Abstract
Reactions to death have been studied extensively from psychological, behavioral, and physiological perspectives. Occupational adaptation to loss has received scant attention. Qualitative research was undertaken to identify and describe occupational responses in bereavement. The constant comparative approach was used to analyze and interpret the occupational responses. Adaptive strategies of occupational accommodation and assimilation were used after the death of a family member. Desire to sustain bonds with the deceased motivated specific occupational engagements. These occupational responses served to reconstruct meaning after the death of a family member. These findings contribute to understanding adaptation after death by adding an occupational perspective to previous theories. Occupational therapists’ abilities to support clients after loss can be enhanced through appreciation of occupational accommodation and assimilation and the role of continuing occupational bonds after the death of a loved one.
Experiencing the death of a family member involves profound and diverse challenges. It is an experience we cannot avoid because it is part of the human condition. Reactions and adaptations to loss are an integral part of mourning. Extensive research has described both normal and abnormal psychological, behavioral, and physical courses of grief after loss (Averill, 1968; Bowlby, 1982; Karl, 1987; Kübler-Ross, 1969; Lindemann, 1944/1994; Rando, 1984, 1993, 2000). Occupational response to such losses has received surprisingly scant attention in occupational therapy and occupational science literature.
As occupational therapists, we collaborate with clients to create client-centered, occupation-based therapies with the power to enhance occupational performance and participation for people with a wide range of physical and psychosocial difficulties. With the increasing age of the population and our clients, losses of family members are prevalent and may affect individual choices of occupations and participation. Addressing loss is integral to holistic, client-centered occupational therapy.
A qualitative research project to develop a grounded theory of the relationships between the experiences of loss of a family member and occupational adaptation was undertaken. We found that adaptation to loss takes the forms of occupational accommodation and assimilation and that these processes facilitate continued bonds with the deceased family member and construction of new meaning.
The terms grief, mourning, and bereavement are often used interchangeably by researchers. One school of thought (e.g., Hagman, 2001; Rando, 1984, 1993, 2000; Shelby, 1993) draws the following distinctions among the terms. Grief is the experience of a complex set of reactions—psychological, social, cultural, and somatic—to loss. Mourning is the processing of grief, involving adaptation and “reorganization of the survivor’s sense of self”; (Hagman, 2001, p. 24). Bereavement refers to the condition of having experienced a loss. In this article, we adhere to these definitions.
Mourning and Meaning Reconstruction
Contemporary theories and research challenge long-standing views of adaptation to grief. Prior beliefs that the goal of mourning is detachment and that mourning follows a predictable, staged progression have given way to an appreciation of more complex patterns of adaptation to loss. Current theories suggest that healthy mourning involves meaning reconstruction that affords continuing bonds with the deceased person and renewed life.
Researchers have noted that people who have lost loved ones typically want to converse about the deceased with others who have known them. It has been theorized that such conversations serve as a means for constructing new meanings for a life without the deceased person (Klass, 2001; Walter, 1996).
The world without the deceased person is new and unfamiliar to the griever; loss compels new learning and reconstruction of meaning (Attig, 2001). This process takes the griever simultaneously in two directions: a return to sustaining, nourishing, familiar life patterns coupled with transformation of one's life (Attig, 2001).
The importance of meaning reconstruction and transformation has been demonstrated in a study of 506 young adults in the first 2 years after the death of a friend or loved one (Neimeyer, Baldwin, & Gillies, 2006). The findings from this research suggested that time alone was not a good predictor of resolution of grief, contrary to the assumption that “time heals all wounds.” Instead, when grievers made sense of their losses in personal, practical, existential, or spiritual terms, they had more positive outcomes in terms of less separation distress (yearning, loneliness, preoccupation with thoughts of the deceased) and less traumatic distress (disbelief about the death; feelings of being shocked, overwhelmed, numb, and out of control; sleep disturbances). An important aspect of making sense of the loss (i.e., meaning reconstruction) consisted of establishing continuing bonds with the deceased person. Neimeyer et al. (2006) concluded that such transformations of bonds with the deceased person were related to fewer symptoms of complicated grief (p. 735).
Continuing Bonds
In his classic work “Mourning and Melancholia,” Freud (1917/1957) proposed that adaptation to loss required detachment from the deceased before mourning could be completed. Freud argued that a grieving individual must eventually work through the process by letting go of bonds, goals, and memories associated with the deceased to allow successful adaptation and investment in new relationships.
