A Comparisson of Grief Reactions in Cancer HIV and Suicide Bereavement

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A Comparison of Grief Reactions in Cancer, HIV/AIDS,

and Suicide BereavementJames A. Houck PhD

a

a Pastoral Counseling Studies at the Department of Pastoral and Theological Studies ,

Neumann College , USA

Published online: 04 Oct 2008.

To cite this article: James A. Houck PhD (2007) A Comparison of Grief Reactions in Cancer, HIV/AIDS, and SuicideBereavement, Journal of HIV/AIDS & Social Services, 6:3, 97-112, DOI: 10.1300/J187v06n03_07

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A Comparison of Grief Reactionsin Cancer, HIV/AIDS,

and Suicide Bereavement

James A. Houck, PhD

ABSTRACT. This study compared the grief reactions of people whomourned three different types of death: Cancer, HIV/AIDS, and suicide,and addressed the question whether these bereavement groups can be dif-ferentiated on the basis of their grief, as measured by the Grief Experi-ence Questionnaire (GEQ; Barrett & Scott, 1989). The results indicatethat these groups (cancer: N = 50, AIDS-related: N = 50, and suicide:N = 50) had different grief reactions, specifically, in the areas of stigma-tization andunique reactions to suicide. The implications of these resultsafford grief counselors, health-care providers, and pastoral professionals,intervention strategies that enfranchise people, who may experience oneof these types of deaths, to work through their grief. Furthermore, thisunderstanding of specific grief characteristics can also be assimilated intoa therapist’s preferred bereavement paradigm, for example, stages of grief

(Kübler-Ross, 1969), phases of bereavement (Parkes, 1972), or tasks of mourning (Worden, 2004). doi:10.1300/J187v06n03_07 [Article copies avail-able for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH.

E-mail address: Website: © 2007 by The Haworth Press, Inc. All rights reserved.]

James A. Houck, PhD, is Assistant Professor of Pastoral Counseling Studies at theDepartment of Pastoral and Theological Studies, Neumann College.

Address correspondence to: James A. Houck, PhD, Assistant Professor, Depart-ment of Pastoral and Theological Studies, Neumann College, One Neumann Drive,Aston, PA 19014 (E-mail: [email protected]).

The author wishes to express special thanks to his mentors and colleagues: SharonE. Cheston, EdD, Sr., Suzanne Mayer, PhD, IHM, and J. Sheppard Jeffreys, EdD.

Journal of HIV/AIDS & Social Services, Vol. 6(3) 2007Available online at http://jhaso.haworthpress.com© 2007 by Τhe Haworth Press, Inc. All rights reserved.

doi:10.1300/J187v06n03_07 97


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KEYWORDS. Cancer, AIDS, suicide, bereavement, disenfranchisedgrief, Grief Experience Questionnaire, counseling, and mental health

INTRODUCTION

A common misconception about grief is that it is one-dimensional, thatis, experienced solelyas an emotional turmoil. Instead,grief is a multifac-eted experience, causing a disruption in a person’s physical, emotional,spiritual, social, and philosophical well-being. Worden (2004) proposesthat the grief reaction can be categorized into four areas:

1. Feelings: sadness, anger, guilt, anxiety, etc.2. Physical Sensations: tightness in the chest and throat, lack of en-ergy, dry mouth, etc.

3. Cognitions: disbelief, confusion, preoccupation, sense of pres-ence, etc.

4. Behaviors: sleep andappetite disturbances, socialwithdrawal, etc.

These experiences are considered normal reactions of grief, whichusually diminish in intensity over time ( Sadock & Sadock, 2003).

Review of Grief Reactions: Normal and Complicated

Although it is affirmedby many in the field ofmentalhealth thatgrief

is considered a “normal” reaction to any type of loss, and can be experi-enced on many different levels, there is, however, a point when grief isconsidered abnormal.This phenomenon occurswhen grief andmourningbecome complicated as the level of impairment escalates to the point of severely limiting the day-to-day functioning of one who mourns a loss.From a cognitive perspective, Neimeyer, Prigerson, and Davies (2002)suggest that complicated grief occurs when a person is unable to assimi-late the loss into his/her personal life narrative; in other words, “recon-structa meaningful personal reality” (p.236) by relearning assumptionsabout the world, roles in the family, etc., challenged by the loss.

