Abstract
Reviewed by: Paul C. Rosenblatt, University of Minnesota, St. Paul, MN, USA.
A great strength of Bereavement Care for Families, edited by David W. Kissane and Francine Parnes, is that it provides information about the care model that Kissane has taken the lead in establishing through work at Memorial Sloan-Kettering Cancer Center in New York City and Monash University, Melbourne, Australia. It is a model focused on the care of patients with advanced cancer that brings in key members of patient families.
Despite the title, I find that this book is not so much about bereavement as it is about end-of-life issues for patients. In addition, for the most part, this book is not actually about care for families. Some of the 19 chapters hardly mention families at all but focus instead on patient care. Many chapters were written without attention to family dynamics and the differences among family members. Instead, the authors of these chapters treat families as though they were unified entities, like a person—expressing the idea that the family has feelings, beliefs, perceptions, and so forth. Thinking of a family as a personified, homogeneous unit is convenient when one has little time to work with family members and limited goals for what to do with them. But this approach is far, far from bereavement care for the family.
Another limitation of the book is that the majority of chapters are wedded to a specific individual-focused model of clinical work. In that model, there is a patient at the focus (in many chapters someone with advanced cancer; in one chapter someone with mental illness). Then families are attended to mostly in terms of what kind of care and support they can provide for the patient. That approach to clinical work can make a difference in the lives of many people, but with such an individual focus, the book for the most part does little to lay out the diversity of approaches to clinical work with bereaved families. In addition, of all the possible ways of conceiving clinical work with bereaved families, most of the chapters in the book seem to me to imply that it is the clinician's realities and goals that count. Thus, families are in treatment to get what the clinician thinks is best for them. And if they are listened to, it may be mainly a device for committing them to cooperate with the clinician. There are many clinicians who work differently, including in their work an attention to the diversity of family members in terms of their grieving, what they want, what they are able to do, how they relate to others in the family, and how committed they are to working in therapy. It seems to me, however, that for the most part you cannot know that from this book.
Although not all chapters in this book address bereavement, a key idea in a number of chapters is that family members should interact with each other in bereavement and should be each other's primary source of bereavement support. But there is a literature that contradicts this view, indicating that many bereaved families get along with members saying and offering little to each other about their loss and grief feelings. For example, there is the literature on how grieving family members can be so depleted and needy that they have little to give one another. There is the literature on losses that can set off family relationship difficulties or can aggravate already existing family difficulties in ways that greatly limit family members supporting one another. And there is the literature that shows that in some bereaved parent couples, there can be serious relationship challenges that block mutual support. The research illustrating how common it is in families or couples for there to be little mutual support in bereavement goes back at least 25 years. Two examples are the papers written by Rosenblatt et al. (1991) and that by Brabant, Forsyth, and McFarlain (1995), both of which identified how support relationships within families were more likely to be difficult. More recent research by Hooghe, Neimeyer, and Rober (2012) continues to show that bereaved couples and families may function in bereavement without a great deal of mutual support. Thus, if people find support, it is often substantially or maybe even entirely outside the family. From that perspective, clinical models that push family members toward each other to interact in bereavement and imply that there is not much support for them outside of the family may do some bereaved families a disservice.
Regardless of these limitations, most chapters in the book offer views that a clinician or scholar interested in bereavement and families should know about. Two chapters seem to me to offer a particularly rich family-centered view of bereavement care. Froma Walsh, in Chapter 2, “Conceptual Framework for Family Bereavement Care: Strengthening Resilience,” is attuned to family process, family complexity, the diversity of losses and of family resources for dealing with losses, and differences among family members. Walsh attends to family pathology and offers a basic overview of clinical issues and approaches with grieving families in trouble. There is also much in the chapter about family resilience and strength as well as the bumps that perhaps any grieving family can run into with various kinds of challenging deaths, internal family differences, and vexing circumstances. Walsh does not personify families but consistently keeps track of family diversity and the complex processes arising because family members inevitably have distinct roles, feel different things, and differ in their investments in dealing with a situation. Also, Walsh offers more a sense of therapist as facilitator and less a sense of therapist as knowing best what goals, values, and so forth, a family should have.
Levin and Marguerite Lederberg, in Chapter 5, “Ethical Dimensions of Family Bereavement Care,” do a good job of presenting ethical and conceptual complexities and ethical standards in working with families at the end of life and to some extent in bereavement. The chapter includes useful vignettes and lays out clear ethical guidelines while also addressing a number of situations in which it may not be clear what is best ethically or when practical matters can challenge simple rules for keeping things ethical. These include the family constellation, the progression of a terminal illness, what family members do outside of the therapy sessions, and issues connected to family secrets. Strengths of this chapter include its sensitivity to the risks of pathologizing what goes on in a family, its highlighting of diversity within and across families, and its attention to working not only with the family but with a host of medical players, possibly including a hospital ethics panel. Levin and Lederberg are sensitive to the practical issues in therapy involving someone who is terminally ill and explore the possibilities and potential risks of using telemedicine approaches to therapy.
Among quite a few of the other chapters, there are sections that would be useful to some readers interested in bereavement care and families. For example, even though much of Chapter 11, “Family Therapy following Suicide,” by Sands and North is focused on a single case with all its uniqueness, there are many useful details of interventions the therapist used. In Chapter 15, “Care of Families with Children Anticipating the Death of a Parent,” Muriel offers considerable wisdom about dealing with children at different developmental stages, including helpful suggestions and respect for the variability of children, adults, families, and ways of dying. And in Chapter 17, “Families ‘At Risk’ of Complicated Bereavement,” Lichtenthal and Sweeney offer creative exploration of possibly complicating factors for families in dealing with a loss.
For some, this will be a valued book. The Kissane model is useful to know, and the editors have gathered a large number of experts and leaders to write these chapters. As I have indicated, there are treasures among the chapters. However, for some, this book will seem too narrow, too uneven, and not focused sufficiently on bereavement care for and with families.