Increasingly, contemporary researchers have presented evidence supporting an alternate view: Continuing bonds to the deceased can support healthy adaptation, depending on their form, function, and timing (Baker, 2001; Boelen, Stroebe, Schut, & Zijerveld, 2006; Field, 2006; Field, Nichols, Holen, & Horowitz, 1999; Gaines, 1997; Klass, Silverman, & Nickman, 1996; Neimeyer, 2001a; Niemeyer et al., 2006; Stroebe & Schut, 2005; Walter, 1996). Baker (2001) conceptualized the goal of mourning as transformation instead of detachment and believed that continuing bonds could facilitate adaptation. Successful transformation or adaptation involves maintaining an internal tie with the deceased individual while allowing for the development of new relationships and activities (p. 68). Baker believed that such a continuing bond leads to a balance between inner and outer worlds, enhancing the bereaved individual's capacity to function autonomously after loss.
Researchers have examined whether continuing bonds foster or undermine adaptation to the loss of a family member. Field et al. (1999) studied different types of continuing bonds in 70 people at midlife after the deaths of their spouses. These researchers identified four types of continuing bonds: (1) feeling a recurrent sense of the deceased's presence, (2) maintaining the deceased's possessions, (3) seeking comfort through contact with the deceased's possessions, and (4) gaining comfort through memories. The results indicated that the two types of continuing bonds involving the deceased's possessions, but not the other two types, predicted lesser decreases of grief over time. By contrast, a continuing bond involving fond memories predicted less distress, suggesting that the form of a continuing bond determines whether it will be adaptive or maladaptive.
In an extensive review of the literature, Field (2006) examined this paradox and found that when grievers make the distinction between the past and the present and understand the permanence of the physical separation, continuing bonds are related to successful adaptation. Conversely, when grievers do not make these distinctions, continuing bonds undermine adaptation (p. 750).
These contemporary understandings of grief, continuing bonds, meaning reconstruction, and adaptation have tremendous potential to inform occupational therapists. Occupational therapists and occupational scientists have much to contribute to this discussion. But if we are to explain to other disciplines what we have to offer, and if we are to shape effective, occupation-based therapies for people who have experienced significant losses, we need evidence, illustrations, and theory specific to occupation.
The purpose of this study was to identify, describe, and illustrate the nature of three specific occupational responses after the death of a family member: (1) occupational accommodation, (2) occupational assimilation, and (3) continuing occupational bonds. The goal of these occupational responses is meaning reconstruction, which enables grievers to return to nourishing familiar life patterns and to create needed transformations.
Method
Participants
Participants were initially recruited from Steve Hoppes's friends and colleagues, and the snowball technique completed the sample. All participants had experienced the death of a family member and gave informed consent to participate in the study, which had been approved by an institutional review board.
Thirty-one people participated in the study, including 17 women and 14 men with an age range of 25 to 69 years. All participants lived in one of two metropolitan areas in the Southern Plains. Eighteen participants had lost parents, 5 had lost children, 4 had lost grandparents, 2 had lost spouses, 1 had lost a sibling, and 1 had lost two nieces.
Data Collection
Participants engaged in a single, in-depth interview for approximately 1 hr. Participants selected interview sites, which included a university conference room and participants’ offices and homes. All interviews were recorded and transcribed verbatim. While completing informed consent forms, participants received a brief overview of the study and interview and assurance that it was not the objective of the study to identify “best” approaches at a time of loss but simply to understand participants’ experiences. Because this research explored the loss of loved ones, interviews began with a clear statement that participants could choose to stop the interview at any time.
In a semistructured, open-ended interview based on an interview guide, participants were asked to describe their work before their loved ones’ health became an issue, during the time of illness, and after death. Participants were then asked about leisure and social participation in the same contexts. For example, in exploring a participant's work life, the following questions were asked: How would you describe your work life before loss? How much time did you spend with your work life? How did you prioritize your work life compared with your family life or leisure time? What happened to your work immediately around the time of your loss? What happened to your work life in the weeks and months after the loss? How would you describe your work life currently? Has your work life changed since this loss? If so, how has it changed?