Lazare (1979) suggests that abnormal, or pathological, grief occurswhen one or more of the following symptoms are evident: (1) when aperson is not able to talk about the deceased without experiencing a

fresh grief reaction; (2) when minor events trigger an intense emotionalresponse; (3) when the death of the loved-one is often the topic of con-versation; (4) when there is a reluctance to remove the loved one’s

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possessions; (5) when the survivor reports physical symptoms similarto those of the deceased; (6) when a survivor has made radical and sud-den lifestyle changes following the loss; or (7) when the survivor be-comes preoccupied with the presence of the deceased.

Catalan (1995) affirms that pathological grief can be categorized un-der several headings. Absence or delayed grief is an absence or delay of the manifestations of numbness and disbelief, separation distress, andsubsequent features associated with normal grief. Chronic grief occurswhen the most distressing features of mourning persist over time, andthe intensity of emotions escalates as well. For example, although anni-versary reactions to the death of a loved-one are considered normal,even after many years, a person still may feel unable to move on with

their lives,or complain about being “stuck” in their grief (Worden, 2004). Inhibited or distorted grief is seen in people with an erratic pattern of emotional responses and thoughts. Complaints of somatic symptoms,anxiety, depression, or behavioral manifestations such as hostility, dis-placed anger, and overidentification with the deceased may becomemore prominent than the usual features of grief.

METHODOLOGY

Grief is universal: A normal, human reaction when a person experi-ences a loss. Much in the sameway every human being has a thumbprint,grief is the common denominator in all societies. However, just as no

two thumbprints are alike,no two people grieve in the same manner, norshould they be treated the same by grief workers, therapists, clergy, andother health-care providers. Therefore, I designed a study to identifyspecific characteristics of grief that are unique to cancer, HIV/AIDS,and suicide bereavement.

Social workers, grief counselors, and clinical directors recruited par-ticipants for this study from various hospice and HIV/AIDS facilities,and suicide support groups. Participants included members from adultbereavement groups, who have lost a loved-one most recently to one of three causes of death: Cancer (N = 50), AIDS-related (N = 50), or sui-cide (N = 50). Theabove agencies distributedtake-home packets, whichincluded a letterof appreciationfor their willingness to participate in thestudy, an informed consent form, a brief demographic questionnaire,

and the GriefExperience Questionnaire (GEQ; Barrett & Scott, 1989). Inorder to maintain confidentiality, the researcher did not have any contactwith the participants, but instructed them in the consent form to mail the

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completed packets in a separate addressed and stamped envelope to theagency that recruited them for the study. The packets were then col-lected after 1 month of being distributed.

The purpose of this study was twofold. The first purpose was to deter-mine whether characteristics of group membership could be determinedbased on grief reactions, as measured by the GEQ (Barrett & Scott,1989). Although the participants were previously grouped by the type of loss they had experienced, a discriminant function analysis (DFA) wasused to identify whether the cut off scores were appropriate to distinguishgrief reactions between cancer, HIV/AIDS, and suicide bereavement.The null hypothesis was that there are nodifferences ingrief reactions be-tween the groups. Once the null had been rejected, a second purpose was

to identify which grief variables contributed most to discriminating be-tween the groups. Permission for this study was granted by the Institu-tional Review Board of Loyola College in Baltimore, Maryland.

Instruments

The Grief Experience Questionnaire. The GEQ (Barrett & Scott,1989) was designed to compare the differences in bereavement experi-ences of persons who have had a spouse commit suicide versus personswho had a spouse die anaccidental ornatural death.The measure consistsof55 items concerning the frequency ofvarious grief reactions, eachwitha 5-point Likert-response scale of (1) Never , (2) Rarely, (3) Sometimes,(4) Often, and (5) Almost always. The wording was changed from

“spouse” to “loved-one” to include a broader sample of other types of re-lationships to the deceased. Grief reaction subscales included multidi-mensional aspects of grief, somatic reactions, general grief, search for explanation, loss of social support, stigmatization, sense of guilt, senseof responsibility, sense of shame, sense of rejection, self-destructive be-haviors, and unique reactions to suicide, and have a Cronbach’s Alpharanging from .68 to .97. A copy of the GEQ can be obtained throughthe Journal of Suicide and Life-Threatening Behavior (1989) 19, pp.201-215.

