicated grief
diagnosis: Challenges, dilemmas, and opportunities. In M.S. Stroebe, R.O. Hansson, H.
Schut, & W. Stroebe (Eds.) Handbook of bereavement research and practice: Advances
in theory and intervention (pp. 187-206). Washington, DC: American Psychological
Association.
Rusbult, C.E., Hannon, P.A., Stocker, S.L., & Finkel, E.J. (2005). Forgiveness and relational
repair. In E.L. Worthington Jr. (Ed.), Handbook of forgiveness (pp. 185-205). New
York: Brunner-Routledge.
Russac, R.J., Steighner, N.S., & Canto, A.I. (2002). Grief work versus continuing bonds: A call
for paradigm integration or replacement? Death Studies, 26, 463-478.
Shear, K., & Shair, H. (2005). Attachment, loss, and complicated grief. Developmental
Psychobiology, 47(3): 253-267.
Shuchter, S.R., & Zisook, S. (1993). The course of normal grief. In M.S. Stroebe, W. Stroebe,
& R.O. Hansson (Eds.) Handbook of bereavement: Theory, research, and intervention
(pp. 23-43). Cambridge: Cambridge University Press.
Sepulveda, C., Marlin, A., Yoshida, T., Ullrich, A. (2002). Palliative care: The World Health
Organization‘s global perspective. Journal of Pain and Symptom Management, 24(2),
91-96
Sherman, D.W. (1998). Reciprocal suffering: The need to improve family caregivers‘ quality of
life through palliative care. Journal of Palliative Medicine, 1(4), 357-366.
Silverman, P.R., & Klass, D. (1996). Introduction: What‘s the problem? In D. Klass, P.R.
Silverman, S.L. Nickman (Eds.), Continuing bonds: New understandings of grief (pp. 327). Washington, DC: Taylor & Francis.
148
Silverman, P.R., & Nickman, S. L. (1996). Children‘s construction of their dead parents. In D.
Klass, P.R. Silverman, S.L. Nickman (Eds.), Continuing bonds: New understandings of
grief (pp.73-86). Washington, DC: Taylor & Francis.
Smith, A.C., & Borgers, S.B. (1988-1989). Parental grief response to perinatal death. Omega,
19, 203-214.
Spielberger, C.D., Jacobs, G., Russell, S., & Crane, R.S. (1983). Assessment of anger: The
State-Trait Anger Scale. In J.N. Butcher & C.D. Spielberger (Eds.), Advances in
personality assessment (pp. 161-186).
Springer, D. & Brubaker, T. H. (1984). Family Caregivers and Dependent Elderly. Beverly.
Hills, CA: Sage Publications.
Steinhauser, K.E., Christakis, N.A., Clipp, E.C., McNeilly, M., McIntyre, L., & Tulsky, J.A.
(2000). Factors considered important at the end of life by patients, family, physicians
and other care providers. Journal of the American Medical Association, 284, 2476-2482.
Stroebe, M., Gergen, M.M., Gergen, K.J., & Stroebe, W. (1992). Broken hearts or broken
bonds: Love and death in historical perspective. American Psychologist, 47 (10), 12051212.
Stroebe, M. & Schut, H. (1999). The dual process model of coping with bereavement: Rationale
and description. Death Studies, 23 197-224.
Stroebe, M. & Schut, H. (2005). To continue or relinquish bonds: A review of consequences for
the bereaved. Death Studies, 29, 477-494.
Tabachnick, B.G., & Fidell, L.S. (1996). Using multivariate statistics (3rd ed.). New York:
Harper Collins Publishers.
149
Tedeschi, R.G., & Calhoun, L.G. (2004). Posttraumatic growth: Conceptual foundations and
empirical evidence. Psychological Inquiry, 15(1), 1-18.
Tyson-Rawson, K. (1996). Relationship and heritage: Manifestations of ongoing attachment
following father death. In D. Klass, P.R. Silverman, S.L. Nickman (Eds.), Continuing
bonds: New understandings of grief (pp. 125-145). Washington, DC: Taylor & Francis.
Val, E.B., & Linley, P.A. (2006). Posttraumatic growth, positive changes, and negative changes
in Madrid residents following the March 11, 2004, Madrid train bombings. Journal of
Loss & Trauma, 11(5), 409-424. Cambridge: Cambridge University Press.
Waldrop, D. (2007). Caregiver grief in terminal illness and bereavement: A mixed-methods
study. Health & Social Work, 32, 197-206.
Waldrop, D.P., Kramer, B.J., Skretny, J.A., Milch, R.A., & Finn, W. (2005). Final transitions:
Family caregiving at the end of life. Journal of Palliative Medicine, 8(3), 623-638.
Weissman, M.M., Markowitz, J.C., & Klerman, G.L. (2000). Comprehensive guide to
interpersonal psychotherapy. New York: Basic Books.
Worden, J.W. (2009). Grief counseling and grief therapy: A handbook for the mental health
practitioner (4th ed.). New York: Springer Publishing Company.
Worthington, E.L. (1998). Dimensions of forgiveness: Psychological research and theological
perspectives. Radnor, PA: Templeton Foundation Press.
Worthington, E.L., & Scherer, M. (2004). Forgiveness is an emotion-focused coping strategy
that can reduce health risks and promote health resilience: Theory, review, and
hypotheses. Psychology & Health, 19(3), 385-405.
Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundaments of assessment
and treatment (2nd ed.). New York: The Guilford Press.