Data Analysis
A thematic data analysis using grounded theory's open coding stage (Charmaz, 2006; Glaser & Strauss, 1967; Strauss & Corbin, 1998) was used. In this step, we focused on identifying instances of occupational adaptations and conceptualizing their nature. While engaging in conceptualizing the nature of occupational adaptation, it became clear that this process is similar to occupational accommodation and assimilation as described by Matheson and Bohr (1997). When engaged in axial coding, Spradley's (1979) domain and taxonomic analyses were used to enhance the grounded theory texts. Interpretations of the findings focused on relating them to the existing theories and research and an ongoing discussion between us.
Trustworthiness
Our Stance
We are occupational therapists who embrace the values and perspectives of our profession. In addition, we are greatly influenced in our work by existential writers such as Camus (1991), Frankl (1984), Sartre (1955), and Yalom (1980, 2000). These writers believe that humans recognize (consciously or subconsciously) that they must invent their own meanings and then commit themselves to realizing those meanings as fully as possible. This can only be done by a “leap into engagement” (Yalom, 1980, p. 431).
Accuracy in Data Analysis
Data were collected and analyzed initially by Steve Hoppes. Ruth Segal was asked to join the research and serve as an auditor to verify and refine Hoppes’ analysis. After Segal was convinced of the accuracy of the initial analysis, believing it to be well-grounded open coding, she proceeded to engage in axial coding. At this stage, Hoppes became the auditor, verifying the accuracy of the axial coding. Interpretations and synthesis of the analyzed data proceeded through continued discussions until agreement was reached.
Member checks (DePoy & Gitlin, 1994) were used to verify, correct, and fine tune initial conclusions. Hoppes met a second time with 12 of the 31 participants during data analysis to discuss findings and working theories and to review participants’ individual transcripts in this light. Participants were asked for feedback based on their understandings and experiences; this feedback tended to reinforce and augment findings.
Writing the Manuscript
Writing the manuscript is a seldom-discussed final stage of the data synthesis and interpretation (Charmaz, 2006). Hoppes wrote the initial draft. This draft was edited by Segal, who returned it to Hoppes. The process continued for several rounds. In each round, the discussion and editing focused mostly on refining and developing the interpretation and synthesis of the analyzed data.
Findings
Participants were asked to describe their occupational lives in the areas of work, leisure, and social participation before and after the loss of the family members. Most of the participants described adaptations in the occupational patterns of their lives or in the nature of their engagement in existing occupations. Generally, the participants explained that the experience of losing a family member elicited a process of reflection on their lives and the nature of their participation in life leading to the described changes.
The experience of losing a family member was new information that the participants reflected on and worked to integrate into their lives. When no change occurred in a particular area of occupation, the loss was assimilated into previous schemata (Matheson & Bohr, 1997; Piaget, 1969, 1985). If the experiences elicited a change in an area of occupation, the loss was accommodated (Matheson & Bohr, 1997; Piaget, 1969, 1985). The concepts of assimilation and accommodation seemed to explain the nature of the occupational adaptations that the participants described.
Matheson and Bohr (1997) adapted Piaget's definitions of accommodation and assimilation for application to occupation. They defined accommodation as “[t]he process whereby the organization of information within a schema must be revised or altered because of the inability to fit new information into any existing mental category” (p. 433). They defined assimilation as “[t]he expansion of data within a given category or subcategory of a schema by incorporation of new information within the existing representational structure without requiring any reorganization or modification of prior knowledge” (p. 433).
Applying these definitions to occupational adaptations, we developed the themes of occupational accommodation and assimilation to the loss of a family member. This article presents variations of occupational accommodation and assimilation in the areas of work, leisure, and social participation. These occupational adaptations were purposeful for participants because they facilitated reconstruction of meaning after the deaths of their family members. This reconstruction often included the establishment of continuing occupational bonds with deceased family members.
Occupational Accommodation
Occupational accommodation refers to transformation of occupational patterns in response to changing reality. Participants in the study experienced occupational accommodation when established occupational patterns became unsustainable or irrelevant after the death of a family member. Sixteen of the 31 participants described occupational accommodation for at least one area of occupation (work, leisure, or social participation).
Accommodations in the Area of Work.
When discussing work, 3 participants told stories of making clean breaks with familiar work and transforming this area of occupation in response to the death of a family member. A 36-year-old woman recalled moving from a private medical services company to university teaching after the death of her mother from breast cancer:
After she passed away … I left the job I'd been at for 13 years. I thought, “You know, I don't need this.” You just look at the world differently. I didn't know what I was going to do. I left and didn't worry about it. I wanted to be happier. I wanted to fulfill myself more. I think [my loss] is really the reason I came to the university. It got me away from the business sector and back to a place where I felt I was doing the world some good.