RESULTS

Socioeconomic Status

To ensure an equal number in each group, 150 completed packets(50 per group) were needed for the study. Initially, 350 total packets



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were distributed which provided a 43% return rate. The participants in-cluded 105 women (67.9%) and 45 men (32.1%). Ethnicity in the sam-ple was 10% Hispanic, 43% Caucasian, and 47% African-American.The range of ages was from 19 to 79 years with a mean age of 44.65years. Income ranged from $20,000 to $60,000, with a mean income of $36,000. The education levels for the total sample were 30.9% com-pleted high school, 51.2% attended college, and 17.9% attended gradu-ateschool. When comparinganyof thesocioeconomic demographics tothe grief reactions, no significance correlation (.30), which could dis-tinguish one bereavement group from another, was found.

Specific Grief-Related Demographics

Participants were asked to indicate their relationship to the deceased,how much time had passed since the death of their loved-one, whetherthey attended support groupsfor their grief, andtheir current HIVstatus.

Participants’ relationship to the deceased included the following:24% lost a parent, 21% lost a spouse, 15.4% lost a sibling, 13.6% lostchildren, 10.5% lost a close friend, 7.4% lost a life-partner. Another 9%lost an extended family member such as an uncle or grandparent. At thetime of completing the testing packet, participants were asked howmuch time had passed since their loved one’s death. The range for thisquestionwas 3 months to over 5 years witha meanof24.3 months. Thesespecific grief-related demographics were evenly distributed throughoutthe three bereavement groups.

A stepwise discriminant analysis identified overall significance forthe GEQ variables, p < .001 for each of the group means. This signifi-cance indicates that despite the type of the death, these groups have sim-ilar grief reactions albeit varying degrees. For example, out of the 11variables, 2 were identified as contributing to the discrimination be-tween each of the bereavement groups, namely unique reactions to sui-cide and stigmatization, accounting for 88.6 and 11.4% of the variance,respectively. In addition, these characteristicswere calculated with a com-bined Chi-square= 217.03, p < .000. Even after removal of the strongestcharacteristic, unique reactions to suicide, there was still strong associ-ation between the groups and the predictors, Chi-square = 39.097, p <

.000. Therefore, based on the analysis that the grief reactions differeddepending on which type of grief participants were experiencing, thenull hypothesis of no differences between thethree groupswas rejected.

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In order to determine to what degree the bereavement groups are sim-ilar or different, the most significant functions (Unique Reactions toSuicide and Stigmatization) were analyzed at the group means for eachtype of death (Table 1). For example, the variable Unique Reactions toSuicide (Function1) separatedtheresponses of thesuicide bereavementgroup (1.911) from those of the cancer (1.829) and AIDS-related(.082) bereavement groups. Barrett and Scott (1989) assert that a de-fining characteristic for unique reactions to suicide is attributed to a sur-vivor concealing the circumstances surrounding the death in order toavoid the sensitivity of perhaps having the cause of death broadcast inthe media. The expectation was that the suicide group would scorehigher in this particular category. In addition, HIV/AIDS bereavement

may have only slight characteristics similar to suicide bereavement.Stigmatization (Function 2) separates the responses of the AIDS-