The death of her mother initiated self-reflection that led to an occupational accommodation in the area of work.
Another participant was a 33-year old woman whose mother died of breast cancer. After engaging in unsatisfying clerical work, she left to work for “The Race for the Cure,” a fundraising arm of a foundation dedicated to education, treatment, and search for a cure for breast cancer.
I think I was looking for something that meant a little more. I didn't want to do just any organization. That [Race for the Cure] was the organization I felt connected with. It has been extremely meaningful because of my experience of taking care of my mom. It's nice to give some of that back, and it's nice to have a positive memory rather than just this is someone who died, and that's all there is to it. All the pain you went through and all the things that were suffered are now constructively put to use for a good purpose in the larger scheme of things.
Two other participants who were not working at the time of their losses transformed their occupations into lines of work they related to their losses: one was in high school when three grandparents died within a short period, prompting her to pursue and gain admission to a master's-degree program in occupational therapy; the other was a 50-year-old homemaker when her 13-year-old son died of a heart defect, leading her to seek employment that led to directing a hospital-based program for hospice volunteers.
Accommodations in the Area of Leisure.
Nine of the 31 participants told stories of greatly revising leisure schemas after loss. These participants described engaging in new types of leisure to regain lost balance and joy in their lives. For example, the 50-year-old woman whose 13-year-old son died of a heart defect described new leisure pursuits after her loss:
When I lost him, I kind of lost the meaning to my life. I find myself getting more involved every year in different types of classes. Last fall, I took two pottery classes. I've taken photography classes. I'm very good at photography now. At the end of the class, my husband and I had won every category in the class, which was amazing. I've taken dancing lessons. I'm into stain[ed] glass now. I just keep finding new things I want to learn. It kind of brought some meaning back into my life.
A 40-year-old man reflected on changes in his leisure patterns after the death of his grandmother at the age of 88 after a stroke:
After her death, I didn't put things off like I used to. Work was always there. Suddenly, leisure needed to be there just as often. I was always exercising, but different modes of exercise. I started doing yoga, more meditative types of things. Spirituality, I definitely spent more time reading more poetry. My grandmother really liked reading Walt Whitman, Robert Frost. It was a way to connect with things she liked to do. My spiritual life changed. I went to church more often. I was keeping a journal about a year before she died. I definitely made some significant entries in the journal about her death. Exercise shifted toward some relaxation, meditative stuff, some church stuff a little bit more regularly, and a fair amount of reflection.
Other participants described accommodations to their leisure after the deaths of family members: buying and remodeling a house; engaging in new forms of exercise; completing an extensive landscaping project; taking up drumming and joining a drum circle; taking dance lessons; traveling to new places; attending NASCAR races; and buying a boat and spending time fishing; learning stone carving, pottery, photography, stained glass, painting, and golf.
Accommodations in the Area of Social Participation.
Nine participants told stories of accommodating to social participation. These people found comfort in new relationships, or new types of relationships, after loss. For example, a 33-year-old woman left college to care for her mother, who subsequently died of cancer. Shortly after her mother's death, her social participation included a new relationship with her future husband:
I met [my future husband] when I came back to school. I guess I'd been back in school about a month and a half. My roommate set me up. I didn't play games; I was very honest about a lot of stuff. He came along when I really needed to laugh and have a good time. Maybe I was just more open to something. He was around a few times when I had a meltdown from nowhere, and it didn't freak him out. It may have, but he didn't show it. He knew what had gone on, knew everything about it. He came along and made me laugh and made me feel safe being around somebody. He focused on just me.
Another example is from a 43-year-old woman whose father died of heart disease. During her father's illness and after his death, her social participation changed as she came to a new understanding of her sexual orientation:
Over this same period, before and after my father's death, I was trying to come to grips with [the fact] that I was attracted to a woman. I hadn't dealt with that before. I may lose the intimacy of loving my father, but there is a linkage, it's what you make of it, what you learn from that, it doesn't end here. It's been an interesting journey.
Other participants demonstrated social accommodation after a family member's death by becoming close to the deceased's coworkers; spending increased time with the deceased's friends; ending relationships with certain friends, family members, and acquaintances; becoming close friends with formerly distant acquaintances; and getting divorced.
These participants’ “existing mental categories” of work, leisure, and social participation no longer fit the “new information” in their lives—the deaths of family members—to borrow phrasing from Matheson and Bohr (1997). They adapted to their losses by altering their occupational schemas, moving to different types of occupational performance; that is, they accommodated.
Occupational Assimilation
Participants in the study described filtering losses through current occupational performance patterns to adapt to the deaths of family members. In short, assimilation involves fitting loss into one's current occupational patterns. For example, several participants described maintaining or increasing exercise routines at a time of loss. Twenty-two of the 25 participants who engaged in work at the time of a family member's death told stories of returning to familiar work after their losses or assimilation. Although returning to work was often marked by disruption or distraction after a loss, participants described engagement in this familiar, predictable occupation as therapeutic.
Assimilation in the Area of Work.
Several participants described returning to work as a way to adapt to their losses. For example, a 45-year-old man whose mother died unexpectedly after a brief illness described the comfort of returning to his job after the funeral:
I'm the type of person that if I have too much time on my hands, I think too much, and it doesn't do me any good. I start thinking about all of these things that you can't answer. I would say it was helpful, in a sense, to work because it keeps you from dwelling on the negative so much that you become depressed. I think if I didn't have work, I would've been home and my wife would've been listening to me vent or listen to me talk about just feelings that, you know, can just be overdone. You have those feelings that you feel bad about, but it can be redundant to focus on those feelings and think about them until it just drives you crazy. I would say definitely getting back to work was helpful.
Another example is from a 43-year-old man whose son died of leukemia after a lengthy illness; he described his need to return to work:
After my son passed away on a Friday, and after a 7-month haul and everything that had gone on, I thought I'd take a month off and go have a margarita on the beach. After the funeral on Monday and being at home all week with my wife and daughter and friends, I came to the realization that I needed to go back to work.
In both examples, the participants described the comfort of returning to work; that is, they assimilated the loss through their established work routines.
Assimilation in the Area of Leisure.
Leisure appeared to be the most stable area of occupation after loss for the participants. All 31 participants reengaged in familiar leisure activities after the death of a family member, often with greater frequency. For example, a 52-year-old man whose mother died from cancer discussed his swimming routine before and after her death:
I must have increased the amount I was swimming. I have lots of memories of that year and on into the next year or two of the Northside Y. Because I have all of these memories, I must have been going all the time, four or five mornings a week. Now that I think about it, I was there all the time.
Another example from a 50-year-old woman who was a runner at the time her 13-year-old son died of heart defect said,
In fact, the day my son was dying, I went out for a jog. I really didn't want to go, but being out there in the open and fresh air opened me up to the world. It gave me a breather and reenergized me so I could go back in and deal with what I had to deal with.
Other examples of assimilation of leisure immediately after the death of a family member included maintaining important routines such as a weekly family dinner, continuing teaching a tae kwon do class for boys after the death of a son, maintaining exercise routines, maintaining routines of golfing and playing handball, and continuing to follow a football team's games closely.
Assimilation in the Area of Social Participation.
Participants often cited the continuity of existing relationships with friends and family as one of the most important factors in dealing with loss. For example, a 43-year-old man discussed his social participation with friends after the death of his 15-year-old son from leukemia:
The socialization we have now has probably become more important. My son's friends, I think in their loss, derive a lot of comfort from being with my wife and me and being at our house. I think a lot of their recovery and working through that is to keep a close tie with our family. There's hardly a weekend that goes by that we don't have a handful—sometimes a lot more—of my son's friends over at our house. Socially, that is tremendous for us. Doing things with our friends has always been a priority and continues to be. We derive a lot of strength from that. Our friends now are closer to us. We all lived that situation together. We all experienced the highs and lows and the grief and coping. We're still coping through it with them.
Another example is from a 41-year-old woman whose father's death from cancer closely followed her mother's death. She described the increased importance of social participation with her professional colleagues:
When I think about who I am now, the most important thing to me is relationships. I love the relationships I have with the people I work with. It's that connectedness. Maybe because I don't have parents anymore, there's a need to be connected to others in some other way.
Stories of assimilation of social participation immediately after the death of a family member were common and similar among the participants, involving increased quality and quantity of time spent with family members and friends and offering heightened support after friends’ losses.