related bereavement group (.775) from the cancer (.413) and suicidebereavement (.362) groups. Again, Barrett and Scott (1989) define stig-matization in bereavement as society having a negative perception of the survivor as a result of the death of his/her loved-one. It is not surpris-ing that the HIV/AIDS group scored highest in this category, becausethe literature spoke of HIV/AIDS as being a highly stigmatized disease(Burkett, 1995; Shilts, 1988; Snyder, Omato,& Crain, 1999). Yet, whatis noteworthy is how similar cancer and suicide bereavement are interms of stigmatization. Unlike HIV/AIDS bereavement, where it ap-pears that the stigma is transferred to surviving loved-ones, suicide andcancer bereavement did not demonstrate this characteristic as strongly.Perhaps one reason why stigma appears in the cancer group may berelated to how the person developed the disease (e.g., excessive smok-ing, not taking care of oneself, etc.). At one time society viewed suicideas a highly stigmatized death, however, that trend seems to be chang-ing. What may be attributing to this lack of stigmatization currently isthe way society has become more sympathetic in their understanding


TABLE 1. Function of Significant Grief Reactions for Each Group

Type of Death Function 1Unique Reactions

to Suicide

Function 2Stigmatization

Cancer 1.829 .413AIDS .082 .775

Suicide 1.911 .362


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regarding the causes of suicide, for example, mental illness, despair,etc. (Corr, Nabe, & Corr, 2005). In addition, the growing number of resources and support groups available for surviving loved-ones of both cancer and suicide bereavement may further indicate why survi-vors experience less stigmatization than do survivors in HIV/AIDSbereavement.

A classification table tests the effectiveness of the discriminant anal-ysis in distinguishing three bereavement groups (Table 2). As a statisti-cal tool, the primary purpose of the discriminant analysis is to classify aset of scores into predefined groups versus randomly assigning partici-pants. Since this study started with participants from three self-identi-fied bereavement groups, the discriminant analysis was used to test

whether their grief reaction scores were indicative of the characteristicsfor each type of death they were grieving. Prior to the study, if partici-pants were randomly assigned to one of the three bereavement groups,there would be a 33.3% chance of predicting them correctly. However,based on the actual grief reaction scores, the discriminant analysismatched 82.0% according to the type of death participants reportedexperiencing. For example, the cancer bereavement group had a 94%classification rate with 47/50 cases being classified correctly. The sui-cide bereavementgroup hadan 86% classification rate with 43/50 casesclassified correctly, whereas the HIV/AIDS group had the lowest clas-sification rate (66%) with 33/50 cases classified correctly. This lowerclassification rate for the HIV/AIDS group may indicate that survivorsshare bereavement characteristics of the other two groups. As a result,

20% of the HIV/AIDS group may have more in common with cancerbereavement, that is, traits of a disease model which include antici-patory grief issues (Rando, 2000). Still, the HIV/AIDS group (14%)

James A. Houck 103

TABLE 2. Classification Results

Actual Group Membership Based on Scores

Cancern (%)

HIV/AIDSn (%)

Suiciden (%)

Self-identified group membership

Cancer (N = 50) 47 (94) 3 (6) 0 (0)

AIDS (N = 50) 10 (20) 33 (66) 7 (14)

Suicide (N = 50) 3 (6) 4 (8) 43 (86)


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may also have some characteristics unique to suicide bereavement(e.g., concealing the true nature of the death, feeling the death wassenseless and a waste of life, etc.).

Additional Data

Comparison of Means. When comparing the 11 GEQ variables meanscores between the three bereavement groups, an obvious separationbetween the groups occurred (Table 3). For the most part, the lowestmean scores occurred in the cancer group, with the HIV/AIDS groupscoring much higher. The highest mean scores of the three occurredin the suicide group and may be indicative of a more intensified grief re-action resulting from a sudden and unexpected death of a loved-one.Furthermore, although cancer and HIV/AIDS are classified as life-threatening diseases, the level of stigmatization is significantly lowerin the cancer group than in the HIV/AIDS group. Yet despite this con-trast, the variable search for explanation is slightly higher in the cancergroup mean scores (2.432) than the HIV/AIDS group mean scores(2.396). Perhaps the higher score in the cancer group may indicate how,despite research and awareness, many bereft loved-ones still strugglewith not only the mysteries of the origins of cancer, but also perhaps therapid spread of this disease within the body.


TABLE 3. Comparison of Group Means

Variables Cancer (N = 50) AIDS (N = 50) Suicide (N = 50)

Somatic reactions 2.176 2.442 2.552

General grief reactions 2.056 2.386 2.720

Search for explanation 2.432 2.396 3.412

Loss of support 1.572 2.322 2.932

Stigmatization 1.172 2.305 2.822

Sense of guilt 1.928 2.517 3.116

Sense of responsibility 1.320 1.890 2.560

Sense of shame 1.316 2.241 2.496

Sense of rejection 1.172 2.212 2.816

Self-destructive behavior 1.348 1.940 2.360Unique reactions to suicide 1.292 1.992 2.828

5-point response scale: (1) Never , (2) Rarely , (3) Sometimes , (4) Often , and (5) Almost always.


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DISCUSSION

Major Contributions

This study examined whether three separate bereavement groups,cancer, HIV/AIDS, and suicide have their own distinct grief reactions.Although the discriminant analysis supports three distinct bereavementgroups, one major contribution of this study reveals that stigmatizationis significantly higher in HIV/AIDS bereavement than canceror suicidebereavement, accounting for 11.4% of the variance.

According to the GEQ (Barrett & Scott, 1989), stigmatization is de-fined as how society looks upon people and is measured by the follow-

ing questions:

1. Think that people were gossiping about you or the (deceased)person.

2. Feel like people were probably wondering about what kind of per-sonal problems you and the (deceased) person had experienced.

3. Feel like others blamed you for the death.4. Feel like the death somehow reflected negatively on you or your

family.5. Feel somehow stigmatized by the death.

The role stigmatization plays in discriminating the HIV/AIDS be-reavement group from the other two groups may be attributed to society’s

continued discomfort, fear, and intolerance surrounding the disease. Forexample, in addition to the deceased, the surviving loved-one also feelssomehow morally depraved and flawed because of his/her association tothe deceased (e.g., spouse, life-partner, parent, sibling, caregiver, etc.).

A second contribution of this study involves the differences betweenthe HIV/AIDS and suicide bereavement groups. Previously classifiedby Doka (2002), as types of death that result in disenfranchised grief,the HIV/AIDS and suicide groups were further differentiated in thisstudy by the GEQ category of unique reactions to suicide. This “unique-ness” accounts for 88.6% of the variance and is measured by the follow-ing questions:

1. Wonderabout your loved-one’s motivation fornot livinglonger?2. Feel like your loved-one was somehow getting even with you by

dying?3. Feel that you should have somehow prevented the death?

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4. Tell someone that the cause of death was something different thanwhat it really was?

5. Feel like the death was a senseless and wasteful loss of life?

In the past, society may have placed someof the blame for the suicideon the family members, thus offering less social support than it wouldfor survivors of a natural death. As a result, survivors may have feltalienated from their friends and acquaintances, because of the blame,rejection, and lack of understanding on the part of society. Calhoun andAllen (1991) discovered that surviving family members tended to bemore psychologically disturbed, less trusting, and more blameworthythan family members grieving nonsuicidal deaths. Therefore, to cope

with the sudden and unexpectedness of the suicide, family membersmay have refused to discuss the death with friends or coworkers, or mayhave attempted to recreate events mentally leading up to the death. Yet,a unique feature this study demonstrated by the discriminant analysiswas that those who grieve a loved-one’s death from suicide, may not beexperiencing the same level of stigma, versus cancer, or HIV/AIDSgrief, as survivors once did throughout history (Berman & Jobes, 1997;Rubel, 2003). This change in society’s perception toward those whoseloved-one died from suicide, may be attributed to a growing under-standing of the complexities surrounding why people commit suicide,for example, mental illness, inability to cope with overwhelming cir-cumstances, etc.

Implications for Mental Health and Health-Care Providers

Disenfranchised grief poses significant problems for people whenfaced with the death of a loved-one, but are not afforded the right, role,or capacity to openly grieve as other members of society. For mentalhealth and health-care providers, being aware that such stigma still ex-ists within society is vital to helping people work through their grief. Infact, this understanding can also be assimilated into a therapist’s pre-ferred bereavement paradigm (e.g., stages of grief : Kübler-Ross, 1969; phases of bereavement : Parkes, 1972; or tasks of mourning: Worden,2004), in order to educate survivors on issues that might inhibit the pro-cess of mourning.