In sum, these participants incorporated the “new information” of their family members’ deaths within existing schemas of work, leisure, and social participation, “without … any reorganization or modification of prior knowledge,” to return to Matheson and Bohr's (1997, p. 433) model. They adapted to their losses through existing occupations, reconstructing meaning in their lives, and adapting to their losses through the process of assimilation.
The 31 participants in this study described profound passages in their lives. In response to loss, each experienced the emergence of new occupational meanings and strategies. Data from this study support the adaptive power of occupational performance at time of death of a family member through two complementary strategies: (1) occupational accommodation and (2) occupational assimilation.
Continuing Bonds
As noted earlier, Field et al. (1999) identified four types of continuing bonds: (1) a recurrent sense of the deceased's presence, (2) maintaining the deceased's possessions, (3) seeking comfort through contact with the deceased's possessions, and (4) gaining comfort through memories. Participants in this study described another type of continuing bond: engaging in occupations that were meaningful or closely related to the deceased.
For example, a 36-year-old woman described participating in a new leisure activity (an occupational accommodation) because it would have been meaningful to her mother, who had died from cancer:
I went to NASCAR. I'd never done that before. I thought, Mom would love this. She would love the fact if I called her and said, “Mom, I'm going to NASCAR. I'm going to make a day of it.” I think about her when I do those spontaneous jaunts, and I'm there and I think, “She would have loved this.”
A 26-year-old woman described participating in a familiar leisure activity (an occupational assimilation) because of its meaning to her deceased grandfather:
I played softball all through college. That was very important to me, and the grandfather I was very close to came to all my games. So that was really important after he passed away that I continue to do that. He was always in my mind when I was playing because I shared that with him. It almost had more importance afterwards.
Other participants described the following occupational pursuits that sustained bonds with their deceased family members: changing jobs because the new work would have been more meaningful to the deceased, investing an inheritance in real estate because that's what a deceased father would have wanted, volunteering for hospice after the death of a son, pursuing a new interest in reading poetry because a deceased grandmother enjoyed it, engaging in new social relationships with a deceased son's friends, engaging in new social relationships with a deceased father's coworkers, and becoming a speaker on a victims’ impact panel after the death of a son in a car wreck that involved drinking.
Discussion
“Meaning reconstruction in response to a loss is the central process in grieving,” according to Neimeyer (2001a, p. 4). Perhaps nothing in life has more power to shatter meaning than the death of a loved one. Attig (2001) wrote that the death of a loved one has the potential to call into question
that we are connected to something greater than ourselves; that we belong, and are at home, in this world; that it is a safe, orderly, and trustworthy world; that there is a point to going on day to day, pursuing purposes, caring, loving, hoping, and aspiring; that living a human life is ultimately meaningful and worthwhile; that there is a reason to continue and act in the world, however elusive that reason may be. (p. 45)
For many in the helping professions, grief is “understood (and diagnosed) in largely psychiatric terms, as an unwanted constellation of depressive, anxious, or post-traumatic symptomatology”; as a result, grief therapy is viewed as “a rhetorical process” (Neimeyer, 2001b, p. 264). The results of this study suggest that rhetoric alone cannot adequately reconstruct meaning in the aftermath of loss.
“Meaning,” according to Nelson (1988, p. 636), ”is constituted by the interaction between occupational form and the individual's developmental history (a looking back).” Because meaning is embedded in occupation, it is not surprising that occupation takes a central role in meaning reconstruction after the death of a loved one.
Participants in this study described three distinct occupational processes that were fundamental to reconstructing meaning in their lives after the loss of a family member: occupational accommodation, occupational assimilation, and continuing occupational bonds. The study's participants demonstrated great variability in the ways they used these strategies. Sixteen of the study's 31 participants described mixing accommodation and assimilation strategies to reconstruct meaning in work, leisure, and social participation. Fifteen of the study's participants described only assimilation strategies. Thirteen participants used both assimilation and accommodation strategies within a single area of occupation. For example, a participant may have assimilated by filtering loss through an existing leisure activity and accommodated by engaging in a new activity after the death of a family member. No participant accommodated in all three areas of occupation, suggesting that some minimal level of occupational stability and familiarity is essential after the death of a family member. Fifteen of the 31 participants told stories of occupational engagement motivated by a desire to sustain continuing bonds with their deceased family members.