For example, people who grieve the loss of a loved-one’s death tocancer, HIV/AIDS, or suicide may often feel neglected and forgotten.Yet they have specific bereavement needs. One need, in particular, is tobecome “enfranchised” by the therapist (Corr, 1998). Giving people



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permission to grieveopenly legitimizes their statusas mourners. In fact,therapists need to communicate to the surviving loved-one that soci-ety’s perception of thedeath may notnecessarily reflect theirownexpe-rience (Rando, 2000).

Quite often bereaved loved-ones are forced to wrestle with unan-swered questions, withhold their feelings from family members andfriends, etc., and cover up the nature of the death to avoid further judg-ment and emotional isolation. In the early years of HIV/AIDS, the pop-ular phrase “Silence = Death” was used to protest society’s denial of theepidemic natureof a disease that was immediately stigmatized (Burkett,1995). In some instances, suicide maybe particularly troubling to revealin social settings, especially if thesurviving loved-one is in a position of

public authority (Rubel, 2003). Today, silencing the disenfranchisedgrievers only further wounds them into possible social isolation, andplacing them at a far greater risk for bereavement complications.

Active listening, normalizing feelings, expressing empathy, educat-ing people on the process of mourning, and providing a safe environ-ment where thoughts, emotions, feelings, and personal stories can beshared is a crucial step toward healing one’s grief. Many clients maybe apprehensive about sharing their stories and feelings because theymay have never been given permission to talk about the death before.Although therapists may assume this kind of permission-giving will beattractive to many, disenfranchised grievers may be skeptical abouttherapists’ intentions. Too familiar with “guilt by association” judgments

rendered by society, they may have difficulty accessing the therapist’sempathy. Therefore, disenfranchised grievers need to be reassured thatthey not only are viewed by therapists as person’s of value and worth,but they need to know their loved-one’s memory will be afforded thesame courtesy.

Intervention Strategies

Rando (2000) states that in working with disenfranchised grievers,different types of support may be needed not only to facilitate grief, butalso may be required at different times. Such resources include:

• Identify the type of support the mourner requires and what supportis desired, for example, individual verses support group.

• Work with the mourner to identify unmet needs as secondarylosses, for example, loss of income, role, etc.

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• Deal with the mourner’s feelings about not getting needs for sup-port and why those needs are not getting met.

• Review the mourner’s expectations for support to determine whetherthey are appropriate, and help them readjust these if inappropriate,for example, self-medicating through drugs or alcohol.

• Assess the lack of support to determine whether it is owing to alack of assertiveness or other psychological issues.

• Educate the mourner that support for disenfranchised grief oftencanbe found in support groups and/orprinted material.Refer themto these sources.

• Educate themourner on unrealistic expectationsor incorrect infor-mation about the mourner’s needs.

Religious/Spiritual Needs and Support

Pargament, Koenig, and Perez (2000) notes that a grieving person’sreligion and spirituality have become important issues to address incounseling. Whether it is existential issues related to God or the Divine,relationships with others, or finding peace, many pastoral professionalshelp bereft people understand the significance of religious/spiritualcoping in their grief. As in any bereavement setting, listening to a survi-vor’s story, especially one’s religious/spiritual story is a critical part of the process of mourning. To this end, Paragament et al. states that reli-gion/spirituality can function in the following ways:

Preservation: To use religion/spirituality not necessarily to changebut to survive, or to provide stability in everyday life.

Reconstruction: To use religion/spirituality to rebuild prior beliefsabout God and the world that may have been challenged by thedeath of a loved-one.

Re-Valuation: Using religion/spirituality to help people discovernew sources of significance, e.g., letting go of old attachments tothe loved-one and discovering new ways to invest themselves inother people or endeavors.

Re-Creation: Using religion/spirituality as a means of transform-ing a person’s core significance and his/her approach to life, e.g.,giving up of avoidant strategies in search for a closeness with Godand others.



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By focusing on the grieving person’s specific religious/spiritual cop-ingmethods, pastoral professionals may be able to identify the differentways religion/spirituality enhances or hinders the mourning process. Infact, this awareness will make it possible to integrate religion/spiritualitymore fully and effectively in counseling.

Limitations and Future Area of Research

As this study examined the grief reactions, among cancer, HIV/ AIDS, and suicide bereavement groups, there are several limitations tothe study, which lends itself to future areas of research.

Cultural Limitations

This study focused primarily on the grief reactions from a westerncultural perspective. A future area of research would be to compare andcontrast the three bereavement groups in other cultures, for example,African, Asian, Latino, European, Scandinavian, Pacific Islands, etc.This research would address specific cultural issues related to bereave-ment that may or may not be similar to the western culture. In addition,this type of research would be beneficial particularly in Asia and Africawhere HIV/AIDS is at epidemic proportions (Stine, 2005). Nonetheless,there are specific cultural groups within the United States, for example,Asian, African, etc., that would warrant future research in this area.

Specific Groups within Each Group

The study specifically targeted three types of death (cancer, HIV/ AIDS, and suicide). However, there are certainly subgroups within themain groups. For example, it would be worth studying different types of grief reactions and religious/spiritual coping between different types of cancerdeaths. Another example would be to differentiate between HIV/ AIDS deaths resulting from different modes of contraction. In otherwords, would the level of stigmatization be the same or different forloved-ones who contracted HIV/AIDS via an accidental stick with aninfected needle, sexual contact, breast-feeding, or sharing needles fromillegal intravenous drug use, from thegroup at large?Subgroups (differ-

ent methods of suicide) within the larger suicide bereavement groupmight be another area for future research to measure unique reactionsto suicide, for example, how survivors react to loved-ones committing

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suicide by gunshot, hanging, pills, setting themselves on fire, asphyxia-tion, etc.

Other Types of Death

This study was limited to examining grief reactions from three spe-cific bereavement groups. There are other types of deaths not includedin this study. Therefore, a future area of research would be to compareand contrast different types of death including other disenfranchisedgroups, for example, accidental, drunk driving, murder, etc. Also, in lightof the recent research on trauma, comparing specific types of death thatresult in traumatizing bereaved survivors as defined by Jacobs(1999)or

Rando (2000) would be beneficial to the field.

Longitudinal Studies

This study examined grief reactions among three bereavement groupswithin the parameters of 3 months to5 years. A future area of researchwould be to design a longitudinal study among the three bereavementgroups to measure the differences in intensity of grief reactions, levelsof resiliency, use of religious/spiritual coping skills, and sense of disen-franchisement over a 1, 3, 5, and 10-year period of time.

Religious and Spiritual Coping

In recent years, there has been an increasing amount of attentiongiven to the effects religious and spiritual coping have on mental health(Pargament et al., 2000; Shafranske, 1997). In times of grief, manypeople turn to religion and spirituality to find stability, hope, and mean-ing (Doka & Morgan, 1993). Therefore, it would be beneficial to thefield of research on disenfranchised grief to study how these groupscope in terms of religious/spiritual beliefs and practices.

SUMMARY

This study compared thegrief reactionsof peoplewho mourned threedifferent types of death:Cancer, HIV/AIDS, and suicide, andaddressedthequestion whether thethree bereavement groupscanbe differentiatedon the basis of their grief, as measured by the GEQ (Barrett & Scott,1989). The results indicated that these groups had different reactions,



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specifically, in the areas of stigmatization and unique reactions to sui-cide. Despite over 20 years of HIV/AIDS education and awareness,stigma still surrounds this disease. In fact, stigma appears to be trans-ferred to surviving loved-ones in bereavement, to a greater extent thanin cancerandsuicide. However, survivors of a loved-one’s suicide morethan likely will purposefully conceal the circumstances of the deathfrom the media in order to avoid society’s judgment as distinguishedfrom cancer and HIV/AIDS deaths. The result is that both the suicideand HIV/AIDS groups may be forced into a silence regarding grievingtheir losses openly. Nonetheless, for those who offer grief counseling,providing a safe and accepting, nonjudgmental environment where thesesurvivors can tell their story helps facilitate the steps toward healing.