Findings of this study are consistent with occupational therapy's fundamental premise: Occupation is therapeutic. This study broadens and deepens understandings of how occupation is therapeutic when a family member dies. Although further research is needed to arrive at specific occupational assessments and interventions in response to loss, general guidelines from this study can be applied to the work of occupational therapists.
Clients, therapists, and family members will find it useful to understand that people travel highly individualized occupational pathways toward recovery after the death of a family member. For some people, returning to familiar work, leisure, and social participation will facilitate recovery; for others, new occupational pursuits are necessary and therapeutic.
Although this study names, describes, and illustrates two complementary occupational strategies (accommodation and assimilation) and a motivator for specific types of occupational engagement (continuing bonds) after the loss of a family member, it is not important that clients, therapists, and family members be able to name a particular strategy or be made aware of their motivations. It is important, we believe, for clients, therapists, and family members to understand and accept differing occupational styles of grieving.
Further Research
Perhaps the greatest emotional challenges we face in life stem from the deaths of our family members. Findings from this study indicate that occupational engagement is a key to meaning reconstruction after such loss.
The purpose of this study was to better understand occupational processes after the death of a family member. Undoubtedly, this study raises more questions than it answers, and further research is needed to address several issues.
Neimeyer (2001a, pp. 3–4) identified several issues addressed by a new wave of grief research: (1) the maintenance of symbolic bonds with the deceased person, (2) revision of one's self-definition after loss, (3) posttraumatic growth after loss, and (4) comprehension of the ways that loss is negotiated in families and social contexts. This study suggests that occupation is integral to each of these issues; further research can illuminate the role of occupation in these grief processes.
This study focused on a specific type of loss. The death of a loved one, Neimeyer (2001a, p. 5) wrote, is “the prototypical form of loss.” Other types of loss, such as loss of a job, relationship dissolution, loss of self-care skills, or new disability, surely carry occupational implications and involve similar and different occupational processes as those investigated in this study. Further study can illuminate occupational processes with various types of loss.
The purpose of the current study was to develop theory to understand occupational processes at a time of death of a family member. Further research is needed to understand how occupational therapists can effectively intervene to promote healthy occupational recovery.
This study proposes that accommodation and assimilation describe occupational processes at a time of death of a family member. What are the factors that guide choices to use these processes alone or in combination? During the course of this study, we wondered whether gender, age, closeness of relationship with the deceased, unanticipated loss versus expected loss, and caregiver status influenced these choices. In the end, conflicting data scuttled all of these nascent theories. Our current working theory is simpler: If an area of occupation was meaningful and purposeful before loss, a participant tended to assimilate and return to familiar occupational performance patterns. If not, the participant tended to accommodate to find more meaningful occupational expressions and performance patterns. Further research is needed to understand whether this is, in fact, the case.
Limitations
Because participants in this study had generally reengaged in work, leisure, and social participation at the time of their interviews, at least to some extent, they were easier to identify and interview. We suspect this study describes healthy occupational recovery. Stories of people who have not reengaged may be somewhat different.
All participants in this study were from middle-class socioeconomic backgrounds. One participant was of Hispanic heritage; all others were White. Future studies are needed to explore cultural variables that may affect occupation at a time of loss.
Conclusion
Although the findings of this qualitative study are not generalizable, they serve to deepen understanding of occupational strategies and motivations after the death of a family member. These understandings lay the groundwork for further research on the interaction between occupation and loss and for the development of assessments and occupational interventions specific to loss.
In partnership with our clients, we face formidable challenges in understanding and restoring occupational performance after loss. Participants in this study described, in detail, precautions of this difficult life passage: disruption of work, neglected leisure, and diminished social participation. Their journeys also yielded unexpected treasures: work with greater meaning and purpose, leisure that brought joy and healing, and enhanced connectedness with friends and family.
As occupational therapists, no responsibility is more important than walking beside our clients after their losses and offering a guiding hand when needed. We have much work ahead to understand how we can most effectively help our clients after loss.
Footnotes
Acknowledgments
We are deeply indebted to the 31 people who shared their stories, memories, grief, and losses with us. We are in awe of their courage and strength. It has been a daunting task to work with the precious pieces of their lives entrusted to us. Our hope has been to transform their experiences into understandings that will inform occupational therapists as they guide clients after loss. We also thank Sarah Smart, OTR, for her skillful assistance with this study.