To this end, the field of research within disenfranchised grief is vastand limitless. Cultural nuances and societal attitudes may change fre-quently. In fact, what is considered taboo in one society may be consid-ered normal behavior in the other culture. However, what does notchange is an ongoing commitment to study of disenfranchised grief inthe context of social, political, religious, and economic arenas. Al-though tremendous strides have been made in the area of education, re-search, and awareness, fear and public opinion can combine for anoverwhelming way in which stigma and isolation is fed. Nevertheless,there is hope for grieving people to be empowered to rise above suchshunning behavior when practitioners, researchers, policymakers, andclergy become more aware of the grief and stigma factors these personsface, and when thought is given to the types of supports those grievingpersons need at that time.

REFERENCES

Barret, T. W. & Scott, T. B. (1989). Development of thegrief experience questionnaire(GEQ). The Journal of Suicide and Life-Threatening Behavior, 19, 201-215.

Berman, A. & Jobes, D. (1997). Adolescent suicide assessment and intervention.Washington, DC: American Psychological Association.

Burkett, E. (1995). The gravest show on earth: America in the age of AIDS . Boston,MA: Houghton Mifflin.

Calhoun, L. G. & Allen, B. G. (1991). Social reactions to the survivors of suicide in the

family: A review of the literature. Omega, 23(2), 95-97.Catalan, J. (1995). Psychiatric problems associated with grief. In L. Sherr (Ed.), Grief and AIDS . Chichester, UK: Wiley Press.

Corr, C. (1998). Enhancing the concept of disenfranchised grief. Omega, 38, 1-20.

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Corr, C., Nabe, C., & Corr, D. (2005). Death and dying, life and living (5th ed.).Belmont, CA: Wadsworth Publishing.

Doka, K. (Ed.). (2002). Disenfranchised grief: New directions, challenges, and strate-gies for practice. Champaign, IL: Research Press.

Doka,K. & Morgan,J. (Eds.). (1993). Death and spirituality. Amityville, NY:BaywoodPublishing Company, Inc.

Jacobs, S. (1999). Traumatic grief: Diagnosis, treatment, and prevention. Philadelphia,PA: Taylor and Francis.

Sadock, B. J. & Sadock, V. A. (2003). Kaplan and Sadock’s synopsis of psychiatry:Behavioral sciences/clinical psychiatry, 9th edition. Baltimore, MD: LippincottWilliams & Wilkins.

Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.Lazare, A. (1979). Unresolved grief. In A. Lazare (Ed.), Outpatient psychiatry: Diag-

nosis and treatment (pp. 498-512). Baltimore, MD: Williams and Wilkins.

Paragament, K. I., Koenig, H. G., & Perez, L. (2000). The many methods of religiouscoping: Development and initial validation of the RCOPE. Journal of Clinical Psy-chology, 56 , 519-543.

Parkes, C. M. (1972). Bereavement: Studies of grief in adult life. New York: Interna-tional Universities Press, Inc.

Rando, T. (2000). Clinical dimensions of anticipatory mourning: Theory and practicein working with the dying, their loved ones, and their caregivers. Champaign, IL:Research Press.

Rubel,B. (2003). Thegrief response experienced by thesurvivorsof suicide. Retrievedon November 6, 2002, from www.griefworkcenter.com.

Shafranske, E. P. (1997). Religion and the clinical practice of psychology. Washington,DC: American Psychological Association.

Shilts, R. (1988). And the band played on. New York: Penguin Books.Snyder, M.,Omoto, A. M., & Crain, A. (1999). Punished for their good deeds:Stigma-

tization of AIDS volunteers. American Behavioral Scientist, 42, 1175-1192.Worden, J. W. (2004). Grief counseling and grief therapy: A handbook for the mental

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doi:10.1300/J187v06n03_07


Documents

A Comparisson of Grief Reactions in Cancer HIV and Suicide Bereavement